The principles and practice of modern surgery

by Roswell Park

The odor of most anesthetics is so distasteful to patients that they inhale at first with difficulty and with signs of irritation. Much of this can be guarded against by spraying the nasopharynx with a 1 or 2 per cent. solution of cocaine. This expedient will make anesthesia much easier for them. The mouth should be examined; all false teeth or foreign bodies, such as pins, chewing-gum, etc., should be removed. Unpleasant burning of the sensitive mucosa of the nose and lips may be avoided by anointing these parts with cold cream. Attention should be given to the avoidance of irritation of the eyes or the careless escape of an anesthetic into the conjunctival sac; with a struggling patient, or a careless administrator, this may easily happen.

Circumstances which would justify the administration of an anesthetic without the consent of the patient, or the friends or parents, occur but rarely; still in an emergency case, with a patient incompetent to decide for himself, the surgeon must assume the responsibility, in which in all probability the law will sustain him.

The anesthetizer should always be accompanied by an assistant; preferably in the case of a female patient, by a female nurse, who may not only be of assistance to him at the time, but an actual protection should the patient experience any erotic delusions during or after her period of anesthesia. This applies equally well to dentists giving nitrous oxide for the extraction of teeth, or physicians attending cases of accident, convulsions, and the like.

The anesthetics in general use are ether and chloroform. If statistics alone are appealed to it can be easily shown that ether is the safer of the two by a large ratio. But the recovery of consciousness by no means indicates the conclusion of the period of danger. The harm which chloroform does is largely done promptly, whereas the unpleasant effect of ether lasts through a much greater period, and the statistics which give ether an advantage are in many respects fallacious. Chloroform is doubtless the stronger and the more subtle agent of the two, and in careless hands would, in all probability, become the more dangerous. But no anesthetic should be given carelessly, and no one should give it who cannot give it properly. There may be emergency cases, especially in the rural districts, in which the surgeon may have to act in the capacity of anesthetizer and operator as well, and where he may have to transfer the inhaler to some lay assistant who knows nothing of the action of these drugs. If this happen it would be safer to use ether.

When administered by a thoroughly competent person chloroform is the safer anesthetic of the two, and is usually to be preferred. So largely does the personal equation figure in this consideration that it seems unnecessary to reproduce here statistical tables in regard to its efficiency.

ETHER.

The writer’s intention is to confine his views on anesthesia to the practical application of certain drugs whose chemistry, materia medica, and ordinary therapeutic properties are appropriately treated of in other works.

Ether anesthesia has by some been considered to be simply one form of carbon dioxide poisoning; that it may be all of this, in certain cases, may be granted; but it is certainly something more, as is shown, among other things, by the peculiar odor which persists in the breath of the patient for hours or even for days after its use. Various ways of administering it have been recommended. Some give it well diluted with air, and some give it as strong as a patient can possibly bear it, and from the outset. Some keep mixing air with the vapor, while others have devised inhalers, by which the same ether-ladened air is breathed over and over again. These latter produce a certain degree of the carbon dioxide poisoning above alluded to, and are not ideal even if effective.

Even when well diluted with air the vapor of ether causes irritation of the air passages, in both the nose and throat, and leads quickly to a sensation at first of oppression and then almost of suffocation, which is trying to the self-control of intelligent patients and disturbing to those having little or none. An inhaler saturated with ether should not be pressed tightly over the patient’s face, as it is likely to produce struggling to such an extent that weakened bloodvessels may give way and by their rupture produce serious disturbance.

The first momentary period of irritation having subsided, there will likely follow a few deep inspirations, and then perhaps a fixation and immobility of the chest, so that for half a minute or a minute it would seem as though the patient had forgotten to breathe (Hare). But deep respiration is quickly reëstablished, or may be stimulated by slapping the chest, by a few movements at artificial respiration, or at least by compressing the thorax. Then follows the period of “primary anesthesia,” so called, or a period of excitement, during which the patient may rave or become quite disturbed, and in a manner sometimes quite at variance with his ordinary temperament. As this period subsides the state of complete anesthesia begins, and when muscular relaxation is complete, or even before, the surgeon may commence his work. The respiration under complete anesthesia is usually deeper and sometimes more rapid than in health, while as the muscles become more relaxed a positively stertorous breathing is noted, along with an increase in flow of saliva, due to the irritation of the ether vapor. As anesthesia passes into complete narcosis, and this into asphyxia, the color of the surface, especially of the face, changes to a cyanotic hue, the skin becomes moist and clammy, and the pulse, which had been accelerated, fails. The blood also becomes exceedingly dark from lack of oxygen. Under these circumstances the heart may continue to beat feebly for a short time after respiration has ceased. As Hare puts it: “In producing its effects ether first attacks the perceptive and intellectual cerebral centres, next the sensory side of the spinal cord, next the motor side of the cord, then the medulla, and with this last depression death ensues.”