3k THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES Gift of Dr. E. R. Earwood I.EIHWK TABLET TO CRAWFORD W. LONG First to use ether as an anaesthetic in surgery, March 30, 1842. THE ART OF ANAESTHESIA BY PALUEL J. FLAGG, M.D. LECTURER IN ANESTHESIA, FORDHAM UNIVERSITY MEDICAL SCHOOL, ANAESTHETIST TO ROOSEVELT HOSPITAL; INSTRUCTOR IN ANAESTHESIA TO BELLEVUE AND ALLIED HOSPITALS, FOKDHAM DIVISION; CONSULTING ANESTHETIST TO ST. Joseph's hospital, yonkers, n.y. formerly anes- thetist TO the woman's hospital, new YORK CITY 136 ILLUSTRATIONS PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY COPYRIGHT, I916, BY J. B. LIPPINCOTT COMPANY ElectTotyped and Printed by J. B. Lipfincott Company At the Washington Square Press, Philadelphia, U. S. A. 200 To I. H. S. My Dearest Master this book Is Humbly Dedicated 624469 PREFACE The proper administration of an anaesthetic is more than a mere mechanical performance, it is an art. The Art of Atuvsthesia is acquired by becoming famil- iar with the laws which govern its administration and by developing the ability to proj^erly correlate and apply these laws. It will be perceived that while a knowledge of laws is essential, yet this knowledge is suj^erseded by the ability to properly apply them. This controlling element is what constitutes the essence of the art. Experience begets dex- terity, tact and skill. These qualities, while somewhat intangible, are nevertheless indispensable. They imply a correct and spontaneous response to the demands of the patient. The Art of AncestJiesia is not contained within any particular mode of administration. So-called empirical, percentage and shock-absorbing methods have their f)lace, but should not be j)ermitted to dominate over the art in its broader sense. They are its tools and must be observed from a point of view which considers the surgeon, the pa- tient, the time, the place and many other factors. Since^amiliarity breeds contempt, the anaesthetist must never forget to approach each case with a certain degree of courtesy and respect, for the possibilities of success as well as of failure in each are almost unlimited. A thousand ana?sthesias, instead of leading to crude- ness, should make one a thousand times more careful. As one proceeds, one should try to formulate laws, and these one should strive to prove by the next case. vi PREFACE The Art of Anccsthesia implies an intimate knowledge of general medicine, pathology, sm*gery, therapeutics, psy- chology and special branches. Those who are not familiar with these subjects cannot understand the language of anaesthesia. For example, how can a lay person intelligently form an opinion upon such vital matters as acidosis, toxaemia, carbon dioxide, stimulation, and depression? How can he unravel and relieve the untoward symptoms which might arise in a case complicated by respiratory obstruction, mor- phine depression, and reflex inhibition? Death, due to anaesthesia, is not an unheard-of thing in lay conversation. As a consequence some timidity exists towards the taking of an anesthetic. Intelligent people often ask: " How does Dr. know that I can safely take an anesthetic? " This fairly common query implies not only the necessity of a preliminar}^ examination, but of an examination by a physician. Aside from this consid- eration, a surgeon can ill afford to let the public know that he is willing to risk the patient's life at the hands of an anesthetist who is not a medical man. Does not this very evident lack of concern imply to the mind of the thought- ful patient a greater lack of care which ma}' include the operative procedure ? A layman who administers an anesthetic is like a blind guide who is led by the patient, instead of leading him. Unable to properly anticipate the stages of an operation he cannot judge the indications for artificial stimulation. Those who relegate anesthesia to the layman, place the responsibility of the outcome on their own shoulders. To give an anesthetic is one thing, to practice the Art of Ancethesia is another. PREFACE vii This book, therefore, is intended as a groundwork, upon which the student, interne, and general practitioner may acquire a more comprehensive knowledge of the Art of Anaesthesia. Without an understanding of the broad truths which underlie present day an' ' \r ^ x //^c:.7c >>■ ?;•.? / I. t "V^ .^ rrV- , J i' >..-v: ■y ^-' t^-* ■•-^ u->. i K-lj-«C/~ \^<>*/-* ■■/.>. (K 4(' - Z^-- /?v^ Courtesy Dr. Allen I. Smith, (lid Pcnn. Fig. 6. — The first suggestion of the use of ether as an anaesthetic. ^<-<.-€.^.-^i^<^ <^^t^A/ ''^^^t-ri.cS? '.-itiL 54 ANESTHESIA the table so that the weighted, vaginal speculum ordinarily used may hang free. Anaesthesia may be induced with advantage in the lithotomy position where the oj^eration is to be a curettage or some slight anal operation. By this method one need not wait for relaxation of the large thigh and calf muscles liefore prej^arations are begun. Posture for the Closure of U pper Abdominal Wounds (Figs. 42 and 43). — Complete relaxation for the closure of upper abdominal wounds is often difficult to obtain. If the head and the foot of the table are raised, as is shown in Figs. 42 and 43, relaxation will be materially assisted. Tlie Watcher Position. — The Walcher or Hanging Position is purely for obstetrical purposes. The object of this position is to increase the diameter of the pelvic inlet by tilting the symphysis pubis, as shown in Fig. 44. This tilting increases the conjugata vera about one centimetre (Fig. 45). The position is obtained by allowing the patient to rest on the edge of the table on the buttocks with her legs hanging free. ( Fig. 44.) 7. Rigidity in upper abdominal operations is particu- larly embarrassing when the wound is closed. At this time great relief is afforded the surgeon by lifting the head of the table, thereby relieving the tension on the recti (refer to Figs. 42 and 43). 8. Rigidity caused by intra-abdominal distention, which has not been relieved by the operation, is best dealt with by using an open mask, at least during the stage of main- tenance. In this way the maximum oxygenation is obtained and there is practically no residual COo to cause deep and embarrassing respirations. These cases are usu- ally quite sick and succumb easily to the anjesthetic. COMPLETE GENERAL AN^STHESLV 55 Fig. 40. — Table set for lithotomy. Fig. 41. — Patient in lithotomy. 56 ANESTHESIA Fig. 42. — Table set for closure of upper abdominal wounds. Fig. 43. — Patient in position for tlcsure cf upper abdominal wounds. COMPLETE GENERAL AN^STHESL\ 57 9. Rigidity is caused by the anaesthetic per se: Where all rigidity must be abolished, mtrous occide and (hvygen alone will not give a uniform and satisfactory result in abdominal operations. Preliminary medication and nerve blocking or ether must be used. Fig. 44. — The Walcher position. The Third Period of Induction: Relaxation Relaxation is more than mere absence of rigidity. In the normal muscle, which is not rigid, there is a definite tone which differentiates it from the muscle which is completely cut off from the control of the central nervous system. A. The Evidences of Relaxation. — At the begin- ning of the stage of induction before excitement ha.s become apparent, one frequently finds a condition of pseudo-re- laxation. The arms and legs can be fiexed and extended, remaining quietly in place. L^pon a casual observation it is 58 .-VNiESTHESIA almost impossible to differentiate this condition from that of true relaxation. In the case of children, where it is quite commonly found, it may sometimes be detected by sharply tapping the platysma myoides of the extended side ; if the patient is simply sleeping there will be a sympathetic dila- tion of the pupil of the same side. This condition of pseudo-relaxation may be accounted for in the following manner: During the period in question, the anaesthetic is producing chiefly cerebral effects or no effect at all. The 10.9 u-rr^ motor nerves have lost none of their irritability. They are simply receiving no stimuli. The condition is much like that of natural sleep. Later the physio- logical effects of the ether become evident in a dis- charge of energy, which ex- Fro. 45.— Diagram to explain Walcher position, ViiViifc i + cf^lf in rTP>r»fiTnl nr seep. 57. (After Williams' Obstetrics.) niOlLS llSCll 111 geiieitll OI local rigidity. Relaxation appearing shortly after the anesthetic has commenced and which has not been preceded by a definite, however brief, stage of excitement should be regarded with suspicion. OccasionrJly true relaxation does come on in this man- ner, but this is unusual. The preliminary use of morphine may so far do away with the period of excitement that its presence is not noted. In such cases, true relaxation will come on with a quietness and rapidity which will strongly suggest the pseudo-state. One must not depend solely upon the evidences of relaxa- tion. These must be corroborated by the condition of the lid and eve reflexes. COMPLETE GENERAL AN.ESTHESL\ 59 True relaxation may often be distinguished from the spurious by examining- the condition of the masseters. It will usually be found that in true relaxation the lower jaw can be made to move freely up and down, while with pseudo-relaxation, the teeth are tightly clenched. B. The Causes of True Relaxation. — Relaxation may be said to occur when the deep muscle stimuli, which are constantly flowing to the normal muscle, have been inhibited by the action of the anaesthetic. This action, while affecting chiefly the nervous mechan- ism, may also be due to the direct effect of anaesthetic upon the muscle tissue, rendering it less responsive to stimuli. Whether or not the efferent motor mechanism is para- lyzed to the exclusion of the afferent sensorv, as suo:o:ested by Crile, is still open for discussion. However this may be, we may account for muscular relaxation by supposing an anaesthetic " block " acting on the motor nerves. Loss of rigidity does not imply complete relaxation. We must, as already remarked, dispose of the normal tone of the muscle before the desired end can be obtained. C. The Control of the Relaxation. — If the pain stimuli are absent or diminished, the rigidity, which occurs as a reflex effect of this irritation will also be controlled. Local antesthesia applied to the sensory nerve endings, as, for example, the injection of novocaine into the sensitive operative field, before incising, will result in an absence of rigidity on the part of those muscles, which would nor- mally be involved in this reflex. Under a light anaesthesia, such as that secured by nitrous oxide and oxygen there is no doubt as to this action. The control of the relaxation then is largely the duty of the antEsthetist, who will bring about the best results by 60 ANESTHESIA removing and controlling as far as possible the causes of rigidity, i.e., excitement, obstruction to the respiration, too early incisions, position of patient, operations on upper abdomen, gall-bladder and pelvic stimuli, dilatation of sphincter, anesthetic per se and intra-abdominal distention. II. MAINTENANCE Having treated the first stage of a complete general anaesthesia, induction, we now proceed to the second stage, maintenance. The stage of maintenance begins when general relaxa- tion obtains, and when a constant depth of anaesthesia has been reached. It ends when the level, which has been held, is permanently permitted to drop. Two varieties of maintenance may be noted: the con- stant maintenance and the variable maintenance. Constant maintenance (Fig. 46) can only be obtained by means of a special mechanical device made for the pur- pose of delivering vapor in known percentages. Variable maintenance is the tyj^e which occurs when anaesthesia is otherwise carried on. Constant maintenance keeps the patient so completely anesthetized throughout the operation that he will not inconveniently react to deeper stimuli. This type of antes- sia protects the patient from afferent pain stimuli, and considers the amount of ether used as of little consequence. The varying type, which obtains when the open, semi- open or closed drop method is used, aims to anticipate and hold in abeyance the reflex effects of trauma to the deeper structures, by increasing the anesthesia according to indi- cations. It aims to lessen the amount of ether used by allowing a lighter level as often as possible. By a varying maintenance is meant one which varies COMPLETE GENERAL AN.i^STHESL\ 61 only under the immediate direction and control of the antusthetist. The anaesthetist must always be in tlie " lead," so to speak. He must always know just where the patient is and anticipate the call for a lighter or deeper anesthesia. For this reason he should be familiar with the operative procedure. He should know the technic and the demands of the surgeon with whom lie works. Some surgeons ap- preciate a light anaesthesia, while others will not tolerate it. lao MIN Fig. 46. — Curve showing variable and constant maintenance; constant maintenance shown by dotted line, variable by solid. The anaesthetist should know something of the relative sen- sitiveness of the various tissues. He should know that the skin and the peritoneum react much more energetically than the muscle and bone tissues. With this knowledge, he will not be surprised in an operation for inguinal hernia, for example, to find the patient, who is going along peace- fullv enough throug'h the dissection of the involved mus- cles, suddenly come out of the anaesthesia when traction is 62 ANAESTHESIA made upon the hernial sac, whose formation, it will he re- membered, is peritoneal. If we were positive that the amount of ether made no difference, from a ^pathological point of view, and if we were sure that a deep ansesthesia afforded an absolute nerve block, it would be very poor technic to use any method but that which will give a constant level. In view of the present theories touching upon nerve block and shock, however, and our incomplete information regarding the massive effects of ether on the blood and tissues, we are justified in feeling that this varying, or as is sometimes called, empirical method, is really not so unreasonable after all. The control of the stage of maintenance, as has already been stated, depends very largely upon the character of the induction. A stormy and delayed induction will very likely give rise to a stage of maintencnce which is uneven and difficult to control. The obstruction of the respiration is one of the most important elements in the control of the stage of main- tenance. Persistent obstruction, during this stage, usually results in undesirable lightness with consequent rigidity, increased bleeding, and cyanosis. The paralysis of the tongue, which frequently causes this obstruction, can readily be relieved by the use of the throat tube (Fig. 14) , whose great value we once more emphasize. Other types of obstruction, such as laryngeal, pulmonary, intra- and extra-abdominal pressure, must be separately and success- fully dealt with, if one washes a smooth maintenance. If the respiration is deep and free, the patient must be carefully watched for signs of recovery; for it will be readily appreciated that such a respiration will soon dis- pose of the ether which may be in the patient's circulation. COMPLETE GENERAL ANiESTHESLV 63 Such patients call for an increased amount of ether on the open mask or the continuous use of the closed method. On the other hand, tlie patient whose respirations are shallow is conserving most of the ether in his system and requires but a small amount to maintain the level in which we find him. This is quite typical of the patient who has received preliminary morphine medication. Occasionally one sees a patient in the stage of main- tenance forgotten for the time being by the auiesthetist, because of his lack of knowledge of the signs playing before his eyes, and because custom has, so to say. decreed that his work of " carrying the patient to the brink of the grave and leading him safely back again " is not quite: so important as holding the retractors and looking into the patient's belly. Such a neglected patient may do one of two things: If the antcsthetist wishes to make sure of not being disturbed during his observations, and as a safeguard against this annoyance, pours on ether without watching the patient, the latter may die, as has occurred not infre- quently under precisely such conditions. In this case the anaesthetist is not discharged from the hospital for criminal negligence, but the cause of death is registered as cardiac failure or status lymphaticus, which, however, does not clear the anaesthetist of serious guilt, due to his negligence. Or should the ansesthetist, bearing in mind these fatalities, in the course of his bird's-eye view of the field of opera- tions, stop giving ether for safety's sake, then the patient does the other of the two things — he vomits. This invaria- bly directs the condemning glances of the staff directly to the antEsthetist. As a result, anxious to cover up matters as quickly as possible, he does just the wrong thing. He immediately pushes the ether to the utmost. 64 ANESTHESIA The onset of vomiting implies the return of the pharyn- geal reflexes. The reaction to ether is now much as it was in the early periods of induction; concentrated ether gives rise to spasm, rigidity, and delayed induction. The anaes- thetist, in his anxiety to bring the patient back to the stage of maintenance, defeats his own ends. The aucTsthetic should be given slowly until a tolerance is established. It may then be pushed to the desired level without ill effects. ^^^lile the stage of maintenance, therefore, may on the surface appear quite simple, it is fraught with danger to the patient and inconvenience to the surgeon, unless in- telligently carried out. From the surgeon's point of view the stage of main- tenance should have no varying levels. It should be absolutely smooth. When indicated, relaxation should be complete and respiration of such depth that it will not in- terfere with intra-abdominal manipulations. With Ihe variable type of maintenance this ideal is approached and will become j^erf ect according to the skill of the anaesthetist. With constant or unvarying maintenance, devised by Dr. Connell, it is the exception to fall short of this ideal. Constant maintenance implies the use of definite per- centages of ether. Technically such a percentage is sj^oken of as vapor tension. The Percextage or Vapor Tension of Ether. — A short explanation must be given of the physical laws which govern the transfer of ether from the liquid state in the ether can to the state of solution in the blood and nervous system of the patient. " The air around us exists under a pressure of one atmosphere and this pressure is expressed usually in terms of the height of a column of mercury that it will support — COMPLETE GENERAL ANAESTHESIA 65 namely a column of 760 mm. Hg which is known as the normal barometric pressure at sea level. Air is a mixture of gases and according to the mechanical theory of gas pressure each constituent exerts a pressure corresponding to the proportion of that gas present. In atmospheric air, therefore, the oxygen being present to the extent of 20 per cent, exerts a pressure of 1/.5 of an atmosphere or 1 .> of 760 — 162 mm. of Hg. (A saturated atmosphere of ether vapor under like conditions exerts a vapor pressure of 68 mm. Hg at - 20° C, 182 mm. Hg at 0° C, and about 460 mm. at ordinary room temperature. ) Induction. Maintenance. Recovery. Fig. 47. — Diagram showing vapor tension of ethier in alveolar air during the three stages of a complete anaesthesia. " When a gas is brought into contact with a liquid with which it does not react chemically, a certain number of the moving gaseoaas molecules penetrate the liquid and become dissolved. As many molecules will penetrate the liquid in a given time as escape from it, and the liquid will hold a definite number of the gas molecules in solution, it will be saturated for that pressure of the gas. If the pressure of the gas is increased, however, an equilibrium will be estab- lished at a higher level and more molecules of the gas will be dissolved in the liquid. Experiments have shown, in accordance with this mechanical conception, that the amount of a given gas dissolved by a given liquid varies, the temperature remaining the same, directly with the pres- sure, that is, it increases and decreases proportionally with 5 66 ANAESTHESIA the rise and fall of the gas pressure. This is the law of Henry. On the other hand the amount of gas dissolved by a liquid varies inversely with the temperature. It fol- lows also from the same mechanical views that in a mixture of gases each gas is dissolved in proportion to the pressure which it exerts, and not in proportion to the pressure of the mixture. " Air consists in round numbers of four parts of nitro- gen and one part of oxygen. Consequently when a vol- ume of water is exposed to the air, the oxygen is dissolved according to its ' partial pressure,' that is, under a pressure of 15 of an atmosphere ( 1,52 mm. of Hg) . The water will contain only 1/5 as much oxygen as it would if exposed to a full atmosphere of oxygen, that is, pure oxygen. And on the other hand if water has been saturated with oxygen at one atmosphere 760 mm. of pressure and is then exposed to the air, 4/5 of the dissolved oxygen will be given off, since the pressure of the surrounding oxygen has been diminished this much. " When a gas is held in solution the equilibrium is destroyed if the pressure of this gas in the surrounding medium or atmosphere is changed. If this pressure is in- creased the liquid takes up more of the gas, as an equi- librium is established at a higher level. If the pressure is decreased the liquid gives off some of the gas. That pres- sure of the gas in the surrounding atmosphere at which equilibrium is established measures the tension of the gas in the liquid at the time. Thus when a bowl of water is exposed to the air the tension of the oxygen in the solution is 152 mm. Hg; that of the nitrogen 608 mm. Hg. If the same water is exposed to pure oxygen the tension of the oxygen in solution is equal to 760 mm. Hg, while that of COMPLETE GENERAL AN.ESTHESL\ 67 the nitrogen sinks to zero if the gas that is given off from the water is removed. With compounds such as oxyhfemo- glohin the tension under wliich the oxygen is held is meas- ured by the pressure of the gas in the surrounding atmos- phere at which the compound neither takes up nor gives off oxygen. If, therefore, it is necessary to determine the tension of any gas held in solution or in dissociable com- bination it is sufficient to determine the percentage of that gas in the surrounding atmosphere and thus ascertain the partial pressure which it exerts. If the atmosphere con- tains 5 per cent, of a given gas the partial pressure exerted by it is equal to 38 mm. Hg ( 760 times .0.5 ) and this figure expresses the tension under which the gas is held in solution or combination in a liquid exposed to such an atmosphere. (If the atmosphere contains 6..58 per cent, of ether vapor the partial pressure exerted by it is 50 mm. Hg.) " It is important not to confuse the tension at which a gas is held in a liquid with the volume of the gas. Thus blood exposed to the air contains its oxygen under a ten- sion of 152 mm. Hg but the amount of oxygen is equal to twenty volumes per cent. Water exposed to the air con- tains its oxygen under the same tension but the amount of gas in solution is less than one volume per cent. Ten- sions of gases in liquids are expressed either in percentages of an atmosphere or in millimetres of mercury. Thus the tension of oxygen in arterial blood is found to be equal to about 10 per cent, of an atmosphere of 76 mm. Hg. " ( The tension of ether vapor necessary to maintain amesthesia is about 50 mm. Hg. ) " — Howell ; matter in parentheses ours. Were it of advantage that a saturated atmosphere of ether at room temperature be breathed by a patient, so much ether could be dissolved in the blood that the vapor 68 ANESTHESIA tension of the ether dissolved would finally equal that of the vapor in the lung, or 460 millimetres. Yet it is found clinically that a sufficient depth of antesthesia has heen achieved when the amount dissolved in the blood has a vapor tension of 50 millimetres. To insure this amount be- ing dissolved into the blood within a reasonable time, — six to eight minutes being usually employed in induction — it laOmm 150""" 120 mm 90""" 75 mm. 50mm 30""" TIME *^ STAGE 460"""- SATURATION ®22«C ASPHYXIAL INDUCTION ZONE RAPID AND DANCCROUS ZONE FOR RESISTANT SUBJECTS /rapid induction\ / RtLAXATION \ / IN r-IO MIN \ / y^ SLOW IMDUCnON V \ // RELAXATION X\ // IN 12-15 MIN. -X / / IRRITATION, MUCOUS \ SUBCONSCIOUS EXCITEMENT \ /fsLIGHT IRRITATION [^v /(CONSCIOUS EXCITEMENT 1 \^ / PUNGENT ODOR CONFUSION AND SOMNOLENCE ANAESTHETIC Aether odor /[sugmt confusion 1 1 ! EQUILIBRIUM » — ^3 -5MIN. J^ 5-7 MIN. "induction 20-40MIN. ' FUUL surgical' ■ J^ MANY HOURS ^ ANAESTHESIA " ^ Fig. 48. — Vapor pressure of ether in tidal air for induction and maintenance of full ansesthesia. Partial press- ure of vapor in millimetres of mercury (Courtesy of Dr. K. Connell, Johnson's Surgery, Appleton.) is required that a much stronger ether vapor be breathed during induction than is needed merely to maintain anses- thesia. ( Figs. 48 and 49) . To induce anassthesia rapidly, the vapor must be so abundant as to exert a vapor tension of at least 180 millimetres (Figs. 48 and 49). This gradually crowds the required amount of ether into the blood and nervous system. When the blood approaches the proper satura- tion, as indicated by the signs of anaesthesia, the amount COMPLETE GENERAL ANAESTHESIA 69 of ether present in the air breathed is gradually lowered until finally, in ideal anesthesia, the pressure of ether vapor in the lung balances the tension of ether dissolved in the blood and the patient sleeps in quiet, uniform anaesthesia of the desired depth. This is finally achieved at a level of .50 millimetres of ether tension; or by volumetric percentage 120- ISC'"' 50^ ANAESTHETIC EQUILIBRIUM ESTABLISHED AT 50'"'" r\mm TtME 8-12 MIN. AVERAGE ADULT < 20- 4-0 MIN. >!<- PERIOD < INDUCTION X ESTABLISHMENT )^ CONTINUANCE Fia. 49. — Plot of ether vapor pressure in pulmonary tidal air and ether tension in body in 6rst hour of ideal anaesthesia. (Courtesy of Dr. K. Connell, Johnson's Surgery, Appleton.) 6.o8 per cent, of the air breathed should be ether vapor (Figs. 48, 49 and 50). At this level, both the small child and robust alcoholic sleep in anaesthesia of proper dej)th. The foregoing facts throw light on the following : The value of warming liquid ether to promote evapora- tion (not the value of warming ether vapor, which is nil). Safety of the open drop mask with its hoar frost evapo- rating surface (much reduced evaporating temperatm-e). 70 ANAESTHESIA The efficiency of the closed system of aricEsthetization (because of the heat from rebreathing) . The greater efficiency of using a warmed apparatus (warm metal) for induction. If one sets an ether vapor bottle in water 100° F., the ether vapor which issues approaches 100 per cent, instead of being 60 per cent. (460mm. of 760mm.) or less (see p. 148). If with the semi-open method the patient rebreathes a little, this increased heat serves to give us better control of the patient. >^^^ TIME Fig. 50. — Plot of ether tension in body. Recovery stage after full ether anaesthesia. (Courtesy of Dr. K. Connell, Johnson's Surgery.) The Volume Employed. — Following the question of vapor tension or the strength of the ether vapor, the bulk of the vapor administered is our next consideration. In order that the respiration may be tranquil, a sufficient volume must be administered. The amount necessary varies ac- cording to the individual from 10 to 18 litres a minute. The indicator on the ana^sthetometer shows the volume which is being delivered, and we are provided with the means to regulate automatically the amount of ether added to each litre and the consequent percentage of ether vapor. COMPLEIE GENERAL ANAESTHESIA 71 The Pressure at which the Vapor is Deli^t:red. — This vapor, wliicli is now being delivered in sufficient vol- ume to fill all the requirements for tidal volume and at a percentage which is constantly under our control, must be administered to the patient at a pressure sufficient to carry it deej) into the pharynx and to exclude atmospheric air. The necessary volume of 10 to 18 litres a minute should be delivered at a pressure of from 15 to 30 mm., according to the individual in question. The volume is in- tended to be in excess to the respiratory needs and this delivery, under the pressure mentioned above, practically provides the patient with an atmosphere of a known and constant percentage. We have now considered and explained vapor pressure or tension; seen the need of a vapor pressure of 180 mm. or more for the stage of induction, and have established a vaj3or pressure of 50 mm. as a safe and satisfactory press- ure for maintenance. For apparatus see Fig. 78. Control of Maintenance. — The control of main- tenance resolves itself into: First, the undivided and in- terested attention of the anaesthetist. Anything which has a tendency to interfere with this should be eliminated, as trouble is certain to follow sooner or later. Second, the patient must be the final index governing the quality and the amount of the anaesthetic. The patient must never be forced against all his protesting signs to accept what is theoretically correct. The art of ana?sthesia does not permit us to court the patient's death in this fashion. If, for example, the surgeon complains of rigidity during the course of maintenance, remarking, " Won't you please get him under," or " he is like a board," or simply stops his procedure and looks at you in unutterable disgust, do not 72 ANAESTHESIA soak the patient with ether in the presence of a dilated pupil, absent corneal reflex, and cyanosis. Be absolutely certain that you know the cause of the rigidity. Be sure that the respirations are free and that the position on the table is good ; that the patient is really light before you go ahead, and to protect yourself from abuse, give him the last push which sends him " over the brink." You are the pilot on the ship Patient. It is your duty to look out for the shoals and the breakers which threaten her course. Who ever heard of a trustworthy pilot leaving the wheel to lose himself in some diversion going on aboard? Do not let your first warning be a scraping of the keel as she rides over shallows, that is to say, when the patient begins to retch ; or the sudden startling sound of breakers, as the respirations become sighing and cease, and cyanosis becomes deeper and deeper, the eyelids widely separated and the pupils, with the iris almost gone, staring through a lustreless cornea. Unless one is a careful and observant pilot all the time, he will find himself drifting from the course and endangering the life of this human being so wholly under his control. We must realize that this business is a most serious one ; that its frequent execution by the youngest and most inex- perienced interne is a most unjust thing. That in this mat- ter the house officers, who incidentally rank above you and who have given a few hundred anaesthetics are not so expert that from their position at the retractors they can give you precise long-distance information as to the immediate needs of the patient. The color, the respirations, the pulse and the eye signs are our masters. Learn well how to obey these and all will go smoothl3\ If the surgeon and the senior house officers would force the anesthetist to study the symptoms carefully and to be personally responsible for COMPLETE GENERAL ANAESTHESIA 73 74 AN.^.STHESIA everything incidental to the anaesthetic, accepting freely, in case of doubt, the opinion of their pilot, a smoother and a safer anaesthesia would result. We have considered the onset of the stage of mainte- nance, the constant and variable types available for our use and the responsibility of the anaesthetist towards the patient. Let us now take up the question: When does the stage of maintenance properly cease and the stage of recovery begin? Maintenance ceases when we leave the constant or vari- able level, which we have held and reduce or stop the anaes- thetic XLith a view of bringing the patient back to con- sciousness. While carrying on a variable maintenance, we may reduce and even stop the anaesthetic ; but we do not do this with a view of bringing about the complete recovery of the patient. The motive which leads us to finally stop the anaesthetic is that which really constitutes the dividing line between the stages of maintenance and recovery. III. THE STAGE OF RECOVERY This stage begins with the permanent reduction of the anaesthetic and ends with the return of consciousness. Because the inception of recovery is largely automatic, this stage of amesthesia is likely to suffer from dangerous neglect. The anaesthetist is very apt to feel that when he ceases to give ether his responsibilit}^ is at an end, whereas his release does not come until consciousness returns. We may conveniently consider the evidences, types and control of the stage of recovery. A. The Evidences of the Stage of Reco^t:ry. — The stage of recovery becomes evident: («) in the gradual and complete return of the reflexes; {b) in the return of consciousness. COMPLETE GENERAL ANESTHESIA 75 (a) One of the first signs to appear, upon allowing the patient to recover, is a slowing down of the respira- tions. These will drop from 40 to 2.5 or 20 a minute. The pu^^il, which has been moderately dilated during the stage of maintenance, will contract. That which has been smaller than normal will become pin-point or widely dilated from sympathetic stinmli. There will be rolling of the eyeballs, also active lid and corneal reflexes. One may also expect the pulse to increase in rapidity. Rigidity will show itself in the masseters and in increased intra-abdominal tension. The patient will swallow, and, shortly after this, retch. Vomiting usually marks complete return of reflexes. { h ) Following the vomiting, which occurs upon the re- turn of the reflexes, there may be a period of quiet, during which time the patient is slowly recovering consciousness. If this period of quiet does not follow upon several attacks of vomiting, the j^atient may develop either protracted cy- anosis and vomiting, or on the other hand, may become pallid with barely perceptible pulse and shallow breathing. B. The Types of Reco\try.— The chief cause of re- covery is, of course, the withdrawal of the angesthetic. We recognize two types of recovery ( see Figs. 52 and .53). («) recovery by crisis ; {h) recovery by lysis. (a) Recovery hy crisis (Fig. 52) is that type of re- covery in which the interval extending from the end of the stage of maintenance to the return of consciousness is very brief. This type of recovery is of course most desirable. Instead of coming about in the course of hours it takes place in minutes or seconds. The best example of recover}'- by crisis is found in gas oxygen anaesthesia. With this ansesthetic a patient, who has been held in the stage of maintenance for two or three hours, will recover conscious- ness in as many minutes. 