CHAPTER VIIANESTHETICS

Anesthesia of the human may be accomplished in two ways: first, by the employment of a general anesthetic, and, secondly, by the local use of a narcotic agent.

It is not the intention of the writer to dilate upon the nature and use of anesthetics, as their value and indication has been fully exploited. A concise review of these agents, however, will meet with the approval of the special surgeon, inasmuch as they have their particular use in individual cases. Local anesthesia is undoubtedly the most extensively employed, in the performance of the average plastic operation, yet in certain cases it is contra-indicated, and it is to further the proper selection of such that the following may be of value.

It must be understood that general anesthesia has its many advantages and equally its disadvantages. It necessitates the early preparation of the patient and a thorough physical examination as to the state of lungs, heart, and kidneys. Patients having cardiac affections or serious lesions within the lungs should be given the safest anesthetic obtainable; in fact, if the operation can possibly be done by local administration, it should be.

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 abody 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.

Neurotic subjects often insist upon the use of chloroform and the surgeon is frequently tempted to administer it, but little objection should be found with local narcosis, where it can be employed.

The patient must not be allowed food at least six hours prior to operation. In neurotic and anemic subjects a full dose of strong wine or whisky should be given half an hour before operation. Habitual drinkers should be given one quarter grain morphin sulphate. All movable artificial teeth, or other foreign bodies, must be removed from the mouth. Observe the laws of asepsis as heretofore described. Loosen the clothing of the patient about the neck and chest. Only a single garment should be worn during the time of operation—a loose, sterilized night robe, as it may be necessary to move the patient about, and too much or tight clothing might prove to be dangerous in the delay occasioned by its removal.

The operating room should never be cold enough to chill a patient so prepared. Hot-water bottles or a warm pack can be placed between or about the limbs to equalize the external circulation. This is especially necessary when chloroform is administered, as this lowers the temperature of the body. Have the bowels and bladder emptied. Choose the early part of the day for operations of some length, because the stomach is then empty and vomiting with resultant gastric disturbance will be lessened or entirely avoided. The anesthetizer should be experienced and attend to his duty implicitly. He must at all times watch the patient, takenote of the pulse, pupils, and respiration. Close by he must have a mouth-gag, tongue forceps, long-handled sponge holders, containing dry absorbent cotton sponges, and a basin in case of emesis.

He should quietly instruct the patient how to breathe and at first assure him, and as narcosis comes on command him to do what is necessary. No desultory or detracting conversation should be permitted. A small but efficient faradic apparatus must be within call of the administrator. Sterile vaselin should be smeared about the nose and mouth to prevent skin irritation.

(Guthrie) The pure product must be used. It is a colorless, mobile liquid, having an ethereal odor and sweet to the taste. It should not affect litmus or turn brown with sulphuric acid or give a precipitate with nitrate of silver. If there is emphysema of the lungs, bronchitis, or renal disease, chloroform is to be preferred to ether, also in operations about the oral cavity. Children bear chloroform narcosis better than adults.

Fig. 27.—Schimmelbusch Dropping Bottle.Fig. 28.—Esmarch Dropping Bottle.

Fig. 27.—Schimmelbusch Dropping Bottle.

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 syncopemay 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. The best method of giving it is by means of the dropping bottle of Schimmelbusch (Fig. 27) or that of Esmarch (Fig. 28) and a simple mask or apparatus.

Fig. 29.—Schimmelbusch Improved Folding Mask.Fig. 30.—Esmarch Inhaler.

Fig. 29.—Schimmelbusch Improved Folding Mask.

Fig. 30.—Esmarch Inhaler.

The wire frame affair, to be covered with a fold of muslin, designed by Schimmelbusch, is perhaps the best (Fig. 29). Another splendid inhaler is that of the Leiter improvement of the Esmarch folding frame (Fig. 30).

A folded towel, crumpled or pinned into a hollow oval form, may be substituted for the above.

Begin by pouring about thirty drops upon the inhaler, gradually bringing it nearer from a distance of six inches to the mouth and nostrils of the patient; then continue by letting one drop fall upon the apparatus every five or ten seconds until the patient is thoroughly anesthetized; then use one drop about every ten seconds, although it might be necessary to push this quantity at certain moments of the operation. 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 thevapor. 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.

