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Foreign Office: Auckland Mouse, Basinghall Ave., London, E. C., Eng,


ST. LOUIS, MO., JULY, 1898.

No. 7.


(Written for the MEDICAL BRIEF.)

ing has taken place during the past Important Points in the Selection quarter of a century, and who are and Use of Anesthetics for

making, or have made, for themselves Surgical Operations.

names wbich will not easily be forgotten, will agree with me when I say

that success in surgery is not a little BY FREDERIC W. HEWITT,

dependent upon the skillful and efficient M.A., M.D., CANTAB.,

administration of anesthetics. I need Anesthetist at the London Hospital, Charing Cross

not go further into this aspect of the Hospital, and the Dental Hospital of London, London, Eng.

subject; I have merely referred to it in

order to justify myself for entering at In the early days of our present sys- some detail into certain points which tem of anesthesia, the administrator of seem to me to be worthy of attention. an - anesthetic was looked upon as

For the successful administration of an wholly unimportant and irresponsible anesthetic, certain preparations and preperson, and the administration itself as cautions are essential. There can be a perfectly thankless and perfunctory no doubt that the use of the term “minor task. Many years elapsed before it operation” is accountable, to some exbecame clear that in order to induce tent at least, for many of the difficulties and maintain safe and satisfactory un- which are prone to arise during anesconsciousness for a surgical operation, thesia. The healthy schoolboy who, considerable practice and skill were after a good dinner, is taken to an essential. Even at the present time it "oculist” to have a slight "squint” coris interesting to occasionally meet sur- rected, and who, there and then, is geons who, fortunately for the anes- given a "whiff” of chloroform, undoubtthetists who assist them at their opera- edly runs a far greater risk of losing his tions, still regard all difficulties which life under the anesthetic, than many a arise under the anesthetic as necessarily weaker patient who is kept deeply anesdue to peculiarities in the patients them- thetized for an hour for a comparatively selves. Most surgeons, however, and serious operation. There should be no certainly all, those whose surgical train. I such thing as minor surgery from the


anesthetist's point of view. Indeed, upon one side, the head being turned so whenever there is a tendency on the that one cheek rests upon the pillow. part of the surgeon to look lightly upon This rotation of the head to one the case, the anesthetist should be other side does not interfere with breathspecially careful. It is in such appar- ing, but any flexion of the head upon ently simple cases that the patient the sternum, or any extension or bendshould be carefully dieted, that the ing backward upon the spine should be clothing should be perfectly loose, that avoided. If such an extension be necesthe posture should be studied, that an sary, as is often the case in dental operaalternative anesthetic should be at hand, tions, it should not be permitted during and that every appliance which the the inhalation of the anesthetic; but anesthetist would consider necessary in directly this is at an end, the head more lengthy cases should be in readi- may be thrown back for the extracness. During the whole of my experi- tion, great care being taken to prevent ence as an anesthetist, I have only once extracted teeth or roots from entering had to perform laryngotomy; but on the larynx. this particular occasion the operation Extension of the head upon the spine was the extraction of a single tooth at brings the base of the tongue and the the house of a dentist, and had I not epiglottis away from the opening of the bad tracheotomy instruments with me larynx, so that swallowing becomes in my bag the patient would certainly difficult or impossible, and the larynx, have died.

being thus deprived of its natural proAnesthetics should never be given to tection, is liable to be invaded by foreign patients with tightly fitting corsets, or substances, and to be thrown into a waist bands, and this applies as forcibly state of irritability which may greatly to nitrous oxide as to chloroform or interfere with good anesthesia. Whether ether. With regard to food, the best the patient be sitting or lying, the head course is to interfere as little as possible should, therefore, be kept in the long with the patient's usual hours for meals, axis of the body. The worst posture, but to allow an interval of at least four from the anesthetist's point of view, is or five hours between the last meal and that in which the patient's body is half tbe operation. It is a mistake to give way between the vertical and horizontal, patients milk, eggs, soup, etc., at hours and the head is somewhat extended. In when they are not accustomed to take this position, mucus, saliva, and (if the food. It is always a good plan to in- operation involve the mouth or nose), spect the mouth before giving an anes- blood, can only gravitate towards the thetic, and to observe whether the laryngeal orifice, and difficulties, often patient breathes freely through the erroneously attributed to “idiosynnose. Very loose teeth should be noted crasy,” or other causes, will be certain for they may easily become dislodged

to arise. The remarks here made apply, by gags, or by wiping out the mouth.

