Anaesthesia

“ Very few of us have realized, however, the perfection to which anæsthesia was developed, and the possibility this provided for the great surgeons of the later medieval centuries to do operations in all the great cavities of the body, the skull, the thorax, and the abdomen, quite as they are done in our own time and apparently with no little degree of success. ”

“ Any one of the sense-organs, or any sensory region such as the skin or deep tissues of one limb may be rendered anaesthetic by verbal suggestion, aided perhaps by some gentle manipulation of the part. On this fact depends the surgical application of hypnotism. Sceptical observers are always inclined to doubt the genuineness of the anaesthesia produced by a mere word of command, but the number of surgical operations performed under hypnotic anaesthesia suffices to put its reality beyond all question. A convincing experiment may, however, be made on almost any good subject. ”

“ The use of cocaine and adrenalin—even in patients under a general anæsthetic—helps to avoid it,49 and anæsthesia should never be too deep or prolonged. When operating under local anæsthesia it is sometimes wiser not to attempt too much at one sitting, e.g. to treat only one side of the nose at a time. In certain conditions, and when a general anæsthetic is employed, it may be safer to try and complete treatment at one operation. ”

“ Freezing of the skin or other method of local anæsthesia suffices to allow of the painless introduction of the needle. A general anæsthetic should be avoided wherever possible, as the burning sensation experienced by the patient when the nerve-trunk is encountered greatly assists the accuracy of introduction. ”

“ I.—On Anaesthesia and Anaesthetic Substances generally; being an Experimental Inquiry into their Nature, Properties, and Action, their comparative Value and Danger, and the best means of counteracting the effect of an over dose. ”

“ Anaesthesia is also a condition which may be produced in the hypnotic sleep,—a fact well recognized by the ancients, although the attention of scientific men was scarcely drawn to the fact until the days of the notorious Mesmer. The substances which may produce loss of consciousness may be taken intentionally or unintentionally, and maybe taken into the stomach, beneath the skin, or, when gaseous, through the lungs, in which absorption of the same into the blood is very speedy. ”

“ Thanks to the several modern modes of inducing anæsthesia, the patients of to-day need have little fear of the knife, for they are assured that they will be rendered insensible to pain during and for a time after operation. ”

“ On some occasions, indeed, there are groans and cries, as of suffering; but the mind being unconscious of pain, it can hardly be said to exist.
It may be remarked, that complete anæsthesia is never induced in midwifery, unless in some cases of operative delivery. The diminution of common sensibility to a certain extent, together with the diminution or removal of consciousness, suffice to prevent the suffering of the patient during labour; and she never requires to be rendered so insensible as in a surgical operation, when the knife may be used without causing a flinch or a cry. ”

“ Nearly every book on hypnotism gives various rules for detecting simulation of the hypnotic state. One of the commonest tests is that of anaesthesia. A pin or pen-knife is stuck into a subject to see if he is insensible to pain; but as we shall see in a latter chapter, this insensibility also may be simulated, for by long training some persons learn to control their facial expressions perfectly. We have already seen that the pulse and respiration tests are not sufficient. Hypnotic persons often flush slightly in the face ”

“ throw out wine, which is a food, and the vapors which produce the miracle of anaesthesia, and I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind,—and all the worse for the fishes. ”

“ In minor or trivial affairs the elimination of pain is not to be considered lightly, for every patient, even the strongest, will appreciate [Pg 235] anything which will expedite a cure and at the same time will relieve him of suffering. Rather than lose time from their work or suffer the nausea and dangers of general anesthesia, these patients often bear for years conditions which could easily be cured by operations under local anesthesia. In this class one must first think of hemorrhoids; of cysts; of fatty tumors; of foreign bodies in the hands and feet; of verruca and of ingrown nails. ”

“ 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. ”

“ Among the advantages, aside from the number of assistants required and the discomfort immediately following the administration of a general anesthesia, are the absence of remote ill effects of the invasion throughout the entire system of a noxious chemical substance and its direct deleterious effects on many large organs such as the lungs, heart, kidneys, and liver, and the assurance, when a proper drug, dosage, and technic are employed, that death cannot be ascribed to the anesthetic. ”

“ 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. ”

“ Not only is it desirable in the minor surgical operations and the more important ones upon patients suffering with a cardiac or nephritic derangement, where a general anesthetic is positively contraindicated, but in every instance where it is at all possible, the dangers and annoyances of general anesthesia should be avoided, and the regional or local anesthesia should be employed. ”

