Narcosis

“ The danger of asphyxia increases every moment, and it is necessary to have ready the means of throwing in a stream of pure air or of oxygen, through the nose, sprinkling the patient with cold water at the same time. Nagel has also observed that the restlessness and oppression produced by half-felt pain in incomplete narcosis, and the consequently insufficient respirations, may produce an even fatal exhaustion. Narcosis should therefore be properly kept up as long as it is wanted. ”

“ In the next stage, the narcosis deepens into dangerous coma; the patient can no longer be roused by noises, shaking, or external stimuli; the breathing is loud and stertorous; the face often pale; the body covered with a clammy sweat. The pupils are still contracted, but they may in the last hours of life dilate: and it is generally agreed that, if a corpse is found with the pupils dilated, this circumstance, taken in itself, does not contra-indicate opium or morphine poisoning. Death occasionally terminates by convulsion. ”

“ The symptoms of ether [143] narcosis are very similar to those produced by chloroform. The chief point of difference appears to be its action on the heart. Ether, when first breathed, stimulates the heart’s action, and the after-depression that follows never reaches so high a grade as with chloroform. Ether is said to kill by paralysing the respiration, and in cases which end fatally the breathing is seen to stop suddenly: convulsions have not been noticed. The post-mortem appearances, as in the case of chloroform, are not characteristic. ”

“ The narcosis has no relation to the stimulation but one of accidental sequence. This is proved by the fact that in cases where a narcotic dose is absorbed with great rapidity, no signs of preliminary stimulation occur." [15]
This disposes of the popular objection to stimulants—based upon the long-exploded theories of vitalistic physiology [16] —that every stimulus is followed by a reaction. It is seen that when a man feels ill and depressed after the use of alcohol or tobacco, it is because he has not stimulated but narcotized himself. ”

“ They show us that it is possible by means of narcosis to convert an extreme type of a living system, with decrementless conductivity, into another extreme type of living substance, in which excitation in its progress meets with a strong decrement, like that seen in the rhizopods. The same results may also be obtained by asphyxiation and other forms of temporary and permanent injury of the nerve. ”

“ In the light of this observation it will be interesting to measure the tension both of normal and glaucomatous eyes during narcosis in a large series of cases, and if it is confirmed there will be an additional reason why in many circumstances general narcosis is advantageous in glaucomatous patients. ”

“ In all probability, the demand for an increased narcotic effect is due to a gradual alteration in the molecular structure of the nervous system caused by frequently repeated narcosis; and if narcosis be invariably avoided, in systems which are free from its inherited structural effects, the craving is never awakened. ”

“ If the narcosis has been conducted correctly the patient should become conscious promptly after operation. The premonitors of awakening are readily recognized, the 32corneal reflex becomes more active, the tonicity of the eyelid approaches the normal, a tear may appear in the eye, beads of perspiration are seen on the forehead, the patient may begin to mutter incoherently, the pulse becomes faster, the breathing loses its snoring character, and the patient begins to move his head. ”

“ Pupil In patients who have not received morphine before narcosis the pupil is, as a rule, a guide of some importance. If the pupil is narrow, examination of its reaction to light is generally superfluous. A wide pupil, however, often means one or the other extreme of narcosis. A wide pupil which reacts promptly to light indicates superficial anesthesia; the patient may need more of the anesthetic. A wide pupil which reacts to light sluggishly or not at all means that the danger line has been overstepped; the anesthesia is too deep; the patient must have air. ”

“ 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. ”

“ 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. ”

“ Corresponding to the cerebral paralysis, the blood pressure sinks, and the heart beats slower and weaker. [170] The Hyderabad Commission made 735 researches on dogs and monkeys, and found that in fatal narcosis, so far as these animals are concerned, the respiration ceased before the heart, and this may be considered the normal mode of death; but it is probably going too far to say that it is the exclusive form of death in man, for there have been published cases in which the heart failed first. ”

“ If the presence of a certain oxygen reserve in living substance is entirely set aside and a different explanation sought for the primary continuance of irritability after a complete withdrawal of the oxygen supply from without, the great difference of time in the setting in of the depression in narcosis and that of the complete elimination of the oxygen supply from without would make it necessary to assume the processes occurring in narcosis are entirely different in nature. ”

“ According to Jumelle, plants can even be narcotised, ceasing to assimilate and no longer being sensitive to the stimulus of light. Isolated animal cells, like leucocytes, lose through chloroform vapour their power of spontaneous movement, and many bacteria cease to multiply if in contact with chloroform water. According to Binx, chloroform narcosis in man is to be explained through its producing a weak coagulation of the cerebral ganglion cells. ”

“ There are a few persons who are never stimulated, but always poisonously depressed, by certain particular narcotics. There are a few persons—ourselves among the number—in whom a very temperate dose of coffee will often give rise to well-defined symptoms of narcosis. There are others in whom even the smallest quantity of alcoholic liquor will produce giddiness and flushing of the face. And there are still others upon whom tobacco, no matter how minute the dose, acts as a narcotic poison. ”

