CHAPTER Il, (Part 1)

CHAPTER Il, ANESTHESIA. Anesthesia is necessary in most emergency operations, not only to obviate pain, but because it is often essential to a good operation, Unfortunately, on the other hand, it adds to the doctor's task and pre- sents some special difficulties. In certain grave conditions, a5 intestinal occlusion, strangulated hernia, or abdominal traumatism, it may be the actual cause of death, however carefully administered. Not only in emergency work, but in any case, general anesthesia should be cautiously induced and narrowly watched; and for this reason it is especially embarrassing to the doctor compelled to entrust it to the untrained in cases of urgency. Chloroform has the advantage that it requires no special apparatus for its administration; and the smaller bulk is an item of importance, especially in military practice; moreover, it is much more pleasant to the patient. Unfortunately, it is many times more dangerous than ether, even in the hands of the skilled. Tn licu of a special inhaler, such as Esmarch’s, fold a handkerchief, napkin, or compress several times to forma square. Begin by pouring on several drops and gently approaching it to the mouth and nose of the patient. The inhaler should be managed with the left hand, leaving the right hand free to raise the eye-lid, or feel the pulse, or handle the container, Do not hold it too close to begin with, but give the pationt plenty of air; in other words, give the chloroform well diluted Give the patient time to get accustomed to the odor, Advise him to breathe through the mouth and distract his attention as much as possi- ble; get his confidence, flatter him, and, in the meantime, study him and test him. ‘The few minutes spent in this way will soon be regained. Pour on five or six drops of chloroform at a time; and, as the respira- tion becomes deeper, hold the inhaler closer, giving the chloroform less u 12 ANESTHESIA, diluted with air. Replenish the supply every half minuto, sprinkling it on the ander side of the compress and quickly inverting it over the face. As the stage of excitement comes on, push it more. When the anesthesia is complete, reduce the dosage but increase the Irequency of renewal. ‘The drop method is ideal after the anesthesia has been attained. Small doses frequently applicd mean the smallest total amount, which must be the anesthetist's constant aim (Fig. 1). The good anesthetist is not the one who cin use the largest amount of chloroform without death, but the one who can hold the patient merely unconscious and relaxed with the smallest amount possilile, If the patiest coughs or shows signs of nausea, increase the dosage at once. Do not begin the preparation of the feld or any part of the operation tntil the anesthesia is complete. Keep the pulse, the pupil, the face, and the thorax under comstamt surveillance, for in this way alone may one determine the prognosis, good or bad, of the anesthesia The ancsthesia is usuully described as occurring in three stages! the first, stage of excitement; the second, loss of consciousness; the third, loss of reflexes or stage of surgical anesthesia. There is a fourth, stage of paralysis of the automatic centers, but this is a stage which the good anesthetist will never reach, ‘The excitement of the initial stage, in whieh the patient struggles or talks at rancom, ix followed by loss of consciousacss, but the redexes: Ss ETHER ANESTITESIA, . 3 are active, the pulse is full and bounding, the pupils respond to tight, the eye-lid resents the corneal touch, the skin is sensitive, the face is flushed, and the breathing deep and regular. Beware at this time of sudden blanching of the face, of dilated pupils, of weakened pulse,or disturbed breathing. If these symptoms arise, withdraw the anesthetic and prepare for artificial respiration. ‘The patient is not ready for the operation and yet he may die in this stage. Often pallor and dilated pupils precede vomiting, but when the pulse and respiration are good, the nausea if to be quieted by more chloroform, When the reflexes are finally abolished, the pulse should be full, though perhaps a little slowed, the respiration quiet and regular, the pupils slightly contracted, and the face moderately pale. Any marked deviation from this standard during the operation is a matter for concern. Weak heart action, uncertain respiration, dilated pupils, deep pallor or cyanosis, mean approaching paralysis of the automatic