Plastic and cosmetic surgery

by Frederick Strange Kolle

The wire frame affair, to be covered with a fold of muslin, designed by Schimmelbusch, is perhaps the best ([Fig. 29]). Another splendid inhaler is that of the Leiter improvement of the Esmarch folding frame ([Fig. 30]).

A folded towel, crumpled or pinned into a hollow oval form, may be substituted for the above.

Begin by pouring about thirty drops upon the inhaler, gradually bringing it nearer from a distance of six inches to the mouth and nostrils of the patient; then continue by letting one drop fall upon the apparatus every five or ten seconds until the patient is thoroughly anesthetized; then use one drop about every ten seconds, although it might be necessary to push this quantity at certain moments of the operation. To obtain complete anesthesia by this method takes about ten minutes. The vapor should be thoroughly mixed with air in the proportion of ninety-five per cent of air to five per cent of the vapor. The amount administered during operation can rarely be determined, because of the uneven respiration of the patient, who takes more during frequent inspiration than during ordinary breathing. By all means do not let the chloroform trickle upon the skin or into the eyes, as it causes considerable irritation.

The respirations are at first full and deep, soon becoming shallow and rapid. At first the pulse is slightly stronger and fuller than the normal, but it soon loses its strength and volume and becomes more rapid. The pupils are at first dilated, and as narcosis is induced, contract. Should they contract after this, during operation, it is a danger signal not to be neglected. Death may come on suddenly.

If the patient struggles violently under early anesthesia, as is often seen in alcoholics and athletes, it is not advisable to push the chloroform nor should total muscular relaxation be effected. The arrest of reflex movement is all that is required.

As the reflex action of the cornea disappears last of all, the anesthetizer can use this as a guide during further administration to avoid all danger. This is accomplished by gently touching the cornea with the index finger, raising the eyelid with the third finger.

Chloroform lowers the body temperature, due undoubtedly to its aiding in the dissipation of heat and by reason of its effect on the nervous mechanism of heat production. It is rapidly eliminated by both the lungs and the kidneys, because of its high volatility, and as little is given, the irritation to these organs is not as great, volume for volume, as with ether.

In case of asphyxia the lower jaw must be pushed far forward, the tongue be drawn forward with forceps, and the head extended and lowered, by raising the feet off the table. Cold water should be dashed over the face and chest. Slapping the chest with a wet towel and vigorously rubbing with hot cloths or brushing the palms and soles. Brandy and water, one to two parts, can be introduced into the rectum, or faradization of the nasal mucous membrane can be tried. These means failing, artificial respiration (Sylvester’s method) must be resorted to. This being of no avail, tracheotomy must be done.

If the patient is induced to vomit, he should immediately be turned on his side to prevent the indrawing of the ejected matter into the lungs. After it has ceased, thoroughly wipe out the mouth with a long-handled sponge. The anesthetic must now be crowded slightly to overcome the irritation of the mucous membrane of the stomach. Often during the early stage of anesthesia the patient stops breathing, which must be overcome by slapping the chest or by two or three forceful downward movements on the epigastrium.

If the face of the patient takes on a sudden change of color or breathes heavily the anesthetic should be withdrawn for a few moments, until the symptoms abate. If the mucus collects about the glottis it is liable to cause respiratory difficulty and must be swabbed out. If the inversion of the patient does not relieve syncope and the methods already mentioned fail to relieve, injections of normal salt solution into the median basilic vein must be employed as a last means.