of course, to patients who are not the Not very long ago a case occurred at the subjects of any respiratory affection. London Hospital in which a “quid” of Should the patient breathe better in one tobacco, which was present in the mouth position than in another, his wishes and before the anesthetic was given, set comfort should be studied and modifiup symptoms of an asphyxial character, cations in the usual rules should be which, however, subsided when the for- adopted. eign substance was expelled by coughing. Whilst everyone admits that nitrous By far the most frequent error, so far

oxide is the best anesthetic for very as preparation is concerned, is a faulty brief operations, opinions are stih position of the patient's head. This divided as to the most suitable agent applies particularly to dental practice, in general surgical practice. All statisand to operations involving the mouth, tics, worth consideration, go to show throat, or nose. In ordinary surgical that, so far as the risk upon the operacases the administrator should com- ting table is concerned, ether is very mence the inhalation with the patient greatly in advance of chloroforni in lying either perfectly flat or slightly point of safety. But that fatalities from ether-bronchitis and ether-pneumonia cumstances permit, to have another may occur, there can be no doubt; and anesthetic-I refer to the A. C. E.* until some properly organized inquiry | mixture - other inhalers, and certain into the frequency of such sequelæ has restorative drugs, such as amyl nitrate, been made, it is impossible to say what strychnine, and digitalis at hand; but the precise risks from these two anes- these are of secondary not of primary thetics may be. Again, in hot climates, importance. The more one sees of anesexperience goes to show that chloroform thesia the less need does one find for the anesthesia is safer than it is elsewhere; use of any restorative measures, save so that even though the chloroform early and efficiently performed artificial death-rate may be very considerable in respiration, and proper posture. I do England, we must not assume that it not deny that ether may be very adwill be equally high in other countries. | vantageously used as a restorative when The use of chloroform, indeed, seems to pallor and feebleness of pulse arise be far less likely to be attended by acci- | under chloroform; nor do I wish to say dent in tropical than in more temperate anything against the injection of strychclimates.

nine or digitalis when the patient's cirIt is fortunate that this is so, seeing culation has been depressed from that the use of ether in high tempera- surgical causes. But I am convinced tures is a matter of difficulty or impossi- that valuable time has over and over bility. There is yet another point to be again been lost in applying these and borne in mind in discussing the choice other remedies, when the anesthetist of anesthetics. We must take into ac- ought to have been directing his attencount the general circumstances under tion to re-establishing breathing, and which the operation is undertaken. placing his patient in a proper posture. Whilst we may hold very strong views With the equipment which I have menas to the best lines of procedure in a tioned as essential, either (1) ether may well-appointed London operating thea- be given throughout, or (2) chloroform ter, it is obviously ridiculous to expect throughout, or (3) ether may be prethe country practitioner, already labor- ceded by chloroform, or (4) chloroform ing under great disadvantages as to preceded by ether. The first plan is assistance, appliances, etc., to work useful in anesthetizing vigorous men, upon such lines. All we can say is, that for, when Clover's inhaler is used in speaking in the most general terms, the proper manner struggling is generetber is safer than chloroform, and for ally avoided. The second is to be prethis reason should be used whenever ferred in anesthetizing infants, young circumstances permit.

children, and elderly persons; it is also The discovery of Clover, that the advisable when any distress in breatheffects of ether may be safely and con- ing is present, in mitral stenosis or veniently intensified by employing a regurgitation with pulmonary sympbag-inhaler bas had the effect of render- toms, and in similar conditions. The ing the use of this anesthetic far more third is indicated when ether produces satisfactory than it formerly was. difficult breathing, cough, or much musMuch less ether, too, is needed than cular spasm. And the fourth plan may when using comparatively "open" in- be followed if the patient dislikes a halers. Every one in general practice closely fitting mask, the chloroform ought, therefore, to make himself thor- being only given up to, but not beyond oughly acquainted with Clover's ether the point, at which rigidity and struginhaler, and to follow Clover's instruc- gling begin. Such lines of procedure as tions in its employment. Equipped with those just sketched out may be adthis, with a simple chloroform mask, vantageously followed by country pracwith bottles containing the two agents, titioners to whom simplicity is a conand with a Mason's gag, a tongue for- sideration. Should the anesthetist have ceps, and tracheotomy instruments, the nitrous oxide, or the A. O. E. mixture, great majority of cases may be success- or both at his disposal, a better system fully anesthetized. I do not mean to

*The A. C. E. mixture consists of alcohol, one say that it is not advisable, when cir

part; chloroform, two parts; ether, three parts.

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