cen- ters governing the circulation and respiration, and the anesthetic must be withdrawn until the symptoms improve under measures employed to stimulate, Tn the case of the average adult, one and one-half to two ounces should be sufficient for the first hour and much less subsequently, Children and the debilitated require less. Ether has the dlisadvantages In emergency work that it is dangerous to use near a Hight or fire, and that its administration is «little more com~ plicated; but, beyond that, its anesthesia is never attended by sudden death in the early stages, as is that of chloroform. It is followed by less shock after abdominal operations or other prolonged intervention, Bronchial affections are its chief counterindications. An inhaler may be fashioned out of a newspaper rolled into a cone, cotton or gauze being fastened in its apex, on which the ether is poured. _ Begin with a drachm; let the patient get accustomed gradually to the ether, diluting it well with air by holding the inbaler an inch or so from the face and gradually approaching. In that way, the fecling of suffocation is avoided. As the patient approaches unconsciousness, hold the mask “ : ANESTHESIA. closely <0 as to shut out the air, and the stage of anesthesia will be ‘quickly reached without excitement, - =a If one proceeds timidly at this stage, the anesthesia will be hard to obtain and much more ether wil] be required, Once the reflexes are abolished, use small quantities, frequently applied. The “drop method" may be employed with ether as well as with chloroform, and reduces the danger to the minimum. The accident most to be feared is respiratory paralysis. ‘The signs indicating the favorable progress of ether anesthesia during the operation are: pulse full and regular; respiration deep and slightly snoring; face flushed; and pupils slightly dilated. Cyanosis is the signal for more oxygen. Any disturbance of the respiration demands immediate attention, For excessive mucous formation, Ford recom— mends spraying on the mask at intervals of five or six minutes, when necessary, an adrenalin solution, Three parts of water to one part adrenalin solution (1=1000) are used in an ordinary atomizer, Ford claims that it also acts as a circulatory stimulant. Occasionally patients will be found who do not take ether well, but who will take chloroform without the least untoward effect. TREATMENT OF THE ACCIDENTS OF ANESTHESIA. Certain measures are recommended as forestalling the dangers of anesthesia ; though they are, as a rule, more appropriate in the general surgery of hospitals. A preliminary gastric lavage will 5 eases. In fuct, this should be an invariable rule, when compelled to operate on patients who have eaten only a short time previously, A preliminary subcutancous injection of normal salt solution will sustain the patient in the cases of anemia and grave septic infection. Many surgeons precede a chloroform anesthesia by hypodermic injection of morphia or strychnis. Boldt (Med. Record, May 29) 1909) condemns as dangerous the practice of precedin, anesthesia by the morphia-scopolamine narcosis. He 1 however, for patients who are apprehensive and nervous a singhe e embarrassment in certain ARTIFICIAL RESPIRATION, 1s dose of morphia and atropia thirly minutes before the anesthesia is given. ‘This is desirable too in operations on regions in which the reflexes are more active, far there is scarcely a doubt that some of the circulatory disturbances under chloroform are reflected from the field of operation, This is true of the testicle, the spermatic card, the anus, and the peritoneum. None of these methods lessens the anesthetist’s responsibility and duty to watch every point, If the circulation grows weak, the pulse small, rapid, compressible, due to the effect of the anesthetic agent and not to shock or hemorrhage, withdraw the agent and lower the head, draw out the tongue and begin artificial respiration, and the danger is usually soon passed, Hypodermie injection of stimulants, such as strychnia or camphor- ated oil, aften do good under these circumstances; but when the circulation is paralyzed and syncope has supervened, their use is illusory. Do not waste time preparing them, though an assistant may do £0; but proceed to make rhythmic traction on the tongue, and artificial respiration, both being carried out methodically. If an assistant is at hand, carry out the two measures simultaneously; otherwise, try the tongue traction