Practical Points in Anesthesia

Part 1

PRACTICAL POINTS IN ANESTHESIA

FREDERICK-EMIL NEEF B. S., B. L., M. L., M. D. NEW YORK CITY

NEW YORK, U. S. A. Surgery Publishing Company 92 WILLIAM STREET 1908

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COPYRIGHT, OCTOBER, 1908 BY SURGERY PUBLISHING CO. NEW YORK

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PREFACE

I have tried to present some of my impressions on the correct use of chloroform and ether and of a very useful combination of these—anaesthol. No doubt, my observations and conclusions will have to be modified in many details by the experiences of others. I have merely voiced a simple and coherent working theory, which has gradually forced itself upon me as my views on the practice of anesthesia have become a little broader and more comprehensive.

FREDERICK-EMIL NEEF

941 Madison Avenue New York

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CONTENTS

Preface, 5

The Induction of Anesthesia—The German Hospital System, 9

Cardiac Collapse, 12

Respiratory Collapse, 13

When Shall the Patient be Declared Ready for Operation, 15

Maintenance of the Surgical Plane of Anesthesia, 16

Some Important Reflexes, 22

Vomiting During Anesthesia, 23

Obstructed Breathing, 24

The Use of the Breathing Tube, 26

Indications for Stimulation during Anesthesia, 28

The Influence of Morphine on Narcosis, 30

General Course of the Anesthesia, 31

Awakening, 31

Recession of the Tongue after Narcosis, 33

Post-Operative Distress, 34

Part 2

Morphine-Anaesthol-Ether Sequence, 36

Minor Anesthesia with Ethyl Chloride, 38

Intubation Anesthesia, 38

Cases Requiring Superficial Anesthesia, 43

Cases Requiring Anesthesia Of Moderate Depth, 44

Cases Requiring Profound Anesthesia, 44

Conclusion, 45

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PRACTICAL POINTS IN ANESTHESIA

THE INDUCTION OF ANESTHESIA.

I can spare the reader the ordeal of many words by beginning in a concrete way with the outline of a system of anesthesia that is now largely followed at the German Hospital, New York City.

The Schimmelbusch mask is used; this fits the face and is large enough to include the bridge of the nose and prominence of the chin. It is covered with a piece of thin flannel, and, over this, impermeable cloth in the center of which a lozenge-shaped fenestra (1½”×1”) has been cut. In the upper half of this little window with the flannel pane, on the inside of the mask, a small wad of gauze is fastened. The mask is then complete and can be used for administering any anesthetic by the drop method—chloroform, anaesthol or ether. In giving ether one makes use of the upper half of the fenestra with its separate ether pad; while chloroform and anaesthol are given to advantage through the lower portion. The chin, cheek and bridge of the nose are anointed with a little white vaseline at the line of contact with the mask, and then the latter is allowed to rest lightly on the face of the patient for a few moments, until he can reconcile himself to the strange procedure, and resumes his normal breathing. There must be absolute quiet. The anesthetist alone may speak when he deems fit.

The beginning is made with anaesthol or chloroform drop by drop. The slightest objection on the part of the patient that the vapors are too strong must be considered; irritation of the throat, slight coughing, all merely emphasize that the introduction must be very gradual. If the patient is solicitous about the efficacy of the anesthetic he should be assured that there is no hurry, and he should be enjoined to take deeper breaths, if he breathes too lightly. As long as the patient is conscious he will respond to the injunction to take a deep breath; if he does not respond to this request he has reached the stage of unconsciousness—the state of primary anesthesia.

Sometimes a remarkable calm, a period of relative apnea, precedes the stage of excitement. At other times, this stage ushers the patient directly into the state of complete anesthesia. There need be no stage of excitement at all. This is especially true if morphine has been administered hypodermatically before narcosis, and if the induction of the anesthetic is cautious and gradual.

The surgical degree, the state of complete anesthesia, is announced by the respiration when it assumes the more or less well marked snoring character of one who is fast asleep.

