Part 4

The volume of the pulse diminishes during protracted narcosis. The volume may be expected to decrease about one-third in the course of an hour, and as much as one-half in a two hours’ anesthesia. If, in a chloroform or anaesthol anesthesia, the pulse gives the impression, to the palpating finger, of having lost more than one-half of its original volume, stimulation is indicated. If ether feeding through the Schimmelbusch mask, and one drachm of 25% camphor-ether hypodermatically do not improve the volume notably, an intravenous infusion of physiological saline at 98°-105° F. should be given without delay. If the anesthesia has been conducted with ether instead of anaesthol or chloroform, camphor-ether stimulation is not in place; the resort is to strychnine stimulation instead—one twentieth of a grain of strychnine sulphate hypodermatically, which may be repeated in half an hour. If there is no prompt improvement in the condition of the pulse, the intravenous infusion should not be postponed. It must also be borne in mind that, not drugs, but infusion of fluid alone can make good any great loss of blood.

THE INFLUENCE OF MORPHINE ON NARCOSIS.

During the course of any operation, the surgeon is responsible for a long chain of ingoing impulses, which travel along the sensory paths from the site of operation to the spinal cord and brain. Morphine diminishes the awakening effect of these impulses by benumbing the perceptive centers in the brain. The correct plane of anesthesia for a patient who has had morphine, for example, one quarter of a grain of morphine sulphate hypodermatically half an hour before narcosis, must appear very superficial as compared with a case to which morphine has not been administered. Not only is considerably less of the anesthetic required, but the lid, for instance, may be quite tonic without indicating that more of the anesthetic is necessary. These observations apply cardinally to anesthesias with chloroform, or chloroform combinations, such as anaesthol.

GENERAL COURSE OF THE ANESTHESIA.

The ideal narcosis is tranquil. It resembles a natural sleep. The breathing is unimpeded and easy. Any change in the character of the breathing sound, or the rhythm, demands attention. If, for the moment, the anesthetic has been given too hurriedly, a few breaths of air will restore the calm. If, on the other hand, signs of awakening are discovered—the lid becomes more tonic, the corneal reflex more active, a tear appears in the eye, the patient begins to sweat, saliva collects in the throat, the pulse becomes more rapid—a few drops of the anesthetic should be administered until the desired free and unembarrassed respiration returns.

AWAKENING.

If the narcosis has been conducted correctly the patient should become conscious promptly after operation. The premonitors of awakening are readily recognized, the corneal reflex becomes more active, the tonicity of the eyelid approaches the normal, a tear may appear in the eye, beads of perspiration are seen on the forehead, the patient may begin to mutter incoherently, the pulse becomes faster, the breathing loses its snoring character, and the patient begins to move his head.

If the operation is a laparotomy and the patient is under the influence of morphine-anaesthol, the narcosis is terminated by giving a drop occasionally when the surgeon puts his first sutures into the abdominal wall; after the fascial repair, the anesthetic is stopped entirely. The narcosis may be so timed that the patient becomes conscious and responds to questions promptly after the last stitch has been placed.

If the morphine-anaesthol narcosis has been continued with ether by the drop method, as is frequently indicated, and if considerable ether has been used, the patient will be a little tardier in arousing, and the administration of the narcotic should be stopped at an earlier period. To be less abstract, in the case of a laparotomy the anesthetist desists at once from giving ether when the surgeon has applied the peritoneal suture for the closure of the abdominal wound.

RECESSION OF THE TONGUE AFTER NARCOSIS.

Sometimes, especially in individuals who show this tendency during narcosis, a marked obstruction in breathing is met with, attended by increasing cyanosis, a condition due to dropping back or recession of the base of the tongue into the laryngo-pharyngeal space. Changing the position of the head does not improve the breathing, the jaw cannot be pushed forward because the masseter is rigidly contracted and the teeth are clenched tightly. To draw forward the tongue would require a rough procedure, with wedge, gag, and forceps. If a soft rubber catheter or the breathing tube be passed through the nostril into the pharynx the respiratory air streams freely through the tube.

POST-OPERATIVE DISTRESS.

