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Title: Practical Points in Anesthesia
Author: Neef, Frederick-Emil
Language: English
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                            PRACTICAL POINTS


                          FREDERICK-EMIL NEEF
                       B. S., B. L., M. L., M. D.
                             NEW YORK CITY

                        [Illustration: colophon]

                           NEW YORK, U. S. A.
                       Surgery Publishing Company
                           92 WILLIAM STREET


                        COPYRIGHT, OCTOBER, 1908
                         SURGERY PUBLISHING CO.
                                NEW YORK



I have tried to present some of my impressions on the correct use of
chloroform and ether and of a very useful combination of
these—anaesthol. No doubt, my observations and conclusions will have to
be modified in many details by the experiences of others. I have merely
voiced a simple and coherent working theory, which has gradually forced
itself upon me as my views on the practice of anesthesia have become a
little broader and more comprehensive.

                                                     FREDERICK-EMIL NEEF

 941 Madison Avenue
 New York



 Preface, 5

 The Induction of Anesthesia—The German Hospital System, 9

 Cardiac Collapse, 12

 Respiratory Collapse, 13

 When Shall the Patient be Declared Ready for Operation, 15

 Maintenance of the Surgical Plane of Anesthesia, 16

 Some Important Reflexes, 22

 Vomiting During Anesthesia, 23

 Obstructed Breathing, 24

 The Use of the Breathing Tube, 26

 Indications for Stimulation during Anesthesia, 28

 The Influence of Morphine on Narcosis, 30

 General Course of the Anesthesia, 31

 Awakening, 31

 Recession of the Tongue after Narcosis, 33

 Post-Operative Distress, 34

 Morphine-Anaesthol-Ether Sequence, 36

 Minor Anesthesia with Ethyl Chloride, 38

 Intubation Anesthesia, 38

 Cases Requiring Superficial Anesthesia, 43

 Cases Requiring Anesthesia Of Moderate Depth, 44

 Cases Requiring Profound Anesthesia, 44

 Conclusion, 45


                          PRACTICAL POINTS IN

                      THE INDUCTION OF ANESTHESIA.

I can spare the reader the ordeal of many words by beginning in a
concrete way with the outline of a system of anesthesia that is now
largely followed at the German Hospital, New York City.

[Sidenote: The Mask]

The Schimmelbusch mask is used; this fits the face and is large enough
to include the bridge of the nose and prominence of the chin. It is
covered with a piece of thin flannel, and, over this, impermeable cloth
in the center of which a lozenge-shaped fenestra (1½”×1”) has been cut.
In the upper half of this little window with the flannel pane, on the
inside of the mask, a small wad of gauze is fastened. The mask is then
complete and _can be used for administering any anesthetic by the drop
method—chloroform, anaesthol or ether._ In giving ether one makes use of
the upper half of the fenestra with its separate ether pad; while
chloroform and anaesthol are given to advantage through the lower
portion. The chin, cheek and bridge of the nose are anointed with a
little white vaseline at the line of contact with the mask, and then the
latter is allowed to rest lightly on the face of the patient for a few
moments, until he can reconcile himself to the strange procedure, and
resumes his normal breathing. There must be absolute quiet. The
anesthetist alone may speak when he deems fit.

[Sidenote: The Induction]

[Sidenote: Primary Anesthesia]

The beginning is made with anaesthol or chloroform drop by drop. The
slightest objection on the part of the patient that the vapors are too
strong must be considered; irritation of the throat, slight coughing,
all merely emphasize that the introduction must be very gradual. If the
patient is solicitous about the efficacy of the anesthetic he should be
assured that there is no hurry, and he should be enjoined to take deeper
breaths, if he breathes too lightly. As long as the patient is conscious
he will respond to the injunction to take a deep breath; if he does not
respond to this request he has reached the _stage of unconsciousness—the
state of primary anesthesia_.

Sometimes a remarkable calm, a period of relative apnea, _precedes_ the
stage of excitement. At other times, this stage ushers the patient
_directly_ into the state of complete anesthesia. There need be no stage
of excitement at all. This is especially true if morphine has been
administered hypodermatically before narcosis, and if the induction of
the anesthetic is cautious and gradual.

[Sidenote: Surgical Degree]

_The surgical degree, the state of complete anesthesia_, is announced by
the respiration when it assumes the more or less well marked snoring
character of one who is fast asleep.