76 ANESTHESIA (b) Recovery by lysis (Fig. 53) is a common occur- rence in hospital anaesthesia where the anaesthetist uses a high level of maintenance to the end of the operation. Patients who experience this type of recovery may not regain consciousness for four or five hours after the end of the stage of maintenance. The most marked cases of this type of recovery are found in diabetic patients. Occasion- ally these patients never recover consciousness. lO Mm. 20 I 1-5 MIN. '"MIN. G. 52. — Recovery by crisis. The following factors tend to induce recovery by crisis: nitrous oxide oxygen ansesthesia ; deep, free, rapid respira- tions; alcoholism; a short stage of maintenance; the use of closed method with good oxygenation and employment of rebreathing ; the surgeon who permits early recovery. The following factors tend to produce recovery by lysis : ether ansesthesia ; a long stage of maintenance; preliminary morphine medication; acidosis; shallow or obstructed res- j^irations ; the use of the closed method with persistent high maintenance and cyanosis. C. The Control of the Stage of Recovery. — The control of the stage of recovery divides itself naturally into : (a) that portion dating from the onset of the stage to the COMPLETE GENERAL ANESTHESIA 77 time when the reflexes have completely returned ', (b) that portion dating from the complete return of the reflexes to the return of consciousness. We recognize these two periods of recovery because this division naturally comes about in the treatment of the pa- tient. Before the reflexes have returned the patient is un- der the immediate supervision of the anaesthetist. After the complete return of the reflexes he usually passes into the hands of the nurse. Recover>' by lysis. {a) The flrst period of the stage of recovery should take place in the operating room on the operating table. The vomiting, which accompanies the return of the re- flexes, should be over by the time the patient leaves the operating room. Some patients do not vomit upon the return of the re- flexes, but the large proportion who do not at least retch once or twice. It will be understood that at this time, con- sciousness having not yet returned, such retching and vom- iting are not distressing to the patient. Our chief problem in controlling the stage of recovery is to determine when to begin. The exact time at which 78 ANESTHESIA the anesthetic may be stopped is governed largely by ex- perience. This is one of the features which go to make up the A?'t of Ancvsthesia. Broadly speaking, in the case of abdominal operations, a moderate level of maintenance having been carried, the anaesthetic may be permanently reduced as soon as the fascia is closed. When the surgeon begins to sew up the skin the face piece may be removed. In operations other than intra-abdominal, the anaesthetic may be reduced at an earlier period, the index in these cases being the comfort and freedom of the surgeon from objec- tionable signs, as rigidity, vomiting, movement, etc. If the throat tube has been in use during the course of the operation, it should be left in place until retching begins. By maintaining a free airway, an early recovery is thus obtained. If the Trendelenburg position has been used, when the head of the table has been raised, a lessened cerebral circulation will result. If this position be ex- aggerated as in the case of upper abdominal operations, the pulse should be carefully observed for shock. The anaes- thetic may also be reduced and withdrawn at an earlier period. If the induction has been stormy, and the main- tenance controlled with difficulty, the aucesthetist should pay particular attention to the patient during the stage of recovery, for there are likely to be attacks of vomiting ac- companied by masseteric spasm and distressing cyanosis. If this trouble is anticipated, the mouth tube should be held in place until the reflexes have returned to such a degree that the active laryngeal reflexes will not permit of the inspiration of vomited material. (6) It will readily be appreciated that the second period of recovery (after the reflexes have returned) will be in- fluenced by the fact that the operation has been done in the COMPLETE GENERAL AN^STHESLV 79 home instead of in the hospitaL In this case, unless speci- ally trained nurses be available, the patient must be watched carefully until consciousness has returned. The return of consciousness need not consist of a complete orientation, a clear-cut appreciation of all that has taken place. It is sufficient that the patient answers questions intelligently. It is sufficient that she "has found herself," so to speak. As the patient approaches the amesthetic somewhat confused by the action of the preliminary mor- phine, so it is not only permissible but advantageous to leave her in some confusion regarding her condition and somewhat irresponsive to the pain which would otherwise torment her. Ninety-nine cases out of one hundred would probably make an uneventful recovery, if abandoned to themselves after the reflexes have returned. The remainin"- one miffht die. Is it not worth the possible saving of one life in a hundred cases to watch carefully the recovery of each? If that life was ours there would be but one answer. The recovery may worry us either because the patient develops continual spasm, cyanosis and vomiting, or, on the other hand, because of pallor, almost imperceptible pulse, and a slow and very shallow respiration. The first trouble is usually noticeable at once. In this case the wooden mouth gag may be introduced, the teeth separated, and tip of tongue pulled forward for a mo- ment by grasping it with gauze or with an ordinary sponge forceps. If it is impossible to separate the teeth, or if there is not room enough behind the last molar and the ascending ramus of the jaw to pass in the finger and depress the tongue, then a large catheter, moistened with the jjatient's saliva, should be passed through one of the nostrils by the 80 ANAESTHESIA seat of obstruction into the larvngopharynx. Air is what patient needs and when it is admitted the spasifi will pass. As the olfactory sense returns, the patient, upon smell- ing her expirations laden with ether, will often vomit re- flexly. This type of vomiting frequently responds to treatment designed to obscure the odor or reduce the re- ceptive powers of the olfactory mucous membrane. A piece of gauze moistened with vinegar, essence of orange FiG. 54. — Gauze on upper lip moistened with essence of orange. or some aromatic oil, placed on the upper lip, will often produce the desired result (Fig. 54). The author recalls a recent case in which this particular form of reflex vomiting was relieved by inhalations of es- sence of orange. The jDatient, a rather high-strung young woman, had previously been twice anaesthetized by ether. Her recovery and post-ansesthetic period were character- ized by persistent and distressing vomiting. Following a subsequent and rather prolonged ether anaesthesia with a COMPLETE GENERAL AN^STHESL\ 81 high level of maintenance, the patient gave signs of recovery by crisis. The reflexes returned rapidly and she retched and threatened to vomit. As she hegan to retch, essence of orange on a gauze wipe was jjlaced over her nose and mouth. The retching stopped at once and did not re- turn ; the subsequent recovery was entirely tranquil with a single brief attack of retching after an interval of liours. The second class of j^atients, those who suddenly de- velop imperceptible pulse and very shallow respirations after the return of the reflexes, act in response to compli- cations which are ol)scure and difficult to meet. This change usually comes suddenly, following in the course of a normal induction and maintenance and early recovery. It may be seen in the robust as well as in the delicate. An unusually profound reaction to morphine, loss of CO:;, or a condition resembling ordinary syncope, may bring about this condition. Such patients, however, usually pass on to an uneventful recovery. When the nurse is placed in charge of the patient in the second stage of recovery, she should be instructed to keep the patient well blanketed, to watch closely the color, the respirations, and the vomiting. She should note carefully the position of the hot water bags, which have been applied to the patient. Continuous cyanosis, shallow, slow respira- tions (10 or less per minute) should be reported at once. When vomiting occurs, the patient should be placed on her side and the head extended. If there be pallor, with rapid running pulse, indicating possibly internal hemorrhage, the physician should be summoned promptly. The sooner consciousness returns, the better the patient is able to cope w4th his condition. Generally speaking, we may say that recovery by crims argues well for the final and uncomplicated surgical recovery. 6 CHAPTER III THE SIGNS OF ANAESTHESIA The signs of anaesthesia may be considered under five headings: the respiratorij ; the color; the muscular; the eije; and the j^ulse. During the periods of excitement and rigidity, we are concerned chiefly with the first two, the respiration and the color. As anaesthesia progresses, the ilmscular signs be- come of value, later the eye sign and lastly the pulse. During the early periods of induction, the respiration and the color must be under satisfactoiy control. The phe- nomena exhibited by the other groups at this time are but incidental and of negative value. That is, they but serve to show us that the patient is not under the mfluence of the anaesthetic. As anaesthesia progresses, however, these signs become of positive value by assuring us that the patient is under the influence of the anaesthetic and in our control. 1. THE RESPIRATORY SIGNS Perhaps the most important single sign of this group is the respiration. We should watch the respiration closely from the beginning of induction to the end of re- covery. We should be intimately acquainted with the nor- mal respiration and be able to detect any deviation from the normal limits by the sound alone. Experience lends one a sense of safety which becomes so acute that abnor- malities grate upon the hearer and spur him to relieve that 82 THE SIGNS OF ANESTHESIA 83 which he might otherwise suffer to persist. On the other hand this experience will also breed confidence and delib- erate action in circumstances which might otherwise ter- rify and lead to mani^^ulations, dangerous and injurious to the patient. For example, a moderate but persistent de- gree of obstruction might be unnoticed by the beginner, while the experienced man, by making use of the throat tube, will relieve this obstruction and secure a much de- sired relaxation. On the other hand, during the stage of induction, the beginner may become terrified by a duski- ness, which is not really dangerous, and break a tooth in an effort to relieve a spasm, which would otherwise have passed off spontaneously without active interference. We may consider the normal respiratory phenomena by noting the rate rhythm and amplitude, during the stages of induction, maintenance and recovery, as exhibited when the open and closed methods are respectively used. The Normal Respiration Under Ether When the Open ^JIethod is Used. — When anaesthesia is induced by the drop method, the respirations are at first of normal rate, rhythm and amplitude. As the patient passes into the period of excitement, the rate increases and the rhythm remains constant, and the breathing becomes deeper. As anaesthesia progresses, the rate increases, the rhythm })e- comes slightly irregular while swallowing and some hesita- tion is prone to occur. The amplitude will vary from a scarcely noticeable respiration to a deep, free breathing. As the stage of maintenance is reached, the rate will in- crease to 35 or 40 respirations a minute ; the rhythm will be resumed, and the breathing will be deep with a stertor of varying intensity. The first incision will produce no no- ticeable effect. As maintenance progresses the rate will 84 ANiESTHESLl continue constantly between 40 and 50 a minute. The rhythm will be occasionally interrujited by gall-bladder work, when there will be an eo'piratory grunt, and by pelvic work, when there will be an inspiratory sighing. AYhen work is being done on the stomach and intestines, the rliythm will usually remain undisturbed. The amplitude will have a tendency to become less as the stage of mainte- nance progresses. The degree of this shallowness will de- pend upon the extent to which rebreathing is permitted and upon the integrity of the dia^^hragm. As ana?sthesia progresses the respirations are likely to become more and more shallow, but remain regular in rhythm. The stage of recovery having developed, the rate of respirations will decrease, the rhythm will become halting, and the breathing will become quite shallow. The Normal Respiration Under Ether When the Closed ^Method is Used and X-O is Employed. — Almost immediately following the application of the face piece, the respirations will become rapid, regular, and much deeper than normal. This is due to the specific effect of the X2O, creating what is known as the " besoin de respire," or the necessity to breathe. If ether is now given cau- tiously, but with constantly increasing strength, the jjatient will shortly lapse into a stertor. As air is permitted, the rate will fall somewhat, but the rhythm will continue and the depth will be somewhat less. Under these conditions we pass into the stage of maintenance. Here we will ex- perience differences due to rebreathing and dependent upon the regularity with which our apparatus permits us to de- liver ether. If we pour in a large amount at long intervals, the respirations will be slow, spasmodic and shallow imme- diately uj^on receiving the dose, smoothing out as the toler- THE SIGNS OF ANESTHESIA 85 ance is established. Small doses often repeated tend to produce undisturbed respirations. Briefly, during the stage of induction, when the closed metJjod is used, the respirations are more rapid and deeper. During maintenance, less rhythmical and deeper; during recovery, more rapid, regular and deeper. It will be seen that these variations from the open method are advantageous, since deep respirations give us better control of the patient. Respiratory Abnormalities Which are Likeey to Occur AVhen Both the Open and Closed Methods ARE Used. — We may take up separately the abnormalities occurring in induction, maintenance and recovery. Abnormalities which may Occur During the Stage of Induction: Bate. — The patient may scarcely breathe, ex- cept in a very shallow, superficial sort of way, or, on the other hand, the respirations may be very rapid. The former conditions will sometimes occur in women who have had morphine; the latter will be frequently seen in children. AVith a view of securing a speedy induction, rapid breath- ing will of course be advantageous. Slow breathing will delay the completion of amTsthesia, and frequently be accompanied by vomiting. The use of a closed ether apparatus with a gas ether sequence usually overcomes the embarrassment incident to this type of resj^iration. Rhytlim.— Unless care is exercised to avoid all occa- sions of excitement, especially over concentration of ether at the outset, spasm of the respiration is almost sure to occur. This implies a respiration whicli is jerky in character, with a varying degree of obstruction. Such unsatisfactory rhythm will automatically adjust itself when the obstruc- tion is overcome and the anaesthesia deepens. Broadly 86 ANESTHESIA speaking, true relaxation and satisfactory maintenance do not co-exist with a spasmodic, obstructed respiration. Amplitude. — A reduction in the necessary volume of the respired air will result in delayed induction. One of the most frequent causes of the patient not " going under " is the lack of deep respirations. The tension or the jDcr- centage of ether in the blood depends entirely upon the amount which is offered to the circulation at the walls of the pulmonary alveoli. If the breathing is superficial, the ether enters only the trachea and larger bronchi, and must depend entirely upon diffusion to reach the finer alveoli. This type of induction frequently occurs when the open method is used, and also where the face piece of the closed apparatus is not in contact with the face at the bridge of the nose and under the cheek. Such cases seem to be going along favorably, the breathing is quiet and the color is good, sometimes a slight stertor is heard. As preparations are made to scrub up, however, the patient will suddenly make a smothered remark and begin an active period of excitement. During the stage of induction the patient must breathe raindly, rhythmically and deeply, if the best results are to he obtained. Abnormalities tvhich may Occur During the Stage of Maintenance. — Rate. — When the stage of maintenance has been entered into, the rate of the respiration may sud- denly increase or drop as the skin is incised or the peri- toneum is opened. If this increase is co-existent with ab- dominal rigidity, the level of the anesthesia must of course be raised, otherwise a change in rate may be ignored. This sign is often a valuable index to the true depth of the anaes- thesia. If the patient does not react to these manipula- THE SIGNS OF ANESTHESIA 87 tions, he is to be considered under satisfactory angesthesia, even thougli the other signs of Hghtness may be present. Excessively rapid breathing occasionally develops. When the respiration increases to 50 a minute, the anaesthetic should be stopped, even thougii some signs of lightness may exist. One will usually find tliis rapid respiration co-existing with an absent corneal reflex, dilated pupil, and muscular relaxation. As a rule, withdrawal of the ana\sthetic is quickly followed by a reduction in rate. Very sick patients, those who are septic or who have suffered from hemorrhage, will often react in this manner in the face of a light anaesthesia. If the relaxation b^ satisfactory, one should always keep these patients upon the lightest possible anaesthesia. Unusually slow respiration in the presence of signs of deep anaesthesia may be due to the effect of morphine or too much rebreathing. This sign is particularly distressing because it is so difficult to treat. If occurring where the open method is employed, morphine having been used, the closed method should be resorted to, in the hope that the accumulated COo will serve to stimulate the respiration. If following in the course of excessive rebreathing, the condition may be due to a depres- sion of the respiratory centre by the use of too much CO- or to lack of oxygen. Patients who do not react to re- breathing should be given a hypodermic of 1/100 gr. of atropine. Rhijthm. — The rhythm of the respiration during the stage of maintenance is either a source of comfort or the occasion of much anxiety. Disturbances of rhythm occur- ring upon gall-bladder or pelvic manipulation are usually reassuring, as they indicate a moderate lightness of anes- thesia. Respirations which lack rhythm from unknown 88 ANESTHESIA causes frequently indicate deep-lying trouble. CerebraJ hemorrhage into the base, pulmonary embolus or overdos- ing with ether will often show itself by such a form of dis- turbance. Occasionally one meets with Cheyne- Stokes respiration. The author recalls such a case, in which Cheyne- Stokes respiration immediately preceded a fatal issue. Disturbances of rhythm often occur where the level of the anaesthetic has been permitted to drop, the ether having been partially or completely withdrawn. In such a case, upon the reapplication of the mask into which ether has been poured, the respiration will become spasmodic. If the level has been very low, complete stoppage may result, followed by spasmodic breathing until the patient is once again anesthetized. If the level is higher, the effect will be a temporary slowing, followed by an increase in rapidity. Amplitude. — The amplitude of the respiration in the stage of maintenance appears to depend upon the action of the diaphragm and the presence or absence of COo. If a closed method is used, the breathing will be deeper throughout. If open, the reverse is true. If the level of the maintenance is moderate, 50 mm., the action of the diaphragm is vigorous and the respirations are deep; if the level is high, 80 mm., the action of the diaphragm is progi'essively affected and the respiration is shallow. During upper abdominal operations, we must try to les- sen the respiratory effort so that abdominal movement will be reduced as much as possible. First of all the respira- tions must be unobstructed. The consequent limitation of oxygen and the accumulation of CO2 in these cases cause embarrassing movements of the diaphragm. If the res- pirations are as free as possible, and the abdominal respira- THE SIGNS OF ANESTHESIA 89 tion is still annoying, we must partially paralyze the action of the diaphragm by raising the level of the maintenance. In this connection we may speak of the danger of trying to secure such relaxation where nitrous ojcide and oxygen is the anaesthetic. In this case ether must be used. The securing of a higher level of maintenance in such cases should proceed with caution and in compliance with the signs of deep anaesthesia, as exhibited by the other signs of anaesthesia which we have at our command. The free use of oxygen often leads to decreased respiratory efforts and the desired result is thus ol)tained. This treatment should always be followed, and when successful is always preferable to raising the level of the anaesthetic. Occasion- ally when absolute freedom of the respiration obtains and no rebreathing is permitted, the patient will cease to breathe. This a23noea may continue for a minute or two. When enough CO- has accumulated to stimulate a respira- tion, the patient will breathe spontaneously. If cessation of the respiration occurs in the presence of good color, pulse and eye signs, which show a moderate degree of antes- thesia, one need not worry, for there must be other signs of depression before the patient is really in danger. The Trendelenburg position often affects the ampli- tude of the respiration. This is particularly true of large, fat subjects. A low level of maintenance in these cases will cause embarrassing abdominal respirations. A high level will be prone to result in respirations which are alarmingly shallow. Abnormalities in the Respiration which may Occur During the Stage of Recovery. — In the first half of re- covery : The rate of the respiration during the first half of the 90 ANAESTHESIA stage of recovery, that is, to the complete return of the reflexes, is subject to the amount of manipulation which the patient experiences at this period. In the beginning of the stage there is little change ; but as the reflexes return, the respiration may be increased or diminished. As the pa- tient suddenly loses the stimulating effect of CO2, the res- pirations will drop in frequency, but as the pain of the stitches is felt, the respirations will again increase. Dis- turbances in the rhythm and amplitude are subject to at- tacks of retching and vomiting. In the second half of recovery: In the second half of the stage of recovery, between the complete return of the reflexes and the return of consciousness, the rate may drop to six or eight respirations a minute. The rhythm may be regular or may resemble Cheyne- Stokes. The amplitude may be either small or large. Such cases may be ascribed to a profound reaction, to morphine or to a reaction which follows in the course of excessive rebreathing. One should differentiate these two types of cases, as the treatment for one would be the worst thing possible for the other. The depression of the respiration from the use of morphine will usually be associated with a pin-point pupil and will have a tendency to persist. Where a reaction to rebreathing is the cause, the pupil will be normal or enlarged and the con- dition will tend to pass off. When the patient will not breathe spontaneously, artificial respiration must be in- duced as follows: Artificial Respiration. — Artificial respiration is for the purpose of intermittently replacing the air in the mouth, trachea and bronchi. The nature of this replacement must approach the ideal offered by spontaneous respiration. The rate, the volume, and the pressure under which fresh THE SIGNS OF ANESTHESIA 91 air finds its way into the lungs are the standards which govern artificial respiration. Respiration consists of two phases, inspiration and ex- piration. We are chiefly concerned with inspiration. Ex- piration comes about spontaneously through the natural resiliency of the structures involved. There are two methods of artificial respiration: (1) negative ventilation; (2) positive ventilation. Normal respiration brings about negative ventilation. The ribs being raised and the diaphragm contracted, the cavities containing the lungs are enlarged. Atmospheric pressure within the latter quickly fills the partial vacuum thus formed. With such normal respiration negative ven- tilation is most efficient. Where spontaneous respiration has failed, however, artificial respiration by negative ventilation can bring about only a partial inspiration because the diaphragm has ceased to act. The ribs may be raised but the diaphragm cannot be lowered as in normal respiration. Negative ventilation is exemplified by the well-known method of Sylvester, the technic of which is as follows : 1. The tongue is grasped by sponge or artery forceps and pulled well forward. This first manceuvre is abso- lutely essential to insure freedom of the airway. Complete extension of the head over the edge of the table should be practised, as shown in Figs. 55 and 5Q. 2. With the patient lying flat on his back, the head well extended, the operator stands at the head, grasps the arms just above the elbows and presses them firmly and steadily against the sides of the chest (Fig. o5). After a couple of seconds the arms are extended and brought over the patient's head. This act by lifting the ribs causes in- 92 ANAESTHESIA spiration by negative ventilation (Fig. 56). These two movements should be repeated sixteen to eighteen times a minute. Artificial Bespiration by Positive Ventilation. — By positive ventilation we endeavor to intermittently distend the lunffs bv air delivered directly into the trachea or into the pharynx. At the time of distention (inspiration) the chest incidentally expands. We say incidentally because the movements of the chest are passive; they are only an index of the degree of lung expansion. At the time of distention the paralyzed diaphragm sinks, being forced downward by the increased intrapul- monary pressure. Expiration occurs through the return of the diaphragm and the falling of the ribs. The most important single factor in positive ventila- tion is the pressure at which the air is thrown into the lungs. This pressure should not exceed 2,5 to 30 mm. of mercury. If greater pressure is employed rupture of the delicate air vesicles may result. Positive ventilation may be brought about by intratracheal insufflation. The technic of this procedure is identical with that described on page 163 for intratracheal anaesthesia, the only difference being that air alone is delivered intermittently instead of constantly. This is the most reliable method of positive ventilation and may be done by an improvised catheter or small tube, to which is attached an ordinary foot bellows, and simple j^ressure gauge. A pressure gauge may be improvised by putting one and one-half inches of mercury in the wash bottle attached to the oxygen tank. The short tube is left free, the long tube projects 25 mm. (one inch) below the surface of the mercury and is connected to the tube which delivers the THE SIGxXS OF AX.ESTHESL\ 93 air from the })ellows to tlie patient (see Fig. 57). Any pressure in this tube greater than 2.5 mm. or one inch of mercury will escape out of the bottle. If mercury is not available, a pitcher or jar of water 1.5 inches deep will do. A tube projecting into this water for a depth of ISy^ inches will give the same result since the sj^ecific gravity of mercurv is 13. .59. Fig. oo. — Sylvester method of artificial respiration, first position. Positive ventilation by intrapharyngeal insufflation is not quite so efficient. Air delivered into the pharynx es- capes in four directions : into the mouth, into the nose, into the oesophagus and stomach, and into the trachea. Every exit but the tracheal must be shut off. The mouth may be closed by a strip of adhesive plaster fastened at one end under the chin and at the other to the forehead. Escape through the nose is controlled by the presence of the nasal 94 ANAESTHESIA tubes (Figs. 83 and 86) through which the air is being dehvered. Accumulation of air in the stomach is j^revented by placing a heavy weight (twenty pounds) on the abdo- men and strapping this in position. The operator may sit on the abdomen if a weight is not available. If artificial respiration must be carried on during a laparotomy, a stomach tube should be passed and left in situ. This will I'lG. ,j(>. — Sylvester method of artificial respiration, second position. dispose of air which may accunmlate in the stomach. The abdomen being open the operator may make manual press- ure on the stomach, thus preventing its distention. Pressure on the abdomen j^er se tends to overcome the circulatory shock which is present. In addition to both negative and positive ventilation, inversion is frequently beneficial. The patient, even though full grown, is hung with the head down and swung THE SIGNS OF ANESTHESIA 95 to and fro for some moments. Such treatment by increas- ing tlie cerebral circulation is often of decided benefit. The "Lewis Pendulum Swing" (Fig. 58) is carried out as follows: The patient should be suspended by the fully flexed knees and swung forcibly from side to side for a period of from one to two minutes. Except with children, it is necessary for the operator to stand upon a box or other elevation sufficiently high to allow of a free swing. The to potient -from foot b<2lloyv.s Fig. 57. — Simple form of Mercurj- Manometer. suffusion of the neck and face, which is brought on by this swinging, is the index by which one may judge the effect of the centrifugation. Recapitulation. — Broadly speaking, we may say that our chief respiratory difficulties in the stage of induction are disturbed rhythm and shallowness. Stoppage of the respiration in this stage is due to obstructed respiration or acapnia. In maintenance, disturbances of rhythm and increased rate. Stoppage of the respiration in this stage is due to too much ether or acapnia. In recovery, disturbances of rhythm and reduced rate. 96 ANESTHESIA Fig. 58. — Lewds pendulum swing. Stoppage of the respiration in thi.s stage is due to obstruc- tion of the respiration or to the untoward effect of mor- phine. Wlien the open drop method is employed, our chief THE SIGNS OF ANESTHESIA 97 difficulty will be decreased amj)litude. This will retard induction, diminish our control of maintenance and delay the recovery. When the closed method is used, we will be annoyed by excessive respiratory efforts and, unless provision is made for constant small dosage as in the case of the closed drop method, we will find a frequent and embarrassing change in rhythm. It will also be found that the closed method will obscure respiratory sounds, which would be distinctly audible with an open mask. In order to better appreciate the significance of abnor- malities in respiration, it has been suggested that the anes- thetist occasionally try upon himself the rate of rhythm and amjilitude which the patient exhibits. II. THE COLOR SIGNS. In company with the respiration, the color is one of the signs which becomes immediately available when ana?sthe- sia is induced. AVhile the color necessarily depends on the pulse, yet in many instances it is of more value, and cer- tainly at all times deserves sej^arate consideration. The color sign is especially useful during the stage of induction when, generally speaking, the pulse may be entirely ig- nored. During the stage of itiaintenance we are able to check up a doubtful duskiness by observing the color of the blood at the site of the wound. Dark blood will call for increased oxygenation in spite of an apparently good color of the lips and ears. It will be observed that in ether anaesthesia even those who have little or no color will, after induction, show a very definite ever-changing tint. This color will necessarily be more in evidence in the florid, full- blooded individual than in the septic or anaemic. It will 7 98 ANESTHESIA vary from a bright red through duskiness, blueness, gray- ness and pallor. What color shall we endeavor to main- tain? The l)est color is the normal color of the patient, plus the flush which is the physiological effect of the ether. The cheeks and ears should be pink and the lips red. The blood issuing from the wound should be bright. The faces, necks and chests of the full-blooded, dark-complexioned individuals are very likely to be bright scarlet, fading as anaesthesia progresses. Occasionally an erythema appears, which persists for a short time. The ears and lips of the septic and ana?mic should be pink ; this will often be accom- panied by a hectic flush of the cheeks. If the respiration is normal and sufficient oxygen is admitted, the color will be normal. All those factors which influence the respira- tion, as obstruction, posture, etc., will invariably react on the color. We may consider three extremes of color — bright red, cyanosis and pallor. Carbon dioxide, the respiratory stimulant, may be con- sidered present in redness and cyanosis, where a condition of excessive respiration or hypercapnia exists. Pallor, however, implies a state of acapnia concomitant with an ab- sent or greatly diminished respiration. Incidentalh'^ it will be well to remember that the absence or presence of carbon dioxide has nothing to do with the cyanosis. COo is pres- ent in the serum as a complex acid and does not enter into union with the hsemoglobin. It is true that a cyanotic patient may suffer from an excess of COo, but he may like- wise suffer from a lack of it and yet remain blue. Cyano- sis has so frequently been associated with conditions which tend to accumulate COo, that the inference lias frequently been made that the two are identical. The practical appli- THE SIGNS OF ANESTHESIA 99 cation of these facts may he hrought out hy considering, for example, a patient who is rehreathing oxygen from a hag. As he continues to rehreathe he will hecome saturated with CO2, hut his color will remain unchanged. On the other hand, a patient who is made to ])reathe to and fro into a hag containing atmospheric air (the respirations in their course heing made to pass through lime water which will remove the CO2), will soon dispose of the CO2 in his system. He will become cyanotic then, not from the CO^ which has heen removed, but from the lack of oxygen. When the Opex Method is Used. — ^The color is usually entirely satisfactory during induction. As main- tenance progresses, however, the patient is prone to de- velop acajjnia from loss of CO2. More or less pallor then appears and persists through the stage of recovery. One often finds associated with this loss of color a cold, perspir- ing skin. When the Closed Method is Used. — During the stage of induction, with a closed method, using a gas-ether sequence, the patient while breathing the nitrous oxide is prone to assume a dusky appearance, which rapidly passes to a marked cyanosis, if the air is excluded. Limitation of oxygen during the period of excitement is thought to increase the potency of the ether and to hasten the onset of maintenance. The patient should never be per- mitted to be more than slightly dusky. A limited exclusion of air is recommended only because its use in sufficient quantity, to insure complete oxygenation, leads to a marked dilution of the strength of the ether vapor. Where oxygen may be had, this difficulty is overcome, and we may have perfect oxygenation during this stage. Marked cy- anosis will be followed not only by delayed induction but 100 ANESTHESIA by an increase in blood-pressure, which is very hkely to be harmful. When stertor has come on, and while the stage of rigidity still jJersists, air should be freely admitted and rebreathing encouraged. Even though the respirations seem satisfactory, one should not rest until the color is absolutely satisfactory. It will be recalled that obstruction may occur in the mouth and nose, in the pharynx, in the larynx, in the pulmonary absorbing surfaces and by ex- ternal pressure on all these parts. Persistent cyanosis in the presence of free breathing, with no obstruction in the upper airwaj^, would suggest an asthmatic or pneumonic process or possible cardiac insufficiency with an accumula- tion of blood in the right heart. In such a case oxygen may be given directly and efficiently by means of a closed apparatus. During maintenance, a bright-red color is commonly associated with a .warm skin and a profuse perspiration. Such patients should be carefully guarded against draughts which, by evaporating the surface moisture, will reduce the patient's temperature. When there is marked hemorrhage it is ^particularly important that a good color of the nmcous membranes be maintained. Cyanosis at this time means more to a patient than it does when there is a large amount of circulating blood. In this condition the cheeks and ears become waxy in appearance. Free oxygen must be used in these patients to insure a good color. In the stage of maintenance , when the closed method is used, the control of the color is either not so good or better than where the open method is employed. This will de- pend upon the ease with which atmospheric air or oxygen may be admitted to the apparatus. If the rebreathing is hampered by gauze in too large quantities or wrongly THE SIGNS OF ANAESTHESIA 101 placed, it will be found difficult to hold a good color. If the rebreathing is entirely free the stimulation from the CO2, by inducing a deeper respiration, will also afford a means of more easily oxygenating the patient. The surgeon will sometimes remind us of the color index by remarking that the blood is very dark at the site of operation. This sign may also be quite marked even when the color of the lips and ears seems satisfactory. In the Stage of Recovery when the Close d Method is Used. — During this stage we may find a tendency to pal- lor. This, however, will not be so marked as when the open method has been used. The presence or absence of color, and by color we mean pinkness, dejjends upon the depth of the respiration. A strong man breathing deeply may be bright red, while the same man scarcely breathing will sometimes appear waxy. Jaundice. — We often meet patients who are intensely jaundiced. It is quite difficult to maintain a satisfactory color here. The mucous membranes must be depended upon to show the proper amount of oxygenation. A slight degree of cyanosis will often pass by unnoticed. This cyanosis, being a sign of deeper trouble, will often interfere with the smoothness of the anaesthetic. The color of the blood at the site of the wound will often be our best guide as to the proper oxygenation. Negroes. — This race of people shows a very unsatis- factory color index. Here again we must depend upon the color of the lips and the hue of the blood at the site of the wound. Pallor is sometimes evident as a clayish appear- ance of the skin, which may feel chilled and be bathed in cold perspiration. NoO and O should not be used upon colored patients