Anesthesia

“ 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 ”

“ Nurses speak of the post-anesthesia patient as living hope in their struggle to emerge from the deadening effects of the anesthesia; as living honestly in fretful, fearful thrashing. Nurses help these persons sustain hope and extend honesty through their care. ”

“ 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. ”

“ 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. ”

“ Whether the ANESTHETIZED cells are influenced or not must be determined by noting the physiologic functions of the body after anesthesia has worn off, and in animals by an examination of the brain-cells as well. It has long been known that the vasomotor, the cardiac, and the respiratory centers discharge energy in response to traumatic stimuli applied to various sensitive regions of the body during surgical anesthesia. If the trauma be sufficient, exhaustion of the entire brain will be observed after the effect of the anesthesia has worn off ”

“ 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. ”

“ 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. ”

“ Assuming that no unfavorable effect is produced by the anesthetic and that there is no hemorrhage, the cells of the brain cannot be exhausted in the course of a surgical operation except by fear or by trauma, or by both. Fear may be excluded by narcotics and special management until the patient is rendered unconscious by inhalation anesthesia. ”

“ Whatever drug is used, strong solutions are seldom necessary for application to the mucous membranes but the necessary time for its absorption is a prime requisite. To secure anesthesia of the conjunctiva and cornea, the solution is dropped into the eye at the outer canthus and as it flows off with the tears, it must be replenished three or four times until anesthesia is accomplished. In the nose, a spray over the site of incision or a pledget of cotton saturated with the anesthetic solution and allowed to rest in contact with that locality, will suffice. ”

“ 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. ”

“ 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. ”

“ He went to the hospital, and the anesthetist began to prepare him for the anesthesia. He told them that he wanted no anesthesia, as he was going to have the operation done without taking anything. The surgeon was loath to operate without some kind of general or local anesthetic, but he told him he wanted nothing, as he thought he could control himself. The surgeon consented, but had ready chloroform and a hypodermic with cocaine. The Doctor clinched his teeth and hands with all his might, and put himself into as powerful a tension as possible for about three minutes before lying on the table. ”

“ 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. ”

“ In many of the more severe conditions not to be classified as minor surgery, the surgeon may consider the comfort of the patient and his own convenience and employ local in preference to general anesthesia, even tho the patients may be of the most robust type. ”

“ 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. ”

“ In some cases of breech presentation, particularly among primiparæ, it is necessary to assist nature in the delivery of the child in order to save its life. Complete anesthesia is usually necessary at such times and the patient is preferably on a table or at the edge of the bed in a lithotomy position. ”

“ If the traumata under inhalation anesthesia are sufficiently strong and are repeated in sufficient numbers, the brain-cells are finally deprived of their dischargeable nervous energy and become exhausted just as exhaustion follows such strenuous and prolonged muscular exertion as is seen in endurance tests. Whether the energy of the brain be discharged by injury under anesthesia or by ordinary muscular exertion, identical morphologic changes are seen in the nerve-cells. ”

“ Anesthesia.—With the exception of the operator, the anesthetizer is the most important person at an abdominal operation. A careful, experienced anesthetizer is desirable in all operations, but especially so in an abdominal operation. Much more depends upon him than upon the assistant. The custom of trusting the anesthesia to the least experienced man is reprehensible. Many fatal cases after celiotomy may be attributed directly to the anesthesia. ”

“ The men who made the universities what they have continued to be down to the present time, had open minds for any great advances that might come. Accordingly, when the histories of anesthesia tell us that there was a form of anesthesia introduced during the thirteenth century by Ugo da Lucca, and that even some method of inhalation was employed for this purpose, it will be a surprise only to those who have never properly realized all that our educational forefathers of the early university days succeeded in accomplishing. ”

“ Under ether anesthesia the damage to the nerve-cells is at least four times greater than under nitrous oxid. Inhalation anesthesia is, therefore, but a veneer— a mask that "covers the deep suffering of the patient." The cause of the exhaustion of the brain is the discharge of nervous energy in a futile effort to energize the paralyzed muscles in an attempt to escape from the injury just as if no anesthetic had been given. ”

“ There is such a thing as anesthesia of pain, engendered by pain too exquisite to be borne. ”

“ Technic of Removal of Foreign Bodies from the Larynx.—The patient is to be placed in the author's position, shown in Fig. 53. No general anesthesia should be given, and the application of local anesthesia is usually unnecessary and further, is liable to dislodge and push down the foreign body.* Because of the risk of loss downward it is best to seize the foreign body as soon as seen ”

“ 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. ”

“ Nor in this connection should the rather too frequent untoward outcome of ordinary operative procedures and post-operative care be thoughtlessly passed by. Sometimes, even on the operating table, or more frequently during the period of recovery from anesthesia, or, in fact, at any time later, the sensitive mind may thus receive impressions which may persist permanently and prove to be sources of painful invaliding beyond all expectation. ”

“ 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. ”

“ Nowhere in the domain of surgery is the influence of the mind more important than in the production of anesthesia for surgical purposes. It is well known that intense preoccupation of mind will make an individual completely anesthetic even for very severe injuries. In battle men frequently are severely wounded, yet do not know it, or at least have no idea of the extent of the wound and of the pain that ordinarily would be inflicted by it. ”

“ 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. ”

“ It is to be remembered that in a majority of these cases the operation is undertaken to remedy a deformity, however caused, one that is not necessarily serious to health, and it would indeed be unwise to place such a [59] body in jeopardy or to take undue chances if they can be avoided. Ofttimes several operations, a few weeks apart, must be done and the frequent repetition of a general anesthetic might impair the health of the patient—a condition not associated with local anesthesia. ”

“ A limited amount of anesthesia may often be established by pressure over any resistant bony surface, in any zone compressed, and often the mere momentary contact with the galvanic cautery, or pressure with a sharp-pointed applicator, or with the thumb or finger-nail, will produce the same result. Contacts, especially with aluminum combs or pointed instruments, may be momentary, if frequently repeated, but protracted contacts are often necessary. ”

“ 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 39very 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. ”