Appendix Iii.

THE ACTION OF ANÆSTHETICS UPON THE BLOOD.

The Blood Gases in Anæsthesia.

Buckmaster and Gardner (Journal of Physiology, vol. xli., p. 246), analysed the blood gases in various stages of chloroform anæsthesia, and some of their results are shown below in tabular form. They show a very definite reduction in the oxygen content of the blood. So far as one gathers from the text of the paper, the animals were not subjected to any considerable trauma during the progress of the anæsthesia, so that the figures arrived at with regard to the CO{2} content do not bear upon the Acapnia question. If there was no trauma, there would be no deep breathing, and a reduction of CO{2} could not be expected.

+---------------------------+------------------+-------------------+---------------+ | |Average volume in |Average composition| | | |c.c. per 100 c.c. | per cent. | Relation | | | of blood | of gas | of | | |------+-----+-----+-------------------|O{2} to CO{2}| | |CO{2}|O{2}|Nitr.|CO{2}| O{2}|Nitr.| | +---------------------------+------+-----+-----+------+------+-----+---------------+ |Normal cats. | 25·07|13·60| 1·00| 63·2| 34·28| 2·52| 1 to 1·84 | | | | | | | | | | |Reflexes just re-appearing | 29·02|11·49| 1·33| 65·06| 25·44| 2·87| 1 to 2·55 | | | | | | | | | | |Reflexes just disappearing | 29·57| 7·78| 2·15| 69·14| 18·17| 5·09| 1 to 3·8 | | | | | | | | | | |2nd Stage Anæsthesia | 36·00| 8·14| 1·49| 71·27| 16·12| 2·95| 1 to 4·32 | +---------------------------+------+-----+-----+------+------+-----+---------------+

Other Blood changes in Anæsthesia.

Hamburger and Ewing (Journal of the American Medical Assoc. 1908) examined the blood changes incidental to surgical anæsthesia. Their results may be condensed as follows:--

Nitrous Oxide.--Hæmoglobin is not permanently decreased and no anæmia follows the administration. Hæmolysis is not increased. The coagulation time of the blood is not always affected in the same direction. Usually it is slightly increased.

Ether.--The hæmoglobin is slightly reduced and anæmia persists for seven to ten days. Hæmolysis is not however materially increased. There is some evidence of blood inspissation. The coagulation time is markedly increased.

Chloroform.--The hæmoglobin is reduced and a distinct anæmia produced. Hæmolysis is definitely increased. There is a slight increase in the coagulation time.

INDEX.

Abdominal operations, ix, 7 local anæsthesia in, 187

Abdominal muscles, rigidity of, 19

Abnormalities of anæsthesia, minor, 38 major, 140

Acapnia, 10, 29, 39

Accidents of anæsthesia, 140

Acetonuria, 153

Acidosis, 153

Adenoids, 127, 166 in status lymphaticus, 148

Adrenalin, 175 danger of, with chloroform, 113, 166

Aedentulous patients, 23

After-effects of anæsthetics, see Sequelae

Ages, dosage of morphia at various, 45 selection of anæsthetic at various, 164

Airshaft, natural, 96

Airway, natural, 15, 31, 114, 145 artificial, 23

Alcoholics, anæsthesia in, 2, 87, 103, 137, 165

Alkaloids, 12, 43, 88, 103

Aneurysm, 56

Anoci-association, 11

Anoxæmia, 15

Arm, management of in anæsthesia, 157 regional anæsthesia of, 181

Arteries, spouting of, x, 37

Arterio-sclerosis, 56, 167

Artificial respiration, 146

Asphyxia, 15

Athetosis, 38

Atropine, 43, 45, 112, 147

Auer and Meltzer, 96

Barth 3-way tap, 50

Bicarbonate of soda in acidosis, 156

Bladder, reflexes from, 39, 168 local anæsthesia in operations upon, 190

Blistering, by chloroform, 109

Blood, changes in, during anæsthesia, 207 spouting of, from cut arteries, x, 37

Blood-pressure, in natural sleep, 1 in shock, 6 in asphyxia, 17 in nitrous oxide, 46 in ether, 75 in chloroform, 110 in ethyl chloride, 122 clinical observation of, 37