The respirations are at first full and deep, soon becoming shallow and rapid. 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.

As the reflex action of the cornea disappears last of all, the anesthetizer can use this as a guide during further administration to avoid all danger. This is accomplished by gently touching the cornea with the index finger, raising the eyelid with the third finger.

Chloroform lowers the body temperature, due undoubtedly to its aiding in the dissipation of heat and by reason of its effect on the nervous mechanism of heat production. It is rapidly eliminated by both the lungs and the kidneys, because of its high volatility, and as little is given, the irritation to these organs is not as great, volume for volume, as with ether.

In case of asphyxia the lower jaw must be pushed far forward, the tongue be drawn forward with forceps, and the head extended and lowered, by raising the feet off the table. Cold water should be dashed over the face and chest. Slapping the chest with a wet towel and vigorously rubbing with hot cloths or brushing the palms andsoles. Brandy and water, one to two parts, can be introduced into the rectum, or faradization of the nasal mucous membrane can be tried. These means failing, artificial respiration (Sylvester’s method) must be resorted to. This being of no avail, tracheotomy must be done.

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.

If the face of the patient takes on a sudden change of color or breathes heavily the anesthetic should be withdrawn for a few moments, until the symptoms abate. If the mucus collects about the glottis it is liable to cause respiratory difficulty and must be swabbed out. If the inversion of the patient does not relieve syncope and the methods already mentioned fail to relieve, injections of normal salt solution into the median basilic vein must be employed as a last means.

(Jackson, Morton.) Sulphuric ether is used in the pure form, free from alcohol and water. It should be a colorless, volatile, mobile, and highly inflammable liquid, having a peculiar penetrating odor. As its vapor is much heavier than air, and owing to its combustible nature, lights about the room should always be placed above the patient. Often its vapor is ignited by the careless use of the electro-cautery.

Ether for anesthesia should not affect blue litmus. It should not give a blue color to ignited copper sulphate—thetest for the presence of water. Alcohol is indicated when it turns red by adding fuchsin.

Ether is less toxic than chloroform, therefore it requires a greater quantity to induce narcosis.

If properly administered it is by far safer than chloroform, Ollier, of Lyons, reporting only one fatality directly due to its employment in four thousand patients. If the anesthetic is crowded cyanosis with jugular pulsation is noted—the signs of inefficient oxygen and cardiac distention. In most recorded cases of death there were complications of a nephritic pulmonary nature. Ether should not be used where there is bronchitis, gastritis, or peritonitis, owing to its irritant effect on mucous membranes, nor in nephritis, aneurysm, or advanced atheroma. 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. Coughing comes on quite often, which is overcome by increasing the ether. Soon there comes a state of respiratory forgetfulness. This is caused by the irritation of the trigeminal and vagal nerves (Hare). This is corrected by dashing ether upon the epigastrium or by sudden and repeated pressure at this point. There is also choking and struggling, the face becoming suffused and red and there is an injection of the conjunctiva. As the ether is pushed the patient becomes quiet, followed by a second seizure of struggling, so intense, that force must often be employed to hold him on the table. With this there are the various attacks of laughing, crying,singing, or yelling—a semiconscious exhibition of the state of the mind of the individual.

As anesthesia progresses relaxation takes place and the time for operation is at hand. Often the throat fills with mucus, owing to the irritant effect of the vapor on the mucous membranes. This must be wiped out with the sponges.

If vomiting occurs the head of the patient is turned to one side until relieved. The mouth should be cleansed thoroughly thereafter to prevent the contents getting into the lungs and causing bronchial irritation and often broncho-pneumonia. If the patient gets too little air, shown by laryngeal stertor, frequent and feeble pulse, livid face or pallor, tonic spasm, thoracic breathing with fixed diaphragm, and drawing in of the abdominal walls with inspiration, the ether should be let up and the jaw pushed forward by placing the fingers under the rami. The tongue should be drawn forward, as already described, and such methods be used as have been mentioned in connection with asphyxia in chloroform narcosis. The pupils fixed in dilatation is indicative of immediate danger.