unless positive indications exist, since this 102 ANiESTHESIA type of anjEsthesia depends more upon the color sign than upon any other. Briefly reviewing we find that the color and the respira- tion go hand in hand. The color may be taken as an index of the efficiency of the respiration; and will serve to indi- cate the necessity or inadvisability of interference. A good color is a guarantee of the safety of the patient at the par- ticular moment under consideration. The color, while dependent upon the condition of the pulse, will neverthe- less warn the anaesthetist of danger before a perceptible change can be felt in the rate or quality of the latter. High color or duskiness is often associated with profuse perspiration and a warm skin. Hemorrhage and shock become evident in pallor, and a cold perspiration, which breaks out on the forehead. Cyanosis must never be looked upon with complacency. Pallor concentrates the attention upon the pulse, which now becomes our best guide as to the condition of the patient, and our most reliable index as to his need of stimulation. III. THE MUSCULAR SIGNS We have considered normal muscular tone, rigidity and relaxation. We have tried to emphasize the causes and the control of each. The signs exhibited by the muscular system depend for their value upon a variable degree of relaxation. Three signs may be easily observed: The masseteric, the lid and the diaphragmatic. The Masseteric Sign consists of a relaxation of the muscles, which control the lower jaw, permitting the mouth to be opened and closed without resistance. When one is in doubt as to the general relaxation which obtains the presence of relaxation of the lower jaw will almost THE SIGNS OF ANAESTHESIA 103 always settle the question. Occasionally, however, even when complete relaxation is present elsewhere, respiratory disturbances will cause incomplete freedom of the lower jaw, when one attempts to elicit this sign. During the period of excitement, rigidity and early relaxation, this sign is of course negative. If a " low " level of mainte- nance is held, this sign may not show itself in its fulness throughout the course of the anaesthesia. During a stage of maintenance suitable for abdominal relaxation, however, it is almost invariably present. As recovery j^roceeds one will note the relaxation pass off, the normal tone and rigidity of the masseters taking its place. This disappear- ance of the relaxation during the stage of maintenance is one of the early indications that the patient is recovering and must be either carefully watched or carried along at a higher level. Where short operations are done for intra-oral work and an incomplete anesthesia is all that is required, the anesthetist should begin his induction with a mouth prop or cork between the patient's teeth, for with such a type of anesthesia, rigidity of the masseters is the rule. Relaxation of the Upper Eyelid. — During normal sleep the eyelids, owing to the tone of the orbicularis palpe- brarum, remain closed. In the late part of excitement and through the period of rigidity, one will find that if the eyelid is lifted and then released, it will fall back into place with more or less snap. Later it will remain open. The lid sign is present when the eyelids on being sepa- rated remain separated. This sign should be taken on each side and the most inactive lid taken as the standard. In the later periods of induction, when stertor has come on and one is anxious to determine the exact condition of the pa- 104 ANAESTHESIA tient, this sign with the masseteric sign will be found very valuable. The lid reflex is usually described as an eye sign. We feel, however, that it relates more directly to the mus- cular system. Furthermore the signs of true muscular relaxation during the stage of induction are none too many and may well be augmented by this addition. Fig. 59. — Diagram showing normal move- ment of diaphragm and abdominal wall during inspiration. Fig. 60. — Diagram showing movements of diaphragm and the abdominal wall during inspiration, just before a fatal issue. The Diaphragmatic Sign. — This sign deals with the tonus of the diaphragm. It is of value when one is obliged to carry a high level of maintenance, as is sometimes the case in upper abdominal operations. We base our deter- minations of the relaxation of the dia2Dhragm upon the character of the abdominal respirations. Normally, when THE SIGNS OF AXyESTHESlA 105 inspiration takes place, the diapliragin moves downward upon the al)d()niinal viscera and causes a (hstention of the abdomen, whicli raises the abdominal wall (Fig. .59). The amount of the abdominal movement is greatest during the period of excitement when the movements of the diaphragm are excessive. As anesthesia progi-esses, these move- ments become less, })ut the abdomen still swells upon in- spiration. If the level of the amesthesia be excessively raised, however, the diaphragm relaxes, and the abdomen, instead of being distended, will sink during inspiration (Fig. 60) . This sinking in of the abdomen during inspira- tion is one of the gravest danger signs and indicates that anaesthesia has been pushed beyond its legitimate limit. Preceding this paralysis the breathing will become almost entirely thoracic. These are the cases who have absolute relaxation, absent corneal reflex and a dilated pupil, and whose breathing is rapid and shallow'. Occasionally we are obliged to " go the limit," but we should at least understand what constitutes " the limit." Our first concern then is to secure relaxation of the eyelid and lower jaw. When we have passed into the stage of maintenance and we know that the patient is deeply auitsthetized, we should narrowly observe the move- ments of the abdomen during inspiration until the stage of recovery has begun. IV. THE EYE SIGNS The eye signs consist of three groups, the lid signs the globe signs and the pupillary signs. The Lid Reflexes consist of reflex responses to irrita- tion of the sensitive conjunctiva and cornea. These signs 106 ANAESTHESIA are as follows: The Conjunctivo- Palpebral Re flea:, the Corneal Re flea? and Parsons's Sign. The ConjuncHvG-Pnlpehral Reflex is the reflex which causes the eyelid to close when the tip of the finger, in sepa- rating the lids, gently brushes over the margin of the upper fid. This reflex must be differentiated from the lid reflex, which has been described under the muscular signs, and is due to the tone or the elasticity of the muscle which moves the lid. The Corjieal Reflex. — This reflex is without doubt the most valuable eye sign which we have. It is elicited as follows : Standing behind and above the patient, the opera- tor gently bathes the orbital conjunctiva by moving the upper lid over it several times. He then separates the lids with his index finger. When the lids have been slightly separated, the index finger is removed and the pulp of the middle finger, moistened with vaseline, is very gently caused to brush over the centre of the cornea. The degree of activity, with which the eyelid then closes, constitutes one of the most unvarying signs of the depth of the anaes- thesia. The operation is concluded by again washing over the orbit by the upper lid. This particular sign and its elicitation have been the subject of much adverse criticism. It has appeared to many a somewhat barbarous practice. The author once held this view. Needless to say it is not a sign to be used thoughtlessly or roughly. It is a sign which one uses to corroborate other signs. We have yet to see any trouble arising from its use. Compare this very mild form of irritation to that too often produced by a piece of gauze placed over the eyes, to protect them during the course of the anaesthesia. The lid reflex having been lost, the bare gauze rubs constantly and harshly against THE SIGNS OF ANAESTHESIA 107 the sensitive cornea. The result is a varying degree of conjunctivitis or worse. We cannot hide our heads Hke the ostrich and say that there is no harm because it is not visible. Some advise that the eye signs, or at least the corneal reflex be disregarded. This may be done if one is not particular as to the exact condition of the patient at any given time. Such a course would appear analogous to one objecting to the taking of a blood count because of the possible danger of tetanus from infection, caused by the pin prick. The corneal reflex is without doubt the best corroborative sign which we have and, properly taken, is free from danger or annoyance to the patient. During the period of excitement and rigidity, the corneal reflex is snappy; as relaxation comes on the sharpness of the reflex gradually decreases. When maintenance has been entered into, the reflex has either become quite sluggish or is absent. The reappearance of the corneal reflex and its variable activity during the stage of maintenance will give one a most satisfactory idea as to the exact depth of the ana?sthesia. When the stage of maintenance is carried at such a high level that the corneal reflex has disappeared, its prompt return in the first stage of recovery will always prove a great comfort. Generally speaking we may say that a dangerous level of maintenance and an active corneal reflex do not coexist. One should not take this sign re- peatedly on the same eye, as the sensitiveness will rapidly diminish. The most active of the two eyes should be taken as the standard. The use of morphine will frequently dull this reflex. When NoO and O are used without ether, one will usually find a snappy reflex during an entirely tran- quil stage of mamtenance. Unexpected variations in this 108 ANESTHESIA reflex will be found in little children and very sick patients. Again we would urge that the individual patient be caused to form his own index of activitj^ and while this sign is most valuable ijer se, yet it should be supported and sus- tained by other signs. Parsons's Sign.—T^hh consists of a retraction of the lower lid towards the internal canthus, when the carti- laginous rim of the upper lid is pressed against the cornea immediately over the jDupil. The degree to which the re- traction of the lower lid takes place indicates the depth of the ana?sthesia. The Orbital Signs. — The presence or absence of move- ments of the eyeball during anaesthesia will often be found of value. As a sign purposeful movements will usually be recognized by the peculiar look of animation and expres- sion. When these intelligent, calculating eyes look at us, we are likely to feel apologetic and to cover them over with gauze or a towel. When consciousness is lost, however, and the period of excitement or rigidity is well developed, we find that the eyeballs are fixed or that there is a slow move- ment from side to side. Movements of the eyeball from side to side are almost always a sign of light anaesthesia. We will be very likely to find such movements in the period of excitement, rigidity and early relaxation. During ordi- nary maintenance movement is absent, but it may occur when a very low level is carried. During the stage of recovery this sign will usually be found strongly in evi- dence and a precursor of approaching consciousness. Dur- ing the stage of inaintenance, when NoO and O are the ansesthetic, the eyes will often be found looking fixedly downward. When ether is used, they are usually fixed centrallv. THE SIGNS OF ANAESTHESIA 109 Generally speaking, we may say that when the eyes are stationary, looking either downward or straight forward, loss of consciousness is certain, and usually induction is nearing conclusion, or maintenance has heen entered upon. The Pupillary Signs. — Let us first consider briefly the physiology of the jnipillary changes which may appear. We must explain three reactions: Dilation of the pupil; contraction of the pupil, and the reaction to light. ^cJ^Zt^ ^ V OM^^^//^.e £,n.^ Ojrjy>i W ^ . ^ • / 3V Qrantat ^crte ouperior Cemcal ' 'J-o^ O-ftary y/Yertrt9 Optic /^eryc %SptnaJ. Cord u Z)i/afpr ^■apzUa^. ^apt/iae _ , ^^ , • -JAor/- O^'o^v -^crre Qi/tar-y Qanaiton -^ FlQ. 61. — Diagram showing enervation of the dilator and sphincter pupillae. Modified from Howell's physiology. Fig. 61 will show clearly the mechanism with which we have to deal. Txm) sets of nmscles. — The dilator pupiike and the sphincter pupilla?. Txico nervous systems — The sy in pathetic, which sup- plies the long ciliary nerves to the dilators, and the central, which suj^plies the short ciliary nerves to the sphincter muscles. Two general conditions, which effect this mechanism — Stimulation and paralysis. 110 ANiESTHESIA Stimulation. — The pupil dilates when the sympathetic system is stimulated. The pupil contracts when the cen- tral system is stinmlated by light ( afferent impulses travel by retime and optic nerve; efferent by third cranial and short ciliary). Paralysis. — When the sympathetic system is paralyzed, the pupil contracts by virtue of the tone of the sphincters, aided by the engorgement of the ciliary blood-vessels. When the central system is paralyzed, the pupil dilates by virtue of the elasticity of the elastic fibres of the pupil and by the emptying of the ciliary blood-vessels, which permit the lens to bulge forward. The understanding of these simple mechanics will en- able one to anticipate the signs which may be expected in the various stages of anaesthesia. The Pupillary Signs in Induction, Maintenance AND Recovery Indiiction. — During the periods of excitement and rig- idity, the sympathetic system is everywhere stimulated, consequently the pupils at this time are usually dilated. The amount of this dilatation will depend upon the excita- bility of the sympathetic system at the time under con- sideration. If there is a greatly reduced irritability, as where morphine has been given before operation, this dila- tation may be very brief and occasionally absent altogether. As the period of relaxation comes on, the sympathetic sys- tem will become paralyzed and the pupil will contract. The central system being intact, however, the reflex to light will remain. Maintenance. — The exact condition of the pupil in the stage of maintenance will vary according to the degree to THE SIGNS OF ANESTHESIA 111 which the sympathetic system is ana?sthetized. If only partly, there will be moderate transient dilatation upon pain stimuli. If dee^^ly, the pujjil will be smaller than normal and show little or no reaction to sympathetic stimuli. Movements of the margin of the pupil, more or less rhythmical in character, may show themselves when pelvic or gall-bladder stimuli are apjjlied. When the pupil is contracted, the reflex to light will vary with the irrita- bility of the central nervous system or the level of mainte- nance. If the ana\sthesia is now pushed, the pupil will dilate by virtue of the paralysis of the central nervous system. Since the light reflex depends upon the integrity of the same, this reflex will likewise be lost. The corneal reflex will have disappeared and other signs of complete aucBsthesia will manifest themselves. However clear this condition may appear upon theoretical consideration, it is often rather puzzling, especially to the beginner, to determine whether a dilated pupil is a sympathetic dilatation of light anaesthesia or a paralysis of profound ansesthesia. The fol- lowing test should always be made where doubt exists : Stop the ancesthetic completely and give air. If, after a few moments, the pupil contracts (from shallowness of the ansesthesia ) , then the dilatation was that of profound anaesthesia or dilatation of paralysis. The eye in this case is usually dry and lusterless from an inhibited lacrimation. If, on the other hand, the pupil remains unchanged in the face of shallower ancesthesia, the dilatation was caused by sympathetic stimidation and took place because the ancesthesia was incomplete. The eye in this case is usually moist, the lacrimation being abundant. Occasionally one finds a patient who is morphinized, or who, for some unknown reason, loses his corneal reflex 112 ANESTHESIA early, having a persistently dilated pupil, which cannot be reconciled with other signs. In such a case it is always wiser to give the patient the })enefit of the doubt and to permit him to drop to a lower level of maintenmice or to " come out." If moderate dilatation is present with an active light reflex, we may conclude that this dilatation is not the dila- tation of paralysis, but that the patient is safe. The most satisfactory condition of the ])u\)\\ during the stage of maintenance is when it is moderately contracted and re- sponds to light. Recovery. — During the stage of recovery, the condition of the pupil will again vary, dej^ending upon the respective action of the various stimuli applied to the central or sym- pathetic system. As a rule the action of the latter is more pronounced, and consequently the pupil usually dilates. This is particularly true when the patient is about to vomit. Where morphine has been used and the recovery is entirely tranquil, the pupil may become pinpoint. The light reflex is present and becomes more and more active as the patient recovers. In recapitulating we find that the eye signs are divided into the hd, the orbital and the pupillary signs. The pres- ence of the conjunctivo-palpebral reflexes means a shallow anaesthesia, its absence a moderate height. The presence of the corneal reflex depends upon its activity. Its absence almost invariably indicates a complete anaesthesia. When the eyeballs move the patient is light. When they are fixed, either looking forward or downward, the patient has certainly lost consciousness, and is probably well anses- thetized. A dilated pupil with moist eyeball, which does not contract when the anaesthesia is withdrawn, with an THE SIGNS OF ANESTHESIA 113 active corneal and light reflex, means shallow anaesthesia. A dilated pupil with a lusterless eyeball, with an absent light reflex and corneal reflex, which contracts when the anesthetic is withdrawn, means profound anaesthesia, or a high level of maintenance. A contracted pupil with an active light reflex is a safe sign. A contracted pupil without light reflex indicates mor- phinism and may suddenly be followed by a marked para- lytic dilatation. The total absence of the light reflex independent of the size of the pupil implies interference with the central nervous system, usually a profound anaes- thesia. By this we mean the reaction to a strong light, not the ordinary daylight. From the foregoing it is therefore clear that one ex- amines the orbit for motion, the pupil for size and for light, and lastly the cornea for lid activity. V. THE PULSE SIGNS The pulse is an index of the operative condition of the patient. One should note its rate, its rhythm and, most important, its volume. During the period of excitement and rigidity the pulse will be of little value as a sign. As relaxation becomes complete, however, and the stage of maintenance is begun, we should observe it carefully. When the radial artery is not accessible, as it seldom is, then we should locate the temporal on the side most convenient, palpating it with the pulp of the middle finger. If we palpate the same artery in the same location with the same finger throughout the anaesthesia, Ave will form concepts of small variations in quality, which would otherwise be passed over. Rhythm is normally constant. The skipping of beats, 114 ANESTHESIA when occurring frequently, is a danger signal and should be reported to the surgeon. This is more particularly true when the pulse has been regular during the early stages of the operation. The rate and volume must be considered together. The pulse rate will often soar from pain stimuli or some deep reflex. Certain types of cases such as, for example, exoph- thalmic goitre, will have an exceedingly rapid pulse. If the volume is maintained there is not much ground for anxiety ; if, however, the volume falls through hemorrhage or shock, the operator must be informed. Generally speaking, the surgeon should be notified when the patient consistently runs a pulse of 140 or over. If, in addition to an increase in rate, the pulse becomes small and rather difficult to pal- pate, jjreparation should be made for the administration of saline solution. This is the first and best treatment for such conditions. One of the easiest ways to give saline is to pour it directly into the abdominal cavity. The most direct and effective method, however, is to give an intra- venous injection into the median basilic vein of either fore- arm (Fig. 62 and 63) ; the technic of this is as follows: {a) Tie a tourniquet (bandage) about the arm above the elbow \ {h) paint the bend of the elbow with iodine ; ( c) find the vein if possible. If it cannot be found, cut down to where it should be. When it is found, dissect it free for about an inch. Tie a ligature below ( distal ) and place an untied liga- ture above (proximal) ; nick the vein with a scissors. See that the saline runs freely through the cannula and that the latter is free from bubbles. With the saline flotcing, insert the cannula into the proximal end of the vein ; tie in place with one knot. With the saline elevated about four THE SIGNS OF ANESTHESIA 115 feet above the vein and the tourniquet about the arm re- moved, let the solution flow slowly. The amount given should vary witli the needs of the patient; from .500 to 1.300 Fig. 62. — Intravenous admimstration of saline: nicking vein. (Annals of Surger>M cc. will usually be found sufficient. If too much fluid is admitted there will be increased pressure upon the right heart, which may suddenly dilate. The volume of the pulse should be watched, and when its character has improved 116 ANESTHESIA p: Fig. 63. — intravenous administration of saline; cjinnula tied in proximal end of vein. (AnnaLs of Surgery.; THE SIGNS OF ANESTHESIA 117 sufficiently, the flow should he stoj^ped. The cannula is withdrawn and the vein securely tied. The skin is then sewed with silk or linen and a sterile handage applied. Needless to say this operation should he completed with despatch. If the pulse has heconie very small, rapid, or imperceptil)le hefore the saline is given, it is well to give immediately strychnine gr. l/3() or camphor in oil gr. 2. While this treatment is taking place, the patient should be as as lightly anjusthetized as possible. The indications here are to give enough anaesthetic, and only enough, to keep him quiet. Oxygen may be resorted to with advantage and rebreathing is beneficial. Cases which receive rebreathing with oxygen will be much })etter off than those who are held by the open drop method. The author has frequently carried jDulseless patients for more than an hour rebreath- ing oxygen and just enough N-O to control undesirable movement. The full retarded pulse following a saline is often misleading, as it is artificial and will soon lose its quality. It behooves one to get the patient to bed as soon as possible. If the operative procedure is such that the patient cannot be moved, and if the pulse loses its quality and once more becomes rapid, the saline may be repeated in the other arm. The condition of such a patient is desperate and his response to strychnine and camphor will be unsatisfactory. Where it is inadvisable or impossible to give an intra- venous injection, the fluid may be given by hypodermocly- sis, under the loose tissues of the breast (Fig. 64), which method is very satisfactory. The Trendelenburg position will improve the pulse ; the opposite will weaken it. Sudden stoppage of the heart is fortunately rare with ether; such a condition not responding to artificial respira- tion may be handled by the method described by Abrams. 118 ANESTHESIA Fig. 1)4. Hypuduri.iorl> .-is THE SIGNS OF ANAESTHESIA 119 This is called Kuatzu or the Japanese method of restoring life, and is a definite method of resuscitation used by jiu-jitsu adepts. The patient is placed in the prone position with arms extended sideways; the operator with his wrist lands severely on the seventh cervical vertebra with the regularity of a carpenter wielding a hammer. This stimulation is thought to act by overcoming the vagus inhibition responsible for the cessation of the heart's action. The hypodermic injection of 1 100 gr. of atropine directly in the heart has been suggested and found valuable in some cases. Direct massage of the heart, when the abdomen is open, will also prove beneficial at times. CHAPTER IV ETHER ANESTHESIA GENERAL CONSIDERATIONS Ether, sulphuric ether, ethyl oxide or vinous ether is a very volatile fluid possessed of a suffocating odor and a bitter taste. It is colorless, about two and one half times as heavy as air and boils at body temperature. Ether is very inflammable and should be cautiously employed in the presence of an open flame, red-hot cautery and the like. Ether vaj)or, when allowed to escape from a container, falls until it comes in contact with the floor, operating table or body of the patient. It then travels in a thin layer close to the surface with which it is in contact until it is dissipated in the air. A flame or hot cautery which is brought within two inches of such a surface will cause the ether to burst into flame. This may happen in the cauterization of hemorrhoids for example. The smoother the surface along which the ether travels the more likely it is to retain its concentration and ignite. Water has practically no effect on burning ether. If carelessly applied it may scatter the fire thereby increasing the danger. Ether-soaked gauze or free ether which has caught fire should be carefully and systematically smothered by the use of blankets, towels, etc., beginning at the patient's face. Etlier is commonly prepared as follows : Ethyl alcohol reacts with sulphuric acid to form ethyl sulphuric acid and water. In the presence of an excess of alcohol, ether is formed and sulphuric acid is reformed as a residue. This is known as the continuous etherification process. Ether, 120 ETHER ANAESTHESIA 121 which has heen exposed to air and Hght, should not he used for anti'stliesia, as the irritation of products formed by oxidation may prove injurious to the patient. Ether for ana?sthesia is ordinarily sold in one-quarter pound and one- half pound sealed cans. The smaller-size cans are prefera- ble because there is less likelihood of stale ether being carried over to the next case. A brief consideration of the discovery of ether will be found in the Introduction. The various methods of admin- istering ether have been taken up in Chapter IV. The signs of ether anaesthesia are discussed in Chapter III. A classification of the stages of ether anaesthesia has been suggested in Chapters I and II. The post-operative treat- ment of a case anaesthetized by ether will be found in Chapter XV, page 285. I. ADMINISTRATION OF ETHER BY ORAL INSUFFLATION By oral insufflation we mean the substitution of ether va23or for the atmosphere which the patient ordinarily breathes. ( See page 9) . This ether vapor may be presented to the jjatient in a great variety of ways. Anything from a gauze handker- chief to an expensive nickel-plated apparatus will accom- plish the desired result. While we may in an emergency ffet along with a handkerchief, we do not do so from choice, but from necessity, as such a method is least efficient and most wasteful. We recognize two methods of administering ether by the method of oral insufflation: 1. The %7/i^ method. 2. The vapor method. 122 ANESTHESIA By the liquid method we mean that method in which we present liquid ether to the patient upon a medium suita- ble for its speedy evaporation by the respiration. In this method we depend largely upon the patient to vapor- ize the ether. By the vapor method we mean that method in which the ether is presented to the patient already vaporized. In this method the patient's respiration has nothing to do with the rate or the amount of the evaporation. The liquid method is best exemplified by the well- known drop method. There are three distinct types of drop method: Open, Semi-open and Closed. The Open Drop Method Apparatus. — The essential elements of the apparatus are as follows: (rt) A wire skeleton face piece of substantial construc- tion, having a smooth surface for contact with the pa- tient's face; {b) covering for the face piece, consisting of stockinet bandage or gauze; (c) provision for the supply of ether in large, clean droj^s. The Face Piece. — One of the most widely used and satisfactory drop masks is that of the Yankauer pattern (Fig. 65).' This fits the face well, presents a smooth surface in contact with the skin and is substantiallj' built. The Covering. — One of the best materials for an open drop evaporation surface is that afforded by stockinet bandage. The spring ring, which holds the covering, is slipped into a six-inch section of the bandage and forced down over the wire frame. Stockinet bandage, being more closely woven than gauze, gives a more satisfactory evap- ETHER ANAESTHESIA 123 orating surface. When gauze is used, between ten and twelve thicknesses should be employed. The Drop Bottle. — To obtain the best results one should have a device which will give large drops, the rapidity of which may be varied at will. We speak of clean drops in contradistinction to the drizzle which one will obtain from a fraved bit of "auze. The anaesthesia resulting from such a drizzle or spray FiQ. 65. — Yankauer-Gwathmey Drop and Vapor Mask. method is not nearly as smooth as that obtainable by a clean drop. The best drop bottle is prepared as follows (Fig. QQ) : Cut the lead cap neatly out of the ether can. Take the ether can cork and cut two deep grooves in the sides. In one of the grooves place a little wick of cotton (not gauze) ; leave the other groove free for the admission of air. Place the cork with the cotton wick in the can ; allow the wick to become soaked with ether, which will drizzle off the frayed end. With a pair of scissors, cut the wet wick so that the end is square instead of frayed. A large, clean drop, whose rapidity is easily controlled, is then obtained. An emer- gency drop bottle may be provided by making a single pinhole in the centre of the lead cap in a can of ether, which 1£4 ANAESTHESIA k:^. ^ O c'l C.S c , M.O s a ETHER ANAESTHESIA 125 has not been ojjened. If the ean is now grasped in the pahn of the liand, the rise in temperature resulting will cause the ether to spray out when the can is inverted. A drop may then be secured by controlling the spray with the finger tip. The Administration. — When the open drop method is employed, ether, as a rule, is the sole ana\sthetic employed. One may sometimes render the induction more pleasant for the patient by dropping upon the mask a little essence of orange, wdntergreen or some pungent essential oil, before the ether is given. This occasionally serves to mask the disagreeable odor. The trick of a smooth induction, however, consists in two things: First, in causing the pa- tient to breathe somewhat more frequently and deeply than normal. Secondly, in the control of the drop so that there wall be no spasm of the respiration. One of the best methods of controlling the respiration is to ask the patient to count slowly and loudly. This requires a certain atten- tion and decidedly increases the tidal volume. In addition to this, the patient will give evidences of disturbed cere- bration, which will indicate the progress of the induction. Most patients cannot count slowly and loudly for more than one hundred. We increase the drop as rapidly as w^e can and " let up " if the patient catches his breath. If this method is pursued, the patient w^ill rapidly develojj a tolerance, and by the time he has ceased to count he will be accepting without spasm an amount of ether which almost or entirely saturates the mask. When such an in- duction is brought about, the rule is — no excitement oc- curs, rigidity is slight and transient, and relaxation comes on slowly but completely. The respirations become ster- torous, the lid reflex disappears, the jaw relaxes, the eye- 126 ANiESTHESIA balls become fixed, the pupils contract and the corneal reflex becomes sluggish, indicating the onset of the stage of maintenance. Maintenance is best controlled by a constant drop, which may be increased or diminished according to a de- mand for a high or low level of anaesthesia. If the anaes- thetist becomes weary or loses interest during tliis stage, he will very likely change the drop into a spray or j^our method. This will surely result in an uneven anaesthesia. The best results can only be had by employing a constant drop. As maintenance progresses, the color will fade, the patient will lose surface temperature and the respirations will become quite shallow from excessive ventilation. Since little ether is lost, little will be needed to hold a con- stant level of maintenance. In some cases relaxation will be difficult to secure ; but in cases where it has become com- plete, it will have a tendency to persist. The eye signs will respond to an increase or decrease of the rapidity of the drop, but they are usually quite constant, fixed balls, contracted pupils, absent lid reflexes and sluggish corneal reflexes being the rule. Since the anaesthesia is under nice control, the stage of recovery may be begun earlier. The patient is usually brought to the point of vomiting before leaving the table. The shallow respirations, however, tend to retard the re- turn of the reflexes and the return of consciousness. The advantages of the open drop method are as follows : 1. The simplest apparatus is required. 2. Perfect oxygenation is obtained. 3. It is fool proof. 4. Even anaesthesia, easily controlled In suitable cases. 5. The best method for inducing anesthesia when ether alone is used. ETHER ANESTHESIA 127 6. The best method for nuiintaining anaesthesia in young" children, when the vapor nietliod is not avaihihle. The disadvantages of the ojjeti drop method are as follows: 1. Certain subjects, as vigorous young people and alco- holics, cannot be controlled by this method. 2. It is extremely wasteful of ether. 3. The anesthetist becomes literally soaked by the ether forced into the atmosphere by the exhalations. 4. The method is frequently attended by acapnia and shock, through the excessive loss of COo. ( See page 299.) 5. The jDatient easily loses bodily heat. 6. Induction is always prolonged and never as pleas- ant as when N2O is used. 7. It is unsuitable where morphine has been used as a preliminary medication. The Semi-Open Drop Method The semi-open drop method is nothing more than the open method so modified that the communication wdth the outside air is restricted and a certain amount of rebreath- ing thereby induced. When this method is employed, the drop method, strictly speaking, is not used as consistently as in the open method. The necessity for concentrated ether which this method usually implies calls for a spray or pour method. The open drop method can easily be modified into the semi- open method by the use of towels or a rubber dam. By the open drop method and the semi-open drop method, one is in a position to handle every case suitable for oral insufflation. Any patient from a baby to a two- hundred-pound alcoholic may be controlled by the use of 128 ANESTHESIA these two methods. This does not mecan that one can thus obtain the best results, but that in an emergency we can anaesthetize any patient who will respond to ether anses- thesia, if we are given time enough and sufficient ether. Apparatus. — 1. The oDcn drop mask covered with at least twelve layers of gauze. Fig. 67. — Ether by the semi-open drop method. First position, i'lrst towel in place over the eyes. 2. Three small towels or a piece of rubber dam 6 inches by 12 inches with a 1-inch hole in the centre. 3. A bottle which will permit of a spray or a small stream of ether. The Anaesthesia. — A folded towel is placed over the eyes (Fig. 67). Anaesthesia is induced precisely as with the open drop method. When the patient has lost con- sciousness, as will be shown by his inability to count intelli- gently, the second towel folded lengthwise is placed over the upper third of the mask (Fig. 68), the ends being ETHER ANESTHESIA 129 Fig. 68. — Ether by the semi-open drop method. Second position. Second towel in place covering upper third of mask. Fig. 69. — Ether by the semi-open drop method. Third position. Third towel in place coverinjr lower third of mask. 130 ANESTHESIA tucked neatly under the occiput. The drop is now in- creased in frequency and held just below the point of spasm of the respiration. The third towel folded length- wise is now stretched over the lower third of mask, one end is tucked under the head, the other is left free (Fig. 69) . We now have two-thirds of the mask covered by towel- ing, the middle third is exposed and receives the ether dropped upon the mask. With this semi-open method Fig. 70. — Ether by the semi-open drop method. Fourth position. The free end of the third towel is being laid over the exposed third of the mask. almost every case can be subdued. When a particularly obstreperous case refuses to become relaxed the mask is covered with ether and the free end of the third towel is thrown over the exposed portion of the mask. In this manner outside air is practically excluded and the most refractory patient will become anaesthetized (Fig. 70). This towel method will be found very convenient and effective, r.s the mask is thereby held in place, leaving both hands of the anaesthetist free. ETHER ANESTHESIA 131 A somewhcat more simple procedure, but one requiring an additional accessory, consists of covering the open drop mask with a sheet of rubber dam. hnving a liole in the cen- tre through which ether is dropped. This method effec- tiveh^ restricts the admission of air, but is somewhat more cumbersome in manipulation (Fig. 71). Fig. 71. — Ether by the semi-open drop method. A piece of rubber dam with a one-inch hole being used in place of towels. The advantages of the semi-open method over the open method in the late stages of induction and in maintenance are: 1. Vigorous subjects may be anfesthetized, 2. Less waste of ether. 