Blowing respiration, 34, 89

Boothby, on ether percentages, 99

Boyle, Mr Leonard, 70

Brachial plexus, nerve blocking in, 181

Brain, see Nervous System local anæsthesia for operation upon, 191

Breath-holding, 34, 112, 114

Breathing, deep (see Acapnia)

Bronchitis, 150

Carbon-dioxide, 10, 18, 206

Cardiac cyanosis, 37

Cardiac disease, 107

Cardiac failure (see Syncope)

Castration, anæsthesia in, 169

C.E. mixture, 84, 134, 137

Cells, nerve, changes in, 5

Centripetal impulses, 6

Children, 45, 94, 125, 164

Chloretone, 93

Chloride of ethyl (see Ethyl Chloride)

Chloroform, administration of, 113 decomposition of, 109 delayed poisoning by, 153 physiology of, 109

Choice of anæsthetics, 162

Circulation, observation of, x, 37 in shock, 10 in asphyxia, 17 in valved breathing, 29 in nitrous oxide, 46 in ether, 75 in chloroform, 110 in ethyl chloride, 122 in C.E. mixture, 131 failure of (see Syncope)

Circumcision, anæsthesia in, 169

Clarke’s apparatus, 69

Clenching of Jaws, 15, 24

Clinical phenomena of asphyxia, 18 of normal anæsthesia, 33

Closed ether, 78

Closed method, features of, 29

Clover’s inhaler, 78, 138

Cocaine, 170

Collapse (see Syncope)

Conduction of nerve impulses, 3

Connell, Karl, 90, 205

Conjunctival reflex, 31, 35

Convulsions, 17

Corneal reflex, 32, 35

Crile, Prof., 5, 9

Crowing respiration, 16, 169 night crowing, 148

Cyanosis, 18, 37, 53

Cylinders for nitrous oxide, 43 for oxygen, 64

Dangers of chloroform, Prof. L. Hill upon, 120

Death, causes of, 17, 110, 140, 144, 148

Decomposition of chloroform, 109 of ether, 74

Deep breathing, 10

Degrees of anæsthesia, 31

Dental anæsthesia, 54, 57, 128, 131, 163

Depth of anæsthesia, 36

Dextrose in acidosis, 156

Difficulties of anæsthesia, major, 140 minor, 38

Dilatation of pupils, 5, 17, 35, 53, 66, 125, 136, 141, 143

Disease, relation of anæsthesia to, 166 acute infectious, 168

Dislocations, anæsthesia in reduction of, 164

Dorsal position, 157

Dosimetric method for chloroform, 114 for ether, 90

Dott, Mr N., direct laryngoscope, 104

Douche method, 20

Dread (see Fear)

Drop bottles; chloroform, 117 ether, 83

Drop method, 30, 83

Drugs for local and spinal anæsthesia, 170 to 174

Emphysema, 167

Empyæma, 167, 187

Enema, before operation, 42

Ether, 74, et seq. closed, 78 intratracheal, 96 open, 83 physiology of, 75 rectal, 93 warmed vapour, 90

Ether, respiratory sequelæ of, 150

Ether tremor, 38

Ethyl chloride, 122, et seq. combined with nitrous oxide, 128 freezing anæsthesia by, 200

Eucain, 174

Excitement (see Struggling)

Extraction of teeth (see Dental Anæsthesia)

Eye reflexes, definition of, 31

Face-down posture, 157

Face, adaptation of masks to, 21, 52, 84

Face-pieces for nitrous oxide, 51

False anæsthesia, 41

Faradism of motor nerves in anæsthesia, 3

Fat patients, 158, 165

Fatty changes after anæsthesia, 153

Fear, effects of, 9 prevention of, 11, 43, 88

Feeble patients, 168

Ferguson, Dr., W. J., 87

Fingers, regional anæsthesia for, 184

Flame, open, dangers of, 74, 104

Forceps, tongue, 24

Food before anæsthesia, 42

Foreign bodies in the larynx, 16

Freezing analgesia, 201

Fright (see Fear)

