Anesthesiologist

“ 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 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 ”

“ It is wiser to give a general anæsthetic, such as gas and oxygen, as the pain of the operation may be intense. If this is refused, local anæsthesia by Gray’s solution (see p. 310) or by a subcutaneous injection of cocaine and adrenalin may be employed. In infants an anæsthetic is not necessary.
The patient may be sitting up or lying down. If a general anæsthetic has not been given, the patient’s head must be held firmly by an assistant in order to prevent sudden movement. The surgeon works by reflected light in order to obtain a clear view of the tympanic membrane. ”

“ 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 deliberate and confident manner and word of the surgeon go a long way in guiding the feelings of his patient, and a worried or apprehensive surgeon makes for a doubtful and sensitive patient, ready to cry out at the first prick of the needle. Therefore it is a part of good general technic for the surgeon to deport himself in a way conducive to cheerfulness, and conversation must be guided along these lines.
There are many who will writhe and groan at sensations (which they will admit later were not painful) incident to local anesthesia, such as the grating vibrations of instrumentation. ”

“ Care, however, should be taken to inject just sufficient of the solution to penetrate beyond the zone of operation laterally, to insure sufficient space for the insertion of sutures into anesthetized tissues. Only a small quantity of fluid is necessary in this procedure as it comes in direct contact with nerve terminals. By touching the injected line with the needle in several places along its length and inquiring of the patient if it is felt, we may make sure of the completeness of the anesthesia before making the incision which should begin and end inside the anesthetized area. ”

“ 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. ”

“ Without dissection what can they know of anatomy? and unskilled in anatomy, how can they guide the knife healingly among the intricacies of the human frame? Yet all the operative surgery in this hospital is the care of the native surgeon, by whom the most formidable operations are successfully performed. ”

“ Can anyone then doubt that under existing conditions a great deal of unnecessary and mischievous operating is bound to go on, and that patients are encouraged to imagine that modern surgery and anesthesia have made operations much less serious matters than they really are? When doctors write or speak to the public about operations, they imply, and often say in so many words, that chloroform has made surgery painless. People who have been operated on know better. The patient does not feel the knife, and the operation is therefore enormously facilitated for the surgeon ”

“ To this poor sufferer insensibility is next to heaven. For the past half century all the formidable operations of the surgeon have been performed with the aid of anæsthetics and without suffering to the patient, producing happy recoveries, and greatly contributing to the success of the result by relieving the surgeon of the distraction of the patient’s pain, and the interference of his involuntary movements. Quite a number of anæsthetics are known and used to-day. Those more generally employed are—naming them in the order of their first application—nitrous oxide gas, ether, and chloroform. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ The surgeon, before commencing an operation, is enjoined to equip himself with all the requisites, such as the instruments, salts, bandages, honey, oil, water, etc. He should have practical experience of his art, and should have seen many surgical operations performed by others. He should be intelligent, steady, skilful, and should execute his work with a light hand. He should have by his side steady and strong attendants to assist him. The patient should be allowed to take light food before any operation is performed upon him. ”

“ When there are evidences of chronic myocarditis or a history of broken compensation and the borderline of compensation and dilatation is very narrow, or when there is arteriosclerosis, the danger from an anesthetic and an operation is much greater; it may be serious, in fact, and the decision must be made whether or not the operation is absolutely necessary. Under any circumstances it is understood that the anesthetist must be an expert, as there can be no carelessness and nothing but the best of judgment in causing anesthesia when there is cardiac defect. ”

“ An assistant then holds it upwards, while the surgeon, or (if the arm is very muscular) another assistant, brings the arm forwards well across the patient's chest, thus exposing the posterior aspect of the joint. This may have very possibly been already opened during the transfixion; the attachments of muscles must now be divided, the knife passed behind the head of the bone, which is dislocated forwards, and a suitable flap of the tissues in front cut from within outwards. The assistant is to follow the knife with his finger and compress the vessels. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ Sixty-five years ago, for a young medical practitioner in an obscure village, far from contact with centers of thought, removed from railroads, enjoying but modest postal facilities, with no great hospital organizations or medical associations to confirm his professional research, for a modest, diffident, young physician to claim so startling a discovery as anesthesia has proven to be without first securing most exhaustive proof of its worth, would have brought upon him the adverse criticism of his elders, and possibly the laughter of his colleagues. ”

“ The discovery of anæsthesia and the promulgation of the germ theory of inflammation, together with the subsequent perfection of the means of destroying microbes, all within the memory of many now living, have revolutionized surgery to such an extent that the surgeon reaches fearlessly into regions which before were impracticable, and undertakes operations which620 were never even dreamed of a generation ago. One can readily imagine that no surgeon would care to undertake, and no patient would endure, the agony of an operation lasting for several hours without an anæsthetic ”

“ 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 surgeon, a little, fussy man, but I believe with some skill to justify his pretensions, now entered the room, carrying his case of instruments, and followed by servants bearing basins and water and bandages of linen. He relieved our doubts by instantly assuring us that 'the patient' was still living; and at the same time professed his determination to take advantage of the muscular relaxation which the faint had induced to examine the wound—adding that a patient was more easily 'handled' when in a swoon than under other circumstances. ”

“ His text-book of surgery is full of expressions that reveal the man and the teacher. He said the surgeon who cuts the human body without a knowledge of anatomy is like a blind carpenter carving wood. He insisted that men should make observations for themselves and not blindly follow others. He discussed operations on the head, the thorax and the abdomen. He said that wounds of the intestines would surely be fatal unless sewed up, and he described the technique of suture for them. His specialty was operation for hernia. ”

“ 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. ”