General 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. ”

“ 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. ”

“ CHAPTER IV—ANESTHESIA FOR PERORAL ENDOSCOPY A dyspneic patient should never be given a general anesthetic. Cocaine should not be used on children under ten years of age because of its extreme toxicity. To these two postulates always in mind, a third one, applicable to both general and local anesthesia, is to be added—total abolition of the cough-reflex should be for short periods only. General anesthesia is never used in the Bronchoscopic Clinic for endoscopic procedures. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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, 22he 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. ”

“ 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. ”

“ 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. ”

“ 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 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ If the patient is induced to vomit, he should immediately be turned on his side to prevent the indrawing of the ejected matter into the lungs. After it has ceased, thoroughly wipe out the mouth with a long-handled sponge. The anesthetic must now be crowded slightly to overcome the irritation of the mucous membrane of the stomach. Often during the early stage of anesthesia the patient stops breathing, which must be overcome by slapping the chest or by two or three forceful downward movements on the epigastrium. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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 ”

“ 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. ”

“ 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. ”

“ 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. ”

“ At first the pulse is slightly stronger and fuller than the normal, but it soon loses its strength and volume and becomes more rapid. The pupils are at first dilated, and as narcosis is induced, contract. Should they contract after this, during operation, it is a danger signal not to be neglected. Death may come on suddenly.
If the patient struggles violently under early anesthesia, as is often seen in alcoholics and athletes, it is not advisable to push the chloroform nor should total muscular relaxation be effected. The arrest of reflex movement is all that is required. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ 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. ”