It is not the intention of the writer to dilate upon the nature and use of anesthetics, as their value and indication has been fully exploited. A concise review of these agents, however, will meet with the approval of the special surgeon, inasmuch as they have their particular use in individual cases. Local anesthesia is undoubtedly the most extensively employed, in the performance of the average plastic operation, yet in certain cases it is contra-indicated, and it is to further the proper selection of such that the following may be of value.
GENERAL ANESTHESIA
It must be understood that general anesthesia has its many advantages and equally its disadvantages. It necessitates the early preparation of the patient and a thorough physical examination as to the state of lungs, heart, and kidneys. Patients having cardiac affections or serious lesions within the lungs should be given the safest anesthetic obtainable; in fact, if the operation can possibly be done by local administration, it should be.
It is to be remembered that in a majority of these cases the operation is undertaken to remedy a deformity, however caused, one that is not necessarily serious to health, and it would indeed be unwise to place such a body in jeopardy or to take undue chances if they can be avoided. Ofttimes several operations, a few weeks apart, must be done and the frequent repetition of a general anesthetic might impair the health of the patient—a condition not associated with local anesthesia.
Neurotic subjects often insist upon the use of chloroform and the surgeon is frequently tempted to administer it, but little objection should be found with local narcosis, where it can be employed.
Preparation for General Anesthesia
The patient must not be allowed food at least six hours prior to operation. In neurotic and anemic subjects a full dose of strong wine or whisky should be given half an hour before operation. Habitual drinkers should be given one quarter grain morphin sulphate. All movable artificial teeth, or other foreign bodies, must be removed from the mouth. Observe the laws of asepsis as heretofore described. Loosen the clothing of the patient about the neck and chest. Only a single garment should be worn during the time of operation—a loose, sterilized night robe, as it may be necessary to move the patient about, and too much or tight clothing might prove to be dangerous in the delay occasioned by its removal.
The operating room should never be cold enough to chill a patient so prepared. Hot-water bottles or a warm pack can be placed between or about the limbs to equalize the external circulation. This is especially necessary when chloroform is administered, as this lowers the temperature of the body. Have the bowels and bladder emptied. Choose the early part of the day for operations of some length, because the stomach is then empty and vomiting with resultant gastric disturbance will be lessened or entirely avoided. The anesthetizer should be experienced and attend to his duty implicitly. He must at all times watch the patient, take note of the pulse, pupils, and respiration. Close by he must have a mouth-gag, tongue forceps, long-handled sponge holders, containing dry absorbent cotton sponges, and a basin in case of emesis.
He should quietly instruct the patient how to breathe and at first assure him, and as narcosis comes on command him to do what is necessary. No desultory or detracting conversation should be permitted. A small but efficient faradic apparatus must be within call of the administrator. Sterile vaselin should be smeared about the nose and mouth to prevent skin irritation.