In the German Hospital system the patient, male or female, is given a
quarter of a grain of morphine sulphate hypodermatically half an hour
before narcosis. The anesthesia is always induced with anaesthol or
chloroform. _Where much blood is lost or the operation is of very long
duration one may at any time make the transition to ether by the drop
method without changing the mask._ As a rule, a morphine-anaesthol
narcosis is given with a few drops of ether now and then (ether
feeding), when a little stimulation is indicated. In a small number of
cases, among them choledochotomies and other operations on the
gall-bladder, particularly where there is jaundice, the
morphine-anaesthol introduction is followed by the ether drop method.

                           CARDIAC COLLAPSE.

Cardiac collapse is fortunately uncommon. It usually occurs during the
induction of anesthesia. Suddenly there is a marked pallor of the face
and the pulse becomes weak. It happens in chloroform, and occasionally
in anaesthol narcosis. When such a tendency is discovered _ether_ should
be given by the drop method.

_Gradual induction_ of anesthesia until the patient’s tolerance to
chloroform is ascertained, is of cardinal importance.

                         RESPIRATORY COLLAPSE.

Obstructed breathing developing during the induction of narcosis is apt
to be due to _crowding_. If obstructed breathing becomes manifest later,
that is, during the course of the operation, it may be due to
_inhibitory reflex elicited by the surgeon_. Traction on the gall
bladder or mesentery will sometimes evoke a peculiar noisy breathing
which does _not_ mean that the patient is insufficiently under the
influence of the anesthetic. The breathing becomes normal and
unrestrained as soon as the surgeon desists from these vigorous

[Sidenote: Crowding]

[Sidenote: Respiratory Collapse]

_Probably the most common of mistakes is crowding the anesthetic._ The
anesthetist becomes aware of faint, high pitched notes in the
breathing—the beginning of obstructed respiration. He examines the lid
and corneal reflex and these convince him that the patient is in the
state of _superficial_ anesthesia. Naturally, he gives more of the
anesthetic. To his great chagrin the breathing becomes progressively
more stertorous. The cyanosis which was at first slight, deepens. The
noisy breathing attracts the surgeon’s attention. The perspiring
anesthetist is enjoined to push the jaw forward; but the spasm of the
muscles is too great. The teeth are pried apart, barbarous instruments
are brought into play to pull the tongue forward. The patient has not
received sufficient air all this time—his face is slate-colored. The
nasal or pharyngeal tube, tongue traction, oxygen, artificial
respiration with rhythmic chest compression, stretching of the sphincter
ani, all follow in an illogical onslaught, until finally a long deep
breath is induced and the victim is resuscitated. The condition was one
of _respiratory-collapse_. The cause was crowding of the anesthetic.

                       WHEN SHALL THE PATIENT BE
                     DECLARED READY FOR OPERATION?

As soon as the first, unimpeded, snoring respirations are heard, the
cleansing of the field of operation may begin. If the cleansing
manipulations do not disturb the rhythm of the snoring respiration, the
rate of the pulse does not increase and the patient makes no defensive
movements, he is very likely already in the proper plane of anesthesia.
Note is at once made of the state of the pupil and lid corresponding to
this plane.

[Sidenote: Initial Incision]

When the surgeon makes the initial incision observation is again made as
to whether the rhythm of the respiration and the rate of the pulse
remain undisturbed and whether the patient continues to be passive; if
this is the case, the patient is considered to be in the correct plane
of anesthesia—the plane in which he must be kept throughout the

[Sidenote: Awakening Stimuli]

Of course, it is clear that the depth of the narcosis must, in a
measure, be proportionate to the magnitude of the awakening impulses set
up by the surgeon’s manipulations. In abdominal work these impulses are
more intense near the solar plexus of nerves, that is, in the upper part
of the abdomen. Traction on the mesentery or the introduction of long
gauze tampons into the abdominal cavity for “walling off” sets up
powerful awakening stimuli.

                             OF ANESTHESIA.

In order to conduct a narcosis scientifically one must know the signs of
sufficient anesthesia and the signs of awakening.

[Sidenote: Respiration]

The respiration is studied by watching the movements of the chest or
abdomen, by placing the hand in the vicinity of the nostril to feel the
respiratory current of air, or, best of all, for the respiration is
rarely noiseless, by listening to the breathing. The quality of the
breathing is noted. The faintest indication of a snoring respiration
means that the surgical degree has been reached. Any change in the
quality of the breathing compels the questions “Has the patient escaped
from the proper surgical plane?” “Is the anesthesia too deep or too
superficial?” or “Is the change simply a _respiratory reflex_ induced by
the surgeon’s manipulations?”

