Handbook of anæsthetics

Appendix 201

INDEX 209

LIST OF ILLUSTRATIONS.

FIG. PAGE.

1. Shock (Grey and Parsons) 6

2. Shock (after Crile) 8

3. Diagram to Illustrate Anoci-Association (after Crile) 11

4. Apparatus for Lane’s Saline Infusion 13

5. Diagram of the Vicious Circle of Asphyxia 20

6. Hewitt’s Mouth Props 22

7. Bellamy Gardner’s Mouth Props 23

8. Phillips’ Modification of Hewitt’s Artificial Air-way 23

9. Silk’s Nasal Tubes 23

10. Tongue Forceps and Glossotilt 24

11. Apparatus for Opening Clenched Jaws 25

12. Frame for Adapting Vertical Cylinders to Foot Use 47

13. Nitrous Oxide Cylinders (upright and angle) 48

14. Complete Nitrous Oxide Apparatus 49

15. Barth 3-way Nitrous Oxide Tap 50

16. Hewitt’s Wide-bore Nitrous Oxide Valves 50

17. Ash’s Modification of Paterson’s Nasal Gas 58

18. Hewitt’s Apparatus for Nitrous Oxide and Oxygen 63

19. Diagram to Illustrate Action of Hewitt’s and Teter’s Gas-Oxygen Methods 67

20. Details of Clark’s Expiratory Valve 68

21. The Clarke Gas-oxygen Apparatus 69

22. Marshall’s Sight-feed Gas-oxygen Apparatus 70

23. Clover’s Ether Inhaler, with Nitrous Oxide Attachment 77

24. Clover’s Inhaler, Diagram of a Vertical Section 78

25. Hewitt’s Wide-bore Ether Inhaler 80

26. Ormsby’s Ether Inhaler 81

27. Bellamy Gardner’s Mask and Ether Dropper 83

28. Four Photographs to Illustrate the Administration of Open Ether 84–5

29. Shipway’s Warmed Ether Apparatus 91

30. Diagram of Intratracheal Apparatus 98

31. Electric Blower for Intratracheal Method 99

32. Kelly’s Intratracheal Apparatus 100

33. Shipway’s Intratracheal Apparatus 102

34. Hill’s Direct Laryngoscope 104

35. Diagram of Blood-pressure Curves Obtainable with Chloroform 110

36. Vernon Harcourt’s Percentage Chloroform Inhaler 115

37. Chloroform Mask 116

38. Chloroform Drop Bottles 117

39. Junker’s Chloroform Apparatus 119

40. Tube of Ethyl-Chloride 122

41. Ethyl-Chloride Inhaler 124

42. Guy’s Gas and Ethyl-Chloride Inhaler 128

43. Details of Guy’s Inhaler 129

44. Diagram of Gas-Oxygen Method Introduced by Dr Guy and the Author 130

45. The Guy Ross Gas-Oxygen Instrument 131

46. Rendle’s Cone 135

47. Clover Inhaler adapted for the Ethyl Chloride-Ether Sequence 139

48. Two Photographs illustrating Sylvester’s Artificial Respiration 146–7

49. Sitting-up Posture for Operations upon the Head and Neck 159

50. O’Malley’s Posture for Intra-nasal Surgery 160

51. All-metal Syringe for Infiltration Anæsthesia 176

52. Infiltration of the Brachial Plexus 183

53. Needle and Syringe for Spinal Analgesia 194

54. Position of the Patient for Spinal Analgesia 196

INTRODUCTION.

The securing of a safe anæsthesia during operations is more important than ever before, partly because of the mere number of operations, and partly because of the greater extent to which other operative risks--hæmorrhage, shock and infection--have been overcome. The risk from the anæsthetic is now so very small that the joint aim of the surgeon and anæsthetist to abolish it altogether is not far from being accomplished. The author of this volume has done a good deal to accomplish this end, and it is a matter of congratulation that he has now published an account of his methods, so that a larger circle may benefit from his teaching and his experience.

The author very properly goes further and maintains that anæsthesia must not only be safe but must also be good; good anæsthesia is absolutely vital to good surgery. Only a generation back many surgeons professed to see no difference as to who gave the anæsthetic; at the present day no one willingly embarks upon a difficult operation without the aid of a skilled anæsthetist.

In various parts of the book the author has very rightly laid great emphasis upon the influence which the work of the surgeon has upon that of the anæsthetist. The latter may learn much from an occasional glance at the field of operation. He should not interest himself in the details of operative procedure to the distraction of his mind from his own responsibilities; but he can, in abdominal surgery, see for himself whether the muscles are properly relaxed, and observe the state of operation, so that he can when necessary deepen the anæsthesia in good time, while not maintaining deep anæsthesia when a light one would suffice. Finally, he can check his other sources of information as to the condition of the circulation by noticing the force with which cut arteries spout, the colour of the blood and the size of uncut veins.