Strychnin and digitalis should be given hypodermically or the intravenous use of ammonia may be employed. If the stertorous breathing is due to mechanical causes, not to too much ether, the hypodermic use of ether will bring about reflex respiratory movement by reason of the local pain and irritation thus produced.

Fig. 31.—Allis Inhaler.Fig. 32.—Fowler Inhaler.

Fig. 31.—Allis Inhaler.

Fig. 32.—Fowler Inhaler.

Fig. 33.—Juillard Mask.

The anesthetic may be administered with the aid of various masks or inhalers. Simplicity of construction is to be preferred to more complicated apparatuses. The aseptic metal inhaler of Allis (Fig. 31) or the folding form of the same modified by Fowler (Fig. 32), are much used in the United States, while the Juillard mask—a metal frame covered with several thicknesses of gauze—is used abroad. (SeeFig. 33.)

It is to be remembered that in operations about the face ether anesthesia is not practicable, owing to the repeated lifting of the mask which allows the patient too much air. It can only be given by specially constructed inhaling devices, which are more easily used with chloroform or the mixed anesthetics. Their specific use and construction will be referred to later.

It is often desirable to get the patient as quickly as possible under anesthesia and still overcome the depleting effects of chloroform narcosis. A common method to accomplish this is to give chloroform to the point of relaxation and with a change of inhaler continue with ether. In this way anesthesia can be kept up safely a long time with a minimum amount of ether. There are, however, a number of mixtures used in place of this interchangeof anesthesia, all having their particular merit. Some of the best known are:

Alcohol-Chloroform-Ether(A. C. E. Mixture, English Formula, 1:2:3).—This induces rapid anesthesia without the danger of syncope or the other objections to chloroform or ether when used alone.

Chloroform-Ether-Alcohol, in the proportion of 3:1:1, and known as Billroth’s mixture, is extensively used in the same way.

Chloroform-Ether.—This mixture, in equal proportions, is known as Tillman’s mixture, and has been employed by many well-known surgeons.

Nitrous oxid, as advocated by Sir Humphrey Davy, is a safe product, but the anesthesia produced thereby is of too short duration to be of practical value in plastic surgery. Its employment is resorted to only for such operations as the opening of abscesses or the removal of small cysts, etc.

While ethyl bromid is a product that cannot be said to be absolutely safe, Terrier, of Paris, has used it largely to induce anesthesia, following it up with chloroform. It should be given freely with deep inspiration, the sixth inhalation producing total loss of consciousness. A moment after complete muscular relaxation is attained, with congestion of the face and dilated pupil. The average time necessary to accomplish this is about one minute, in which about three to five grams are used. In this way the stage of excitement is overcome and immediate narcosis is obtained. As the chloroform is substituted it must be given fairly strong, reducing it gradually. The facial congestion slowly diminishes and the pupillary dilation gives way to contraction. About sixteengrams of chloroform are required to keep up anesthesia for fifteen minutes. The after-effects of chloroform are entirely overcome by the above method.

Hawley, in reviewing the use of ethyl chlorid as a general anesthetic in minor operations, states that after several years of more or less constant use of ethyl chlorid, both in clinical and private practice, he has still to see the first case in which it has caused him the slightest uneasiness. The following precautions in its administration should be observed: (1) The patient should be prepared as for chloroform or ether; (2) whatever mask is used, it should fit the face snugly; (3) a graduated tube with a large aperture should be used; (4) the anesthetic should be well supplied with air and as little given as possible; (5) care should be taken not to present it at first in too large a quantity; frequently a dram is quite sufficient for short operations; (6) the patient should rest a while after its administration, as faintness sometimes supervenes; (7) a mask should be used which does not receive the drug close to the patient’s face, otherwise one is liable to either freeze the face of the patient or to cause asphyxia by the moisture from the expired air freezing on the gauze in the mask, and thus preventing the free passage of air to the patient.

The use of ethyl chlorid has the following advantages: (1) Safety in administering; (2) ease of administration; (3) it rapidly produces surgical anesthesia; (4) it can be used where chloroform or ether would be contra-indicated; (5) the patient can be kept in any position during anesthesia, upright or prone; (6) no cyanosis need occur during administration; (7) the patient recovers promptly without after-effects; (8) it is inexpensive; (9) it can be used for a long or short operation with equal success; (10) it is especially useful as a preliminaryto other anesthetics, decreasing the time required for the production of anesthesia and avoiding shock and discomfort to the patient.