[Sidenote: Color]

The color of the _ear_ is a most useful guide. This does not hold good
of the color of the forehead. The forehead in some individuals becomes
cyanotic with slight changes of posture. The ear is not so subject to
postural influences and is therefore a less misleading indicator of the
venous condition of the blood. Even a slightly bluish tinge of the ear
demands attention. Usually, crowding is the cause, and a little more air
allows the normal red flush to return. Slight pallor developing during
the course of the narcosis should always be regarded as a danger sign.
It means that the patient is in profound anesthesia, and that the heart
is threatening collapse. The mask should be removed promptly and the
patient allowed to breathe pure air. As long as the pulse is not weak or
irregular one need not worry about the outcome.

[Sidenote: Pulse]

There are some advantages in choosing the temporal pulse as the guide,
instead of the radial pulse, which is ordinarily followed; occasionally
the temporal can still be felt when the radial has become impalpable.
The pulsation of the temporal artery is best felt by placing the index
finger flat over the tragus into the depression at the root of the ear.
The pulse is important because it tells how the heart reacts towards the
anesthetic and the surgeon’s manipulations. The _frequency_ is not very
important. Exceptionally, it may be 120 or 130 during the greater part
of an anesthesia without vital significance, if the _quality_ is good. A
diffuse and weakening pulse is a signal that the narcosis is too
profound and that the heart is in danger of collapse. A somewhat
irregular pulse may immediately precede or accompany the act of
vomiting, and it is not a cause for alarm.

Accessory to the respiration, color and pulse, but of lesser
significance, are the pupil, the cornea and eyelid, and the secretions.

[Sidenote: Pupil]

In patients _who have not received morphine before narcosis_ the pupil
is, as a rule, a guide of some importance. If the pupil is narrow,
examination of its reaction to light is generally superfluous. A wide
pupil, however, often means one or the other extreme of narcosis. A wide
pupil which reacts promptly to light indicates superficial anesthesia;
the patient may need more of the anesthetic. A wide pupil which reacts
to light sluggishly or not at all means that the danger line has been
overstepped; the anesthesia is too deep; the patient must have air.
Without knowledge of the reaction, every markedly dilated pupil should
be looked upon as prognostic of danger.

[Sidenote: Cornea]

To touch the cornea repeatedly with the finger for the purpose of
obtaining the corneal reflex, is a bad habit. The reflex can be tested
just as satisfactorily by shifting the eyelid gently across its surface.

A point worth remembering is that in the morphine-anaesthol (or
morphine-chloroform) anesthesia the corneal reflex may remain quite
active, while with ether it soon becomes feeble or extinct.

[Sidenote: Eyelid]

A useful indicator of the degree of muscular relaxation is, I believe,
the tonicity of the eyelid. The usual arm test is very misleading.
Flexing the elbow once or twice may give the impression that the muscles
are thoroughly relaxed, and yet, on repeating the manipulation five or
six times one may be surprised to obtain a sudden, powerful contraction
of the biceps, showing that the patient is still not fully under the
influence of the narcotic.

Normally the upper lid has a certain tonicity. If it is lifted gently by
means of the superimposed ball of the finger it springs back to its
natural position promptly. When the patient is fully under the influence
of the anesthetic, this tonicity is partly or completely lost and the
lid returns sluggishly to its natural position, or not at all. The
patient can sometimes be kept in a proper surgical plane by giving a few
drops of the anesthetic each time as the tonicity returns, and ceasing
when relaxation of the eyelid is obtained.

[Sidenote: Secretions]

[Sidenote: Individual Idiosyncrasy]

When the patient is under anesthesia to the surgical degree the activity
of the salivary, sweat and tear glands ceases. The accumulation of mucus
in the mouth, the appearance of a tear in the eye, beads of perspiration
on the brow all mean that the anesthesia is becoming superficial, that
more anesthetic is required. It is worth bearing in mind that these
indicators of the depth of narcosis do not, in all individuals, react
in exactly the same way. While initiating the narcosis the anesthetist
can get his bearings in regard to this point, and watch for any
individual idiosyncrasy which may exist.