3. Less ether in the air of the operating room. 4. Less likelihood of acapnia. 5. Less loss of body heat. 6. Induction is more expeditious. 7. Because of rebreathing, this method may be used with more safety where preliminarj^ morphine and atropine have been given. 132 ANAESTHESIA The disadvantages, as compared with the open method, are as follows : 1. Oxygenation not so good. 2. Control not so delicate. 3. Not entireh^ fool proof. 4. Not so good for early induction. 5. Xot suitable for little children who are to he carried in maintenance for some time. The Closed Drop Method For all patients with the exception of very young chil- dren, seven years or under, the closed drop method is by far the best (all round) method of oral insufflation. When this method is employed with nitrous oxide followed by ether, it is not only most efficient from the anaesthetist's point of view, but it is also by far the pleasantest mode of anaesthesia for the patient. This method is separate and distinct from both the open and semi-open method. A suita])le apparatus must be employed, if one wishes to secure the best results. The apparatus which may be had for the closed method of etherization is varied. Our task is to suggest features of value which should govern our selection. 1. It must be possible, at the will of tlie operator, to absolutely exclude atmospheric air ; otherwise nitrous oxide cannot be satisfactorily used for induction. 2. It should be light in weight and rest comfortably on the face. 3. It must be possible to clean and sterilize the appara- tus. Small inaccessible parts, and therefore difficult to clean, are to be discouraged. 4. The rebreathing must be unobstructed. p:ther anaesthesia 133 ."). Tliere sliould be some device whereby ether may be automatically given in small, frequent doses, in such a manner as to sinmlate the drop method. 6. It should be possible to easily and frequently change the gauze or crinoline, j^laced in the apparatus for the pur- pose of assisting in the evaporation of the ether. 7. It is a great convenience to have some arrangement, whereby atmospheric air may be freely given the patient without removing the inhaler from the face. 8. It will be found that a transparent face piece, such as is offered by celluloid, will be exceedingly valuable in watching the vomiting, position of the throat tube and the color of the lips. When one wishes to employ N2O and O for induction and the latter part of maintenance and recovery, the inlet for these gases should be situated at some point in the ap- paratus between the bag and the face piece, not, as is the usual custom, by means of a stopcock at the base of the bag. By the admission of N2O and O in this way, we may have immediate results; we need not wait for the baar to be emptied. There should also be provided a valve, which will allow the escape of expirations, but which will prevent the admission of air during inspiration. The author has succeeded in embodying most of the foregoing principles in a device, shown in Fig- 72. Anv contrivance which exhibits the same principles will give equally good results. The above-mentioned apparatus is a modification of a standard face piece, the detailed con- struction of which is unimportant since other face 2^ieces might be substituted with equally good results. The following features of this apparatus are worthy of notice : 134 ANESTHESIA 1 . A device for giving ether by the closed drop method. This consists of an ordinary oil cup with a sight feed. The cup is filled with ether as required, and the drop is regulated by a screw at the top. This cup forms a part of a section which may be easily slipped on and off the face piece section. 2. A tube for the admission of the gases N2O and O, located between the bag and the face piece. This is also part of the above-mentioned section. Fig. 72.— The author's apparatus for the administration of ether by the Closed Drop Method and for Gas Oxygen Ether Ansesthesia. 3. An expiratory valve for use when N2O and O are used. 4. The entire apparatus weighs only two-thirds as much as the well-known Bennett. 5. The face piece is comfortable and transparent. 6. Atmospheric air may be readily and freely ad- mitted through the air valve without removing the face piece. 7. The use of a roll of fine wire gauze, 100 to the inch, for an evaporating surface (Fig. 73). The last feature named is of the utmost importance. ETHER ANAESTHESIA 135 as will be seen in the following consideration: The wire gauze in strips 2 inches by 15 inches is rolled up like a jelly roll. This roll is placed in the ether cup section so that the ether, which drops into the apparatus, will become entangled in its meshes. There is practically no obstruc- tion to the respiration, which passes freely through this wire tube. The evaporating surface is large, and the material does not collapse when wet with ether. Fig. 73. — Wire gauze roll; size, 100 to the inch, ADMiNiSTRATiotN^. — ^Whcu the closed drop method is employed. Induction. — With the air vent open, the wire gauze in place, and the ether in the cup, the bag is filled with gas. The face piece is then adjusted and the patient is permitted to breathe the air. After a few moments, the air vent is closed and the patient breathes nitrous oxide to and fro. At the end of about forty seconds, or when the respirations become involuntary, as is shown by their increased depth and rap- idity, ether is very cautiously added drop by drop. The frequency of the drop is increased as rapidly as possible without causing spasm of the respiration. The rubber tube which admitted the N2O mav now be detached. The air 136 ANAESTHESIA which may enter through this tube will not be found ob- jectionable. By opening the air vent during inspiration and closing it during expiration, we may oxygenate the patient and dilute the percentage of the ether in the bag. Stertor usually appears when we have vaporized about half an ounce of ether. Consciousness is lost easily and pleasantly. The period of excitement is reduced to a minimum. Spasm of the res- piration sometimes occurs, but nmscular movements are rare. The respiration, unobstructed by tightly packed gauze, is usually full and deep ; the color responds quickly to oxygenation by the atmospheric air. When it does not so respond, oxygen may rapidly be admitted through the tube designed for this purpose. The color of the lips may readily be seen through the transparent face piece. The lid reflex disappears and the masseters become re- laxed. The eyeballs soon become fixed and the pupils somewhat contracted. The light reflex, however, remains active and the corneal reflex sluggish. In this condition the patient enters the stage of maintenance. Before describing the stage of maintenance, we may say that the induction of anaesthesia by the closed drop method will give as good results, and occasionally better results, than the pour methods usually employed with other apparatus. It is in the stage of maintenance, however, that this method becomes most useful. Maintenance. — If the breathing is not perfectly satis- factory, we will do well to introduce a throat tube. (Fig. 14.) This will guard against oral obstruction during the subsequent ana^sthetization. The operative procedure hav- ing been commenced without disturbing the patient, we may set the drop at a rate which seems most fit, in view of the ETHER ANESTHESIA 137 character of the induction. If the latter has been stormy and dehiyed, we will be obliged to exercise more control over the early stages of maintenance. At frequent intervals, depending upon the patient's color and the depth of the respiration, we fill the bag partially or completely with fresh air. If the inlet tube for the gas be oj^en all the while, permitting the gradual escape .of the contents of the bag, it will be found unnecessary to completely empty the bag, except when the respirations become unusually deep or the patient perspires freely. The simple adding of atmos- pheric air through the air valve will "be all that is required to keep an even and tranquil anaesthesia. If the patient requires much ether, it is advisable to add air more fre- quently in addition to increasing the speed of the drop. This closed drop method approaches the ideal which is offered by the percentage method. With a free respiration, as is provided by the throat tube, a non-obstructing but efficient evaporating surface and a visible automatic drop, we have the patient under a delicate and even control. As one becomes familiar with the signs of anaesthesia, he can carry a low level, changing rapidly to a higher, as required by special manipulations. From a rather extensive and recent personal experience with this method, in experienced as well as in inexperienced hands, the author is satisfied that it is the best method where a variable but absolutely con- trollable level of maintenance is desired. Recovery. — We know of no method of ana?sthetization which will permit the anaesthetist to begin the stage of re- covery as soon as will the closed drop method. The anaes- thesia being under perfect control, one may, for example, in an abdominal section, stop the drop as soon as the peri- toneum is closed, ^^^^ile the patient rebreathes his own 138 AN.ESTHESL\ expirations to and fro in the bag, he tends to lower the tension or percentage of ether present in his circulation. We may easily further decrease the strength of this ether by reducing the rebreathing and adding atmospheric air. Confidence born of control Avill allow one to attempt light- ness, w^hich, under other circumstances, would court failure. If the anaesthetist is watchful, he can always recover the reflexes before the patient leaves the table. As the rebreathing induces respirations of large tidal volume, the ether in the circulation is rapidly thrown off and the second period of recovery or the return of con- sciousness is soon completed. The medical profession and the general public owe a debt of gratitude to Dr. Thomas Bennett of New York City for introducing gas ether anaesthesia in this country. We believe that the success of his apparatus lay in the fact that it was one of the earliest in which the gas ether sequence was used, and furthermore that the method em- ployed was a closed one. The device became known by its constant use by Dr. Bennett and later gave its author wide publicity. As this device is found in a large number of hospitals, it deserves more than a passing glance. While cumbersome and costlj;, it will yet give splendid results in experienced hands. (Figs. 74, 75.) It is arranged for a nitrous oxide ether sequence. The ether is given by pour- ing it upon the gauze, packed in the ether chamber through small holes in the sides of the same. Before starting, the ether chamber should be closely packed with gauze ( it must be remembered that the patient does not breathe through this gauze, but around it) in the space between the cage and the air-tight wall of the ether chamber. Tlie gauze in the ether chamber is then well moistened with ether, about ETHER ANAESTHESIA 139 lialf an ounce being poured in. The indicator is turned to " air." The gas bag is filled and the face piece is applied. The patient is made to rebreathe X2O. When the respira- tions become deep and more rapid than normal, the ether is cautiously turned on. If there is no respiratory spasm, it is "•raduallv increased. When full ether is reached, the gas bag is replaced by the rebreathing bag. A small amount of ether is poured into the ether chamber, through each of the three holes. Relaxation comes on quickly and Figs. 74. — Bennett apparatus, with gas attachment and bag for induction. Fig. 75. — Bennett apparatus with ether rebreathing bag for maintenance. the stage of maintenance is soon reached. When properly managed, the stage of induction is all that can be desired. During the stage of maintenance, however, we are likely to feel that improper provision has been made for: (a) The changing of the gauze, which has become water soaked by the condensed respiratory moisture; ih) the giving of small, constant doses of ether; (c) unob- structed rebreathing. Furthermore, we cannot see the patient's mouth 140 ANESTHESIA through the opaque, metal mask and, after an hour or more, the weight of the apparatus hecomes trouhlesome. Unless one is very expert, the patient will not be under proper control. The wet gauze will not hold the ether poured upon it, allowing the latter to run down into the face piece. With care and good judgment these disad- vantages are not so marked. They will be found especially noticeable, however, with the beginner, who has not de- veloped the skill necessary for their proper avoidance. The stage of recovery cannot be started as early as one would wi^h for the reason that the control is not sufficiently delicate. The return of consciousness is delayed, since it has been necessary to carry a high level of maintenance; a low level being dangerous, as spasm supervenes where ether is added too freely. We have taken the liberty of selecting the Bennett apparatus as a popular and widely used exemplification of a type, which does not offer the most satisfactory means of inducing and maintaining anesthesia, especially from the point of view of the beginner. Long usage, mixed w^ith interest and intelligence, as has been before mentioned, often overcomes these shortcomings. The device which the author employs is also one show- ing forth a type, the detailed construction of which is in- cidental and which may easily be improved upon. The Disadvantages of the Closed Drop Method as Compared With the Open and Semi-Open Drop Method 1. The apparatus is more cumbersome and expensive. 2. It cannot be used when the tidal volume is unusu- ally small, as in babies and very young children. 3. It is not fool-proof. ETHER ANAESTHESIA 141 The Advantages of the Closed Drop Method as Com- pared Avnii THE Open and Semi-Open Drop Method 1. It may be used with more efficiency in a larger range of cases. 2. Tlie ability to use X^O gives a speedier and pleas- anter induction. 3. It is most economical in the use of ether. 4. The body heat is preserved. 5. The rebreathing prevents acapnia. C. Preliminary morphine medication may be used with greater safety. 7. The control of the patient is more delicate and effective. 8. The stage of recovery may be begun earlier. 9. During the stage of induction and maintenance, oxygen may be given in the most effective manner, namely, mixed with CO^. 10. During the stage of recovery N^-O and O may be used and much of the ether may thus be thrown off. 11. The operating room is almost free from the odor of ether. 12. The anajsthetist may give ether all day and at the close have absorbed little or no ether himself. Observations on the Use of the Open and Semi-Open Drop Methods in Large Clinics, a^ith Special Reference to the Means Employed to Overcome THE Objectionable Features of These Methods In observing the anaesthesia at various clinics, we are forced to the conclusion that differences of opinion exist in regard to the definition of " A good anaesthesia. " We are under the impression that a good ana?sthesia im^^lies: A rapid and pleasant loss of consciousness, a short period 142 ANAESTHESIA of excitement, a relaxation, which comes on quickly and which is well under way before the operation is commenced, a stage of maintenance under the comj^lete and ready con- trol of the amesthetist and a knowledge, on the part of the anaesthetist, of the exact depth of the anesthesia at any given time. To our surprise, we often find a satisfactory anaesthesia summarized in : A delayed and distressing loss of consciousness ; a period of excitement often prolonged and followed by rigidity extending well into the course of the operation, which is habitually begun so early that there is almost invariably a reflex rigidity as a consequence; an uneven stage of maintenance, not under good control and leading rather than being led by the anaesthetist. The keynote of a good anasthesia appearing to be, to give as little ether as possible regardless of the convenience of the surgeon, who must adapt himself to this essential. There is no doubt that such a method of anasthesia is seldom exposed to the danger of overdosage, or of vagus inhibition, because fortunately the anasthetic is not chloro- form but ether. Ether may be given in this fashion with comparative safety by a lay person, who need pay little attention to the signs of anasthesia, the essential indication being to increase the amount of ether administered when the patient coughs or moves, and to reduce the amount or stop the ether if the patient is quiet. The delay in the induction of anasthesia by this method of open and semi-open drop ether is overshadowed by one or all of five reasons: 1. The fact that operations are going on in more than one operating room at the same time, and visitors are not obliged to wait for the next patient but may be otherwise entertained. ETHER ANESTHESIA 143 2. The patient is anfesthetized on the operating table in the operating room, and the dehiy incidental to trans- portation after anaesthesia is induced is ohviated. 3. If tlie operative position is a difficult one to obtain, i.e.^ for kidney work, the patient is placed in tliis position before the anaesthesia is induced. 4. The preparation of the field of o^^eration takes place as soon as the patient is on the table, usually before con- sciousness is lost. 5. Lastly, and of great practical importance, the pa- tient is thoroughly restrained by strapping. This obviates the danger of his lifting his hand in a subconscious effort to protect himself when the first incision is made, as would certainly occur in many of these cases where the operation is begun during the early periods of induction. This control makes possible a method which otherwise could not be tolerated. The rigiditi/ incidental to incomplete aniesthesia is largely overcome by the employment of large incisions and the use of self-retaining retractors. In discussing this method of anaesthesia, we try to sepa- rate it from the fame which it sometimes borrows from its environment and to consider it per se, as it would actu- ally appear if shorn of its surgical support and trans- planted to a locality where it would be obliged to stand upon its own merits ; for this is the condition obtaining with those who adopt this method. Possibly under some con- ditions no better method can be found. The Administration. — Patients who are able to walk are sometimes assembled in a small waiting room a short distance from the operating rooms. When the operating- room is dressed, they walk in, disrobe and lie upon the 144 ANESTHESIA table. A strap is then thrown over the knees and bands of webbing, sometimes two, sometimes four, hold the arms to side. The nurse speaks a few words to the patient and, after covering the eyes with gauze, begins the administration of ether by the drop method. The mask, at first some dis- tance from the face, is gradually lowered as anesthesia progresses. Consciousness persists for from three to four minutes. Since the respirations are shallow, the induction is delayed so that at the end of ten minutes marked rigidity is often still present and reflexes to pain persist. The open drop mask is sometimes converted into a semi-open mask by winding a strip of gauze about it, something after the fashion of a bandanna handkerchief. The preparation of the field of operation begins before consciousness is lost and is usually concluded before the induction is well under way. When the jjreparation is complete, the incision is fre- quently made, often with little respect for the signs of anesthesia. If the patient resists, the operator is con- strained to wait. If the resistance is slight it is usually overlooked. Since the patient is well restrained the danger of his hand finding its way to the wound is slight. The pain of the first incision usually stimulates the respiration so that a certain amount of ether is eventually absorbed. During the stage of maintenance, the chief symptoms observed are presence or absence of straining or movement, coughing or retching. Little effort is made to anticipate these signs and their occasional appearance is usually overlooked. The incomplete relaxation which obtains, prevents ob- struction of the airway by the falling back of the tongue, ETHER ANAESTHESIA 145 but on the other hand permits masseteric spasm by reflex irritation. The stage of recovery is what might be expected from the use of this method, the advantages and (hsadvantages of which have been taken up in a preceding section, page 127. It may not be unfair to assume then that the open or semi-open drop method is the routine method of choice in some chnics: 1. Because it is so safe as to permit its administration by lay people. 2. Because it is the belief of the authorities that the use of small amounts of ether is more important than the obtaining of complete relaxation. 3. Because such a method involves apparatus of the simplest possible ty23e. 4. Because provision may be made for the delaj'ed in- duction incidental to drop ether by placing the patient in the operative position on the operating table, in which posi- tion he is restrained and the anaesthetic started. The field of operation being prej^ared at once and little heed being paid by the audience, who are entertained in neighboring rooms. 5. Because provision may be made for imperfect relaxation by employing large incisions and self-retaining retractors. The Vapor Method of Oral Insufflatiox In the vapor method of oral insufflation, we offer ether to the patient in vapor form. The respiration has nothing to do with the production of this vapor, which is brought about by mechanical means. It is not our object to catalogue the various apparatus 10 146 ANESTHESIA at our disposal but to reduce the method to its simj)lest terms. We will attempt to describe the most simple form of vajDor ana?sthesia. a method which has given continued satisfaction in the hands of many operators. Apparatus. — 1. Cautery bellows or tank of oxygen. 2. A suitable bottle for vaporizing the ether. 3. A suitable mask, through which the patient receives the vapor delivered. 1. The bellows and the oxygen tank need no explana- tion. 2. The wash bottle attached to the operating room oxy- gen tank will make a perfectly satisfactory vaporizing bot- tle. This is usually an eight-ounce bottle with a large neck, into which fits a rubber cork perforated with two holes. Through one of these holes passes a tube long enough to pass below the surface of the ether. Through the other a small tube, which reaches just below the cork. The cau- tery bellows or tubing from the oxygen tank is attached to the long tube, so that when air or oxygen is introduced, it will bubble through the ether. The short tube, for the exit of the vapor, is connected with tubing which leads to the face piece (Fig. 76). B. The ordinary semi-open drop mask may be em- ployed by passing the tube, which delivers the vapor, be- neath this. AAHien purchasing a drop mask, however, the best plan is to buy one designed for use with vapor, as shown in Figs. 65 and 77. This mask will therefore serve the double purpose of drop and vapor mask. The vapor method of oral insuffiation is especially adaf)ted to babies and very young children. We know of no method which is subject to as delicate a control. The ETHER ANAESTHESIA 147 FiQ. 76. — Apparatus for the vapor method of oral insufflation and for intrapharjmgeal insufflation where concentrated vapor of small volume is employed. Showing oxygen tank, cautery bellows, wash bottle in which ether is placed, Lumbard vapor mask, throat tube and nasal tubes. tidal volume of a baby's respiration is often so small that it will not properly vaporize ether dropped upon the mask. No argument is necessary to emphasize the value of the A device for heating the vapor method in these cases. 148 ANESTHESIA ether container is unnecessary, as the evaporation is com- paratively slow. In those unusual cases where heat is desired, the most simple method of applying this is to set the ether bottle in a dish of hot water; any dish will do. We are never without hot water where an operation is to be performed, while electrical conveniences are frequently absent. The addition of heat increases the concentration of the ether vapor from 60 per cent, or less to almost 100 per cent. See page 70. It will be found that the use of oxygen, instead of atmospheric air by the bellows, is not only more efficient Fig. 77. — Vapor mask. because it provides thorough oxygenation, but, being auto- matic, it is much easier of administration and can readily be controlled. The expense is of small consequence, as the ether necessary to control an adult in this manner will be vaporized by less than twenty gallons of O per hour, repre- senting an expense of less than one dollar. An infant re- quires much less. The Administration. — The administration is exceed- ingly simple, our chief care being to give the vapor gradu- ally and to watch carefully for signs of deep anaesthesia, as exhibited by a rapid respiration and a fixed, dilated pupil. In very young children, our chief care should be ETHER ANESTHESIA 149 to keep the small patient quiet with as little anaesthesia as possible. For any type of operation in babies and small children, where the oral method of insufflation will suffice, we believe that this vapor method will give the best results. II. INTRAPHARYNGEAL INSUFFLATION In intrapharyngeal insuffiation, instead of presenting ether to the paljient in the external atmosphere, which he breathes, we go a step further and place the ether vapor in the posterior pharynx. It is unnecessary to state that the ether must be previously vaporized. It cannot be given, as with oral insufflation, in both the liquid and the vapor form. There are two distinct methods of giving ether by the intrapharyngeal insufflation : {a) In the first, we supply to the patient a mixture of ether and air of sufficient volume to meet all his respiratory needs. This volume ranges from twelve to eighteen liters a minute. We not only do not depend upon the addition of atmospheric air, but we exclude it by giving the vapor under a pressure ranging from 20 to 40 mm. of mercury. (b) In the second case, we give the patient a small volume of very concentrated ether and depend upon the mixture of atmospheric air to both dilute this and supply the total volume necessary. The jirst method is of course the ideal, since it enables us to completely control the percentage of the ether in- haled. Knowing the limits of depth and lightness in terms of vapor tension to be about 180 mm. to .50 mm. (see page 64 et seq. ) our control of the patient well-nigh approaches perfection. 150 ANAESTHESIA This type of intrapharyngeal insufflation is best exem- plified by the apparatus known as the anaesthetometer, 78). designed by Dr. K. Connell Fig. Fig. 78. — ^Ansesthetometer. Designed by Dr. K. Connell. Apparatus for Ixtkapharyngeai, Insufflation. — There are three divisions: 1. The air supply. 2. The mixing chamber. 3. The section for delivery to the patient. 1. The air supply may be procured by foot power. ETHER ANESTHESIA 151 steam or electricity. There may or may not be a reservoir for the air. before entrance to the mixing chamber Foot power will be found satisfactory where the bellows, shown in Fig. 79, is employed. Steam power is the type used at Roosevelt Hospital, Xew York City. The plant is somewhat costly and cumbersome for any but a large Fig. 79. — Foot bellows. institution (Figs. 80 and 81). Electrical power (Fig. 82) is quite satisfactory. 2. The mixing chamber. The Ana?sthetometer. 3. The section to the patient consists of a rubber tubing to which is attached a so-called nasal tube. (Figs. 83 and 84.) The nasal tube is constructed of nickel-plated brass of a shape corresponding to the patient's face. It ends in two nipple-like projections which are bent so as to enter the nostrils and prevent angulation of the catheters which are attached thereto. The catheters usually employed are Xo. 18 French, velvet-eyed. Special catheters have been de- signed having open ends resembling a small rectal tube in Fig. 80. — Steam pump for air supply at Roosevelt Hospital. (Courte.s\- Dr. K. Connell.j Fig. 81.- -Large reservoir tank and wash tank into which air from steam pump is delivered before being piped to the operating rooms. (Courtesy Dr. K. Connell.) ETHER ANAESTHESIA 153 construction. Tliese, while efficient, are not entirely neces- sary. The length of the catheter to be used is equal to the distance between the a\se of the nose and the auditory meatus. This distance carries the tube well into the pos- FiG. 82.— Electrical unit (Connell). terior pharynx. If the tube is made too long it will enter the oesophagus and dilate the stomach. It nnist be prop- erly lubricated or a nose bleed will result. The Administration. — The induction is usually 154 ANAESTHESIA brought about by the employment of a semi-open or closed drop method. When the patient has entered the stage of maintenance, the vapor apparatus is started, the indicator being placed at 60 or 70 mm. The catheters, well mois- tened with the patient's saliva, are slipped gently into each of the nostrils. If one is occluded, both catheters may be Fig. as. — Nasal tubes Fig. 84.^Nasal tube in place. placed in one nostril. In accomplishing this, one should ele- vate the tip of the nose and keep the catheters close to the floor of the nares. The operation is completed by placing an adhesive strip over the nasal tube. Fig. 85 shows insertion of the catheters. Fig. 86 shows catheters in position. The anesthesia may now be continued with the head Fig. 85. — Intrapliaryngeal anaesthesia, showing the insertion of the nasal tubes. The catheters are moistened with the patient's saliva. The nose is tilted backward and the tubes are passed along the floor of the nose downward and backward. Fig. 86. — Intrapharyngeal anaesthesia. Nasal tubes in place and strapped to the patient's forehead by adhesive plaster. 156 ANiESTHESIA covered by towels and the anesthetist at some distance from the patient. One gradually reduces the percentages beginning at the end of half an hour, until 40 or .50 mm. is reached, at which point the patient may be carried for hours. As has been before stated this type of ana?sthesia is con- stant and does not attempt to vary its level according to the manipulations of the surgeon. The anaesthetist must be continually alive to the patient and the apparatus, however, for trouble may arise in either or both. This trouble will be more difficult to detect and must be met more promptly than where a more simple method is emj^loyed. The second method, in which a small volume of very concentrated ether is given, depending upon the patient to dilute this with atmospheric air, is offered for that very large class of patients, particularly in private work, where the percentage method is not available. This method at its best but approaches the ideal offered by the former. It will be found very serviceable and efficient, however, if prop- erly managed and will enable one to meet those manj^ re- quirements for nasal anesthesia encountered outside the hospital. The Apparatus. — The apparatus is identical with that suggested for the vapor method of oral insufflation with the difference that we substitute the nasal tubes for the vapor mask. A throat tube is also necessary. When intraj)haryngeai insufflation is administered in this fashion, it is very important to use the throat tube. This will insure the proper tidal volume and sufficient air to dilute the concentrated ether delivered into the pharynx. In order to keejJ the patient sufficiently anesthetized, how- ETHER ANESTHESIA 157 ever, one will find it necessary to induce a certain amount of rebreathing. This is most easily accomplished by the towels which are placed over the patient's head for the asepsis of the field of operation. These towels may, with advantage, be placed in position at the early convenience of the operator. When in position they should not lie directly upon the rebreathing tube but at some distance from it. The Admixistratiox. — Anaesthesia is induced by the open, semi-open or closed drop method. When the stage of maintenance has been entered upon, the catheters are slip2)ed gently into place. Ether vaj^or is then slowly bub- bled through these (preferably by oxygen) into the poste- rior pharynx. The throat tube should now be introduced. If the ether vapor causes cough or sj^asm, stop the vapor but do not remove the tubes. Give ether orally by the drop method. Tolerance will soon be established for the vapor, and when spasm no longer occurs the vapor will be freely admitted and the drop method discontinued. The mask, however, is held over the mouth until complete control of the patient is established. The freedom of both hands w^hich the oxygen method affords at this stage w^ill be found a great convenience. When the sterile towels are placed over all, the anaesthetist should make sure that they do not block the pharyngeal tube. In this type of maintenance we must watch the patient somewhat more closely than in the percentage method. For our maintenance is here of the variable type and depends upon the signs imme- diately expressed by the patient for an elevation or de- pression of the level which is carried. It is always safer to carry the patient too low than too high, for many of the signs are masked. As we depend chiefly 158 ANAESTHESIA upon the muscular signs and the respiration, it is safer to allow the patient to " come out " now and then to the point of a slight spasm of the respiration than to keep him " deep " all the while. The Indications for Intrapharyngeal Insufflation 1. Operations on the head and neck excluding intra- nasal operations ; glands of the neck, tonsils and adenoids ; tumors of the face; intraoral operations. In operations for hare lip and cleft palate, the vapor may be delivered by one catheter through the intact nostril. 2. Whenever the immediate proximity of the anaesthe- tist endangers the asepsis of the field of operation, as in upper abdominal operations ; breast operations ; operations on the shoulder or chest. Contraindications When the percentage method of intrapharyngeal in- sufflation is employed, the method may be used in any type of case with the possible exception of the very young and those patients who have double nasal obstruction, or who are to suffer nasal manipulations. When the variable method by air bulb or oxygen is used, the method is contraindicated in all cases which do not specifically demand the method. This is because this varia- ble type depends much more on the signs exhibited by the patient for even progress of the anaesthesia than does the constant or percentage type. In these cases, since we are unable to constantly follow the eye signs and the color, we are working at a disadvantage which, when avoidable, should not be incurred. ETHER ANESTHESIA 159 III. INTRATRACHEAL INSUFFLATION In intratracheal insufflation we deliver ether vapor directly into the trachea of the patient, usually at a short distance from its bifurcation. We do not intend by this method to supplant the normal respiratory efforts by an artificial respiration, but to deliver the ether in a position most available for use by the patient. Instead of having two tubes delivering vapor into the pharynx, as is the case in the pharyngeal method, we have one long tube delivering vapor into the trachea, past the site of the vocal cords and upper air passages, where obstruction to the resj)iration is prone to occur. We provide neither the inspiratory nor the expiratory effort. By placing our vapor directly into the rigid res- piratory tree, beyond all obstruction, under a positive pressure of from 20 to 30 mm. of mercury, we naturally make inspiration easy for the patient. This is evident in the shallow respirations which he experiences. By using a tube of a much smaller diameter than the glottis, we pro- vide for the free esca^DC of the expirations and any excess vapor admitted. We do not here, as in intrapharyngeal insufflation, use concentrated ether vapor, diluting this with the atmospheric air, but we give a volume sufficient for all the respiratory needs of the patient. This volume, under sufficient pressure, is such that even during the inspiration with the glottis, but partially obstructed by the tube, no at- mospheric air will enter ; there will be no inward flow at any time into the trachea along the sides of the tube. On the contrary, there should be a constant flow to the outside. This flow will naturally be less at the time of inspiration but it will never altogether cease except when the delivery is cut off. 160 ANAESTHESIA If this idea of a constant flow out of the lungs is under- stood, then the great value of this method will be seen in cases suffering from hemorrhage or vomitus in the upper respiratory tract. We might imagine such an anaesthetized patient entirely immersed in water and yet receiving none in his respiratory tree. Sufficient pressure (20-30 mm. Hg) , is necessary, not only for the exclusion of atmospheric air but in order to prevent the lungs from collapsing when the intrathoracic pressure is withdrawn during operations in the thorax. The lungs are normally distended by virtue of the nega- tive pressure in the thoracic cavity. This appears to be due to the fact that these structures remain smaller than the thorax in the course of development. The negative pres- sure may also be represented by the natural elasticity of the lungs. If the pleural cavity is opened and this elas- ticit}' allowed to act, the lungs will collapse. The pressure varies from 4.5 mm. at expiration to 7.5 at inspiration. Obviously then, if we are delivering vapor into the trachea at a pressure of 20 mm. when the chest is opened, the lungs will have a tendency to expand rather than to collapse. This is what actually occurs: Since the lungs do contract at regular intervals during normal respiration, we should simulate this action by fre- quently releasing the positive pressure. We do this in practice. Since the interchange of the gases in the lungs results chiefly from diffusion rather than from actual replacement, a constantly changing stream of oxygenated vapor in the trachea and large bronchi will serve the vital purposes of respiration. We may then, with the greatest benefit, em- ploy this method in artificial respiration (see page 29) where free diffusion is present in the lung tissue, that is in those ETHER ANESTHESIA 161 cases where fluid is absent, drowning cases, etc., excluded. In the normal case, liowever, it is unsafe to continue the administration in the face of suspended respiration. Fig. 87. — Portable an8e.li into the colon. This is then drawn off and two to four ounces of olive oil are introduced, with a view of neutralizing any ether which may remain unexcreted. The Advantages of the Method When efficient, the nature of the induction in the pa- tient's hed is certainly a great boon. The apparatus is most simple and economical (this for many is the " raison d' etre ") . The control when effective is most simple, i.e., increas- ing the freedom of the res2)iration by a tube to lighten the amesthesia, decreasing it by a towel over the face to deepen it. When the intratracheal method is not available this method may be used with satisfaction for operations on the oral passages, the nasal passages and the neck. The Disada^antages of the Method 1. It is certainly dangerous. 