Like other branches of medicine, adequate study as well as practical experience is required in order to master the art of administering anæsthetics, and that a reliable manual of instruction is essential, goes without saying; I feel on perfectly safe ground in recommending this book as such both to the student and the practitioner.

ALEXIS THOMSON.

PREFACE.

This little book is an attempt to present to the student and practitioner a condensed account of modern anæsthetic views and practice. In choosing a general scheme I have tried to lay emphasis upon the relation of anæsthesia to general medical science rather than upon elaborate descriptions of anæsthetic apparatus and methods which a few years hence may be superseded. I have therefore devoted the first four chapters to an account of the various forces which modify the physiology of the patient during an operation under a general anæsthetic, in so far as we at present understand them. I trust that they will prove not only a sound basis for the information given in the rest of the book but also a help towards forming a judgment upon new methods and appliances as and when they meet the attention of the reader.

In making a selection of drugs and appliances for description, I have eliminated those which do not appear to me to have any real sphere of usefulness.

The account of nitrous oxide and oxygen has been given in some detail. Both the profession and the lay public have arrived, through the experiences of the war, at a more just appreciation of the possibilities of this combination than was at all general before the year 1914. At the present day, no one who proposes to engage in anæsthetic work can afford to remain unpractised in its administration.

I have an apology to make to my women readers. Throughout the book, when speaking of the anæsthetist, I have presumed the male sex. Such phrases as “his or her” and “he or she” are tedious and inelegant, and their omission must not be taken as forgetfulness on the author’s part that women frequently make very good anæsthetists.

Professor Alexis Thomson has added to the many kindnesses I have received at his hands by writing the Introduction which immediately precedes this Preface, and I wish to express my sincere thanks to him for such a valuable addition to the book.

From Mr David Wallace, F.R.C.S.E., I have received much valuable help and guidance in anæsthetic matters. It was largely due to his kindly assistance and moral support that I was encouraged to persevere with my early attempts to use nitrous oxide and oxygen in major surgery. The hints which are given in connection with Genito-Urinary Surgery are also derived from him.

The chapters upon Local and Spinal Anæsthesia are entirely the work of Mr Wood, to whom I must express my gratitude for the admirable way in which he has done the work.

I must also thank Dr Torrance Thomson most sincerely for his useful contribution in chapter X, which constitutes a complete monograph upon Intratracheal Anæsthesia.

To Dr Wm. Guy I am indebted for the photographs which appear in the book, and I must express my sincere gratitude to him for the trouble he has taken in the matter.

Much thanks are also due to the following firms who have been kind enough to lend illustrative blocks:--Messrs Claudius Ash & Co. Ltd., G. Barth & Co., De Trey & Co., J. Gardner & Son, Allen & Hanbury’s Ltd., Meyer & Phelps, Coxeter & Son, Down Bros., Ltd., Krohne & Sesemann, and Mr J. H. Montague.

Lastly, I must express my high appreciation of the courtesy which the publishers have shown to me, and of their generosity in the matter of illustrations.

J. STUART ROSS.

October 1919.

Handbook of Anæsthetics.

CHAPTER I.. Physiological Action of anæsthetic Drugs.

PHYSIOLOGICAL ACTION OF ANÆSTHETIC DRUGS.

Every anæsthetic drug has certain pharmacological peculiarities of its own, but all have much in common, and it is to these common features we shall first direct our attention.

Reaching the blood stream by absorption from the lung alveoli, the drug enters into loose combination with the red blood corpuscles; a small proportion only is carried in the plasma. Within the corpuscles it must of necessity displace a certain proportion of the oxygen normally carried: this factor is of great importance only in the case of nitrous oxide gas, which readily displaces the larger part of the normal oxygen content. In the case of other anæsthetics, the same process occurs; but to a less extent. Detailed figures of the extent to which the blood gases are altered in various stages of chloroform anæsthesia will be found in Appendix III.

The actions of individual drugs upon the circulatory, respiratory, and excretory systems differ so considerably that a small section has been devoted to this subject in each of the chapters devoted to nitrous oxide, ether, and chloroform respectively. One feature is, however, dependent upon the state of anæsthesia rather than the action of the particular drug, and that is a certain slight fall of blood pressure. This phenomenon is seen even in natural sleep, and is presumably due simply to lack of normal stimuli such as tactile, visual, and auditory impressions which in the ordinary circumstances of life, help to maintain the tone of the vasomotor system. That such a fall is due to the state of anæsthesia admits of little doubt, but the fact is not always easy to demonstrate since each of the drugs themselves have a marked influence upon the B.P., which masks the pure effect of the anæsthetic sleep.

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