It is unsafe to concentrate the attention on one sign, lest the general
aspect of the patient be overlooked.

The anesthetist watches _constantly_ the rhythm and quality of the
breathing, the color of the ear and the character of the pulse. From
time to time, only as occasion demands, he refers to the accessory signs
for confirmation. Should he, at any time, be in doubt about the depth of
the narcosis, the first step is always to desist from giving more of the
anesthetic until he has regained his bearings or the signs of awakening
are recognized.

                        SOME IMPORTANT REFLEXES.

[Sidenote: Pharyngeal Reflex]

(1) _Pharyngeal reflex._ Coughing does not necessarily indicate
awakening. It usually means that the vapor of the anesthetic is too
concentrated and irritates the air passages. “Holding the breath” occurs
even in fairly deep narcosis and has the same significance. The
treatment is to dilute the anesthetic by admitting air.

[Sidenote: Ano-respiratory Reflex]

(2) _Ano-respiratory reflex._ The crowing inspiration heard during
operation on the perineum or rectum, _does not indicate that the patient
should have more anesthetic_.

[Sidenote: Splanchnic Reflex]

(3) The reflex produced by traction on the gall bladder or mesentery is
similar in its significance to that of the ano-respiratory reflex.

                      VOMITING DURING ANESTHESIA.

[Sidenote: Vomiting]

It may happen to the conscientious anesthetist, who desists from giving
more of the anesthetic until he has regained his bearings, that the
patient suddenly shows signs of awakening, and vomiting begins. This is
a disagreeable, but generally not a serious interruption. The
anesthetist is absolute master of the situation. Although the patient’s
face turns somewhat blue during the vomiting efforts, the anesthetist
_should not attempt to push the jaw forward or exert traction on the
tongue_. The face is merely turned to the side and kept in position by
placing the hand on the cheek. The mouth and pharynx are cleansed gently
with a piece of gauze and the anesthetic is continued, drop by drop. It
is often surprising in such cases how rapidly the patient can be brought
back into the proper plane of anesthesia. There need be no fear that the
patient will fully awake.

                         OBSTRUCTED BREATHING.

Many anesthesias are unsatisfactory because the breathing is obstructed.
To my mind the prime cause of obstructed breathing is too great a
concentration of the anesthetic. The importance of avoiding the
_crowding of the anesthetic_ is the secret of a good narcosis.

[Sidenote: Concentrated Anesthetic]

The irritability of the air passages varies greatly in different
individuals. Concentrated vapor may cause reflex spasm of the larynx
and, consequently, obstructed breathing. This is the condition that
leads to what is ordinarily called _respiratory collapse_. It is due to
crowding—undue concentration—rather than excessive quantity of the
anesthetic. If there were no superior laryngeal and trifacial nerves to
warn the inexperienced or inattentive by closing the larynx to more of
the anesthetic, real _respiratory paralysis_, which is apt to be fatal,
and is due to direct toxic action of the anesthetic on the respiratory
centre, might be more common.

“Have I crowded the anesthetic?” is the first question that should be
considered when there are signs of obstructed breathing. The jaw is
rigid, the patient is almost awake, and yet the mask is lifted to admit
more air. Paradoxical as it may seem, the jaw begins to relax, the
breathing becomes free and the anesthesia at once more profound. The
reason is simple. As long as the spasm of the larynx persists the
anesthetic cannot readily pass the barrier to exert its physiological
action. As soon as the spasm is overcome by admitting air the anesthetic
can be freely inhaled. By observing the precaution to dilute the
anesthetic generously with air pharyngeal irritation and laryngeal spasm
can be avoided and an undisturbed narcosis secured.

[Sidenote: Valve-action of the Lips]

Sometimes, however, the obstruction is purely mechanical. It may be due
to compression of the trachea by a shoulder brace. In aged individuals,
after removing the tooth plate, progressively increasing cyanosis may be
due to _valve-action of the lips_. Expiration is unhindered, but
inspiration becomes impossible on account of collapse of the lips and
cheeks. The difficulty is overcome by turning the head to one side and
placing a spindle of gauze in the dependent angle of the mouth to keep
the lips apart.