first, or at least get it pulled out well. Traction of the tongue to do good, must be rhythmic. The tongue must be caught up carefully with forceps and no force must be used. Often the tongue is seriously injured by the feverish pulls of the agitated operator, who has quite forgotten that the maneuver is effectual only when rhythmic. Likewise, the artificial respiration must be rhythmic. Grasp the patient's elbows and draw them gently and steadily up- ward until they meet above the head. ‘The pectoral muscles are put upon the stretch and the chest expanded and inspiration produced. At the same time the tongue is drawn outward (Fig. 2). The arms are next brought with a steady movement to the chest wall and the diaphragm compressed. (Stage of expiration.) At the same time, the tongue is permitted to retract (Fig. 3). These movements are to be repeated at the rate of about twenty per minute and should be persisted in without intermission for at least @ half hour before giving up hope of resuscitation. Direct compression of the heart is a procedure of real value and it may often be readily managed through the abdominal walls. In the 16 ANFSTELESIA. ‘case of abdominal operations, the hand may be passed up the to dia~ phragm and the heart seized and kneaded in that manner. ‘The vomiting after ancithesia is often troublesome and is uswally im direct ratio with the amount of the agent used. Every effort should Veo, 1 Stage Xb this movement. (Séewwrt ) be made to hasten its elimination from the blood by keeping the slefn warm and active, and helping the kidneys with suline enemata, ‘These i Warm soda water drunk freely belps enemata Pos 3-—Btags ch enpiration. Tongve peredted vo drop Yactcin mosth. (Sesiars to wash out the stomach and thus hastens relief of active vomiting: Five to fifteen drops of aromatic spirits of ammonia hypodermically, or, well diluted, by moath, o Other forms of general a: sia will not often be of service in LOCAL ANESTHESIA. . a emergency practice for obvious reasons, however valuable they may otherwise be. It is hardly necessary, therefore, to consider nitrous oxide or ethyl chloride and their congeners; or general anesthesia by way of the rectum, which promises to be of value in operations on the face, mouth, neck, and thorax, LOCAL ANESTHESIA. ‘The doctor, isolated and without assistants, will many times find aid and comfort in local anesthesia by hypodermic injection; but to be efficient, it must be properly induced. A definite technic must be followed. Either cocaine or stovaine may be used, the latter safer, the 10, 4-—Teeal anesthesia: method of introducing gentle. (Veax) former slightly more active, the two used alike. Having determined the line of incision, pinch up a fold of skin (Fig, 4), introduce the needle at one end of the line and push it into the skin, but not through the skin. ‘The injection {s intradermal (Fig. 5). As the needle is steadily ad- vanced, the syringe is emptied slowly, and the line of injection is in dicated by the formation df a wheal. When the needle has entered its Jength, it is reintroduced in the same line and in advance of the pre~ vious puncture, but within the area already anesthetized. In this way, only the first puncture is felt. When the line of incision has been in- filtrated in manner throughout its entire length, it will be com- pletely insensitive after a wait of one to two minutes. The width of the zone of anesthesia will depend upon the rate of movement of the needle through the skin (Figs 6, 7). It need hardly be said that the 2 1B ANESTHESIA. needle and solution must always be sterile. It is better to pour the solution out into a sterile dish or glass, rather than to aspirate it from the bottle. ‘The air must be forced out before the needle is introduced; care must be taken not to throw the injection into a vein. Pro, $.—=Local anesthesia, the needle docs not apane te whote thickness of ekin" batra-dermbe” injection, (Veu,) When an area, rather than a line, is to be infiltrated, in 2 case where some dissection is anticipated, Schleich's method is better, in which the needle is plunged directly into the tissues and a sufficient quantity of Pio. 1, —Lexal aneythesing the broad when the needle i sed they. {Veen the solution discharged to raise a wheal. ‘The necdle is then reintno duced alongside the wheal for another injection. ‘The anesthesia may be renewed {rons time to time during the operation SCHLEICH'S SOLUTION. 