Post-operative gas pain is often the source of great distress to patients who have undergone the ordeal of laparotomy. It is due to a temporary paresis of the gut and consequent distension with gas. When the trouble is in the lower bowel considerable relief may follow the insertion of the rectal tube. Irrigation of the colon, when permissible, may stimulate peristalsis in the higher segments of the bowel. A routine intended to militate against intestinal paresis in celiotomies, and worth a fair trial, is to administer with the morphine sulphate a small dose of eserine sulphate hypodermatically. For the ordinary adult the dose should be about one-fourth of a grain of morphine sulphate and one fiftieth of a grain of eserine sulphate given subcutaneously one-half hour before narcosis.

When it is important to avoid post-operative vomiting, gastric lavage with plain water, made faintly alkaline with lime water or milk of magnesia, may be done as soon as the narcosis is ended and while the patient is still on the operating table. During the procedure the head end of the table is lowered a few degrees.

I have gathered the impression that crowding is one of the prime causes of excessive vomiting after anesthesia. It has been my experience that cases in which I could truly say that I had not crowded the anesthetic and where it was not swallowed to any extent during the induction, have suffered little or not at all from this disagreeable after-effect of the narcosis.

The attentive nurse will find that there are numerous little things, seemingly insignificant, that help greatly toward the patient’s comfort. She may support the wound during a coughing spell or if the patient vomits. If her charge is tormented with nausea a piece of cotton saturated with a mixture of alcohol and acetic acid can be dropped into a tumbler and the patient allowed to inhale the vapor. If the lips and throat are dry and parched, moisture is grateful and small pieces of gauze wet with iced water may be laid over the lips and nostrils.

If the patient is suffering after operation, one should be generous with morphine. It should always be given hypodermatically. To the adult less than one quarter grain as a dose is of little avail. In such post-operative use there need be no fear of inculcating the morphine habit.

MORPHINE-ANAESTHOL SEQUENCE.

For general use in every day practice the morphine-anaesthol sequence already described is most satisfactory.

As indicated, the adult receives a quarter grain of morphine sulphate hypodermatically one-half hour before anesthesia.

Anaesthol, a fairly stable combination of chloroform, ether and ethyl chloride in molecular proportions, is given by the drop method, but in slightly greater quantity than pure chloroform. For the average “interval” case of appendicitis, for example, about 15 to 20 cc. should be used for the induction, and 40-60 cc. for the entire narcosis.

The morphine, in susceptible individuals, sometimes causes very shallow respirations so that the conduct of the anesthesia to the stage of unconsciousness becomes prolonged because the patient does not inhale sufficient of the anesthetic at each breath. Crowding would be incorrect. The solution is patience, and a little ether to excite deeper respirations. The patient has but a slight stage of excitement, often none at all. The narcosis is continued until the first unimpeded, snoring respiration is heard, and then the surgeon may begin. Much of the narcotic is not required and the anesthesia can be so conducted that the patient promptly becomes conscious after the placing of the last suture.

Post-anesthetic distress is, on the whole, less marked than with pure ether. Not infrequently there is neither nausea nor vomiting.

MINOR ANESTHESIA WITH ETHYL CHLORIDE.

In surgical office work, there is occasionally the need of a rapid and fleeting anesthesia which does not necessitate the use of a cumbersome apparatus for its induction. In these cases, in place of chloroform, anaesthol or ether, the ethyl chloride spray can be used on the Schimmelbusch mask already described. It produces a prompt anesthesia during which an abscess can be opened, washed and dressed without causing the patient the slightest pain.

INTUBATION ANESTHESIA.

In intubation anesthesia, or tube anesthesia, as it might be called, the patient does not receive the anesthetic directly from a cone or mask. It is inhaled through a soft rubber tube which is introduced into the pharynx through the nostril or mouth. It is most successful in cases that do not require a very profound narcosis. It is indicated in operations on the head, enabling the anesthetist to be at a distance from the field of operation and out of the surgeon’s province.

An important preliminary is to give the patient morphine sulphate, gr. ¼, hypodermatically one half hour before anesthesia is begun, as much less of the anesthetic is then required.