Gags, 25

Gardner, Mr Bellamy, 23, 24, 83

Gas and air, 54

Gas and ether, 138

Gas and ethyl chloride, 128

Gas-oxygen, 60

Gasping, 40

Genito-urinary operations, 168

Glossotilt, 24

Glottis, spasm of, 16, 20, 26, 105

Goitre, anæsthesia for, 160, 185

Goitre, exopthalmic, 9, 167

Grey and Parsons on shock, 6

Guy, Dr Wm., 128

Guy-Ross, gas oxygen method, 131

Gwathmey, warmed ether vapour, 90 oil-ether, 93

Hæmorrhage, as a factor in shock production, 9 observation of, by anæsthetist, x, 37

Hæmorrhoids, local anæsthesia for, 191

Harcourt, Vernon, 114

Head and neck operations, position for, 158

Head and neck, raising, 152 lowering, 110, 145 extra pillow in deep chested patients, 157

Heart, failure in asphyxia, 17 observation of, 37 action of ether upon, 75 of chloroform upon, 110 of ethyl chloride upon, 122 failure of, in secondary syncope, 144

Heart disease, anæsthetics in, 167

Henderson, Yandell, 10, 29

Hernia, local anæsthesia in, 189

Heroin, 44

Hewitt, Sir Frederick, 22, 50, 62, 81, 137

Hill’s direct laryngoscope, 104

Hill, Prof. Leonard, 111, 120

Hornabrook, 87, 123

Hydrochloric acid, as an impurity in chloroform, 109

Hypnotics, 12, 42

Hypodermic medication, 12, 42

Impurities of anæsthetics, 74, 109, 122

Infiltration analgesia, 175

Inhalers, Clover, 78 Clarke, 68 Guy, 128 Guy-Ross, 130 Hewitt, 50, 62, 81 Junker’s, 115 Ormsby, 81 Paterson, 58 Rendle, 135

Inhibition, vagal, 111, 143

Intestinal obstruction, 141, 189

Intranasal surgery, 160, 166, 192

Intratracheal method, 96 Kelly’s instrument for, 100 Shipway’s, 101

Inversion, Leonard Hill’s experiments upon, 110, 111

Jactitations, 53

Jaundice, 154

Jaws, clenching of, 15, 26 falling back of, 16 operations upon, 166 management of, in anæsthesia, 23, 85

Joints, anæsthesia in dislocation of, 164

Junker’s inhaler, 115

Kidney, position for operations upon, 168

Kelly’s intratracheal instrument, 100

Labour, anæsthesia in, 44, 169

Lane, Sir Arbuthnott, 14

Laryngeal stridor, 16, 20, 26, 40, 169

Levy, Goodman, 112, 145

Light anæsthesia, dangers of, in chloroform, 9, 112 Levy’s views, 113

Light reflex, 32

Local anæsthesia, 170 et seq.

Lowering of head and shoulders, 110, 145

Lumbar puncture, site for, 196

Lungs, ventilation of, by normal breathing, 96 by intratracheal method, 97

Lymphatism, 148

Malcolm, J. D., 9

Marshall, Dr Geoffrey, 70

Masks for chloroform, 110 for ether, 82 for perhalation method, 28

Massage of heart, 148

Mechanical asphyxia, 15

Meltzer and Auer, on intratracheal method, 96

Menstruation, 169

Micturition before nitrous oxide, 51

Mixtures, C. E., 84, 134, 137 of nitrous oxide and oxygen, 60 of nitrous oxide and ethyl chloride, 128

Morphine, 12, 43, 152

Mouth, breathing through, 22

Mouth, operations upon, 165

Mouth props, 22

Mucus in air passages, 40

Musculo-spiral paralysis, 157

Muscles in anæsthesia, ix, 3, 19, 34

Muscle tone, 3, 19, 53

Nasal breathing, 23, 166

Naso-pharyngeal catarrh, 151

Nasal methods of giving nitrous oxide, 57

Nasal tube for Junker’s bottle, 119

Neck, position of, 20 relaxation of muscles of, 21 posture for operation upon, 159 tumours and inflammatory swellings in, 7, 166

Nephritis, influence of, upon choice of anæsthetics, 77, 168

Nervous system, effects of anæsthetics upon, 2, 75

Nerves, peripheral, unaffected by anæsthetics, 3

Nerve blocking, 12, 179

Night-crowing, 148

Nitrous oxide, 46 with air, 54 with ether, 138 with ethyl chloride, 128 nasal, 57 physiology of, 46 contra-indications to, 56