“ There is a widespread sentiment in existence that it is not a respectable thing to be even partly paralyzed by alcohol, but how few there are who consider narcosis as in any way connected with the use of tobacco. Its effect is more diffused and masked, and is not so acutely serious in individual cases, but through its interference with vital activity, tobacco is probably more generally injurious to the race than alcohol. ”

“ Just as in those habituated to the use of opium a full dose of the drug, which in the unhabituated would produce profound or even fatal narcosis, acts merely as a gentle stimulant, so in those constantly exposed to, and actually infected with, malaria from infancy, the poison sometimes fails to act as a febrogene. ”

“ There is only one point which at the first glance would not seem to agree entirely with the assumption. This is the fact that depression sets in with a relatively greater rapidity in narcosis than when the supply of oxygen is completely withdrawn. Depression of the centers in the spinal cord, which begins in about five to ten minutes after artificial circulation of an oxygen-free, alcohol-containing, saline solution, is not brought about for more than an hour when the same saline solution but without alcohol is introduced. ”

“ What has been commonly spoken of as the recoil from the stimulant action of a true narcotic is, in fact, simply the advent of narcosis owing to a large impregnation of the blood with the agent after the occurrence of stimulation, owing to a small one. Thus a man drinking four ounces or six ounces of brandy gradually, has not in reality taken a truly narcotic dose till perhaps half the evening has worn away ”

“ Rabbits of the ordinary weight of 2 kilos. are fully narcotised by the subcutaneous injection of 1 grm.; the sleep is very profound, and lasts several hours; the animal wakes up spontaneously, and is apparently none the worse. If 2 grms. are administered, the narcotic effects, rapidly developed, are much prolonged. There is a remarkable diminution of temperature, and the animal dies, the respiration ceasing without convulsion or other sign. Moderate-sized dogs require 6 grms. for a full narcosis, and the symptoms are similar; they also wake after many hours, in apparent good health. ”

“ In the great majority of cases, however, the incapacity has been probably induced by chronic narcosis resulting from the long-continued abuse of tobacco. Recent researches have shown that confirmed drunkards have after a while modified the molecular structure of their nervous systems to such an extent that they can never for the rest of their lives touch an alcoholic drink with safety. ”

“ This slight degree of alcoholic narcosis causes in man a temporary feeling of pleasure and gayety to which he soon becomes accustomed. In this way there is created in him a desire for more, too often with increasing doses.
Most narcotics, especially alcohol (either fermented or distilled) , have the peculiarity of exciting the sexual appetite in a bestial manner, thereby leading to the most absurd and disgusting excesses, although at the same time they weaken the sexual power. ”

“ Even a slightly bluish tinge of the ear demands attention. Usually, crowding is the cause, and a little more air allows the normal red flush to return. Slight pallor developing during the course of the narcosis should always be regarded as a danger sign. It means that the patient is in profound anesthesia, and that the heart is threatening 18collapse. The mask should be removed promptly and the patient allowed to breathe pure air. As long as the pulse is not weak or irregular one need not worry about the outcome. ”

“ We physicians, especially those who see many instances of nervous derangements, are constantly coming in contact with the deplorable derangements caused by hypnotic drugs, many of which are ordinarily classed as innocent. The action of narcotics presents none of the characteristics of normal sleep except the temporary arrest of consciousness; hence narcosis is not true sleep. It does not refresh and regenerate vigor as does normal sleep. To be sure, drug unconsciousness may and often does pass into sleep. ”

“ Now when a narcotic dose of alcohol is taken, the flow of gastric juice is prevented by local paralysis of the nerve-fibres distributed to the stomach. What then must happen? Solid food may remain undigested, in the stomach; [26] but liquid alcohol is easily absorbable, and has two ways of exit,—one through the portal system into the liver, the other through the lacteals into the general circulation, by which it will be carried chiefly to the organ which receives most blood,—namely, the brain. It is thus probable that no alcohol can be transformed after narcosis begins. ”

“ Old inebriates bear operations badly, and the mortality after any operation in such subjects is distinctly higher than in normal individuals. One reason for this is that considerably more ether or chloroform is required to produce narcosis in alcoholic subjects than in ordinary individuals. Ether and chloroform are very irritant to the kidneys. The kidneys are prone to be affected more or less in old alcoholic subjects. Death from oedema of the lungs or from some form of pneumonia is not infrequent in these post-operative cases, and gives as a rule but little warning of its approach. ”

“ The antitoxic properties of the thyroid against different products is also shown by the observations of Lanz [53] and Walter Edmunds, [54] who have found that animals without thyroid resist 23narcosis badly; and, as we have shown in a communication to the Paris Biological Society, [55] chloroform, like alcohol, produces a condition of hyperactivity in the thyroid gland, which results also in an excited mental condition. The observation that cases of Graves’s disease and of severe diabetes cannot stand narcosis may be related to this fact. ”

“ Fig. 28.—Esmarch Dropping Bottle.
Chloroform first affects the brain, then the sensory tract of the spinal cord, then the motor tract, followed by an involvement of the sensory path of the medulla, paralyzing the respiratory centers, while cardiac syncope [61] may come on at any time during narcosis. Death may be either due to respiratory or cardiac failure, often from both. To overcome this the anesthetic should not be crowded, nor should the apparatus be held too close to the mouth of the patient. ”