[Sidenote: Recession of the Tongue]

There are other cases in which the base of the tongue drops back into
the oropharynx, and hinders breathing. There is a peculiar, noisy,
“fluttering” respiration which indicates this condition. The jaw-grip,
that is, pushing the jaw forward, is often insufficient. Most of us have
been taught to use the wedge, mouth-gag and tongue forceps at once in
such an emergency, but it is certainly desirable to escape this maneuver
whenever possible. A naso-pharyngeal catheter, or breathing tube of soft
rubber, passed through the nostril into the pharynx sometimes instantly
relieves the obstruction.

                     THE USE OF THE BREATHING TUBE.

[Sidenote: Breathing Tube]

The breathing tube is a soft rubber tube 5/16” in calibre and 7¼” in
length. The end is smooth and beveled and has an opening, there being a
second opening on the side, about a quarter of an inch distant. To
introduce it, the tip of the nose is lifted and the rounded end of the
catheter directed into the larger nostril perpendicularly to the face.
The use of a little white vaseline obviates friction and unnecessary
traumatism. The tube is pushed gently back into the pharynx behind the
receded base of the tongue until the respiratory air streams freely
through it. Very rarely, it is necessary to pull the tongue forward
until the tube is in position. At times it is of advantage to support
the angle of the jaw lightly, in order to get the full benefit of the
tube breathing. Oxygen, it is true, improves the color when the tongue
has receded and there is partial asphyxia, but no one will argue that it
_eliminates the cause of the obstruction_, viz., that the base of the
tongue has dropped back into the pharynx and occludes the way to the air

Sometimes, when the recession of the tongue is slight, supporting the
angle of the jaw helps, because the base of the tongue is carried
forward with it. Frequently, this is insufficient. The tongue may be
drawn forward by means of forceps or suture, but this method is crude
and necessitates also the use of a wedge and mouth gag. The same
accessories are imperative, when an attempt is made to introduce a
breathing tube _through the mouth_ into the pharynx. It is for these
reasons that the nasal route is preferred. The method outlined is
uncomplicated—its efficacy is often striking. It seems to be the
simplest solution of the problem to re-establish the respiratory air
channel, which has been occluded by the recession of the tongue.


[Sidenote: Volume of the Pulse]

[Sidenote: Camphor-Ether]

[Sidenote: Strychnine]

[Sidenote: Venous Infusion]

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

[Sidenote: Morphine]

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.


[Sidenote: Tranquil Narcosis]

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.


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.

[Sidenote: Termination of Narcosis]

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

[Sidenote: Post-operative Asphyxia]

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.

[Sidenote: Gas-Pain]

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.

[Sidenote: Vomiting]

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.

[Sidenote: Nausea]

[Sidenote: Thirst]

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.

[Sidenote: Pain]

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

                      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.

[Sidenote: Anaesthol]

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.

[Sidenote: Morphine Breathing]

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

[Sidenote: After-effects]

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

[Sidenote: Office Anesthesia]

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.

[Sidenote: Intubation Narcosis]

The method is simple. The anesthesia is carried to the surgical degree
in the ordinary way with anaesthol or chloroform. A soft rubber catheter
with an opening at the end and side, and varying in diameter between ¼
and ⅜ inch, is made smooth with sterile vaseline and then passed through
the nostril down into the naso-pharynx for a distance of about 7¼ inches
in the adult, to the vicinity of the larynx. If the respiratory air
streams freely through the tube it is assumed to be at the proper level
and the tube is anchored and held in place by making a single turn of
zinc oxide adhesive plaster about it, near the nostril, and fastening
the ends to the cheek. It is important that these straps adhere firmly
and the skin should therefore be cleaned with a little ether or
chloroform before they are attached. This naso-pharyngeal tube must now
be connected with a second tube, the _conducting tube_, to which a
perforated funnel covered with gauze is attached, or which is dipped
into a tumbler containing loosely packed gauze; the conducting tube
should lie by the side of the patient, beneath the sterile sheets and it
should be so long that the anesthetist can sit at the foot of the
operating table to administer the anesthetic.

Catheters, a piece of rubber tubing, some zinc oxide plaster, and a
tumbler containing some gauze, are, therefore, all that one needs in
order to improvise, in a few minutes, an adequate intubation apparatus.
In practice, simplicity is frequently important.

[Sidenote: Cocainization of the Pharynx]

_Cocainization of the pharynx is an unnecessary procedure._

For operations on the mastoid or brain the pharynx need not be tamponed
about the tubes. This is done only when blood is apt to flow down into
the air passages, as in resecting the upper jaw, in Kocher’s excision of
the tongue and various _intrabuccal_ operations.

