When the conjunctival reflex is present together with dilatation of the pupil, movements of the tongue, and other “reflex” efforts, the amount of chloroform should be increased.
During the first stage of the operation, when hæmorrhage is profuse, deep anæsthesia is undesirable for fear of blood passing into the larynx. To prevent this, after the incisions have been made, sponge pressure should be applied, and the head turned on one side. Any gurgling in the throat, or dusky colour of the face, indicating threatening laryngeal obstruction by blood-clot, needs an efficient application of a sponge on forceps behind the tongue, the effect of this being not only to remove blood, but also to stimulate closure of the glottis. The bleeding having been arrested, and the later stages of the operation reached, a deeper anæsthesia is necessary. Sudden increase or decrease of the amount of the anæsthetic will readily induce vomiting, and if much blood has been swallowed in the earlier stages, this contretemps may be inevitable in spite of all precautions.
Duties of the Assistant.
For the efficient performance of the various steps of the operation a skilled assistant is absolutely essential. His duties will consist, first and foremost, in keeping the pharynx clear of blood; secondly, in such dextrous use of sponges as will allow the parts to be clearly seen by the operator; thirdly, in the judicious use of a tongue depressor, when necessary; and fourthly, in exercising a careful supervision over the stitches before they are finally fastened.
For the purpose of clearing the pharynx, he must be provided with a pair of long smooth-nosed forceps ([Fig. 61 B]), and some small loose pieces of purified sponge; or the sponges may be fastened on pieces of stick about six inches long in such a manner and so securely that the necessary manipulations shall not detach them. The former of these methods is, I think, preferable.
The great art in clearing the pharynx consists in letting the sponge slide over the dorsum of the tongue, and then by a rotary movement of the wrist the clots are entangled upon its surface and easily removed. In this manipulation the sponge should not touch the palatal structures more than is absolutely necessary, as any friction or bruising of the edges when pared is highly injurious. Vomiting, moreover, is readily excited by too frequent sponging, especially about the uvula and soft palate.
Instruments.
Fig. 57.—T. Smith’s gag with tongue plate (Arnold).