19 Schleich’s formula is as follows: NO. t, STRONO, oe Hydrochlor., Bodli Chior.” Aq, Destillat,, NORMAL. Sodii Chioridi., Aq. Destillat., KO. 3, WEAK. Cocain. iit hior., 3 Aq. Denliae, WF alles, ‘Two or three drops of a so per cent. solution of carbolic acid may be added to preserve. The solution must be kept cool. Twenty-five Pio. 4—Complete anesthesia of finger induced ni by deen imiections on heh iy cinco taiecion at hs ‘tie wore she primacy rule injection. ( syringefuls of Number 1, fifty syringefuls of Number 2, and 500 of Number 3, may be used without danger. ‘The putient should not be permitted to sit up during the anesthesia oo 20 ARESTIRESIA, If cocaine is used, for it exposes him to the risk of heart failure, It is safer to keep him recumbent for a half hour or so after the oper: If a finger or toe is to be amputated, first make an anesthetic ring involving the skin only (Fig. 8), and follow this with two deep lateral injections to obtund the main nerve trunks (Fig. 9). Bier has lately introduced a method of intravenous anesthesia; which, it is to be hoped, will prove practical In the hands of the general practi- tioner, Its use is limited to operations upon the extremities and this & the technic: The limb is first elevated and a constrictor applied from the hand {or foot) upward. The limb is thus emptied of blood, A tourni- quet is next tightly applied, one above and one below the proposed field of operation. ‘The principal vein is next exposed in the distal portion of the field, the incision being made under local anesthesia by Schleich’s method. The yein once exposed is opened, a cannula introduced and 56 to 100 €«. novocaine solution injected under considerable pressure, In three to five minutes a complete local anesthesia is produced. At the end of the operatidn the solution is allowed to eseape; the velns are then washed out with normal salt solution and the tourniquet removed, ‘The technic must be carefully studied before attempting the pro- cedure. SPINAL ANESTHESIA. Spinal anesthesia with stovaine can only very rarely be of use to the general practitioner in emergency work, although it is of value under certain circumstances. It is of special use in operations involving the anal and perineal regions, By this method the heart and lungs are not dangerously affected. It is a solace to those patients whose dread of a general anesthesia is greater than their dread of death, and who will refuse operations of absolute necessity rather than take ether or chloroform. The most definite contra-indication is uncertainty of asopsls, since the chief danger of the procedure is meningitig, It should not be used in the young, in advanced arterio-sclerosis, in cases of septicemia, or central nervous disease. The average duration of the analgesia thus produced is one hour. ‘The effects are fairly uniforms SPINAL ANESTHESIA, ar the chief after-effects are headache and nausea. One of the author's patients, operated for hernia under spinal anesthesia complained for several months of loss of sensation in the penis and rectum, though not materially interfering with the functions of cither. The preparation employed by the author is that of Chaput: stovaine, 1ogr. ; sodiichloridi, 10 gr. distilled water, 1 c.c. This is put up in hermetically sealed am- poules, each containing 1 c.c, of the solution, which is sufficient for an injection. Bier regards cocaine as the most dangerous and tropaco- caine the safest, and this latter he employs in doses of 3/4 to'1 grain. ‘The syringe employed must be easily sterilized and with a capacity of atleast acc, Along platinum needle is best. A special glass syringe with needle for this injection can be readily secured. ‘Technic.—The patient's back, the instruments, the solution, the operator's hands, are duly prepared. The needle is attached to the syringe and the contents of an ampoule aspirated and the needle de- tached, ‘The patient sits bending forward to make the lumbar spines more prominent and to enlarge the intervertebral foramen which is to be traversed by the needle. Locate the iliac crests and mark their position with the finger nails. The line connecting the highest points of the iliac crests intersects the fourth lumbar spine which is next to be located in the middle linc. ‘The next spine above is marked and be- tween these two points the puncture is made. Hold the left index finger on the third lumbar spine. Hold the unattached needle In the right hand, and enter its point