In such cases, the Roser mouth gag is inserted and the tongue drawn
gently forward out of the way, while, aided by the index finger of the
right or left hand, a piece of gauze tampon is placed snugly about the
naso-pharyngeal tube or tubes. If a stream of expiratory air issues from
the tube it is certain that the pharyngeal openings in the tube have not
been plugged by the tampon or tenacious secretions. In certain
operations on the nose where _both_ nostrils are involved it becomes
necessary to introduce the tubes through the mouth—oro-pharyngeal

[Sidenote: The Surgical Plane]

[Sidenote: Pulse]

The anesthetist need not be at sea, although he is at a considerable
distance from the face and eyes, which he is accustomed to watch with
such care during narcosis. In any case, the _pupil_ is no longer a very
useful guide because the patient has received morphine. There is access
to the pulse at the wrist or the dorsal artery of the foot and its
regularity and quality can be noted. A _diffuse_ and _weakening_ pulse
wave is at once appreciated as a danger sign—too much chloroform—and
the tube should be disconnected from the funnel to admit pure air,
until the pulse has recovered its quality.

[Sidenote: Color and Breathing]

The color of the face can be observed; also the breathing movement of
the chest and abdomen, and the respirations are readily heard through
the tube. Any change in the character of the breathing or any hindrance
in inspiration or expiration is readily detected. From time to time the
funnel is disconnected and fluid which may have accumulated in the tube,
as for instance condensed anesthetic, is allowed to flow out.

[Sidenote: Clogging of the Tube]

Secretions clogging the pharyngeal end of the tube are expelled by
“milking” the tube, that is, forcing an occluded column of air through
it by stroking it between the finger and thumb in a direction towards
the patient, or allowing a gentle stream of oxygen to flow into its

As long as the breathing remains unembarrassed and regular, the pulse is
of good quality and a general, passive condition maintained, the patient
is in the normal plane of surgical anesthesia and any interference would
be meddling.


(1) Suprapubic prostatectomy and cystotomy after the skin incision is

(2) Nephrectomy in general, but especially in tuberculous and enfeebled

(3) Mastoid and brain operations.

(4) Osteotomy and operations on the extremities.

(5) Curettage and obstetrical manipulations.

                            MODERATE DEPTH.

(1) Trachelorrhaphy, Colporrhaphy and perineorrhaphy.

(2) Stretching of the sphincter and hemorrhoid operations.

(3) Resection of the rectum by the perineal or sacral route.

(4) Perineal prostatectomy.

(5) Inguinal and femoral herniotomy.

                        CASES REQUIRING PROFOUND

(1) Gynecological laparotomies: salpingo-oophorectomy and hysterectomy.

(2) Operations on the stomach or gall-bladder: gastro-enterostomy,

(3) Orthopedic manipulations necessitating complete muscular relaxation:
reduction of congenital dislocation of the hip.


Anesthesia is a science which deserves more attention.

The extensive use of ether and the experience that its incautious
administration is fraught with but little immediate danger, has gotten
the hospital interne into reckless habits which cling to him in
practice. There the anesthetist finds himself frequently compelled to
use chloroform, a narcotic many times more powerful than ether. In the
hands of the inexperienced, and above all, the inattentive, chloroform
is certainly a dangerous drug. But this does not detract from its great
value as an anesthetic and it would be illogical to condemn its use.

In the aged, we know that it is not so much the operation itself as
the broncho-pneumonia that often follows the anesthesia which deserves
grave consideration. Chloroform, or a chloroform-ether combination,
such as anaesthol, is undoubtedly, in such cases, preferable to pure
ether, because it causes less bronchial irritation. In the
morphine-anaesthol-ether sequence which I have tried to outline,
chloroform and ether are blended in a way most adequate for
anesthesia, and the system is so flexible that it readily adapts
itself to an anomalous case.

The difficulties in respiration so frequently encountered, even by the
experienced anesthetist, find a natural solution; if he has been
studying the case he will be able to judge whether the trouble is due to
crowding or to a mechanical cause.

I have no hopeful word for the anesthetist who is inattentive. Whether
the case is an apparently simple or a critical one, it should be
remembered that the good anesthetist, like the good surgeon, is he who,
besides being competent, has a conscience, and feels his responsibility,
who appreciates _that there are some who are anxiously awaiting the
outcome, and have a deep interest in the life that is in his hands_.