2. The preliminary preparation is frequently inefficient and often distresses the patient. 3. The method is unreliable, even in the hands of the experienced and must often be supplemented by oral in- sufflation. 4. The addition of an anaesthetic by mouth in addition to that in situ in the rectum is more than ordinarily danger- ous, as we do not know what part of the latter will be suddenly absorbed. 5. Distention of the rectum is prone to occur. 6. It is undesirable in cases where the Trendelenburg: 174 ANAESTHESIA position is used (Fig. 18), as the injection has a tendency^ to force its way up the gut hy gravity. 7. Injections which are producing untoward effects frequently cannot be recovered. We doubt the possibihty of completely irrigating the colon at will. 8. Ulcerations of the colon and operations about the lower gut positively contraindicate the use of this method. 9. The respiration may form a vicious circle, i.e., the more ether absorbed the more shallow the respirations are likely to become ; the more shallow the respirations the more ether accumulates in the circulation. 10. Since the ether which is not broken up by the body tissues must be excreted by the lungs, we doubt the effi- ciency of this method in pulmonary tuberculosis. 11. Ninety per cent, of the injections into the rectum find their way to the csecum by virtue of reverse peristal- sis. Can we recover such injections at will? 12. Cases which present respiratory obstruction, obese individuals, goitre cases, etc., would appear to contrain- dicate this method, as such obstruction interferes with our chief safety valve, the freedom of the respiration. 13. Emergency cases necessarily lacking the proper preliminarj^ perparation are unsuited to this method. 14. The untoward effects of morphine in cases having received a rectal injection of a solution of ether are more difficult to combat. V. THE DIRECT METHOD OF ANESTHETIZATION BY INTRAVENOUS ANESTHESIA Intravenous anaesthesia is that type of anaesthesia in which we introduce into the circulation of the patient, by way of a convenient vein, a solution which contains ether^ ETHER AXiESTHESIA 175 The strength of tliis sohition varies from .5 to 7 per eent. The amount of the sohition a(hninistered depends upon the duration of the anaesthesia. This amount is from 500 to 3.500 ec, 1000 ec. an hour being the average. The solution is given continuously, no accumulative action being permitted. We do not, as is the case with rectal anaesthesia, give a dose and trust to the patient to absorb it or excrete it according to our expectations, depending upon enemas to undo mis- chief after it has occurred. When one ceases to adminis- ter the intravenous solution, the patient " comes out " at once. The control is delicate and free from many of the complications which one is prone to meet in insufflation methods. We speak of intravenous anaesthesia as the direct method of anasthesia because by this method we do not require the assistance of an intermediary system, such as the respiratory or the gastro-intestinal to assist us in our anasthetization. We place our anasthetizing agent directly into the blood stream, through which medium it presumably acts upon the central nervous system. From the point of view of the anasthetic, then, the method is direct. From the point of view of the anasthetist, however, tlie matter is not so simple. The proper introduction of the solution implies: (1) satisfactory local anasthesia for the isolation of the vein of introduction; (2) a surgical opera- tion (the introduction of the cannula). The speedy, skillful and painless administration of an intravenous injection implies familiarity with surgical tech- nic. Such a procedure requires perfect asepsis and dex- terity bred of experience. While the average anasthetist might succeed in finding a vein in most cases and in success- 176 ANAESTHESIA fully introducing a cannula in a smaller number, the chances of his doing so rapidly and painlessly would be less. This type of anaesthesia may be classed as an anaesthetic feat and, while most attractive in many of its aspects, will never achieve a broad practicability. It will be of interest, however, to consider the method and to become familiar with the essentials of the technic. Apparatus. — 1. Accessories for local anaesthesia (see page 257). 2. Instruments for isolating vein. 3. Apparatus by means of which the solution is deliv- ered to the patient. 4. The solution administered. 5. Apparatus for maintaining free respiration. 1. The accessories for the production of local anaesthe- sia consist of a proper syringe, needles and solution. A detailed description of these various elements will be found under the consideration of local anaesthesia, page 257. 2. The instruments necessary for the isolation of the vein consist of a scalpel, two haemostats, blunt pointed scis- sors, ordinary forceps and a pair of small artery forceps. 3. Apparatus for the intravenous solution proper con- sists of: (a) A reservoir, preferably glass, having a capacity of 2000 cc. with an outlet in the bottom. (b) Tubing whose proximal end is attached to the res- ervoir and whose distal end terminates in a small cannula, which is to be introduced into the vein. (c) An arrangement whereby one can readily and con- stantly estimate the amount and rate of flow of the solution into the vein is essential. In the apparatus shown in Fig. 92, this is done by means of a specially constructed glass ETHER ANAESTHESIA 177 globe through which the solution is made to flow on its way from the reservoir to the cannula. This globe, known as a dropper, is an indispensable feature of the apparatus, for the rate of flow of the solution, about 16 cc. per minute, must be constantly indicated. The action of tlie dropper is as follows : When the solution is flowing, it enters the upper part of the globe in the form of a spray or drop through a small, nipple-like projection. This is allowed to col- lect in the lower half of the globe, the control being established by a clip attached to the distal tubing. The constancy with which this level is kept in the presence of a continu- ous flow through the nipple indi- cates the flow to the patient. 4. The solution, a 5 to 7.5 per cent, solution of ether in sterile Ringlers solution (a solution con- taining sodium, potassium and cal- cium chloride), or in ordinary normal saline, at a temperature of 8.5" F. .5. A pharyngeal tube. The Administration. — It is quite essential that the usual pre- liminary treatment, as indicated in the section covering tlie control of the period of excitement, page 24-, be carried out. The preliminary visit is especially valuable for the bene- ficial effect of suggestive therapeutics. The patient must be brought into tlie operating room and placed on the 12 Fio. 92. — Intravenous apparatus. 178 ANAESTHESIA table half an hour before the time set for the operation. Incidentally this means that the operating room must be set and the anaesthetist on hand some three-quarters of an hour to an hour before the time set for operation. When the patient has been placed on the table, a hypo- dermic of morphine grs. Yb and atropine 1/100 and scopo- lamine 1/1000 is administered. The arm to receive the solution is strapped to the support upon which it rests. The veins of the forearm are made to stand out promi- nently by digital pressure above the elbow. A space as big as a dime is injected with novocaine .5 per cent. The skin is incised and the vein exposed and dissected out. While this procedure is being accomplished, the reservoir is filled with the solution and placed on the stand 8 feet above the floor. The vein having been isolated, a ligature tied dis- tally and an united ligature placed proximally to the open- ing made therein, the cannula with the solution flowing is gently introduced and secured by the loose ligature, which is now tied with one knot. A large gauze pack is now placed over the field and strapped to the arm with adhesive plaster. We may then devote our attention to the indicator and the patient. The solution is allowed to flow slowly into the vein. The patient soon passes into a quiet sleep with little or no excitement. The transition from consciousness to the stage of maintenance is indeed so quiet that one would be led to suspect that ana?sthesia was not present were it not for the loss of the lid and eye reflexes. The airway must be patent at all times. This is best accomplished by the introduction of the Connell tube as soon as the pharyngeal reflexes have disappeared. Anaesthesia is increased (the level of main- ETHER ANAESTHESIA 179 tenance raised) by increasing the flow of the solution, the patient is allowed to "come out" (the level of mainte- nance is lowered) by stopping the flow. It is more satis- factory to keep up a continuous flow than to give the solu- tion intermittently, since the patient recovers j^romptly upon the cessation of the flow. The amount of the solution usually consumed in an hour is 1000 cc. PosT-OpERATI^^E Treat:ment. — The wound in the arm should be closed with a straight needle. It may then be wiped with iodine solution or carbon tetrachloride in thy- mol (50 per cent, solution), and the dressing applied. The patient should be placed in the semi-Fowler posi- tion ( Fig. 122 ) , and he should be turned every hour to over- come the tendency to pulmonary oedema and the formation of spots resembling bruises in the loose, fatty tissue of the back and buttocks. The Advantages of the Method Ideal control of the administration. Not dependent upon the rate or the depth of the respiration. The minimum amount of the amesthetic is employed. There is little or no cunmlative action. The technic is sufficiently complicated to exclude thoughtless experimentation. The Dis.\dvaxtages The general anaesthetic must be preceded b}" an opera- tion under local anaesthesia. The jDreliminaries to the administration of the ana?s- thetic per se involve a loss of much time and, from this 180 ANESTHESIA point of view, the method is impractical as a routine in the large hospital. The proper administration implies familiarity with the surgical teehnic required. The blood pressure is raised. The bleeding is increased and the fluid has a tendency to collect in the abdomen. It is an open question as to the harm done by the injec- tion of a normal saline solution in the blood stream of a healthy individual. The possibility of septic thrombosis must be considered. There is a tendency to pulmonary oedema and spots, resembling bruises, frequently appear on the back and buttocks. CHAPTER V ETHYL CHLORIDE Ethyt- cliloride, or sweet sjDirits of salt, was discovered by Florens in 1847. It is a colorless liquid, very volatile and has a pungent, ethereal odor. It boils at 12.5 C. Ethyl chloride is used for general anaesthesia as well as for local anfusthesia. (See page 249.) While ethyl chloride has been frequently employed as a general antesthetic throughout the stages of induction^ maintenance and recovery, its use as the sole anaesthetic in such a complete arucsthesia should be discouraged. This is because of the narrow margin of safety between a stage of satisfactory maintenance (complete muscular relaxa- tion) and the lethal dose or the dose which may kill. Col- lapse is more liable to follow ethyl chloride than any other anesthetic. From a practical point of view then the administration of this ansesthetic is limited to: (1) the induction of anaes- thesia (as a preliminary to ether anaesthesia) ; (2) incom- plete ancesthemi (that type of anaesthesia without the stage of maintenance) . The administration of ethyl chloride as a preliminary to ether, and its use alone for short operations, is but a matter of degree. With the former our object is to destroy consciousness; with the latter we go a step further and apj)roach the period of relaxation. Ethyl chloride is frequently used as a substitute for N2O. Portability and cheapness are offered as reasons for this. In view of the un(|uestionably greater safety of X^O, however, such a j^rocedure is entirely unjustifiable. The situation is well put by Thomas D. Luke, who says " The 181 182 ANiESTHESIA idea has got about among a large number of both the medi- cal and dental profession that ethyl chloride is a sort of a glorified N-O, which one may carry about in one's waist- coat 230cket and administer to all and sundry, without any special precaution or skill on the part of the administra- tor . . . Nothing further from the facts could be imagined Fig. 93. Fig. 94. Fig. 9.3. — Chloroform containers. Fig. 94. — Ethyl chloride container, spray type. Its highly toxic character and the danger due to the great rapidity of its action should be fully recognized as well as its admirable proj)erties as an adjuvant to chloro- form and ether." Dr. Luke follows his remarks with a report of twenty-three deaths from ethyl chloride in the short span of five years. ETHYL CHLORIDE 183 The administration of ethyl chloride is often followed by headache, nausea and vomiting. These symptoms may appear immediately after recovery or he delayed for five or six hours. When ethyl chloride is administered, the consciousness is rapidly lost as with N2O. Its effects are best seen with a closed apparatus, as with ether. In overdose it kills quickly, as does chloroform. A cork or some other mouth prop must be placed between the teeth before the administration is begun, for masseteric spasm is prone to occur. When a closed apparatus is used the dose should not exceed 1.5 cc. for children and 3 to 4 cc. for adults. This dose should be given slowly and cautiously. When open or semi-open methods are used, the dose may be increased. Ethyl chloride, owning to its very great tendency to evaporate, is marketed in special glass containers. (See Fig. 94.) The delivery from some containers is controlled by a spring lever applied to the vent, in others by a gas- tight screw cap. The Administration of Ethyl Chloride as a Pre- liminary TO Ether Anaesthesia or Alone for the Purpose of Securing Incomplete Anesthesia Apparatus. — The semi-open drop mask, as described on page 128, or a closed apparatus such as described on page 134. When the semi-open method is employed a much larger quantity of the drug will be required. Before starting the anaesthetic a mouth prop is placed between the teeth of the patient; the mask is then arranged as in Fig. 69 or Fig. 71, and the patient is instructed to 184 ANESTHESIA count out loud. Ethyl chloride is carefully sprayed upon the mask. The administration is continued until conscious- ness is lost, when ether in the form of a drop or spray is resorted to. The effects obtainable by this method are not nearly as satisfactory as those which may be secured by the em- ployment of a closed method. Where the latter is em- ployed, the rebreathing bag is filled with the patient's expirations. He is then instructed to breathe naturally to and fro. As he does so, ethyl chloride is sprayed into the apparatus through some convenient vent; either into the bag proper, or into the evaporating mediums, gauze, wire screen, or whatever it may be. The drug is added slowlj^ not more than 4 cc. in all being used. Free air should be administered upon the first evidence of stertor. When ethyl chloride is given per se to produce incom- plete anaesthesia, it should not be pushed to a loss of the corneal reflex and a dilated pupil. An absent lid reflex, page 103, deep, involuntary respirations and absence of muscular excitement being all that is desired. When employed as a preliminary to ether, we have attained our object when consciousness is lost and the pharyngeal reflex has been rendered somewhat less sensi- tive to tlie odor of ether. The loss of consciousness when ethyl chloride is used for induction is not so rapid or so pleasant as when NoO is used. It is, however, more speedy and more grateful to the patient than is ether alone. The dangers of this anaesthetic are twofold: From overdose ; from asphyxia, secondary to spasm occurring in the respiratory tract. The proper anticipation of these difficuties will fore- stall untoward results. CHAPTER VI CHLOROFORM Chloroform was first used as an anfesthetlc by Sir James Simpson in 1847, some months after the announce- ment of the discovery of ethyl chloride by Florens. Chloroform is a colorless liquid with a sweet but burn- ing taste, and possessed of an ethereal odor. The boiling point is 61.2 C. GENERAL CONSIDERATIONS Since its discovery chloroform has been the favorite anesthetic of continental Europe. Ether, however, has found greater favor in this country, more particularly in the large cities. In country practices and small towns in the United States, chloroform is still extensively employed. With chloroform the stage of induction is usually free from excitement; the stage of maintenance is quiet and characterized by tranquil breathing and complete relaxa- tion. The stage of recovery is comparatively brief and the after-effects of the anaesthetic are usually conspicuous by their absence. Chloroform, however, unlike ether, is a distinct pro- toplasmic poison. Chloroform Jiills quickly in overdose (in a concentration of 5 per cent, or more) . Chloroform is most dangerous during the stage of induction, at which time it is most commonly used. As a protoplasmic poison, the evil effects of chloro- form frequently do not become evident until some time after the administration. Such late effects are known as " delayed chloroform poisoning." This condition of de- 185 186 ANESTHESIA laved chloroform poisoning is now well recognized. The degenerative effects which take place closely resemble those found in the liver and kidneys of eclamptic cases. Nmner- ous investigators have pointed out these lesions. We quote the following from a paper by Drs. E. B. Cragin and E. T. Hull of the Sloane Maternity Hospital: " Recent studies of the pathologic changes produced by eclampsia, delayed chloroform poisoning and chloro- form ana?sthesia have shown a striking similarity in the findings in all three conditions." The pathologic picture in each is that of congestion, hemorrhage, degeneration and necrosis. Our knowledge of the pathology of eclampsia is of comparatively recent date, but thanks to the work of Jurgens, Schmorl, Williams, Ewing, Welch and others, the lesions are now well recognized and generally accepted. Delayed chloroform poisoning as such has been fre- quently recognized and carefully studied, both clinically and pathologically, for the last twenty years. Many writers have reported series of fatal cases, all showing symptoms and lesions which are now recognized as typical of the con- dition. A number of these deaths occurred after only twenty or thirty minutes of anaesthesia, untoward symptoms developing a few hours to a few days after the administra- tion. The symptoms include progressive weakness, pallor or cyanosis, restlessness, vomiting- delirium, convulsions, stupor, coma and death. The organs principally affected are the liver and kidneys. The former is yellow and fatty, with hemorrhages often under the capsule and through- out its substance. The typical picture is that of a central necrosis. The cells about the central vein disappear, leaving only a mass of granular material which shows neither nuclei CHLOROFORM 187 nor cell outline. 'Nearer the periphery of the lohule is a zone of swollen cells, which have undergone hyaline and fatty degeneration. A few normal liver cells may remain at the periphery. The kidneys are swollen, markedly congested, with occasional hemorrhages under the capsule, ahout the tuhules, and in the pelvis. The cortex is thickened, the markings indistinct. JNIicroscopically the cells of the tuhules are greatly swollen, granular, and loaded with fat. The lumen is filled with granular material, fat glohules and coagulated serum. The heart muscle often shows some fatty degeneration. The changes are generally con- sidered to he more profound in the liver, though some oh- servers have found the kidney degeneration even more marked. The reports of these cases of delayed chloroform poisoning with their pathologic findings led naturally to a study of the lesions produced by chloroform anaesthesia. jVIany animals were used in these experiments, most often dogs, rabbits and guinea-pigs. These studies were exhaus- tive and include the work of Lengemann, Ostertag, Stiles and McDonald, Stassman and others, together with the more recent work of Howland and Whipple. The most striking result of these studies was the extent of the degen- eration and necrosis found in the liver and kidney after chloroform anaesthesia of a short duration. It has been found that characteristic lesions are regu- larly produced, varying in degree with the duration and depth of anaesthesia, and also with idiosyncrasy. Thus after thirty minutes to one hour anaesthesia with chloro- form, the centres of the lobules of the liver show conges- tion with granular and fatty degeneration, the innermost cells being necrotic, their nuclei not taking the stain and the 188 ANAESTHESIA protoplasm being deeply stained pink with eosin. With more prolonged action the changes approach those found in delayed chloroform jjoisoning in man. The liver ap- pears yellow and fatty with scattered hemorrhages. The cells about the centres of the lobules are entirely necrotic, a granular mass remaining. Outside of this is an area of cells which have undergone hyaline and fatty degenera- tion, with normal cells at the periphery. In some cases the liver cells have almost entirely disappeared with only a few scattered living cells in the portal spaces. In the kidney, chloroform anaesthesia causes a marked congestion with a cloudy swelling and occasionally hemorrhages into the parenchyma. The cells of the tubules are swollen and granular, occluding most of the lumen ; in other places they have disappeared entirely. Fatty degeneration is present and in many cases pronounced. The heart muscle may be pale and show fat droplets in its fibres. Hemorrhages occur throughout the body, particularly in the serous mem- branes, and in the intestinal and stomach nmcosa. Rowland and others were able, almost at will, by con- tinuing the amesthesia to produce delayed chloroform poisoning in dogs, with symptoms and lesions correspond- ing in detail with those of delayed chloroform poisoning in man. Thus we find in these three conditions, eclampsia, delayed chloroform poisoning in man and chloroform anaes- thesia in animals, many similarities. Pathologically there is central necrosis, parenchymatous and fatty degeneration in the liver ; congestion, parenchymatous and fatty degen- eration in the tubules of the kidney and a tendency to hemorrhages throughout the body. Clinically in delayed chloroform poisoning and in eclampsia there are vomiting, jaundice, delirium, convulsions and coma. CHLOROFORM 189 Does ether produce lesions in the hver and kidneys simi- lar to chloroform ( Some work has already been done alono' this line, notably by Handler, Lengemann and Leppmann, and it was partly to confirm scattered observations on this subject that a further study of ether amcsthesia was undertaken. In our experience six mongrel dogs of medium size were given ether by inhalation from an open cone. They were killed with ether forty-eight hours after the last anses- thesia and autopsied at once. Sufficient ether was given to produce complete nmscular relaxation with loss of corneal reflex. In none of these animals could any necrosis in any of the parenchyma be found. In the lungs occasional small areas of a deeper red than the surrounding substance, con- taining an increase in the amount of blood on section, showed congestion. The heart muscle in each dog was found to be of normal color, striations distinct, no appar- ent increase in fat. There were no hemorrhages in the mucosa of the stomach and intestines. The livers were of a good color throughout, the vessels in a few places standing out a brighter red than the sur- rounding structure. The yellow appearance was entirely lacking, the cells throughout preserved their outlines with contents intact. There was no suggestion of necrosis at any point. The protoplasm was somewhat granular and small droplets of fat were found in the cells about the central veins and in the portal spaces. This fat was only slightly in excess of that in the controls. The kidneys were of normal size, capsule not adherent, cortex not thickened, markings distinct. jNIicroscopically 190 ANAESTHESIA the cells of the tubules were well preserved throughout; their outlines were distinct, the nuclei staining sharply, the protoplasm granular, the tubules containing in some places some granular material. Fat globules were present in a few of the straight tubules and in the lining cells. This condition seemed no more than is normally found, and no more marked than in the controls taken. No pathologic changes could be found in any of the sections of pancreas and spleen. These facts seem to demonstrate that in animals, at least, ether 23roduces prac- tically little etfect on the liver and kidneys as compared with the very marked changes in these organs produced by chloroform, and, while it may be argued that this compari- son has been demonstrated only in animals, the similarity between the lesions of delayed chloroform poisoning in man and chloroform ana?stliesia in animals makes it appear more than probable that reasoning as to the effect of ether on the liver and kidney of man, from the lesions produced by ether in animals, is entirely justified. The foregoing facts lead to the conclusions arrived at by the Committee on Amtsthesia of the American Medical Association, June loth, 1912: " 1. The use of chloroform as the anaesthetic for major operations is no longer justifiable. Scientific investigation and clinical experience agree in demonstrating that necro- sis of the liver ( ' delayed chloroform poisoning ' ) follows in a by no means inconsiderable percentage of cases. The mode of causation of this sequel is unknown. There are therefore no precautions that can be intelligently taken against it. Accordingly the surgeon whose patient dies in this manner a day or two after operation must face the responsibility of having knowingly taken an unnecessary CIILOROF(JUM 191 chance — and lost. We see no reason to believe that in respect to toxicity there is more than a sli<>ht (juantitative difference between chloroform alone and such chloroform mixtures as A. C. E., anesthol, etc. " 2. For minor operations also the use of chloroform should cease. In general it may advantageously be re- placed by nitrous oxide, or nitrous oxide-oxygen. It is a mistake to think that a fatality under antesthesia is neces- sarily due to an unusually large administration of the anaesthetic. A previous condition of suffering or anxiety, or a prolongation of the stage of antesthesia excitement renders a subject who would otherwise be able to resist a large dosage, liable to collapse even under a small dosage. The practical importance of avoiding so far as possible all anxiety and pain has been demonstrated on the clin- ical side by Crile, and experimentally by Henderson. It is noteworthy that Levy (with Cushny) has recently demonstrated that in cats a sudden heart failure (fibrilla- tion) is induced by a period of light chloroform anjtsthe- sia, while this form of death is not inducible by deep anesthesia. Risks of this sort are far greater with chloro- form than with ether, and greater with ether than with nitrous oxide. As they cannot be foreseen, they cannot be avoided, except by replacing a dangerous anaesthetic by a safe one. " 3. Chloroform is sometimes found convenient for initi- ating ana?sthesia in alcoholics or other difficult subjects. As a means of avoiding the ill effects of a prolonged period of ether excitement the temporary employment of chloro- form for this j^urpose is j^erhaps sometimes the lesser of two evils. It is justifiable only when nitrous oxide is not available. If chloroform is to be so used, it sliould be given as soon as it is evident that the j)atient will not go 192 ANyESTHESIA under ether readily. Unless the change to chloroform is made early it should not be made at all. We wish espe- cially to emphasize the point that chloroform should never under any circumstances be administered after a pro- longed period (10 or 15 minutes or more) of ether excite- ment. Even a small administration of chloroform is then peculiarly liable to induce respiratory or cardiac death. As soon as full anaesthesia is attained ether should be substituted." It has been argued that the evil effects of chloroform are largely due to impurities found in the drug ; these impuri- ties depending upon faulty preparation or exposure to light and air. If such toxic impurities are so constantly present as to result in the common findings of a large num- ber of investigators, it would seem that the end result is the same as though the evil lay in the drug itself. We can scarcely hope to convince all users of chloroform of the danger of their position and urge upon them a favorite preparation of our own. If chloroform is shown to be con- sistently poisonous we had best forego the pleasure of its free usage and confine ourselves to an anaesthetic which is safer, though somewhat more difficult of manipulation. We who have become accustomed to chloroform will be prone to yield ourselves to its charms and to feel that because clinical distress seldom appears, pathological damage has not occurred. We will recall particularly our rather extensive experience in obstetrical cases, the delight- ful and efficient anaesthesia which we have so often ob- tained, the freedom from excitement in induction and the absence of symptoms upon recovery. We will recall the many instances in which we have anaesthetized children large and small. We are prone to smile when the pathol- CHLOROFORM 193 ogist condemns our most valuable agent " chloroform." We will not abandon chloroform but we will use it less frequently and with more respect. Those of us who are now receiving our obstetrical train- ing will find little difficulty in getting along without this valuable but dangerous agent. The present generation brought up upon a constant diet of pathological findings learn to look with increasing confidence to this authority. We accept its dictates as our own and confidently walk in the light of its decisions. If we accept the conclusions of pathology, chloroform per se cannot be the anaesthetic of choice in the routine case. The indications which present themselves for the use of chloroform must be sufficiently urgent to overcome our aversion to its use. The chief indication is that presented by acute pulmonary disease where N-O and O is not availa- ble, and in the control of individuals who cannot be well handled by ether. One of the most marked characteristics of chloroform is its tendency to bring about circulatory depression. In glancing over the works of Hewitt, Luke and other Englisli authors, one is struck with the frequent reference to cir- culatory shock. We scarcely ever see a case of this nature where ether is the ana?sthetic. The use of ether with chloro- form appears to reduce the likelihood of this type of shock. This explains in part the popularity of the well known A. C. E. mixture (alcohol 1, chloroform 2, ether 3). The alcohol of this mixture is usually omitted, the result being a C. E. mixture. The C. E. mixture is so much safer than the chloroform 2)er se that it has largely supplanted the employment of the latter. 13 194 ANiESTHESIA Containers. — Since chloroform deteriorates upon ex- posure to air it is safer not to use a sample which has been opened (Fig. 93). With this fact in mind manufactories are now putting out ampules and bottles sufficient for one administration. Bottles containing one ounce are inexpen- sive and satisfactory. If the solution is not all used the residue should be sent to the jDharmacy for the preparation of chloroform liniment. The Administration. — Since the addition of ether to the chloroform reduces the likelihood of circulatory depres- sion and improves the quality of the respiration we have practically abandoned the use of chloroform per se. Ether may be given mixed with chloroform in the pro- portion of ether-parts 3, chloroform-parts 2, or the drugs may be given alternately by the drop method. A few drops of chloroform being followed by a somewhat larger amount of ether. Where one is desirous of obtaining the effects of chloroform, more particularly for the stage of induction, the contents of an ounce bottle of chloroform freshly opened is mixed with one and one-half bottles of ether (the empty chloroform bottle being the measure) . As the stage of maintenance is approached, ether is added to the container, one ounce at a time. By the time the stage of maintenance has been entered upon the amount of chloroform present in the mixture will be so small as to be practically negligible. Apparatus. — When the C. E. mixture is employed it may be administered to the patient by: («) the drop method; {h) the vapor method. («) When chloroform alone is used there should be no air restriction whatever. For this reason the use of the semi-open method and the closed method should not be CHLOROFORM 195 tolerated. The open drop mask, as described on page 122, may be employed. If chloroform alone is used the mask should not be i3ermitted to rest against the face. Where the C. E. mixture is the anaesthetic, however, the mask may be used, as in the case of the open drop method of ether administration. One should always remember that one is administering chloroform and that it is dangerous to soak the mask as may be safely done in the case of ether jier se. The mixture should be added cautiously drop by drop, the signs of anjEsthesia being our index as to whether we should push or decrease the administration. {h) The vapor method is a very convenient and effec- tive method of administering the C. E. mixture. Oxygen is preferable to air as a means of producing the vapor. The same care should be exercised as in the case of the drop method. As. antesthesia progresses ether may be added to the reservoir, thereby reducing the risk of chloro- form complications. Chloroform should never be given near a naked flame. A product known as phosgen gas is formed which may seriously effect not only the patient but the operator and assistants as well. The Causes of Death in Chloroform Anaesthesia In the stage of induction chloroform deaths occur as follows : (fl) Spasm of the respiration occurs. The anaesthetist continues to drop the chloroform upon the mask. A large amount of chloroform thus accumulates. Following the relief of the spasm, sjiontaneous or artificial, the patient breathes deeply. A lethal dose of chloroform is carried to the heart muscle, which, weakened by the previous res- 196 ANAESTHESIA piratory spasm, suddenly and permanently dilates. This is the usual cause of death of the large, alcoholic and athletic individual. (h) Vagus inhibition, causing paralysis of the heart muscle, sometimes occurs in high strung, neurotic in- dividuals. In the stage of maintenance chloroform deaths may occur as follows: (a) By the elevation of the head and shoulders syncope may result, vi^hich in turn may develop into definite circu- latory shock and cessation of the respiration. ( b ) By simjjle overdose. In the stage of recovery death may result from: (a) Progressive acidosis secondary to an acute sep- ticaemia or from unrecognized diabetes. Post-operative death occurs as a result of extensive protoplasmic poisoning effecting chiefly the liver and the kidneys. Chloroform fatalities are not likely to occur if the following suggestions are adhered to: If it is excluded in cases of acute septicaemia, acidosis and eclampsia. If it is invariably used with ether and not alone. If the prone position is always adhered to. (Even the position advised for upper abdominal closure, page 43, should be avoided) . If fresh, newly opened specimens of chloroform are used. If the mask is taken off the face during masseteric spasm. If the corneal reflex is always retained, and a lustreless, dilated, fixed pupil never permitted. If the rhythm of the respiration is maintained, and the CHLOROFORM 197 administration changed to straight ether upon the first sign of inexphcable shallowness or irregularity. When the heart stops in chloroform it usually does so as a permanently damaged organ. Its dilation is toxic rather than mechanical, hence the difficulty of resuscitation. The blood in the coronary arteries nmst be squeezed out manually to relieve the condition. Massage of the heart through the diaphragm even though it calls for a special laparotomy should be done ; for death under these circum- stances is a most dreadful thing. Who would refuse a laparotomy upon himself in such an extremity? Trans- pleural pericardiotomy for massage of the heart may also be practised. There is some hope of success even though the heart has ceased to beat for ten minutes. Lieb has suggested that the radial artery be imme- diately exposed. A cannula delivering the saline ordi- narily employed for intravenous injections, at a height of four feet above the artery is introduced and when the flow into the artery actually begins, inject directly through the rubber tubing next to the cannula ten minims of adrenalin. This dose may be repeated four or five times. Artificial respiration by negative and by positive ven- tilation should always be done (page 91) . The Signs of Anaesthesia when the C. E. Mixture is THE Anesthetic When chloroform is used alone a condition of pseudo- relaxation or natural sleep is likely to follow especially in children. When the C. E. mixture is employed this does not occur. The patient must invariably be anaesthetized in the prone position. 