In the German Hospital system the patient, male or female, is given a quarter of a grain of morphine sulphate hypodermatically half an hour before narcosis. The anesthesia is always induced with anaesthol or chloroform. Where much blood is lost or the operation is of very long duration one may at any time make the transition to ether by the drop method without changing the mask. As a rule, a morphine-anaesthol narcosis is given with a few drops of ether now and then (ether feeding), when a little stimulation is indicated. In a small number of cases, among them choledochotomies and other operations on the gall-bladder, particularly where there is jaundice, the morphine-anaesthol introduction is followed by the ether drop method.

CARDIAC COLLAPSE.

Cardiac collapse is fortunately uncommon. It usually occurs during the induction of anesthesia. Suddenly there is a marked pallor of the face and the pulse becomes weak. It happens in chloroform, and occasionally in anaesthol narcosis. When such a tendency is discovered ether should be given by the drop method.

Gradual induction of anesthesia until the patient’s tolerance to chloroform is ascertained, is of cardinal importance.

RESPIRATORY COLLAPSE.

Obstructed breathing developing during the induction of narcosis is apt to be due to crowding. If obstructed breathing becomes manifest later, that is, during the course of the operation, it may be due to inhibitory reflex elicited by the surgeon. Traction on the gall bladder or mesentery will sometimes evoke a peculiar noisy breathing which does not mean that the patient is insufficiently under the influence of the anesthetic. The breathing becomes normal and unrestrained as soon as the surgeon desists from these vigorous manipulations.

Probably the most common of mistakes is crowding the anesthetic. The anesthetist becomes aware of faint, high pitched notes in the breathing—the beginning of obstructed respiration. He examines the lid and corneal reflex and these convince him that the patient is in the state of superficial anesthesia. Naturally, he gives more of the anesthetic. To his great chagrin the breathing becomes progressively more stertorous. The cyanosis which was at first slight, deepens. The noisy breathing attracts the surgeon’s attention. The perspiring anesthetist is enjoined to push the jaw forward; but the spasm of the muscles is too great. The teeth are pried apart, barbarous instruments are brought into play to pull the tongue forward. The patient has not received sufficient air all this time—his face is slate-colored. The nasal or pharyngeal tube, tongue traction, oxygen, artificial respiration with rhythmic chest compression, stretching of the sphincter ani, all follow in an illogical onslaught, until finally a long deep breath is induced and the victim is resuscitated. The condition was one of respiratory-collapse. The cause was crowding of the anesthetic.

WHEN SHALL THE PATIENT BE DECLARED READY FOR OPERATION?

As soon as the first, unimpeded, snoring respirations are heard, the cleansing of the field of operation may begin. If the cleansing manipulations do not disturb the rhythm of the snoring respiration, the rate of the pulse does not increase and the patient makes no defensive movements, he is very likely already in the proper plane of anesthesia. Note is at once made of the state of the pupil and lid corresponding to this plane.

When the surgeon makes the initial incision observation is again made as to whether the rhythm of the respiration and the rate of the pulse remain undisturbed and whether the patient continues to be passive; if this is the case, the patient is considered to be in the correct plane of anesthesia—the plane in which he must be kept throughout the operation.

Of course, it is clear that the depth of the narcosis must, in a measure, be proportionate to the magnitude of the awakening impulses set up by the surgeon’s manipulations. In abdominal work these impulses are more intense near the solar plexus of nerves, that is, in the upper part of the abdomen. Traction on the mesentery or the introduction of long gauze tampons into the abdominal cavity for “walling off” sets up powerful awakening stimuli.

MAINTENANCE OF THE SURGICAL PLANE OF ANESTHESIA.

In order to conduct a narcosis scientifically one must know the signs of sufficient anesthesia and the signs of awakening.

Part 3

The respiration is studied by watching the movements of the chest or abdomen, by placing the hand in the vicinity of the nostril to feel the respiratory current of air, or, best of all, for the respiration is rarely noiseless, by listening to the breathing. The quality of the breathing is noted. The faintest indication of a snoring respiration means that the surgical degree has been reached. Any change in the quality of the breathing compels the questions “Has the patient escaped from the proper surgical plane?” “Is the anesthesia too deep or too superficial?” or “Is the change simply a respiratory reflex induced by the surgeon’s manipulations?”

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