Nitrous oxide and oxygen, 8, 12, 60 various systems for, 67, 70, 130 for use in major surgery, 72 with ethyl chloride, 131

Obesity, 158, 165

Obstruction, intestinal, 141 respiratory, 15, 141

Oil ether, Gwathmey’s method of, 93

Oligæmia in shock, 10

Omnopon, 44

Open method, definition of, 28 chloroform, 117 ether, 83 ethyl chloride, 123

O’Malley’s technique for intra-nasal surgery, 160

Ormsby’s inhaler, 81, 137

Over-dosage, 36, 110, 144 with nitrous oxide, 54

Oxygen, reduction in blood in anæsthesia, 206 as a relief in asphyxia, 27 to old patients, 165 with nitrous oxide (see Nitrous Oxide and Oxygen) with nitrous oxide and ethyl chloride, 130

Paralysis, musculo-spiral, 157

Patella reflex in anæsthesia, 3

Percentages of chloroform and ether required in anæsthesia, 6 of chloroform, 111 of ether, 86, 99, 201, 204

Perhalation method, definition of, 28 ether (see open Ether)

Phenomena of anæsthesia normal, 33 abnormal, 38 of nitrous oxide, 52 of ethyl chloride, 125

Pericarditis as a cause of death in anæsthesia, 168

Phillip’s artificial airway, 23, 160

Physics of natural respiration, 96

Physiology of anæsthetic drugs, 1 of asphyxia, 17 of chloroform, 109 of ether, 75 of ethyl chloride, 122 of nitrous oxide, 46

Phthisis, 167

Pneumonia, post anæsthetic, 157

Position in anæsthesia, 157

Positive pressure in nitrous oxide, 52 in nitrous oxide and oxygen, 66

Post-chloroform poisoning, 153

Post anæsthetic complications, 150

Pregnancy, anæsthesia in, 169

Preliminary hypodermic medication, 11, 43, 152

Preparation of patient, 42

Primary syncope, 110, 143

Protection from shock by general anæsthetics, 8

Pulse, rate in shock, 6 clinical observation of, 37

Pupil, light reflex of, 32 size of, 35 in asphyxia, 17

Purging before anæsthetics, 40

Quinine and urea hydrochloride, 174

Rebreathing method, 18 in nitrous oxide, 68

Rectal administration of ether, 93

Rectal saline, 42

Reflexes as a cause of shock, 4, 6 order of disappearance of, 3

Reflex, conjunctival, 31, 35 corneal, 32, 35 light, 32, 35 patella, 3 skin, 37

Reflex syncope, 8, 112, 145

Regional anæsthesia, 179

Renal disease, 163

Rendle’s cone, 135

Repeated administrations, 60, 156

Respiration, arrest of, 142 artificial, 146 blowing, 34, 89 crowing, 16 depressed, 39, 43 effect of morphia and chloroform upon, 43, 86 normal, 34 obstructed, 15, 141, 166

Respiration, physics of natural, 96 reflex arrest of, 39

Respiratory abnormalities, minor, 39 major, 141

Respiratory system, effects of ether upon, 76 after-effects of anæsthetics upon, 150

Rigidity of muscles in asphyxia, 19, 38, 39 in second stage, 33

Saline injections, per rectus, 42 subcutaneous, 14

Schimmelbusch’s mask, 28, 116

Scopolamine, 44, 103

Secondary syncope, 17, 138, 143

Secretion of mucus, 40, 76 of urine, 168

Sedatives, 12, 42

Selection of anæsthetic, 162

Semi-open method, 28

Septic cases, 9, 60, 156, 168

Sequelæ of anæsthesia, 100

Sex, relation to anæsthesia, 165

Shipway, Dr, 91, 101

Shock, 5 difference between syncope and, 142

Short, Mr Rendle, 154

Sickness (see Vomiting)

