Frederick-Emil Neef

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 46irritation. 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. ”

“ 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. ”

“ 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. ”