198 ANiESTHESIA Induction. — Excitement much less than when ether is used alone. Rigidity of shorter duration. Belajcation more easily accomjDlished. Besjnration regular, moderately deep, increased in rapidity, becoming stertorous. More shallow than with ether alone. Eyes. — Globes rolling vertically or horizontally (as in ether). Pupils: A pin-point pupil is suggestive of light anaesthesia, otherwise pupils are like ether pupils. Corneal reflex: Active as in ether. Light reflex: Active as in ether. Color. — Pallor characteristics of chloroform per se. With the C. E. mixture the color approaches that of ether. Pallor is suggestive of circulatory shock. RehidYition. — Lid relaxation somewhat sooner than with ether. iVIasseteric relaxation somewhat sooner than with ether. If spasm occurs the anaesthetic should be dis- continued at once and not resumed until the breathing is free. Pulse. — The quality of the pulse must be carefully observed. Circulatory depression will give a small pulse of poor tension accompanied by pallor of the face. M A I N T E N A N c E. — Respiration. — Moderate stertor. More shallow and not so rapid as with ether alone. Regu- lar rhythm must be preserved. The regularity of the respiration is the most important sign of chloroform aneesthesia, as failure of the respiration invariably precedes cardiac failure. Color. — Pale. Cyanosis must not be tolerated. If the percentage of ether used be increased a better color will result. CHLOROFORM 199 Eyes. — Globes fixed, lustrous. Pupils about normal or slightly enlarged. Ij'ght reflex present, sluggish. Corneal reflex sluggish; should not be obliterated. Relchvaiion. — Lid reflex absent. ]Masseterie relaxa- tion present. General "muscular relaxation characteristic. Pulse. — A valuable guide. Its tension, size and rapid- ity should be constantly observed. As a symptom of the anaesthesia j^^f * is filled with X'oO. The apparatus is applied and the pa- tient is instructed to breathe out naturally through the mouth. The first three breaths may be spilled into the air by the expiratory valve, or rebreathing may be practised from the start. Where the latter method is employed re- sults are entirely satisfactory and a single bag of gas is usually sufficient. As soon as the respirations have become full and deep, and evidently involuntary, ether is very cau- tiously added. If the rhythm of the breathing is affected it should be withheld for a few moments and then a second attempt made. If no hesitation occurs the ether may be rapidly increased. As soon as the patient has received a few breaths of ether, air is added a breath at a time. By this technic we have no blue or even dusky patients at our gas induction. When Nitrous Oo'ide is Used Alone. — This type of administration is the method usually employed in dental work. When a tooth is to be extracted a mouth prop of cork or other material, made especially for the purpose, must be placed in position before the administration is NITROUS OXIDE 209 begun. The patient furthermore is ordinarily in a sitting position. The head must not be extended but should be on a straight line with the body. The administration is carried out precisely as in the case of NoO induction for ether except that (oxygen not being used) we carry on the administration until slight jactitation of the arms or legs takes place. If ana\sthesia be then discontinued, a period of available anaesthesia amounting to about fifty seconds will result. A B Fig. 99. — The author's cylinder holder. A, brass plate clamp for three one-hundred gallon Cylinders; B.pin screwing into plate and fitting in socket of table clamp; C, table clamp; D, showing by dotted line the buried channel into which the gas of each cylinder empties, all leaving for face piece (not here shown) by a single rubber tubing. During this period any painful procedure may be carried out, such as the extraction of teeth, opening of abscesses, etc. When a longer anaesthesia is desired with this method the face piece may be reapplied before complete conscious- ness returns. If the operation be elsewhere than in the mouth one breath of air should be administered after every four or five breaths of rebreathed N2O. This will give a longer period of available anaesthesia, but does not result in anything like the smooth anaesthesia offered })y tlie addi- tion of oxygen gas to the mixture. The author's clamp and cylinder holder consist of 210 ANESTHESIA two parts; the cylinder holder and a clamp for use when horizontal support may be had i.e., table, etc. The cylinder holder consists of two parts; a nickle- plated brass plate about two inches l)y ten inches and a threaded steel pin, which may be screwed into the plate and removed at will. The plate is drilled so as to receive three cylinders. Each hole has a nipple which receives the Fig. 100. — The author's cylinder holder clamped to the edge of a table. cylinder and a thumb screw which holds the cylinder in place. This arrangement gives us the equivalent of three yolks sufficiently separated and rigidly united. The nipple which receives each cylinder is pierced by a hole which opens into a common tunnel made in the plate. The exit from this tunnel is from a single vent, to which the rubber tubing leading to the face piece is attached. (Fig. 99.) NITROUS OXIDE 211 The plate, therefore, is the essential part of the appara- tus and may he used alone. When the plate is used with- out the elanip (Fig. 101 ) , three cylinders are fitted into the yolks and, thus united, are placed on their sides and used Fig. 101. — Cylinders lying on a chair supported by the author's holder. Covered by a blanket these may be sat upon. in this position. They niay he placed on the anaesthetist's chair (Fig. 101), and when covered hy a hlanket form a comfortable seat. The clamp consists of two flat plates of steel, drilled 212 ANyESTHESIA with three holes each. Two of these holes receive bolts with their nuts, the third receives the pin which is screwed into the plate holding the cylinders. This clamp fits over the corner of a table. The weight of the cylinders does not in- jure the table if the clamp is evenly applied. Tables with Fig. 102. — Cylinder clamp fastened to a wandow-sill. glass tops are not affected, as the clamp covers a compara- tively broad area. The author has used this clamp on the lightest weight, portable operating table (Fig. 100). When the patient is to be moved from the stretcher to the operating table, the clamp is first fixed to the operating table. The anesthetic is then started, either in the ansesthe- NITROUS OXIDE 213 tizing room or in the patient's bed, with the cylinders on their sides on a table or on a chair. When the operating room is reached, the pin of the cylinder holder is conven- iently dropjjcd into the holes of the horizontal plate. This transfer is done easily and quietly. Thus supported the cylinders are completely out of the way. They do not clutter up the floor space; are within easy reach of the anaesthetist and move with the movements of the operating table. The custom of using nothing but a yolk, the cylinder standing on the floor, is not only dangerous because of the liability of the cylinders falling, but is wasteful of gas because the valves are often incompletely shut off. CHAPTER VIII NITROUS OXIDE OXYGEN ANAESTHESIA This mixture was first employed by Dr. E. Andrews of Chicago in 1868. The containers for nitrous oxide are described on page 201. Oxygen is put out in cj^inders containing 10 to 100 gallons. This gas may be compressed to the necessary small bulk without being liquified. Consequently there is little or no trouble with the valves of the oxygen tanks. These containers are usually painted red or bronzed to prevent the possibility of confusing them with N^O cylinders, which are blue or black. Both N2O and oxygen tanks should be held rigidly by some sort of clamp or stand, in order that the administra- tor may manipulate the valves with one hand. The most simple clamp for this purpose is that shown on page 209. This clamp has proven of the greatest convenience to the author. Two one-hundred gallon X2O and one O cylinder may be carried loose in any handbag or dress suit case. At least two cylinders of nitrous oxide and one cylinder of oxygen should always be on hand. A simple and inexpensive stand and clamp for hospital use is shown in Fig. 103. This may be easily made by the hospital carpenter. GENERAL CONSIDERATIONS Perhaps no other type of angesthesia at the present day has received as much attention as has the combination of gases popularly spoken of as gas oxygen. 214 NITROUS OXIDE OXYGEN ANESTHESIA 215 Fig. 103. — A simple wooden stand for three cylinders, suitable for hospital use. In order to produce complete anaesthetic effects, N2O must be delivered in a concentration of about 90 per cent. (The limits being 7.5 to 9,5 per cent.) If the additional 216 ANESTHESIA 10 per cent, be replaced by air the patient will suffer from oxygen starvation (only 1/5 of air being oxygen). If, however, the additional 10 per cent, be supj^lied by pure oxygen no such asphyxial result will follow. This condi- tion holds in practice and explains the great difference seen in NoO anaesthesia with air, and with oxygen. The difficulty then which confronts us in gas oxygen ansesthe- sia is the necessity of giving N2O of sufficient concentra- tion to produce anesthesia, and at the same time supply adequate oxygenation. The permissible variations take place within narrow limits. The aneesthesia is induced quickly and recovery takes place with astonishing rapidity. The exceedingly evanescent effects of the anaesthetic make it by far the most difficult to administer. The anaes- thetist must not only be constantly alert to the ordinary signs of aucesthesia, but he must have learned to distinguish shades of lightness and depth, which are of little con- sequence in anaesthesia by other agents, i.e., ether, chloro- form, etc. In the administration of gas oxj^gen the personal equation is without doubt the most important element. Ana?sthesia by nitrous oxide and oxygen is character- ized by muscular rigidity of varying intensity. This rigidity is sometimes present in a complete and otherwise entirely satisfactory anaesthesia. Some patients become very easily relaxed, others re- main rigid no matter how much the anaesthetic is pushed. In this connection one should always remember that relaxa- tion will never occur in the presence of cyanosis. If the desired result cannot be obtained without the presence of asphyxia then ether should be employed. NITROUS OXIDE OXYGEN ANAESTHESIA 217 When nitrous oxide and oxygen is the anaesthetic em- ployed the a(hninistrator must have the co-operation of the surgeon. The surgeon must unbend and tlie ana'sthe- tist must rise to the occasion. Gas oxygen anaesthesia given by the sub- junior for the chief is very likely to be a failure. With gas oxygen anasthesia, more than with any other agent, we wish to go on record as insisting that the patient he the criterion of the mixture delivered. An anaesthetist, who will not give additional oxygen because his apparatus indicates a certain theoretical percentage, even though the patient be dying of asphyxia, certainly has no business to use this method. The author has seen a patient posi- tively gray, crying out for oxygen by every possible sign, ignored by the anesthetist, who was sure that all was safe because his apparatus showed such and such a percentage mixture in process of delivery. If preconceived and pre- arranged mixtures do not fit the needs of the patient, these must be thrown to the winds and suitable percentages employed. The administration of gas and oxygen is gradually beginning to find its place. It has thrown off many of its early excrescences, such as positive pressure, heated vapors, and the like. Numberless apparatus of beautiful design and workmanship have died of complexity. Unskilful enthusiasts have fortunately lost interest, and are no longer forcing the method where it is counterindicated. Unfortunately, however, their blunders live on in the minds of the surgeons whom they chanced to assist. These ex- periences naturally give rise to prejudice against a method which is invaluable in its place. The administration of gas oxygen anasthesia is intimately bound up with the present 218 ANESTHESIA day theories regarding the physiology of CO2 gas. Since this consideration is deserving of more space than can be devoted in this section, the reader is referred to the chapter on " Carbon Dioxide and Rebreathing," page 296. As the symptoms and signs of gas oxygen anesthe- sia change with great rapidity, we must make use of an apparatus which will be sufficiently elastic to meet these changes of state as they appear. We must be able to produce N2O effects or oxygen effects without delay. This result may be obtained by introducing both the gas and the oxygen proximal to the rebreathing bag, not at the bottom or distal end of the bag as is the usual custom. This principle may be applied to any apparatus. Fig. 72 shows its application in the apparatus used by the author. If this method be employed, should the patient show signs of 'coming out,' he can be given pure nitrous oxide at once. It is not necessary to wait for the contents of the rebreathing bag to discharge itself before the effects of the N2O are felt. The same condition applies to the use of oxygen, immediate effects being secured upon turning on the gas. The preliminary use of morphine and atropine is abso- lutely necessary for smooth gas oxygen anaesthesia. The Signs of Nitrous Oxide Oxygen Anesthesia Color. — The most important sign which we have in gas oxygen anaesthesia is the color. As with ether, duski- ness is more liable to occur in the full-blooded, muscular individual. With ether, however, duskiness or cyanosis is usually directly dependent upon obstruction to the res- piration, while with gas oxygen the condition frequently NITROUS OXIDE OXYGEN ANESTHESIA 219 depends upon the mixture of the gases offered to the patient. As lias been pointed out under general considera- tions, complete antesthesia and a normal color are obtained only when oxygen is employed. Those who are unfamiliar with gas oxygen anaesthesia, but who have had some ex- perience with N2O alone are very likely to purposely avoid a pink color fearing that the patient will " come out." A good color is especially desirable where the best relaxation is required. By pushing the X^O to a degree of asphyxia, we not only do not overcome the rigidity but we superimpose the rigidity which accompanies imperfect oxygenation. For the above reasons gas oxygen anaesthesia per se cannot be satisfactorily administered in the dark, i.e., for nose and throat and for cystoscopic examinations. To employ this method under these conditions is to court fail- ure and to risk the life of the patient. The difficulty of properly judging the color in negroes excludes them from this method unless special indications are present. The color of the patient is the only reliable index of the amount of oxygen which should be delivered. Any apparatus which does not accept the color of the jjatient as the criterion for the increase or the diminution of the oxygen supply is pernicious. Where such apparatus is employed as will deliver definite mixtures of N-O and oxygen there must be some provision made for the imme- diate and copious admission of oxygen, should such treat- ment be found necessary. The margin of safety in gas oxygen anaesthesia is narrow, much more narrow than with ether and we cannot force our methods as we may occasionallv do with the latter. 220 ANESTHESIA Respiration. — Next to the color sign the respiration is the most important symptom of gas oxygen anaesthesia. During the early part of induction the respirations are very likely to be more rapid and deeper than normal. In some athletic patients this may amount to a hypercapnia, which will seriously disturb our induction. If the color is held under good control by sufficient oxygen, however, the breathing soon becomes less rapid and more shallow. A soft snore is one of the first signs of good ancesthesia. If this continues, and the respirations remain regular and somewhat deeper than normal, the preparation of the field of operation may be begun. A patient whose respirations are shallow and slow is not anaesthetized. Air has prob- ably leaked in under the face piece and manipulations begun at this time will result in trouble. One has to " feel out " each patient and determine the approximate amount of oxygen which is required. The reaction of the respira- tion to vigorous " scrubbing up " is valuable. If the rhythm is not affected the incision may safely be made. During the mainte7icmce of the anaesthetic the rhythm and the depth of the respirations, in conjunction with the color, form our chief guide as to the condition of the patient. The most imj^ortant factor in the control of the respiration is the extent to which rebreathing is permitted. The stimulating effect of the CO2 thus obtained is more active than where ether is the anaesthetic (see page 303). Relaxation. — With gas oxygen anaesthesia there is no true relaxation (see page 57). We expect and usually find more or less rigidity. The muscle tone is prone to persist. The impossibility of obtaining true mus- cular relaxation when gas oxygen is the anfesthetic is being borne in upon us by repeated failures where these gases NITROUS OXIDE OXYGEN ANESTHESIA 221 used alone are employed for abdominal work. The proper understanding of this rigidity by the surgeon and the amesthetist will produce far more satisfactory results. The surgeon nmst realize the conditions imder which he is obliged to work. The anaesthetist must realize the effects which he can produce, know when he has reached the limit and not persist in attempting the impossible at the expense of the patient and the surgeon. If absolute relaxation is not essential, however, for the work in hand, gas oxygen anaesthesia is tlie ideal anaesthetic. When induction has been completely brought about the lid reflex will be sluggish. Slight muscular move- ments of the limbs occasionally occur but as a rule the patient is absolutely quiet. Masseteric relaxation is never complete where the gases are employed without ether. The Pulse. — A slow pulse, fifty or less, under gas oxygen anesthesia is a danger sign. Rebreathing should be diminished and the general condition of the patient care- fully watched. The Eye Signs. — When anaesthesia is fully induced the globes are fixed, looking forward, downward or upward. (This sign is a guarantee that consciousness is lost.) During the stage of maintenance the light reflex is active; the pupils are contracted; the conjunctivo palpe- bral reflex is active; the corneal reflex is always snappy. The Point of View of the Surgeon, Anaesthetist and Patient in Regard to Gas Oxygen Anaesthesia The inconvenience of the surgeon adapting himself to an anaesthesia which does not yield complete muscular relaxation is certainly a serious objection. A man who has 222 ANESTHESIA been accustomed for years to the freedom of manipulation which ether affords when properly administered often finds it not only difficult but im^^ractical to work with this anesthetic. His attitude will be largely governed by his estimation of the value of gas oxygen in the recovery and convalescence of the patient. The Ax.esthetist. — Gas oxygen anaesthesia is by far the most difficult of all anaesthetics to administer. From the aspect of mere labor the method is unpopular for those who simply give " dope;" but for the man wno can catch the spirit of the work, for the man who is interested in the Art of Anccsthesia the method is fascinating. The recovery in a case of gas oxygen ansesthesia properly administered is a triumph in itself. The Patient. — From the point of view of the patient the method is the most satisfactory yet devised. After- symptoms are conspicuous by their absence. The patient is scarcely ever sick although retching before consciousness returns is frequently seen. The disadvantage of a rapid return of consciousness is so far outbalanced by the bene- fits as to be of little consequence. To see a patient pass in two minutes from a stage of deep anaesthesia, in which he has been maintained for an hour or more, to complete consciousness is the marvel of present-day anaesthesia. And by consciousness w^e mean complete orientation ; a con- sciousness which is capable of calmly surveying immediate past experiences and which fully understands existing conditions. CHAPTER IX NITROUS OXIDE OXYGEN ETHER ANAESTHESIA Owing to the objectionable muscular tone and rigidit}^ which exist when gas oxygen is given per se, even though preceded by morphine and atropine, etlier has been added to a greater or less degree. The addition of small amounts of ether greatly in- creases the efficiency of the control. Owing to the deep and rapid respirations wliich obtain in gas oxygen anaes- thesia it is quite easy to quickly introduce ether into the circulation. For the same reason ether once introduced and then stopped may be rapidly expelled by rebreathing gas and oxygen. When ether is used in sufficient quantity at the proper time, we believe that the resulting anaesthesia is the best all-round method thus far devised. Where relaxation is necessary for the surgeon, we believe that ether should be freely used. The author's method of choice in all adults where the operation does not involve the respiratory tract is as follows : A preliminary hypodermic of morphine 1/6 and atro- pine 1/150 is given half an hour before the time set for operation. Anasthesia is induced with gas alone or with gas oxygen. If the operation be intra-abdominal, a com- plete ether anaesthesia by the closed method is then ob- tained. The best relaxation is thus secured for explora- tion. If intestinal work is now to be done (the visceral peritoneum being insensitive) the ether is stopped and gas oxygen is used. If the gall-bladder be manipulated and 223 224 ANESTHESIA reflex rigidity ensue, ether may again be resorted to. At the beginning of the stage of recovery (see page 74), or when the peritoneum is closed, the ether is completely shut off and gas oxygen alone is used with very little rebreath- ing. By the time the operation is concluded (15-20 min- utes) so much of the ether has been thrown off that there is scarcely any ether on the patient's breath. The return of consciousness is somewhat more delayed than with gas oxygen per se. The after-symptoms are conspicuous by their absence; persistent nausea and vomiting being very uncommon. (This method has frequently been employed by W. B. Gatch and others.) Such a type of anaesthesia is ideal for the surgeon, more satisfactory for the anfesthetist and from the point of view of the patient approaches the ideal obtained by the use of gas oxygen alone. Where ether is freely used it is not so essential to pre- cede the administration by morphine and atropine. The effects are generally better when this treatment is followed, however, as the pain of the wound is minimized after the recovery of the patient, who often falls into a light sleep shortly after returning to bed. By the employment of this method we believe that we obtain the best all-round results: rapid induction, com- plete relaxation, ready control, minimum after-effects, all with the greatest pathological safety to the patient. The Administration of Gas Oxygen Ether Anesthesia Two methods of administration are recognized : 1. The method of intermittent flow with rebreathing. 2. The method of constant flow (a) with rebreathing; (h) without rebreathing. NITROLS OXIDE OXYGEN ETHER ANAESTHESIA 225 The Administration of Gas Oxygen Ether Anaes- thesia BY THE Method of Intermittent Feow with Rebreathing This method is the simpler of the two, consumes about half the amount of gases but is thought by some to give a somewhat more uneven level of maintenance. This method is the one introduced by W. Gatch, of Johns Hopkins Hospital, Baltimore. It requires the closest attention to detail as does, in fact, any method of gas oxygen amesthesia. The author has enjoyed such success with this method that he is reluctant to replace it by others. For apparatus used see Fig. 72. The administration is conducted as follows : The use of a preliminary hypodermic of morphine gr. 1/4 and atropine gr. 1/150, where not distinctly contraindi- cated, administered half an hour before anesthesia, is absolutelv essential to the success of nitrous oxide oxysfen anaesthesia. Hyoscine gr. 1/100 and morphine gr. 1/4 one hour before anaesthesia are an ideal medication in large muscular people. The disadvantages of hyoscine are largely coun- teracted by the emjjloyment of rebreathing. It is difficult to overestimate the value of suggestion. A few words of sympathetic reassurance will do much towards improving the anaesthesia. Experience only will give familiarity with the apj^ara- tus and the best results. If the nitrous oxide and oxygen cannot be made to work in a particular case, ether and oxygen may be given by the closed method. Before starting the anaesthesia, take a piece of brass wire gauze 2 inches by 1.5 inches of a size known as 100 to the inch. Make a roll of this and place it under the ether 15 226 ANESTHESIA cup. Assemble the apparatus and by a little twist open the dome top. This cuts out the gas and ether chamber. Fill the bag slowly, by little spurts, with nitrous oxide. (Rapid filling causes frozen valves, cold gas and noise.) See that the needle valve is closed. Fill the ether cup. Place an ether can cork, with a string tied to it, on its side between the right front molars. Apply face piece, being particularly careful of the coaptation over the bridge of the nose and under cheek. Turn the head to the right side and instruct the patient to breathe naturally through the mouth. He is now getting only air. Push down air shut-off, and fasten by twist. The patient is now re- breathing nitrous oxide. Open the expiratory valve and the patient will begin to empty the bag. Allow the bag to empty about two-thirds, release the expiratory valve and slowly run in more nitrous oxide and a little oxygen. The amount of oxygen can only be learned by experience. (Freedom from cj^anosis with a light pink color.) The breathing will become deep and full. Presently a snoring will be heard. This is a sign of sufficient amesthesia to start scrubbing up. In shallow breathers this may be delayed for some time. If the snore is absent after four or five minutes, cautiously drop in a little ether. If the respirations continue un- changed, there are good evidences that the patient is well ansesthetized. The conjunctivo-corneal reflexes are so ac- tive that in the early stages particularly they are of little assistance. It is always well to test out the patient's reaction to ether, as later, particularly in abdominal operations, ether becomes an absolute necessity for the relaxation of the abdominal muscles. NITROUS OXIDE OXYGEN ETHER AN.ESTHESL\ 227 The reaction of the respiration and any sHght move- ment during the scrubbing up will give one a good idea of the depth of the anaesthesia. Just before the incision is made, particularly in abdominal cases, increase the per- centage of nitrous oxide by half emptying the bag and refilling with pure nitrous oxide. At the same time have the patient under ether control. That is, have him where he will accept ether without spasm. If the res2)iration is not affected by the incision, if there is no slight movement of the extremities, and the surgeon does not complain of abdominal rigidity, stop the ether and carry the patient along on a faint pink color. The respiration must be kept free. The use of the ether can cork now becomes apparent. In the case of obstruction, the teeth are sufficiently separated to admit of the easy introduction of the mouth gag in the upper or left side of the mouth. The throat tube may then be inserted without difficulty. This will be found of greatest assistance where indicated. Should necessity arise, particularly in the early stages for considerable ether, one need not be alarmed, for this ether can be disposed of by stopj^ing its administra- tion early, using only gas and oxygen, and frequently emptying the bag. During the course of an even an "SB > ^<5 Z K "Joli! 3 3 O (C 1- v> »- 1— Hi O 2 = Z 3 2 DO v> < UJ O UJ e^ "II v> Ul u) lO n -Is o -1 o u 3^ ujO Ul z o a O S o r o o z o <3 OS 5oz tE(-± O a- z z < 5 (T O z o b- Z OO Ul X z 22 < > X t i2 _i < -1 < »- IE o o o O o UJ (£ < Q. O < < !j a -> W r a 0. v> Ul UJ z < "^ o q: o 1- s _l < Ul ^^ ,^ 2. 1- < lO si -1 < 1- a. < 155 9!^ t- u o o o u. O oo. o CO z < Z < —J UJ to §s -•s a. CO O^' ^^ -^"^ < Q. < U. if) bJ Ul uJ UJ J -J -^•^1 < _1 < ■D O bJ Ul Ul y < < ^l:;2 UJ X 1- (- to a a. o a. S o Q: ^ UJ UJ < 5 o o ^ t < z < OZ < u u o o 111 z 11 .'cr r 1 pi -J < z « < => j; O UJ i i z — v> Z >S SS J? >? >? J5 s? o? 5? d ID UJ u> ^ o w lO 10 00 = 2 £ O CM 9< X u> * o O £p o 0) a> (X) CO 00 00 m Q. 1^ ja 1-5 L o 8 a cl O < c tj) < X t O rn* -ri Ih n w u NITROUS OXIDE OXYGEN ETHER ANESTHESIA 235 The intermittent flow is exemplified by the Gatch ap- paratus. In the appended chart sliowing tlie detailed administration of one hundred cases this apparatus was I Fia. 109. — Connell nitrous oxide, oxygen, ether flow control. A, nitrous oxide instanta- neous gas-flow gauge (piston type) ; B, oxygen gauge (piston type) ; C, parachute gauge, com- bined gases; D, ether tank; E, ether dropper; F, gas-control cocks; G, outlet. (Courtesy Dr. K. Connell, Appleton Co., Johnson's Surgery.) employed. The scope of the method, the time of admin- istration, and the amount of gas and O used are here clearly- shown. 236 ANESTHESIA eS -MS ■Jli .cS S"*<3^G^O'*000'000 t« K.-; 03 c is t« J^_c r^^ .... .... -^ ^ ^ .^I^S -§:: oQQQQoQQQQo *" J. ^ ■ H 3^n1^S 3C 0--0 -M.. ~ .— .-.< n c Co b£ .M "" """ t- +^ ^ Jri ^ rtos-ccoj fc^u Oi ;3 »: c« • 0.1 P «:? _^- ^ o U -=^"2 S ^'^ ^ S ^ ?5 S ^-^ ■ ■ • ^ ■ o g^.SZ x:5V5 ^'P'^^ --S 5 Pi, "^ -^^ ^, ^ ^ '^ 5 lid "^^^t^ h"" >^ ^ l^ a; 5 §1^ 5J^ w OJ S'^C .2'k-O o K ^ CO .-I f-l &< (5* O^ CO ^ r-^ CO >^;W fc-SO) tf^Si ja ^ g--.2GO*:j ^ ^r a?=^ 3 3 00 .s-^ "c^toJioJoJ-^^l^'^lZ '?"^ ^00000000 "-fo •s;;csS=3Sii*-Si-- a;^ coo 1; 'Y h^ 2 W ^ ^ "^U o _c gjOr-i^ocococoto'O'^ci ^liiL^QajIg'^ bfl^ ^o^co<^.^co©«cocoo^ o «©• NITROUS OXIDE OXYGEN ETHER ANESTHESIA 237 ©-— 11— iCOCO^i— iCiCO ■CiCS'flClCiCiCtCi-t o c^ ■1— <1-H ,—(,—(,—1^- .^ r— ^- -^ 0» • • -OOOOOOl^OXXGCOCO ■00G0'*-*^rf«'!j0l^O'0O-O»0C0'S*OOOO»0"^OOOOO ooo oooooo o ooooo 1— iCJi-H i-Hl— ll-Hl— ll— I.— I I— I ,--1— If-I,— li-H f-H 1-Hl— o*cDXc<5t-»ocoooo5»o»oi-'5 0or>i:ocoot-c22«;*oS (^^,-1,— iTfxc50^o*(«Tf«ioco»>xoOp-;o^c2;*»2^trggS^2lII ,_i,_i,_i,_i,_i,^r-ii— i(3^O^G^(5^O^O o 1— 1»»0*'^'-<0*'— I 0<-^0»^i— iCC't<'^'** ©»'f<«0'^i— li^r-t .— I o ,-»-'5O»0'5^OOOO»0O»«»-'5»OC:»-'5X00OOO»OOX^»O»Ci«5»OO I-H ^ f— 0< g;z;:z;uuuuu;2;^;z;;z;;z;;z;u:z;uuou;2;;z;;z;u^:z;u;z;;z;;z;. i c«ooo*c«o»o<:i©^©*o*coG*G<;coc^o^o*c^o»cooooo*coo»-'5'^CilOoo ©»c<5'^»o<:oi>xc50i— io^c^'fto»i>xc;Oi— lOJco-^iocoi^xciO NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 239 OOOOOOOOOOOOOOOO I— lOOOOO -OOOOOi-i 0*0* O* 1— (Tf— i-<#Q^»0'#«C»0'-«5»OCOO'*0«OOJO*OJXOOXO •CO-t'00'fOGO •(S'-^O'^'f'O »CiCOO^»O©<»O-^C0'*t>TjXO»r5«00000>0 -OiOOOOtO -lOOOOOO O^O^ i-Hi— II— II— lO^ pHi— (Q^rHisi I— ii-^ u;z;:2;:z;u;z;S;z;Sz:^;z;;2;;z;:z;;z;;z;;z;;z;:z;:z;;z;:z;S:z;;zi;2;;z;;z;:z; OCCQoGOCOCCCGCCiCGCCQc/2CCGCCc/:ChQC i-iC0C0CCC0O'~'0'^0'^0'^0'~''~'0000'~'''^ ca^o3 dgc^^^ ^<^oao3 o8 og ^ da o3<^ oa=8 I— i05»0000»0i— lG0»0TJ G0'*'#0^C0I— lO^O^COOJiO©*!— I ir5»J0©*C0»*^Tj>>O<»G*i>G0'* I— iTft F-i<3COC50i— i©<00tJ<»OCOI>00C:O^l>t^J>l>t>OCCOXOOOCCXXCCXOOCiO:C;CiOiC50i01Ci050 240 ANESTHESIA SUMMARY OF CHART. Youngest 3, oldest 70; 76 per cent, females. Morphine and atropine *in 63 per cent. Total time of administration 103 hours. Nitrous oxide used, 3470 gals. ; O used 768 gals. Operation. Results. 1 Joint examination Failure. 2 Joint examination. Complete success. 3 Laparotomy Failure. 4 Hernia Failure. 5 Suturing lacerated lip Satisfactory. 6 Appendectomy Failure. 7 Incision, T.B. abscess of thigh Success. 8 Secondary appendectomy Complete success. 9 Hysterectomy Failure. 10 Femoral hernia Failure. 11 Cauterization of cancerous cervix Complete success. 12 Appendectomy Satisfactory. 13 Appendectomy Success. 14 Sebaceous cyst of neck Satisfactory. 15 Glands of neck " Satisfactory. 16 Left nephropexy, salpingo ovariectomy. . . Success. 17 Appendectomy Satisfactory. 18 Needle in hand Satisfactory. 19 Foreign body in ear Satisfactory. 20 Pus appendix Complete success. 21 Fracture of humerus Failure. 22 Glands of neck Success. 23 Int. obstruction, pyo salpinx. ....... Complete success. 24 Hysterectomy Satisfactory. 25 Trephine of fractured skull Satisfactory. 26 Needle in thumb Satisfactory. 27 Exploratory laparotomy Satisfactory. 28 Fracture of tibia, set Complete success. 29 Curettage, trachelorrhaphy laparotomy. . . Complete success. 30 Hysterectomy Complete success. 31 Curettage, trachelorrhaphy, perineum appen- dectomy and ant. suspension Complete success. 32 Removal of cyst of broad ligament Complete success. 33 Removal of axillary glands Complete success. 34 Needle in foot Complete success. 35 High forceps. . . . ; Complete success. NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 241 Operation. Results. 36 Modified Gilliam operation Complete success. 37 Laparotomy Complete success. 38 Appendicitis Failure. 39 Appendectomy, double salpingo ovariectomy and curettage Complete success. 40 Curettage . Complete success. 41 Curettage Satisfactory. 42 Injured joint Complete success. 43 Exploratory laparotomy Success. 44 Cellulitis of the face Satisfactory. 45 Cholecystostomy Complete success. 46 Glands of the neck Satisfactory. 47 Salpingo ovariectomy, appendectomy. . . . Satisfactory. 48 Curettage Satisfactory. 49 Posterior colpotomy Satisfactory. 50 Dressing. . Complete success. 51 Lacerated perineum Complete success, 52 Resection of stump Complete success. 53 Inguinal hernia Complete success. 54 Curettage and trachelorrhaphy Complete success. 55 Perineum and ant. suspension Success. 56 Pus appendix Satisfactory. 57 Pus appendix Satisfactory. 58 Inguinal hernia Complete success. 59 Appendectomy Failure. 60 Hernia Success, 61 Curettage Complete success, 62 Hernia Satisfactory, 63 Removal of ovarian cyst Complete success. 64 Ventral suspension Satisfactory. 65 Appendectomy Satisfactory. 66 Secondary cholecystostomy Success. 67 Irreducible umbilical hernia Complete success. 68 Rectal fissure. Complete success. 69 Tonsils and adenoids Satisfactory. 70 Appendectomy Satisfactory 71 Laparotomy Failure. 72 Hysterectomy. • •• • Complete success. 73 Pyo salpinx and appendicitis Complete success. 74 Curettage. Complete success. 75 Hemorrhoids Success. 76 Pus appendix Complete success. 