“ Though the patient may be convinced that he will suffer no pain, the mental attitude toward the local anesthesia, together with fear, may operate so strongly as to constitute a shock to the nervous system so great that a general anesthetic should be used and the local method abandoned, even were it apparently indicated.
Again, the injection of anesthetic drugs in cicatrical and inflamed tissues is quite difficult of accomplishment and because of the peculiarity of these tissues, diffusion throughout a given area is imperfect, hence insensibility is not complete. ”

“ There was anesthesia to pain and heat, as well as in bones and joints, along with the tactile anesthesia. There was a hyperesthetic region on the right side, corresponding with the distribution of the fourth dorsal root. All the cutaneous reflexes up to the abdominals were gone; but defense reflexes could be brought out in foot and leg by skin, bone or joint stimulation. The deep reflexes of the legs were also lost, whereas those of the arms were increased. Retention of urine without incontinence; no retention of feces. ”

“ The choice of the anesthetic is of great importance as to the outcome of the operation. The Basedow’s type with predominating nervous, myasthenic and psychic symptoms is best operated on under general anesthesia, the other cases under local anesthesia. 5. Operation is contraindicated in status lymphaticus; if it can not be avoided, a local anesthetic should be employed. 6. In many cases the operation only lays the foundation for successful internal treatment. 7. The most unfavorable time for operation is that of increasing intensity of the disease ”

“ 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 [62] 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. ”

“ Among the unconscious responses to trauma under ether anesthesia are purposeless moving, the withdrawal of the injured part, and, if the anesthesia be sufficiently light and the trauma sufficiently strong, there may be an effort toward escape from the injury. In injury under ether anesthesia every grade of response may be seen, from the slightest change in the respiration or in the blood-pressure to a vigorous defensive struggle. ”

“ Local or general anesthesia should be resorted to in painful and serious surgical operations, as operations upon all living creatures should be humanely performed and all unnecessary pain and suffering avoided. ”

“ 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. ”

“ The movements of the diaphragm must be constantly watched as it is the first to become paralyzed when anesthesia is carried too far. The same care must be observed with the pupil for cerebral and the pulse for cardiac signs. Before giving this anesthetic the same preparations as for chloroform narcosis should be observed. The stomach should be empty, the nose and mouth smeared with vaselin, and the eyes protected with a towel.
At first the patient is given the ether with a considerable mixture of air, which should be lessened gradually. ”

“ A number of local anesthetics have been introduced, and in some hands only comparatively small quantities of them are needed in order to produce complete absence of pain during operations. In other hands, however, considerable and even toxic quantities may have to be employed and sometimes without entire satisfaction. Infiltration anesthesia depends for its success largely on the personal influence of the administrator over the patient. It is extremely important that the patient should have complete confidence and not have that confidence disturbed in any way. ”

“ For instance, he needs to be warned that he will feel the slight prick of the needle when it is first introduced, for otherwise he will be disturbed by even so slight a pain at the very beginning and will magnify subsequent feelings until satisfactory local anesthesia becomes impossible. Without thorough command over the patient and complete trust, local anesthesia never succeeds except in very minor operations. There are some men, however, who can do even severe and extensive operations with comparatively small amounts of local anesthesia. ”

“ The surgical operations are performed on what are considered auspicious days. The patient is made to sit or stand with his face to the east, the surgeon before him with his face to the west. The surgeon should be cautious that no vital part, artery, vein, joint, or bone is carelessly injured in the course of the operation, and that the instrument does not go deeper than the requirements of the case actually demand. In serious surgical operations, and in diseases of a painful nature, the patient was made insensible by the administration of anaesthetics. ”

“ The breathing becomes normal and unrestrained as soon as the surgeon desists from these vigorous manipulations.
Crowding 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 14respiration. 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. ”

“ Anesthesia is necessary where absolute immobility of the patient is essential and where entire muscular relaxation is indispensable. The anesthetic condition is also favorable for the adjustment of displaced organs. ”

“ The sanguinary part of the operation begins with the insertion of the cannula to supply artificial respiration. Then the right carotid artery is dissected out. Afterwards, while artificial respiration is being set up, a square opening is made in the left wall of the chest with a knife and the bone scissors. The opening is extended far into the right pleural cavity, and widened downwards till it reaches the diaphragm which is severed from the ribs. It is best to make the opening in the chest large enough to avoid any pressure on the heart from the lungs or other neighbouring parts. ”

“ Operative Treatment.—In aggravated cases, when the patient is suffering pain, when his occupation is interfered with by repeated attacks of phlebitis, or when there are large pouches on the veins, operative treatment is called for. The younger the patient the clearer is the indication to operate. It may be necessary to operate to enable a patient to enter one of the public services, even although no symptoms are present. The presence of an ulcer does not contra-indicate operation; the ulcer should be excised, and the raw surface covered with skin grafts, before dealing with the veins. ”