 Anaesthol, 36

 Anesthesia, Complete, 11
   Depth Required by Various Cases, 43
   General Course of, 31
   Induction of, 10
   Intubation, 39
   Minor, with Ethyl-Chloride, 38
   Primary, 11

 Anesthetic, Concentrated, 24

 Ano-respiratory Reflex, 22

 Asphyxia, Post-operative, 33

 Awakening, Signs of, 16, 31
   Stimuli, 16

 Breath, Holding the, 22

 Breathing, Influence of Morphine on, 37
   Mechanical Obstruction to, 25
   Obstructed, 24

 Breathing-tube, 26

 Camphor-Ether Stimulation, 29

 Cardiac Collapse, 12

 Cases Requiring Superficial Anesthesia, 43
   Deep Anesthesia, 44

 Clogging of the Anesthesia Tubes, 42

 Cocainization of the Pharynx, 40

 Collapse, Cardiac, 12
   Respiratory, 14

 Color, 17
   In Intubation Anesthesia, 42

 Complete Anesthesia, 11

 Cornea, 19

 Coughing During Narcosis, 22

 Crowding, 13, 24

 Degree, Surgical, 11
   In Intubation Anesthesia, 41

 Distress, Post Operative, 34

 Ethyl-Chloride, Minor Anesthesia with, 38

 Eyelid Test, 20

 Gas Pain, 34

 Holding the Breath, 22

 Idiosyncrasy, Individual, 21

 Incision, Initial, 15

 Individual Idiosyncrasy, 21

 Induction of Anesthesia, 10

 Infusion, Venous, 29

 Initial Incision, 15

 Intubation Anesthesia, 39
   Color in, 42
   Clogging of the Tubes in, 42
   Pulse in, 42
   Respiration in, 42
   Surgical Degree, 41

 Lips, Valve Action of, 25

 Maintenance of the Surgical Plane, 16

 Mask, Schimmelbusch, 9

 Mechanical Obstruction to Breathing, 25

 Minor Anesthesia with Ethyl-Chloride, 38

 Morphine Breathing, 37

 Morphine, Influence of, 30

 Nausea, 35

 Obstructed Breathing, 24

 Obstruction, Mechanical, Breathing, 25

 Office Anesthesia, 38

 Pain, Post-operative, 36

 Paralysis, Respiratory, 24

 Pharyngeal Reflex, 22

 Pharynx, Cocainization of, 40

 Post-operative Asphyxia, 33

 Post operative Distress, 34

 Primary Anesthesia, 11

 Pulse, 18
   Volume of, During Narcosis, 29

 Pupil, 19

 Recession of the Tongue During Narcosis, 26
   After Narcosis, 33

 Reflex, Pharyngeal, 22
   Ano-respiratory, 22
   Splanchnic, 22

 Respiration, 16
   In Intubation Anesthesia, 42

 Respiratory Collapse, 14

 Respiratory Paralysis, 24

 Schimmelbusch Mask, 9

 Secretions, 20

 Signs of Awakening, 16, 31
   Of Sufficient Anesthesia, 16

 Splanchnic Reflex, 22

 Stimulation During Narcosis, 28
   With Camphor-Ether, 29
   With Strychnine, 29

 Stimuli, Awakening, 16

 Strychnine Stimulation, 29

 Sufficient Anesthesia, Signs of, 16

 Surgical Degree, 11
   In Intubation Anesthesia, 41

 Surgical Plane, Maintenance of the, 16

 Termination of Narcosis, 32

 Thirst after Narcosis, 35

 Tongue, Recession of, During Narcosis, 26
   After Narcosis, 33

 Tranquil Narcosis, 31

 Valve Action of the Lips, 25

 Venous Infusion, 29

 Volume of the Pulse During Narcosis, 29

 Vomiting During Anesthesia, 23
   After Anesthesia, 34


                           TRANSCRIBER’S NOTE

Punctuation has been normalized. Variations in hyphenation have been
maintained. Assumed printer’s errors have been corrected.

The following chapter headings appeared in the book but not in the
original table of contents, and have therefore been added to the
contents section of this e-text:

            Cases Requiring Anesthesia Of Moderate Depth, 44

            Cases Requiring Profound Anesthesia, 44

Italicized words and phrases are presented by surrounding the text with
_underscores_; boldfaced words and phrases are surrounded with =equal

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