Sighing, 40

Sight-feed machines for gas-oxygen, 70

Signs of anæsthesia, 36, 53, 65

Silk, Dr J. W., 23, 87

Single dose anæsthetics, 30, 163

Sitting posture, 21, 158

Slow respiration, 39

Spasm, muscular, 19 of jaw muscles, 15 of larynx, 16, 26, 169

Specific gravity of chloroform, 109 of ether, 74

Spinal anæsthesia, 193

Stages of anæsthesia, 31

Starvation, a cause of shock, 9 of acidosis, 155

Status lymphaticus, 148

Stertor, 40, 53

Stimuli from field of operations, 6

Stomach tube, before operation, 141

Stovaine, 173

Stridor, 16, 26, 40

Struggling, 34

Strychnine, 147

Subcutaneous saline, 14

Swallowing, movements of, 33

Sylvester’s method of artificial respiration, 146

Syncope, 142

Syringe for local anæsthesia, 176 for spinal anæsthesia, 176

Teeth, danger of dropping of into larynx, 16 extraction of, 54, 57, 128, 131, 163

Teter, Dr., on nitrous oxide and oxygen, 68

Thomson, Prof. Alexis, 12, 158

Thomson, Torrance, on intratracheal anæsthesia, 96

Thoracic operations, local anæsthesia in, 186

Three-way tap for nitrous oxide, 50, 128

Thyroid gland, see Goitre

Time for operations, 42

Time afforded by single dose anæsthetics, 163

Tongue falling back of, 16 forceps for, 24 operations upon, 97, 118, 166 local anæsthesia for, 191

Tonsils and adenoids, 127, 166

Trachea, mucus in, 40 pressure upon, 17

Trachetomy, 142, 185

Tremor, ether, 38

Trendelenberg posture, 158

Tropacocaine, 173

Turner, Dr Logan, 125

Urine, secretion of prevented by morphia, 168

Vagus nerve, 110, 145

Valved method, features of, 29

Vapour method, ether, 90 ethyl chloride, 125

Vaso-motor system, in shock, 9 in asphyxia, 17 in nitrous oxide, 46 (and see Physiology)

Veins, large, emptying into heart, 10 engorgement of, 20, 151

Venesection in syncope, 147

Veronal, 12

Vicious circle of asphyxia, 20

Vital medullary centres, 3

Vomiting, 140, 152 impending, 39, 141

War, anti-shock, measures in, 11 lessons of, 61, 151

Warming anæsthetic vapours, 62, 90, 101

Wedge for opening clenched jaws, 25

Withdrawal of anæsthetic, for stridor, 26 for breath holding and struggling, 34 for syncope, 145

FOOTNOTES:

This can be done to a very limited extent indeed if the ordinary valves here described are used. See page 68.

A safeguard provided on some machines is a side lead from the oxygen supply direct to the facepiece whereby pure oxygen can be given if required.

The amount of oxygen in a cylinder is designated in terms of cubic feet. A cylinder which would hold 100 gallons of N_{2}O, will contain 30 cubic feet of oxygen.

In the figure the Clover is shown with gas valves and 2-gallon bag, arranged for “gas and ether.”

Trans. xvii. Internat. Med. Cong. Sub-sect. (vii.) Part i.

Journal Amer. Med. Assoc., Sept. 1913.

Trans. xvii., Internat. Med. Cong. Sub-sec. (vii.), Part i.

Trans. xvii., Internat. Med. Cong., Sub-sec. (vii.), Part ii.

Trans. xvii., Internat. Med. Cong., Sub-sec. (vii.), Part I.

The student should be careful to be sure that the bulb is attached to the inlet pipe: if by accident it be slipped on to the outlet pipe, the first compression of the bulb will eject a stream of liquid chloroform from the instrument.

The author described this method in a paper read before the Scottish Branch of the British Dental Association, and afterwards published in the Journal of the Association under the title “The Edinburgh System of Dental Anæsthesia.” To the use of this term Dr J. H. Gibbs, of Edinburgh, took strong exception in a letter to the Editor of the Journal. The author has and had no desire to convey the impression that this system was universally used in Edinburgh, but simply that it is the method taught by Dr Guy, Dean of the School, to the students in the Extraction Room.

Transcriber’s Notes:

1. Obvious printers’, punctuation and spelling errors have been corrected silently.

2. Where hyphenation is in doubt, it has been retained as in the original.

3. Some hyphenated and non-hyphenated versions of the same words have been retained as in the original.

4. Superscripts are represented using the caret character, e.g. D^r. or X^{xx}.

5. Italics are shown as xxx.

6. Bold print is shown as =xxx=.