77 Curettage and exploratory laparotomy . . . Died. 16 242 ANAESTHESIA Operation. Results. 78 Laparotomy Complete success. 79 Curettage Satisfactory. 80 Curettage Satisfactory. 81 Intestinal obstruction Success. 82 Glands of neck Complete success. 83 Tonsils and adenoids Complete success. 84 Secondary for mastoid Complete success. 85 Radical op. for hydrocele Complete success. 86 Sebaceous cyst of forehead Complete success. 87 Appendectomy Failure. 88 Curettage Success. 89 Wiring fractured humerus Complete success. 90 Cauterization of the vulva, condyloma. . . Satisfactory. 91 Hysterectomy, vaginal and abdominal. . . Complete success. 92 Amputation of the breast Complete success. 93 Laparotomy Success. 94 Urethral dilatation Failure. 95 Opening sinus in arm Complete success. 96 Posterior colpotomy and abdominal section. Complete success. 97 Intestinal obstruction Complete success. 98 Appendectomy Success. 99 Appendectomy Success. 100 Exploratory laparotomy Success.* In a paper read before the Westchester County Medical Society, January 16, 1912, and published in the New York State Journal of Medicine for April, a series of one hundred cases of nitrous oxide oxygen anaesthesia were reported. Case No. 77 is reported to have died. Space did not permit of a detailed report of this case, but as deaths on the table while using nitrous oxide oxygen as an anaesthetic are of importance and interest at the present time, this report perhaps deserves more than a passing notice. It is an open question as to whether or not this death occurred as the result of the use of nitrous oxide oxygen ether as an anaesthetic. The reader may judge for himself from the following facts: Patient, a large, fleshy colored woman, aged 25. She had been bleeding almost continuously for a period of four or five months. Two years ago her right tube and ovary were removed. Before the operation a tentative diagno- sis of uterine fibroid was made. The enlargement upon the body of the uterus which gave rise to this diagnosis proved later to be occasioned by adhesions about the proximal end of the tube, which had been tied oif by a heavy silk ligature. No fibroid of the uterus or appendages could be found. The patient was reported to have had an attack of syncope shortly before the operation. About twenty minutes before being anaesthetized she received * Reprinted from New York State Medical Journal. NITROUS OXIDE OXYGEN ETHER ANESTHESIA 243 ^4 gr. morphine and 1/150 gr. atropine hypodermically.' When she entered the operating room she was in a very nervous frame of mind. The examina- tion of her heart had been negative. The apex beat, however, was heaving and forceful. Anaesthesia was induced at 4 p.m. The patient went under quietly. As there was evidence of shallowness in her anaesthetic state ether was given to the extent of about one dram. Shortly after this the respirations were obstructed by masseteric spasm. The cervix was dilated and the uterus curetted. The respirations were then irregular and obstructed. The operator made the remark that the blood looked dark (the black skin made it difficult to properly judge the normal color). The ether and gas were stopped and a large proportion of oxygen was given. The patient was replaced in the dorsal position and the breathing immediately improved. When the abdominal incision was made the tissues looked extremely anaemic. Moderate muscular relaxation was present. The pulse was of good quality but variable, rapidity about 1^0. The corneal reflex was active and the pupils were contracted. During the course of the operation (which occupied 1.17 from the induction to the cessation of the respiration), the breathing was irregular, slowing to from three to four a minute and then increasing in rapidity. While the abdominal work was being done it was thought that this condition was due to pulling upon the viscera, there being an absence of signs of deep anaesthesia. Toward the end of the operation the cheeks and forehead became cold, as though the patient was suffering from shock. This condition was not war- ranted by the nature of the operation or the loss of blood. The mask was removed several times from the face and the patient rapidly came out. When the mask was replaced a large proportion of oxygen was given. Several times the corneal reflex was lost, to reappear again almost immediately. The breath- ing improved as the operation was concluded. When the patient was raised from the Trendelenburg it improved markedly. At this time the operator said : " She is pretty rigid." As the patient had been behaving badly no ether was given her, but oxygen instead, in the hope that the rigidity was of an asphyxial nature. While the old scar in the skin was lieing cut out the patient showed the effects of peripheral stimulation by breathing more deeply and more rapidly. The corneal reflex was active and the pupils were con- tracted. Suddenly irregular breathing, simulating that which had frequently occurred during the operation, again made its appearance. The patient made a low crowing sound as though about to come out. This was followed by slow, deep respirations. The respirations ceased. As this had occurred several times before, it was not in itself particularly disturbing. The pulse could no longer be felt, however, the pupils dilated suddenly and the corneal reflex completely disappeared. In the presence of these signs artificial respiration was immediately begun, accompanied by everj' possible form of stimulation. The attempted resuscitation was entirely unsuccessful. The following facts were noted: The slow pulse of asphyxial rebreathing did not occur. Patient was in a light anaesthetic state when she died. 244 ANAESTHESIA She showed evidence of shock some twenty minutes before. The color was difficult to make out, but seemed satisfactory. There was masseteric spasm with ether. This did not appear to seriously hamper the respirations, but it showed a tendency to persist even when air and oxygen was given in abundance. The rigidity appeared to be due to shallow anaesthesia, not to asphyxia. Death is thought to have been due to cardiac failure, the remote cause being previous protracted hemorrhages, the immediate cause being the strain thrown upon the vasomotor system by respiratory obstruction incident to a badly accepted anaesthetic. ANESTHESIA BY ANOCI ASSOCIATION OR THE COM- BINED USE OF LOCAL ANESTHESIA AND GAS OXYGEN ETHER ANESTHESIA A visitor at a clinic where complete anoci association is used cannot fail to catch the remarkable spirit of co- operation which pervades the operating j)ersonnel. All things are made to bend to the welfare of the patient. Suggestive therapeutics so valuable as a preliminary treat- ment to the angesthetic are here employed to the fullest extent. The harmonious blending of suggestion and prelim- inary medication before the induction of the anaesthetic; gentleness in voice and touch combined with an absolutely essential and skilful local anaesthesia of the skin during the stage of induction ; the continued use of complete nerve blocking and care in the manipulation of the tissues during the stage of maintenance, work together for a stage of recovery which is ideal. It is the remarkable ensemble which produces the result seen with so much pleasure. There is nothing very unusual about the administra- tion of the gas oxygen per se. It is but complementary to more important elements. Briefly such an administra- tion may be described as a skilful and complete local anaesthesia^ well fortified by preliminary medication, upon NITROUS OXIDE OXYGEN ETHER ANESTHESIA 245 which is superimposed gas oocygen amesthesia, the essen- tial jnirposc of which is to destroy consciousness. Place the gas oxygen anaesthesia first, making the local anaesthesia and j^reliniinary medication of secondary im- portance and the result is certain failure. The nitrous oxide and oxygen (we can scarcely say the antesthetic) is often administered hy nurses esjDccially trained to this particular type of work. Since the anes- thesia does not proceed to relaxation and consequent res- piratory obstruction by the falling back of the tongue, little difficulty is experienced in the anjesthetization. The chief requirement being to control the color. This is easily accomplished by simple and convenient valves in the machine used. An hour before o^ieration the patient receives mor- jDhine grs. li and scopolamine grs. 1/200. If he or she be an epileptic the dose of morphine is increased to ^ grs., the amount of scopolamine remaining unchanged. Cases of exophthalmic goitre are aucesthetized in their beds and carefully transported to the operating room. All other cases are ana?sthetized on the operating table in the operating room. Before ana?sthesia is commenced the an- aesthetist speaks a few words to the patient in order to quell any anxiet}' which may be present. Most of the cases, however, are well under the influence of their pre- liminary medication by this time. Nitrous oxide is then made to flow through the face piece and down over the face of the patient before the mask is actually applied. Cotton is placed over the bridge of the nose, and on the cheeks corresponding to the point of contact of the mask when applied. A little cotton is also placed about the respiratory valve to protect the anaesthetist from the ex- 246 ANAESTHESIA pirations of the patient. An ordinary hand towel is placed under the nape of the neck, the ends lying free. The time of induction varies from ten to fifteen minutes. The period of excitement is seldom seen. Before consciousness is lost no restraint is applied, but four attendants, an assis- tant anesthetist, an orderly and two nurses stand by until anaesthesia is well under way. When consciousness is lost the arms are fastened to the table by wristlets and a strap is thrown over the knees. These restraining measures are most valuable in case of lightness during maintenance. The free ends of the towel lying under the neck are now brought forward together over the face piece and clamped in such a way as to include the latter and hold it firmly against the patient. Cotton is stuffed into the space between the face and the towel. By this arrangement both hands of the anaesthetist are free. (While such a fixation of the face piece would be unwise with ordinary ether anaesthesia, because of the pharyngeal relaxation obtaining, in this very light form of maintenance, the re- tained tonicity of the pharyngeal structures prevents the obstruction which would otherwise occur.) If the opera- tion is to be on the neck, a covering, half sheet, half gauze, is fastened to the patient's chin, the gauze portion being thrown over the head of the anaesthetist. Such a cover- ing is welcomed by the anaesthetist since it permits of much needed ventilation. The respiration being tranquil and the color good, the skin to be incised is carefully and completely infiltrated with a solution of novocaine 1/4.00. This infiltration, or nerve blocking is conscientiously done with every tissue en- countered, particular care being exercised to inject the peritoneum and the pedicels of the pelvic organs, gall- NITROUS OXIDE OXYGEN ETHER ANESTHESIA 247 bladder, etc. A failure to completely block the field of operation shows itself in changes in the patient's respira- tion, moaning, or slight movements, followed by rigidity. Retractors are seldom employed and the utmost gentleness is exercised in handling the tissues. The administration of the gas and oxygen is of second- ary importance ; we find that the chief guide to be followed is the color. The patient is the index as to the inixture which he receives: he is not forced to accept a theoretical mixture. The nitrous oxide and oxygen are usuallj' made to flow continuously, partial rebreathing only being per- mitted. The limitation of the rebreathing causes the res- pirations to be much more shallow than when rebreathing is freely employed. When a constant flow is used N2O is delivered at a rate of about one hundred gallons an hour, the oxygen varying from five to twenty-five an hour. The anaesthetist is constantly attended and assisted by a pupil nurse who is well instructed as to her duties. There being no confusion in the status of the anaes- thetist, as is frequently the case when the junior interne occupies this position, the aneesthesia proceeds without an- noying instructions from the senior house officers. The surgeon, appreciating the fact that the anjesthesia is pri- marily a local and secondarily a general anaesthesia, inter- prets undesirable rigidity as due to incomplete nerve block rather than to the faulty administration of the gas and oxy- gen. In cases of exophthalmic goitre the administration of the gas and oxygen is continued until the patient has been returned to bed and is propjDcd up with pillows. Abun- dant assistance is furnished for the transportation. (As many as five persons assist in the transportation of goitre cases from the place of operation to the room.) 248 ANAESTHESIA The addition of ether in the early periods of induction simplifies the administration to a considerable degree. Ether in small quantities is not infrequently used in this -fashion. Since it is seldom employed during recovery, however, it is soon rinsed out by the pure gas oxygen anaes- thesia which follows and no ether effects are apparent. The free use of ether would comjDlicate rather than assist the anaesthesia, for undesirable relaxation of the tongue and pliaryngeal structures would follow, possibly requiring the removal of the face piece for relief. The recovery from the anaesthesia is rapid and com- plete. INIost patients retch once or twice before conscious- ness returns. » B. LOCAL ANAESTHESIA Local ana?sthesia is that type of anaesthesia which in- volves only the jjeripheral nervous system. It may be brought about by: ( a ) Freezing. (h) Pressure on the nerve trunks or by pressure pro- ducing ischccmia of the part. (c) By regional intravenous injections of novocaine. (d) By tlie injection of novocaine or some other drug into the skin or deeper tissues. CHAPTER X UNUSUAL METHODS L LOCAL ANAESTHESIA BY FREEZING The effect of extreme cold applied locally is to produce a loss of sensation of the part. This is a very common experience following exposure to very low temperatures. One's ears, for example, when first exposed to zero weather at first tingle, then become painful. As the effect of the cold increases, the pain disaj^pears and the sensation is lost. The parts are then more or less anaesthetic. They can be rubbed or j)inched or cut without pain. As thawing is gradually accomplished, the pain returns with greatly increased severity. Even after complete recovery there may be occasional intervals of transient piun familiarly known as chilblains. Freezing may be artificially brought about by the use of the ethijl chloride spray. The rate of evaporation of this liquid is so rapid that the surface temperature is brought below the freezing point and becomes actually 249 ^250 ANAESTHESIA frozen. The freezing process appears to act as a termi- nal anassthetic and is complete in a few seconds. The best results are obtained by holding the nozzle of the sj^ray about ten inches from the skin and by blowing gently upon the surface to assist the evaporation. Freezing is indi- cated bj' the blanching of the part exposed to the action of the spray. AMien cut with a knife the tissues will be found to be hard and somewhat brittle. The degree of anaesthesia produced by this method is variable. It de- pends largely upon the degree to which the skin is frozen. As is the cape with the ordinary freezing, due to exposure, the recovery is painful, and if the freezing has been pro- tracted extensive sloughing is apt to follow. II. LOCAL ANESTHESIA BY PRESSURE Pressure on nerve trunks produces a loss of sensation in the tissue supplied by the compressed nerve. This con- dition often occurs accidently when pressure is allowed to act upon a suj^erficial nerve. Muculospiral paralysis, occurring when an anaesthetized patient's arm is allowed to hang over edge of the table (Fig. 23), produces this effect. Local anaesthesia may be brought about by pressure interfering with the circulation. Who has not awakened after a long sleep and been shocked to find a strange, cold, motionless hand in the bed beside him, and who will forget the sense of relief when this strange hand proves to be his own? Artificially these effects have been jiroduced by pres- sure on the nerves supplying parts to be operated upon. The practice is very ancient in its usage but the pain directly occasioned by the pressure is so annoying that the method is of little practical value. LOCAL ANESTHESIA 251 A certain degree of anaesthesia may be brought about artificially by the employment of an Esmarch bandage, (Fig. 110) . This consists of a long, rubber band some three inches wide and six feet long, which by being tightly wound about the limb beginning at the distal end produces a bloodless or ischtemic condition. One may profitably bear Fig. 110. — Esmarch bandage. in mind this fact when a general ana?sthetic is being given for an amputation of a limb, which has been previously rendered ischa?mic by the use of an Esmarch bandage. IIL LOCAL ANESTHESIA BY REGIONAL INTRA- VENOUS INJECTIONS OF NOVOCAINE This method is applicable to all operations upon the extremities. The most important factor in the technic is to produce a completely ischfemic condition of the limb. 252 ANESTHESIA Our object in this method is first to empty the veins by. the proper use of rubber bandages ; secondly to fill these emptied veins with a solution of 5 per cent, novocaine. By this procedure we bring not only the superficial but also the deep structures under the influence of the anees- thetizing solution. The cephalic or basilic vein in the arm, or the internal saphenous in the leg, should be marked out. With the limb raised an Esmarch bandage is tightly applied from the fingers or toes to a point above the site of the operation. Where this bandage ends, a second, broad Esmarch is applied. This is known as the proximal bandage (being nearest the body of patient). The first bandage, that which was used to produce ischemia, is slowly unwound; the unwinding naturally beginning where it ceased, i.e., next to the proximal band- age and not at the fingers or toes. If some part, say the middle third of the forearm, is to be operated upon, the bandage is unwound to just below this point. A second, broad bandage, the distal bandage, being here applied. The space included between the two bandages (which should be not less than 10 cm. (2^ inches) or more than 25 cm. (10 inches) ) is now cut off from the venous circula- tion above and below (Fig. 111). If the part to be operated upon be the finger or toe, the proximal bandage is applied at the middle of the fore- arm and no distal bandage is employed (Fig. 112). The vein, which we previously marked out, is now located and, under local anaesthesia produced by novocaine, it is dissected out as near to the proximal bandage as possi- ble. A ligature is then tied here. Using this ligature as a retractor, the vein is lifted from its bed and a small slit LOCAL ANiESTHESIA 253 made in its lumen by a pair of scissors. A syringe capable of holding GO c.c, capped with an ordinary intravenous cannula, is introduced into the vein and tied into place. Forty to .>0 c.c, of the solution is then slowly injected. Anaesthesia of the segment of the arm between the proxi- mal and the distal ligature is rapid and complete. The 5m mf?KIN6 OF NOW ISCHEMIC VEIN rr^'^IoV^ Figs. Ill and 112. — Bandage for regional intravenous. solution may be quite easily forced against the obstruction offered by the valves of the veins The veins at first swol- len by the solution, soon collapse indicating the penetra- tion of the fluid into the deep tissues. The anaesthesia of the part continues until the proximal bandage is removed. The reestablishment of the circulation is rapidly followed by a return of the sensation. 254 ANESTHESIA The method may prove serviceable for emergency am- putations in situations where a general ansesthetic is for one or more reasons contraindicated. The method appears more thorough and reliable than that offered by surface ansesthesia, for the solution injected into the vein reaches and anaesthetizes the deepest struc- tures at a single injection. This method has been used more than .500 times by different operators who report success in about 90 per cent, of their cases. CHAPTER XI USUAL METHODS LOCAL ANAESTHESIA BY INJECTIONS OF NOVOCAINS AND OTHER DRUGS INTO THE SKIN AND DEEPER TISSUES Local anaesthesia is usually brought about by: (a) surface application; (b) by infiltration into the tissues (terminal anesthesia) ; (c) by injections into or around nerve trunks (conductive or regional anaesthesia). 1. The surface method is that usually used for work which involves mucous membranes, i.e., nose and throat and genito-urinary operations. Solutions of cocaine .5 to 1 per cent, with adrenalin are the strengths ordinarily employed. 2. Infiltration ancesthesia {or terminal ancesthesia) aims to anaesthetize the terminal end organs by bringing them into contact with the solution. This is the method usually employed for superficial operations. 3. Conductive ancesthesia or regional ancesthesia aims to destroy or directly block the conductivity of the nerves which supply the part to be operated upon. This is per- formed by endoneurial injections (direct injections into the nerves) or perineuria! injections (bathing the nerve trunks with the solution) . This method is often combined with terminal ancesthesia. IXFILTRATIO'N OR TERMINAL AN/ESTHESIA Water injected under the skin causes a transient anaes- thesia. This is painful of accomplishment and unsatis- factory. Solutions of the same specific gravity as the 255 256 ANiESTHESIA tissues will not produce anaesthesia per se; such solutions, normal saline for example, must contain an anaesthetic drug to be effective. If the injected fluid which we em- ploy is rapidly absorbed its effect will be unsatisfactory. To limit this rapid absorption adrenalin is habitually added to the solution. The solution should also be capa- ble of repeated sterilization. The Solutions Used. — Cocaine. — Strength com- monly used 1 per cent, to 1/10 of 1 per cent. The solu- tion may be made up from standard tablets or from Bodines' tubes. The latter are composed of cocaine and sodium chloride in such proportion that when mixed with sterile water a solution ready for immediate use is formed. Novocaine. — Strength commonly used .5 per cent. It is the most widety used of all drugs for local anaesthesia and ten times safer than cocaine. Its solution may be repeatedly boiled. It may be conveniently had in tablet form marketed as novocaine suprarenin tablets. These tablets are supposed to be sterile but it is safer to boil the solution in which they are dissolved. Qiiinine and Urea. — Strength commonl}^ used .5 to 1 per cent. This solution is said to be absolutely non- toxic. The anaesthetic effects which it produces are more lasting than those of cocaine or novocaine. Because of this prolonged effect it is often used with a view of control- ling post-operative pain. Some have claimed that it helps to control hemorrhage after operation by causing a deposit of fibrin over the exposed vessels; others have contended that its employment interfered with the healing of the tissues. If one wishes a prolonged action it is well to wait fifteen to twenty minutes before incising the tissues inj ected. USUAL METHODS 257 The Syringe. — The ordinary hypodermic syringe of ull glass or metal is entirely satisfactory (Fig. 113). Syringes should be boiled in plain water and after using dried carefully and a drop of castor oil run in. This pre- vents the sticking of the piston in the all glass syringe and the drying out of the packing in the metal syringe. Fig. 113. — Case contaiaing outfit for intraspinal and local anaesthesia. (Steel, International Clinics.') Needles. — Steel needles are satisfactory. A variety of sizes should be on hand. These should range from the ordinary short hypodermic needles to those 10 cm. in length. Nickel and platinum needles may be had, and by their longer life are worth the difference in the purchase price. The Preliminary Treatment of the Patient who IS to Receipt?: the Infiltration (Terminal) or the Conductive (Regional) Anesthesia. — An hour before 17 258 ANESTHESIA operation a dose of morphine gr. Yg and scopolamine gr. 1/200 should be given. The operation, no matter how trivial, should be invaria- bly done with the patient lying down. The patient should have a cup of soup or milk. It is best not to operate on an empty stomach. It will be readily understood that the proper employ- ment of suggestion is most important. This applies not only to the immediate treatment of the individual but especially to the provision of a proper environment, quiet, courtesy and the banishment of disagreeable sights. Every effort should be made to distract the attention of the patient. If one is acquainted with his habits and sphere of life, conversation proceeds more freely. A sip of water or vichy may be permitted now and then. Some operators allow their patient to smoke. Operations done under local anaesthesia need not be hastened. Great care and gentleness should be exercised in the use of retractors and in sponging. The Administration of Infiltratiox (Terminal) Anesthesia. — A syringe is filled with the desired solu- tion, and the needle is introduced just beneath the skin and nearly parallel to it. The solution is forced into the tissue and should form a small, blanched elevation or weal. The needle is withdrawn and reintroduced into the hoi'der of this weal, 7iot into a portion of the uninjected skin. If one follows the practice of reintroducing the needle each time into the weal, the only pain which the patient will experience will be the initial introduction. It is sug- gested that novocaine solutions be dyed so that the limit of its penetration into the tissue may be easily seen. When the desired area has been injected, the skin will be found USU.\L METHODS 259 to be anaesthetized. Great care should he exercised to see that the incision does not extend beyond the amesthetized area. The anaesthesia tluis produced will last for two or three hours. Tissues, whose sensitiveness we know to be acute, should be carefully injected before they are touched with the knife or sponged (Fig. 114). LEAST SENSITIVE fat fencfons fasc/cx — v/\sc/ P^r'itane bone. MOST SENSITIVE par/IG 301 show the effect of the reduction and the increase of carbon dioxide in the blood of the conscious subject. Where observations may be made upon unconscious subjects, the effects are more striking as there is no inter- ference by the will. The anjEsthetized subject offers exceptional opportuni- ties to study the phenomena incidental to an increase or diminution of carbon dioxide in the respired air. Such observations may be made not only by the use of the closed method in which case the results are positive, but by the open method as well, in which case the effects of the absence of the necessary CO2 become apparent. Where the Open Method is Used. — One of the most common results of the use of the open method is acapnia. If acapnia becomes marked, as is sometimes the case, dur- ing an induction where there is much excitement, the patient shouting, crying out or breathing rapidly and deeply, a definite period of apnoea may develop. The beginner, who sees his patient stop breathing shortly after a period of excitement in ether anaesthesia, becomes much upset and immediately starts artificial respiration. If this artificial respiration is ineffectual, as is frequently the case, it may not interfere with the normal return of the respira- tion. If, however, it be effective, it may, by increasing the acapnia, materially delay the return of the normal respira- tion. If the patient stops breathing following a period of dyspnoea from excitement, in the presence of normal color, pulse and eye symptoms showing a light anaesthesia, ether being the anaesthetic and morphine having been omitted, it is best to leave the patient alone. He will soon breathe of his own accord even though he be apnoeic for a full 302 ANAESTHESIA minute or more. This phenomenon is very common in children. Acapnia during the stage of maintenance, the open method being used, is of quite common occurrence. Apncea at this time however, is more serious, and is often associated with cold perspiration and circulatory depression. Acapnia during the stage of recovery is not seen as frequently as during induction and maintenance. When the open drop method is used the prevailing ten- dency is apnoea from acapnia. When the semi-open drop method is employed this tendency is reduced in proportion to the amount of rebreathing permitted. Where the Closed Method is Used. — Where a strictly closed method is employed, such as is described on page 132, one does not see the apnoea of induction which is com- mon to the open method, because there is no acapnia. On the contrary there is very likely to be dyspnoea from hj^per- capnia. Where a gas induction is employed, the gas pe?^ se induces a dyspnoea which is superimposed upon that due to hypercapnia. The result is rapid, deep breathing. Rapid, deep breathing at this particular time enables one to quickly saturate the patient's blood with ether, in other words induction is quickly accomplished. Morphine by depressing the respiration usually diminishes this dyspnoea and frequently retards the induction. During the stage of maintenance, however, the dys- pnoea caused by the hypercapnia nmst be controlled. Un- less this is done the excessive breathing is likely to prove a menace to satisfactory abdominal manipulations. If one understands the cause of the excessive breathing, which the patient experiences, he can easily adjust this difficulty. The control of the respirations by reducing or increasing CARBON DIOXIDE AND REBREATHIXG 303 the CO2 by means of rebreathing is exceedingly interest- ing. A patient who is breathing deeply and rapidly may, in the face of an upper abdominal operation, be immedi- ately quieted by entirely emptying the rebreathing bag and filling it with oxygen and air; abdominal rigidity and excessive movement of the diaphragm being at the same time reduced to the minimum by the free use of ether. During the stage of recovery, after the removal of the face piece and rebreathing bag, the respirations will usu- ally drop in rate and depth from the absence of the arti- ficial CO2 stimulation. Shallow breathing may follow for a few moments. This effect however, is not due to acapnia but from a reaction to over stimulation by the CO2. When the closed method is used, the prevailing ten- dency is dyspnoea from hypercapnia. If this is properly controlled it is beneficial in as much as it allows of more rapid introduction and withdrawal of the ether employed. In other words the condition of the patient is more pliable than where there is a tendency to apnoea from acapnia. The tendency to dyspnoea where the closed method is used increases the safety of preliminary medication, the chief characteristic of which is depression. Where Nitrous Oxide and Oxygen is the Ancesthetic. — AVliere oxygen is added to nitrous oxide in a quantity suffi- cient to control asphyxia, the dyspnoea ordinarily seen when nitrous oxide is used alone is not apj^arent. The effect of rebreathing in such cases is much the same as with the closed method of ether administration. Gas oxy- gen being a less depressing tj^pe of anaesthesia, however, the effects of rebreathing are even more marked. Where a constant flow of gas oxygen is employed 304 ANAESTHESIA without rebreathing (see page 233), we may expect to see the apnoea characteristic of the open drop method. Gas oxygen anesthesia with excessive rebreathing becomes annoying by virtue of the very deep respirations experi- enced. The addition of a prehminary dose of morphine reduces the sensitiveness of the respiratory centre to stimu- lation (CO2) and, with this type of preliminary medication, more extensive rebreathing may be permitted. The type of case with which we have to deal determines very largely the extent to which rebreathing may be per- mitted. A full-blooded individual, who has not received preliminary medication, will tolerate little rebreathing throughout ana?sthesia. On the other hand an an£emic individual, who has been permitted to rebreathe an atmos- 2)here of oxj^gen and ether, will appear to be stimulated rather than depressed by the experience. The author is convinced that the sicker, the more septic a patient is, the more are closed methods of administration indicated. In such cases rebreathing with oxygen almost always appears to improve the general condition. The normal, vigorous individual at the end of an anaesthetic by the closed method is almost always in a better general condition than if he had suffered anaesthesia by the open method. The color is invariably better, the pulse shows less depression and the body heat is retained. The beneficial effect of rebreath- ing may be accounted for by the fact that the presence of carbon dioxide in the blood corpuscles increases the free- dom with which the hcemoglobin parts with its oxygen, thus pro7noting oxygenation of the vital tissues. The beneficial effect of rebreathing carbon dioxide and oxygen when depression of the respiratory centre exists, has become so generally accepted that makers of oxygen CARBON DIOXroE AND REBREATHING 305 gas supply a mixture of oxygen and carbon dioxide (5 per cent. ) for therapeutic purposes. We regret that space permits of but a brief intro- duction into this most fascinating subject and refer the interested reader to the appended bibliography. In conclusion we would emphasize the fact that re- breathing is not dangerous to health as was formerly sup- posed, that in ordinary respiration we rebreath six-sevenths of our vital respiratory capacity, and that rebreathing into a bag is a matter of relative importance rather than of absolute difference. We would recall to mind the fact that carbon dioxide is distributed uniformly throughout the mass of blood and that carbon dioxide and oxygen exist in the blood independently of one another. We would impress the fact that carbon dioxide is not the cause of cyanosis, that it is only occasionally incidental to it, and that the color of the blood is entirely due to the amount of oxygen present. We would recall to mind the fact that a reduction of CO2 gives rise to a condition known as acapnia, which may, if extreme, lead to apnoea. On the other hand an increase of COo known as hypercapnia fre- quently results in more or less dyspnoea. The open method is characterized by acapnia and apnoea; the closed method by hypercapnia and dyspnoea. Hypercapnia may be more easily controlled than acapnia, is of distinct advan- tage in the control of the anesthesia, and may often prove beneficial to the patient. We would draw attention to the fact that rebreathing is of distinct advantage where there exists respiratory depression from the use of morphine, and we feel that the closed method is the method of choice whenever the patient is critically ill. The advantage of the closed method, and the rebreathing which it implies, may 20 i -J. ) "= -^ i — ,— s -r 3 ~T — :s U ^ \ !. \ 1 1 ■ ' 1 \ \ -i -» ) \ j T ^ » « "» o £ » : > 3 < y h Pi- o 1 3 C I St - X -^ c ^-^ ^ S r ^4 be explained by the fact that oxyhemoglobin dissociates more readih' in the presence of abun- dant carbon dioxide. Experiment in Respira- tion. — In the course of some ex- periments in respiration bringing out the theories advanced by Yandell Henderson, an under- graduate student in the Univer- sity of California JNIedical School held his breath ten minutes. This was accomplished by having the student lie on a table, with a pneumographic belt at- tached about his thorax and com- municating with a kymograph. Slow, deep inspirations were taken for two minutes: this eliminated a good portion of the carbon dioxide from the blood. A breath of oxygen was then taken and the time marker started. The tracing is here shown. A slight relaxation of the respiratory muscles is indi- cated at two minutes. No desire to breathe was experienced until six minutes had elapsed. The belt having been placed over the diaphragm, the pulse rhythm was shown throughout. From this CARBON DIOXIDE AND REBREATHING 307 time on, the conscious effort to hold the breath increased until an involuntary twitching of the abdominal muscles was quite apparent ; but no respiration took place. All the time the pulse was full and strong, the color good. No oxygen want a^^peared. At the expiration of ten minutes some vertigo occurred, and the impulse to breathe having become imperative, the first inspiration was taken — ten minutes and ten seconds having elapsed. Xo great hyperpnoea, no weakness, no heart changes appeared. The student rose from the table and went about his class work (Fig. 124) . CHAPTER XVII EMERGENCY ANiESTHESIA For the best results in the administration of an anaes- thetic suitable apparatus should be employed. Occasion- ally, however, we find ourselves without our familiar tools and are obliged to improvise others. If the signs of anaesthesia are thoroughly understood, we may often successful!}^ surmount the difficulty confronting us. Improvised apparatus, however, instead of offering the easiest means of administration, usually, by virtue of their inefficiency, make the administration more difficult. In the long run the efficient method is the easiest and the most dependable. The hints which follow are intended to apply only when the exigencies of the occasion preclude the use of the proper apparatus. Their successful application will depend to a very large degree upon the mechanical clever- ness of the administrator. We will imagine ourselves stranded in an out-of-the- way place without our usual paraphernalia. When no Anaesthetic Agents are at Hand. — When the usual anaesthetic agents are not at hand, the employment of morphine and scopolamine hypodermi- cally, in repeated doses will be found very valuable. Hyo- scine and scopolamine being considered identical, we will use these terms interchangeably. The dose of these drugs for an adult is morphine gr. 34' hyoscine gr. 1/100. At the end of an hour the dose may be repeated. The effect se- cured by two inj ections is often sufficient to enable one to 308 EMERGENCY ANESTHESIA 309 operate painlessly. Where after two doses the anaesthesia is not yet satisfactory, the dose may be repeated. The reflex pain whicli results from the surgical manipulation appears to neutralize to a large degree the depressing effects of these drugs. Atropine, hypodermically, in doses of 1/100 gr. and rebreathing applied by means of towels, will help to control respiratory depression. The method is one of necessity not of choice. Freezing the part (page 249), pressure on nerve trunks (page 250), and pressure producing ischaemia of the part (page 251), may be employed in an emergency. Where no\ ocaine and cocaine are to be had, the results will be limited only by the skill of the operator. Cocaine is more plentiful than novocaine and it is only because of this reason that its use is suggested. It is about seven times more dangerous and should never be used in a maxinmm dosage of more than one grain. Where Ether, Chloroform and Ethyl Chloride ARE Available. — Any unopened container with ether, chloroform or ethyl chloride marked for ancestliesia may be considered safe. Ether which has been exposed to the air for some time and which may be suspected of being unsafe should be tested as follows, before being administered. 1. Upon evaporation it should leave no residue. 2. Allowed to evaporate spontaneously there should be no perceptible, foreign odor present when the last traces have disappeared. 3. There should be no change in color on the addition of KOH (color indicating the presence of an aldehyde). 4. Ether should not affect blue litmus paper even after twenty-four hours' contact. ( Indicating absence of acetic acid.) 310 ANAESTHESIA 5. There should not be an undue amount of water or alcohol present. (If 20 c.c. of ether and 20 c.c. of water, previously saturated with ether, be shaken together the ether layer on separation should not measure less than 19.5 c.c). Chloroforin which has been exposed to air and light should be tested as follows, before being administered: 1. It should possess a specific gravity of not more than 1.495 and not less than 1.490. (Lower specific gravity indicates an excess of alcohol.) 2. It should be perfectly transparent and colorless. 3. It should be absolutely neutral to test paper. 4. It should possess an agreeable bland and non-irritat- ing odor. 5. When allowed to evaporate spontaneously it should leave no residue either of water or any substance possess- ing a strong smell. 6. When shaken with concentrated sulphuric acid no brownish coloration should result. It should form no pre- cipitate with a solution of silver nitrate. 7. It should not acquire a brown color when heated to the boiling point with caustic potash. Ethyl chloride is not likely to suffer from exposure to air because of its extremely low boiling point (its very great tendency to vaporize). It should be neutral in reaction and leave no residue when vaporized. The Administration of Ether by an Improvised Open Method. — An ordinary, small, hand towel is folded around the nose and mouth, leaving the latter free. Cheese- cloth in eight or ten thicknesses, or one thickness of a bath towel, is then laid over the tojD of this. The drop bottle is immediately improvised by puncturing the centre of the ether can cap with a single pin hole. The rate of flow of EMERGENCY ANESTHESIA 311 the ether from this hole is regulated by the tip of the index finger. If the head and the face are covered during the course of an operation on the face, ether may be sprayed directly on that part of the sterile sheet over the mouth without disturbing the asepsis of the field of operation. A patient suffering an operation under local ana3sthesia recently was thus anaesthetized by the author. When ether is given in this improvised fashion, we nmst bear in mind the possibility and danger of li(juid ether being allowed to find its way into the mouth of the patient. The Administration of Ether by an Improvised Semi-Open Method. — The use of the towel cone is quite common where the need of a semi-open or closed method is felt but undeveloped. We cannot speak of this method as a closed one because the space devoted to rebreathing is so small as to necessitate the entrance of atmospheric air about the edges of the mask. Such a mask as we are about to describe acts quite efficiently as an open and semi-open method. The material necessary for its construction consists of a towel, a newspaper, gauze, cheesecloth or a few strips of soft, woolen rags. The mask is made as follows: Five sheets of ordinary newspaper are opened wide and laid on a table or on the floor. These five sheets are then folded lengthwise twice. There is now a strip of newspaper twenty sheets thick about six inches wide, and as long as the newspaper is when opened wide. This strip is now laid on an ordinary hand towel (1 yd. x 5^ yd.) lengthwise, so that the paper comes in contact with the long, free edge of the towel. If the strip of paper projects beyond the towel, it may be 312 ANAESTHESIA torn off. The paper may be an inch or two short without effecting the result. A towel three feet long and one and one-half feet wide will now be covered by paper on one- third of its area. The paper and towel are now grasped at one end and a fold of about seven inches is made (Fig. 125 a and h) . The towel is outside and the paper inside. The folding is continued until the entire length of the towel and the paper is included. The result is a tube of paper and towel (Fig. 125 c) . The hand is now thrust through the tube thus formed (Fig. 125 d), and grasps the free end of the towel pulling it through, so as to form a lining for the tube (Fig. 125 e) . The roll (Fig. 125 /) is now held between the knees and the free end is drawn snug. The surplus is then turned down over the top of the roll like a collar (Fig. 125 g). It will fit snugly, needs no sewing and a single pin will serve to hold down the one loose corner. Sewed cones are a nuisance to make, and because of this, one is sometimes tempted to use them twice — a most unpardonable practice. A strip of gauze is now poked gently into the top of the cone, care being taken that it does not come in contact with the face. (When in doubt the cone should be in- spected by turning it upside down.) Ether may now be dropped or sprayed upon the gauze or cheesecloth. When it is desirable to increase the concentration of the vapor, the flat of the hand may be laid partly or wholly over the vent. At frequent intervals the gauze should be taken out and shaken, as it soon becomes saturated with moist- ure from the exj^irations. This inhaler is simple, relia- ble and as efficient as any semi-open method known to us. Incidentally we would mention the towel cone sealed 5"^ 3 to •*JCL O B 314 ANESTHESIA at one end, only ti condemn it as asphyxial and inefficient. The Use of Chloroform ix Emergency Anaesthe- sia. — The use of chloroform in emergency anaesthesia should be strictly limited to the C. E. mixture (see page 194). It should never be employed where there is a limi- tation of air. It should not be used where there is a gas light or other flame. Unless a proper mask is available, the face should be anointed with vaseline to prevent burn- ing of the skin. The use of chloroform in emergency anaesthesia should be limited to the period of induction. The physiology of chloroform anaesthesia (page 185) should be understood, and the causes of death (page 195) should be thoughtfully anticipated. Small quantities of chloroform on a gauze sponge, held before the patient by means of a sterile sponge holder, are sometimes used for operations about the face. The Use of Ethyl Chloride in Emergency Anes- thesia. — The use of ethyl chloride as an emergency anaes- thetic is suggested chiefly as a substitute for nitrous oxide. We would emphasize the necessity of great care in its use and recall to the reader's mind the tendency of the patient to collapse, following its use. It has its place, neverthe- less, and if cautiously used, will be found quite serviceable. Intrapharyngeal Anaesthesia by Improvised Methods. — The patient is anaesthetized by the improvised towel cone. When anesthesia has been well induced, a catheter or small rectal tube is slipped into one of the nostrils. (If two catheters are available, having a " Y" tube connection, so much the better.) The end of the catheter is now fitted over the bottom of a glass funnel; the funnel is filled with gauze; ether or the C, E. mixture is then cautiously dropped upon this gauze. The vapor EMERGENCY ANAESTHESIA 315 thus formed is inspired by the patient. Great care must he taken to prevent liquid ether from finding its way into the catheter. This may be prevented })y holdin^>- the fun- nel on its side, so that liquid ether will run out. Fig. 126 shows the funnel packed with gauze. With this method we depend upon the amount of sue- I :•-■. ]-■'■. -lurin--' with tube for intrapharyngi\il aiuc-tli'-; tion through the tube brought about by the respirations of the patient. This being comparatively small, the method by ether alone is quite inefficient. When the C. E. mixture is used, better results may be expected. Intratracheal Ax.^:sthesia by Improvised Appara- tus. — Intratracheal aneesthesia may be satisfactorily ad- ministered by employing a technic similar to that described 316 ANAESTHESIA for the emergency intrapharyngeal method. When this method is employed, we introduce a tube directly into the trachea, attaching the distal end to a tube which connects it to a funnel as described above. This method is much Fig. 127. — Funnel with tube for intratracheal anaesthesia. (Courtesy American Journal of Surgery.) more efficient than the intrapharyngeal method, because a much larger volume of air passes through the tube. An apparatus similar to the one shown in Fig. 127 has been repeatedly used with much success. The danger of such a method in inexperienced hands is EMERGENCY ANAESTHESIA 317 much greater than that described on page 159, but its usefulness where indicated, in the absence of the usual apparatus, can hardly be denied. By such a method it is impossible to obtain positive intrapulmonary pressure. Accessories to Emergency Anesthesia. — A mouth wedge, necessary when masseteric spasm and cyanosis occur, may easily be im^Jrovised by whittling a piece of hard wood in the form shown in Fig. 13. A breathing tube, acting in the capacity of the Connell thtoat tube. Fig. 14, may readily be made from a five-inch piece of rectal tube or other stout tubing having a diameter of at least half an inch. A safety pin should always be fastened across the outer end. If, in the course of an abdominal operation, the j^ulse becomes small and rapid, indicating hemorrhage and the need of a saline injection, the quickest and most convenient wa}" of administering this is to pour hot saline directly into the abdominal cavity. While this is being done, an ordi- nary fountain syringe should be filled with w-arm saline, and a hypodermoclysis needle attached to the tubing lead- ing therefrom should be thrust deep into the loose tissue under one of the breasts. The height of the rubber bag determines the rate of the flow. It may be started at three feet above the patient and raised if the flow^ is not suffi- ciently rapid. Hypodermoclysis is an exceedingly satisfac- tory means of introducing saline solution into the general circulation. The effects are not so rapid and it may safely be started at an earlier time than can an intravenous injection. The greatest advantage, however, lies in the fact that it does not delay the course of the operation by requiring the attention of the surgeon or his assistant. All the necessary details may be cared for by the nurse, working" under the direction of the ana?sthetist. CHAPTER XVIII THE ANESTHETIST'S RECORDS Those who administer anaesthetics sooner or later find it essential to preserve a fairly comprehensive record of each case. This becomes necessary not alone from a scien- tific point of view, but also for self-protection. It is frequently inconvenient to gather personal data at the time of the operation. To avoid this embarrassment a record card and a self-addressed, stamped envelope may be NAME DATE OF OPERATIONS NO AGE SEX ADDRESS NAME AND ADDRESS OF NURSE OPERATIONS SURGEON ASSISTANTS UNCON8CI0USNCS8 AFTCR OPERATION /0'»'L-<-'^ PREVIOUSLY ANAESTHETIZED / ^1.0 CONOITION or EYCS ArTCP OPERATION Oli „CH»B or INDUCTION i^tC*/*- '/>U>Tt«A*& t TEETH / aMr OUMCsTs RIQIDITY JACwnCTioN UjiPtrxn vomitinq BWfoKi. 0\)tM I Hi C REFLEX iM PUPIL oL c c c (^ oL 160 170 160 160 140 130 120 110 100 90 SO TO 60 BEFORE mtSIHESIt ANAtSIHfSIA BEGUN 1ST MR. 20 40 60 2NO HR 20 40 60 3R0 HR. 20 40 60 coNsaousNBS RETURNED A.M. HJtrr A.M. P.M. < (A t^ sm !li< n tt. • a /■^o • /Oi'f /o.J/» TOTAL TIME OPERATION /. i"<3 ANAESTHESIA 2.<'0 ANAESTHESIA BEFORE OPERATION -/d Fig. 129. — Reverse of anaesthesia record card. System of Ancesthesia. — Open, closed, pharyngeal, in- tratracheal, intravenous, rectal, etc. M. (§ A. — Morphine and atropine. 320 ANESTHESIA Respiration. — Free, obstructed. C. Refleoc. — Sharp, dull, absent. Pupil. — Normal, contracted, dilated. Most records are squared off for five-minute pulse- readings. To save space twenty -minute divisions are here used. Five-minute readings may be shown by a dot one- fourth way across the space.* * Reprinted modiSed from Journal of the American Medical Association. CHAPTER XIX ASPIRATORS The use of aspirators particularly for nose and throat work, is of interest to the anaesthetist, as their employ- ment aids materially in controlling the freedom of the respiration. Four types of aspirators may be recognized : 1. Where the suction is produced by a foot pump. 2. Where the suction is produced by water power. 3. Where the suction is produced by electricity. 4. Where the suction is produced by steam power. The foot pump method is the most simple but the least efficient of the four methods. A foot pump sucker suita- ble for throat and abdominal work is shown in Fig. 130. Aspiration by water power is quite popular. The suc- tion which results is constant and quite efficient. When in use the apparatus is attached to any convenient water faucet. The amount of suction produced depends upon the head of water at command. If the faucet is located at the top of the building some difficulty may be experi- enced in securing sufficient water power to produce the desired result. The essential features of the apparatus are shown in Fig. 131. Aspiration by electricity is often used where ether vapor is being delivered for throat work. In this case the suction produced by the blower which provides air to form the ether vapor is employed. The disadvantage of this particular arrangement lies in the fact that the air used to vaporize the ether is taken (by suction) from the de- 21 321 322 ANAESTHESIA Fig. 130. — Foot aspii ^la lirni-- .It Hospital. ASPIRATORS 323 oxygenated and contaminated field of operation. The noise of the motor is often very annoying and a satisfac- A Fio. 131. — Water aspirator. tory electrical supply must be near at hand. It has the advantage, however, of being very convenient. An example of such an apparatus is shown in Fig. 132. 3^ ANAESTHESIA Aspiration by steam. This type of aspiration is not only of value in nose and throat work, but plays even a larger part in removing fluid from the abdomen and else- f^ G TIETMANN & CO. NCW YORK S^ Fig. 132. — Electrical aspirator. where. The utilizing of steam for suction purposes is brought about by the employment of what is known as an ejector. This ejector, a cross section of which is shown Fig. 133. — Ejector for steam aspirator. in Fig. 133, may be purchased at any steam fitting establishment. The steam in passing from A through F into G and finally into the discharge pipe F produces a partial vacuum ASPIRATORS 325 in the chamber enclosing F and G, which, being connected to the suction tubing marked " supply," performs the intended work. The steam supply pipe A may be one which is tapped at any convenient place in the sterilizing room or else- FiG. 134. — The steam pump aspirator complete with aspirating tongue depressor, Fordham Hospital. where. The discharge pipe E may be led into a pail of water or be discharged at some point in the basement or out of doors. Fig. 134 is a view of the entire apparatus in question — ejector, tubing, receiving bottle (for aspirated material) and aspirating tongue depressor. 326 ANiESTHESIA The bottle which receives the discharge should have a capacity of about 2000 c.c. The tubing between the ejec- tor and the bottle may be of pressure hose or, better still, flexible steel gas tubing, as shown in the illustration. This Fig. 135. — A, Aspirating tongue depressor; B, tongue depressor. tubing should be at least fourteen to eighteen feet long. If a greater length is required it is more satisfactory to replace part of this by permanent piping from the ejector. The distal end of this tube is soldered to a length of brass tube perforating the cork in the bottle. This cork must ASPIRATORS 327 be considerably larger than the mouth of the bottle, else it will be sucked in by the powerful negative pressure. The tubing from the bottle to the aspirating tongue depressor is of heavy non-collapsible rubber, capable of repeated sterilization. Whatever may be the source of the suction produced, foot power, water, electrical or steam, the actual removal of the fluid is accomplished by variously shaped, per- forated, metal tubes. A common type is shown accom- panying the electrical aspirator. A tongue depressor which aspirates, however, is the ideal. Fig. 135^ is the aspirator employed by the author. It is made to corre- spond as nearly as possible to the shape and size of a popu- lar tongue depressor, shown in Fig. 135B, and when in use it does away with the necessity of employing an additional instrument, as it acts in the capacity of an efficient tongue depressor and aspirator at the same time. CHAPTER XX THE POINT OF VIEW OF THE PATIENT Medicine for many of us is the centre about which the world revolves. We see life in its embryonic dawn. We follow it most closely in its morbidity through adoles- cence, maturity and decline, until at last the spontaneous metabolism is at an end. Lead on by experimental curi- osity into the nature of things, we do not leave man here but dissect him with scalpel and microscope to the limit of present day instruments. By electrical and chemical stimuli we effect a parody on life; we make dead muscle move again, and look therein for the secret of life. From within the circle drawn by medicine we limit our speculations as to the great truths. We build our theology out of coarse stuff and wonder why the edifice is so unsatis- factory. We ignore the more delicate tools of logic and philosophy, which are equally as truthful and more penetrating. The medical man has a tendency to relegate the intel- lectual life to the obscure environment of psychiatry. The intellectual life to him, broadly speaking, is but the reac- tion to environment and of comparatively small account at best. The distinction which he draws in his own mind between a man and a monkey is not very acute. While not always openly acknowledged, many present day medi- cal men serve the cult of materialism. With such a more or less well defined materialism they approach their patients. Their patients are the world. The average layman has little or none of the physi- 328 POINT OF VIEW OP PATIENT 329 cian's detailed knowledge and interest in histology and pathology. He has occupied his life in listening to the call of the " ego," that intangible, intellectual entity which is self. Such patients view medicine, and in viewing medi- cine, judge us from a point of view, which it would be well for many of us to appreciate. As a science cannot be broadly judged from its own plane but must needs be seen from without, so can we best serve our patients by viewing our profession from without. The wealthy, by their influence, social and financial, obtain through the very atmos^^here with which they sur- round themselves, a certain consideration, irrespective of our habitual personal mannerisms. The deference paid these by the materialistic man, by him who cannot under- stand the spiritual element, is a deference to the peculiar qualities which the former possess, their keen mentality, their natural refinement and their wealth, rather than to their deeper humanity. His sympathy finds its reward in inmiediate common interests. On this ground the materi- alist is fairly well remunerated, but what stimulus has he for a charity for which he can see no reward ( It is the poor who send up this cry; the poor in the great hospitals and dispensaries. Those from whom we feel that we tolerate much and who are ^perpetually in need of help. They cannot reward us by money, they cannot, and by nature often will not, reward us by sparkling wit or by dull thanks. If we would be compensated we must see an image of the Almighty in their presence. We must feel the unspoken thanks which illiteracy cannot utter. We nmst look beyond the colorless environment of the hospital ward and see the situation from their point of view. 330 ANAESTHESIA Let us pass from the narrow confines of their station in life and go with them to the great hospital with its subtle wonders, a universe in itself. Here the house sur- geon wields a monarch's sway. By his orders we fast or eat, we are allowed to go about or we are obliged to stay abed all the day. He controls the nurses, who have power enough, goodness knows, when he is absent. As for the visiting surgeon, he is a sort of a deity. He rules even the house surgeon. His will is law and his every remark is treasured up to be produced at intervals for the benefit of a coterie of friends. Imagine that celes- tial body, as he moves about in his orbit stopping before one of these people. Imagine the pain inflicted by a curt remark, by a rough manipulation or by a misapplied pun, forgotten in the saying perhaps by him, but treasured through the long, uneventful day by the patient; imagine the unsatisfied thirst for just a little information when the sudden declaration is made: " We will operate to-mor- row at three." To-morrow dawns at last, but it is a long wait before afternoon. During the wait one has nothing to eat and is nervous with apprehension. Three o'clock finally arrives but the minutes pass by in suspense until it is perhaps nearly four; then quite accidentally a nurse may think to inform the patient that the doctor called a few hours ago to say that he had decided to postpone the opera- tion until the following day. The operating staff had been informed of course, but no one had remembered to tell the patient. Then follows the sudden relapse when the tension is released. The suspense is only prolonged, however, for the next day is to come. But now the possi- bility of a second delay enters in and nothing is sure until POINT OF VIEW OF PATIENT 331 the stretcher is brought and the patient is conveyed to the operating room. The anaesthetist is unconcerned. From his point of view the patient entered into his presence from apparent obHvion and will leave him in real oblivion. Perhaps it is a little woman, who trembles now and then; whose teeth chatter and whose eyes persist in filling uj) in spite of her- self. If the anaesthetist would only see her point of view, he could not refuse to comfort her; but instead of this, in an impersonal, colorless voice he sharply remarks " Here, stoj) that nonsense. We can't have any of this fuss." If he only knew how impossible it was for the patient to control herself and how gladly she would stop " that non- sense," if she could. In an equally impersonal manner she is told that no one is going to hurt her, or, what is worse, the anaesthetist may calmly putter for an intermina- ble time in his preparations and when about to start is told to wait, as the case under operation is not far enough advanced to start the next one. Then follows another delay of perhaps half an hour in the close etherizing room with every minute threatening a climax. Finally the order is given to start the anesthetic. Speed is essential, hence concentrated ether, hence cough, suffocation, stran- gling and a sense of sinking into utter nothingness. An effort to free one's self, and one's hands are pinned do^vn on one's breast, which pressure adds to the distress. Long before consciousness is lost someone cries out " Soak it to her, soak it to her." These last words echoing and re- echoing do^vn the long vista leading out of consciousness. This is not intentional cruelty, it is the result of high pressure, of system gone mad and most of all of the lack of appreciation of the patient's point of view. 332 ANESTHESIA But the reduction of the ego to a greater or less amount of Xissel's granules does not elevate one's views, it but con- centrates them. The motive is analogous to that of pure conservation of energy in a machine. It does not attract all. It appeals mostly to the pathologist, to the histolo- gist or to the biologist and its consideration proceeds not from a warm sympathy but from good policy. There are j^ossibihties in men outside the limits of ions and their uncounted subdivisions. There are qualities inherent in that hidden power, which is born in the union of sperm and ovum, predominating and directing cell divi- sion, assigning each to its delicate community task. It is this intelligence which permits the organism to adopt itself to its peculiar circumstances with the marvelous aptitude which we know so well. It controls a system of repair and defense so complex that we can but theorize as to the mode of its action. As we direct our attention to the physiology and the organic chemistry of the cell, we lose sight of the larger, more amazing community life of the countless groujDS of differentiated cells, each working along independent lines for the common good. These groups, if not guided in their ensemble by a central authority, could never adajjt themselves to the vicissitudes of environment. One need not follow the isms of the faddists to be up to date. Truth is not a matter of time or place, it is unchangeable. The acknowledgment of the existence of the supernatural in the soul of man is not an evidence of reversion in tyjje. It is but the result of the acceptance and of the intelligent correlation of a host of facts which we see about us. Admitting the presence of a soul, and as the logical POINT OF VIEW OF PATIENT 333 sequence the attributes and adornments of the soul, may we not awaken and develop tlie loveliest of these, charity, seeing in man, however j^oor and illiterate, the seal of divinity. Courtesy is honored when found in such company. A man who can see the divine, has an incentive which is impossible in the case of the mere microscopist. He can understand that charity is its own reward and as a con- sequence he offers it whenever possible. We can therefore, in adopting- the patient's point of view, eliminate much pain and distress. The acceptance of such a course involves no expense. A moment of thoughtfulness is all that is required. A word, a smile or a sympathetic glance will do much to lighten anxiety and pain. iMorning operations when possible; avoidance of postponements ; a morphine j^recedence ; unfailing cour- tesy and consideration — all these may seem trifles, but in reality are marks of human kindness. In such a measure as a man spends his efforts in doing good to others, in just such measures will he find j^eace and contentment within himself. BIBLIOGRAPHY CARBON DIOXIDE AND REBREATHING Gatch, W. : Nitrous Oxide Oxygen Aiijesthesia by the Method of Rebreathing, Journal A. M. A., March 5, 1910, p. 77.5. The Use of Rebreathing in the Administration of Ancesthetics, Nov. 11, 1911, p. 1593. Rovsing: Abdominal Surgery, Clinical Lectures for Students and Physicians. Translation by Pilcher, Philadelphia, 191*4. Hendeeson- Yandell : 1. Am. Jour. Physiology, 1909, 24; 66. 2. Acapnia and Shock (seven papers). Am. Jour. Physiology, 1908-1913. 3. Respiratory Experiments on INIan. The Jour. A. M. A., April 11, 1914, p. 1133. 4. Tr. Am. Gynec. Soc, 1914. 5. Surg., Gynec. and Obstetrics, 1914, p. 386. 6. Shock After Laparotomy ; Its Prevention, Produc- tion and Relief. Am. J. Physiol., 1909, 21, 60. 7. Fatal Apnoea and the Shock Problem. Johns Hopkins Hospital Bulletin, Aug. 1910, 21, No. 233. Barceoft: Respiratory Function of the Blood. Cam- bridge, 1914. Bryant and Henderson: Closed Ether and a Color Sign. Jour. A. M. A., July 3, 191.5, p. 1. Levi Ettore: Studies on the Patho-Physiologic Action of CO2 and on the Therapeutic Applications in Sur- gery and Medicine of Mixture of (O) and CO2. Estr. d. rev. di. clin. med., 1910, 11, 30, 31. 335 336 ANAESTHESIA Hill and Flack: The Effect of Excess of Carbon Dioxide and a Want of Oxygen on the Respiration and the Circulation. Jour. Physiol., June 30, 1908. Crowder, T. R. : A Study of the Ventilation of Sleeping Cars. Arch. Int. Med., Jan. 15, 1911, 8o. Haldane and Smith: The Plwsiologic Effects of Air Vitiated by Respiration. J. Path, and Bact., 1892 and 1893, 1, 168, 318. Erclents Flugge: Report of Experiments at the Insti- tute of Hygiene at Breslau. Z. f. Hyg., 1905, 363, 388, 405, 433. Hill and Walker: The Relative Influence of the Heat and Chemical Impurity of Close Air. J. Physiol., Nov. 9, 1910. INDEX Abdominal distention, 29 Abnormal amplitude during maintenance, 88 Abnormal rate during maintenance, 8G Abnormal respiration due to Trendelenburg position, 89 Abnormal rhythm during maintenance, 87 Abnormalities of respiration in recovery, 89- 90 Acapnia, 299 Adenoids, obstruction from, 26 Alcohol chloroform ether mixture, 191—193 Amplitude of respiration, 86—88 Anaesthetist's records, 318-320 Anaesthesia by anoci association, 244—248 Anaesthesia, place of, 18 preliminary medication in, 277-284 signs of, 82 Anaesthetic and asthma, 35 and pneumonia, 35 for goitre cases, 35 history, 16 period, 4—6 Anoci association, 244-248 Apparatus, Bennett, 139 Connell, 153 Flagg, 133-138 Miller, 230 Artificial respiration, 90-97 Aspirating tongue depressor, 327 Aspirators, 321-327 Asthma with anaesthesia, 35 Atropine and morphine preliminary to ana'sthesia, 277-284 Bennett apparatus, 139 method, 138-140 Brachial paralysis, 41-42 Breathing tube, 33-34, 317 Bromides preliminary to anaesthesia, 277 Carbon dioxide and cyanosis, 298-299 and rebrea thing, 296-307 chemistry of, 297-298 effect of increasing amount in blood, 300-301 effect of reducing amount in blood, 299 in the blood, 297-298 origin of, 297-298 percentage to cause dyspnoea, 296 percentage to stimulate respiration, 296 Cardiac massage, 119 Cerebral hemorrhage, 88 Cheyne-Stokes respiration, 88-90 Chloroform, 185-200 administration of, 194 containers for, 194 delayed jjoisoning with, 186-192 testing quality of, 310 Chloroform anaesthesia, apparatus for, 194- 195 causes of death in, 195-197 general considerations of, 200 mortality in, 200 position for, 197-200 present status of, 190-192 signs of, 197-199 Chloroform ether anaesthesia, 193 Chloroform poisoning, pathology of, 186—192 Circulatory shock, 292 Close drop method, 132 as compared with open drop, 140 as compared with semi-open drop, 141 requirements for, 132 Coaxing the reflexing, 20 Cocaine solution for local anaesthesia, 256 Coccygeal operations, position for, 43 Combined general and local anaesthesia, 244- 248 Complete anaesthesia, curve of, 12 stages of, 11 Conductive anaesthesia, administration, 259 Constant maintenance, control of, 71 pressure of vapor delivered, 70 volume employed in, 70 Containers for nitrous oxide, 201-202 Control of vomiting, 79 Color signs, 97-102 with closed method, 99-101 with jaundice, 101 with negroes, 101 with open method, 99 Conjunctivo-palpebral reflex, 106 Corneal reflex, 106-107 Cyanosis and carbon dioxide, 298-299 Cyanosis, post-operative, 289 Degeneration of liver with chloroform, 186- 192 Deviated septum, obstruction from, 26 Diaphragmatic sign, 104 337 338 INDEX Diet, post-operative, 7,295 preliminary, 17 Diffusible solution, 262 Dilatation of sphincters, 28 Distention, abdominal, 29 Driving the reflexes, 20 Drop bottle, 123 Duties of Nurse after anaesthesia, 287 before anaesthesia, 285-287 during anaesthesia, 287 Emergency anaesthesia, 308—318 accessories to, 317 chloroform in, 314 ethyl chloride in, 31Jr Endoneural injection, 260 Erb's palsy, -11 Esmarch's bandage, anaesthesia with, 251 Estimating amount of nitrous oxide in cylinder, 202 Ether, absorption of, 66 administration of by oral insuflBation, 121 anaesthesia, zones of, 72 cone, 311-313 effect on viscera, 189, 190 frolics, 4 intravenous administration of, 174-180 per rectum, 169 preparation for rectal administration, 169 properties of, 120 rectal administration of, 172 saturation, 26 solution for intravenous administration, 311-313 tension in body, 69 testing quality of, 309 vapor tension of, 6-4 Ethyl chloride, lSl-184 administration of, 183, 184 apparatus for, 183 dangers of, 184 freezing with, 249, 250 properties of, 181 Ethyl chloride, anaesthesia, sequelae of, 183 Excitement in induction, 19 Eyelid signs, 103 Eye sign, 105 Facepiece for open drop method, 122 Flagg apparatus, 133-138 anaesthesia with, 135 features of, 134 induction with, 135 maintenance with, 136 recovery with, 138 vaporization in, 134 Flagg method, 135-138 First surgical anesthesia, 4 Freezing with ethyl chloride, 249, 250 Gall bladder position, 43 General anaesthesia, classes of, 1 1 definition of, 9 degrees of, 11 production of, 9 Glottis, oedema of, 26-34 Goitre cases with anaesthesia, 35 Gwathmey method of rectal anaesthesia, 171- 173 Hemorrhage, 291 cerebral, 88 Henry's law, 65 History of anaesthesia, 1-6 Hypercapnia, 299 Hypodermoclysis, technic of, 117 Hysteria, 292", 293 Induction, time of, 12 Improvised breathing cone, 311—313 Improvised breathing tube, 317 Incomplete anaesthesia, 13 curve of, 13 Induction, 15 Induction, periods of, 15 Infiltration anaesthesia, administration of, 258 Infusion, technic of, 114 Intra-abdominal administration of saline, 317 Intrapharyngeal insufflation, 149—158 administration, 153—157 apparatus for, 150—156 contra-indication, 158 difficulties of, 167 improvised, 314—315 indications for, 158 Intratracheal insufflation, 159-169 administration, 163-167 advantages of, 168 apparatus for, 161-163 difficulties of, 167 disadvantages of, 168 improvnsed, 315, 316 Intravenous anaesthesia, 174-180 administration of, 177-179 advantages of, 179 apparatus for, 176 disadvantages of, 179, 180 ether solution for, 175 post-operative treatment in, 179 Intubation, technic of, 164, 165 Jackson laryngoscope, 163 i Jaundice in anaesthesia, 101 INDEX 339 Kidnej' position, 43 Kuatzu inclhoil of resuscitation, 1181, 19 Laryngoscope, Jackson's, 163 I^ewis" pendulum swing, 95 Lid reflex, 103, 10.), 10(i Liquid method of oral insufflation, 122 Lithotomy position, 5M Liver, fatt\' degeneration with chloroform, 186-192 ' Ix)cal anaesthesia, 249-260 by freezing, 219 by pressure, 2.50—251 definition, 9 needles for, 257 preliminary treatment for, 257-258 production of, 9-10 solution of cocaine for, 256 novocaine for, 25() quinine and urea for, 256 syringe for, 257 unusual methods of, 249-254 usual methods of, 255-260 Maintenance, 59-67 constant, 60 control of, 61—63 curve of, 60-64 vapor tension necessary for, 67 variable, 60-61 Masseteric sign, 102 spasm, 290 Methods of ansesthesia, Bennett, 138-140 Flagg, 135-138 Gwathmev. 171-173 Miller, 230 Mixed anesthesia, 9, 10,261,273 definition of, 9 administration, 265-273 advantages of, 271 apparatus for, 263 disadvantages of, 273 general considerations of, 261-265 production of, 10 treatment of overdose, 268 Morphine and atropine preliminary to anaes- thesia, 277 contra-indicated, 284 indicated, 284 scopolamin preliminary to anaes- thesia. 277-281-284" Mortality in chloroform antrsthesia, 200 Mouth wedge, 33 Mucous, removal of, 34 Muscular signs, 102 Musculospiral paralysis, 41, 42 Neck operations, position for, 47 Needles for local an;esthesia, 257 Negative ventilation, 91 Nitrous oxide, administration, 207, 208 apparatus, 133-138 containers for, 201, 202 preparation of, 203-206 Nitrous oxide oxygen auicsthesia, 214-222 administration of, 218 characteristics of, 216 color in, 218 eye signs in, 221 physical signs in, 218-221 preliminarv medication in, 283 pulse in, 221 relaxation in, 220 zones of, 234 Nitrous oxide oxvgen ether anresthesia, 223- 248 administration, 224-235 administered bv constant flow, 230-233 intermittent flow, 225, 229 difficulties in, 227, 229 resume of 100 cases, 236- 244 Nondiflusible solution, 262 Normal respiration with ether and nitrous oxide, 84 with open metho