Ethyl chlorid is a colorless, mobile liquid, which boils at 52° F. This is furnished in thirty- and sixty-gram glass tubes, sealed with a metal screw cap or spraying device. As this cap is removed the liquid in the tube begins to boil, owing to the temperature of the room, or, better, the operator’s hand, and a fine vapor spray is ejected from the opening.

The tube end is held from six to eight inches from the part to be anesthetized. Immediately the skin is frosted over and the lanugo hairs become covered with snow. The skin turns white and becomes slightly elevated, appearing to be thickened; at the same time the patient feels a stinging pain in the area. This may be overcome greatly by first smearing the part with sterile vaselin. In a few moments the skin is frozen and rendered antalgic, and operations of short duration can be performed. The only disadvantage with this method is that the part to be operated on is frozen stiff, hence the skin cannot be neatly dissected away from the subcutaneous tissue as under other local anesthesia, nor can the tissues be moved about as readily, as in the case with flap operations, owing to this stiffness.

The parts thaw out quickly with a returning sensitiveness, and it may be necessary to apply the spray repeatedly until the operation has been completed. Ifelastic constrictioncan be employed, the antalgic effect is more quickly produced and more lasting.

As the parts thaw out there is considerable prickling, which can be mitigated by applying sponges soaked inhot sterilized water. More or less redness of the skin will be noted even for some time after the operation.

(Methylbenzoylecgonin)

(Gädeke, Nieman, Bennett, Koller.) Cocain is the alkaloid derived from several varieties ofErythroxylon coca. It should appear as a permanent white crystalline powder in colorless prisms or flaky leaflets. The salt used for anesthetic purposes is the hydrochlorid; it is soluble in 0.4 part water, 2.6 parts alcohol, 18.5 parts of chloroform, and insoluble in ether.

Locally applied on mucous membranes and open wounds, it exerts an analgesic effect, but not of the unbroken skin. Punctures or abrasions are necessary to permit of absorption in this event. When locally applied it paralyzes the peripheral sensory nerves, and at first blanches the parts by reason of its active contraction on the arterioles, which is soon followed by marked congestion.

Krymoff has made extensive experiments to determine the anesthetic effects of cocain solutions sterilized in various ways. He claims that the best results in minor surgery are obtained with the one-per-cent solution pasteurized at 60° C. for three hours. The same solution pasteurized at 80° C. for two hours or at 120° C. for fifteen minutes gave results far less satisfactory.

While the pasteurized solutions accomplished an anesthesia lasting from one to two hours, sterilized solutions (boiled at 100° C.) overcame pain only for a period between twenty and thirty minutes.

Pasteurized solutions have the advantage of being sterile and do not decompose as the boiled solutions would. The pasteurization is accomplished as follows: The necessary amount of cocain is dissolved in sterilized water. The solution is put into a sterilized glass bulb,which is sealed hermetically and subjected to a temperature of 60° C. for three hours.

Since cocain is a nerve poison, its systemic absorption must be avoided. The constitutional effects of a given amount injected about the head, face, and neck are more marked than when injected in other parts of the body or extremities. This is due to two causes: a more rapid absorption and the proximity to the brain (Ricketts). For this reason less cocain should be used and the blood vessels be avoided.

Idiosyncrasy influences greatly these toxic effects. In neurotic patients of irritable and impressionable type the hypodermic use of this agent has especially induced serious syncope. Very serious symptoms and even death have been caused by its local use (⅛ grain hypodermically).

Untoward effects are manifested by nausea, vertigo, emesis, syncope, followed by clonic convulsions, delirium, and death.

Cocain first stimulates, then paralyzes, the pneumogastric nerve; the respiration is first accelerated, and then paralyzed, death being due to failure of respiration.

Should these symptoms occur, the patient should be placed on his back with the head low. Amyl nitrate inhalations act as the antidote and reduce the cerebral anemia (Feinberg). Morphin or caffein is to be given hypodermically, or the former is associated with potassium bromid internally.

To overcome the toxic qualities of the anesthetic it may be combined with morphin in solution, Schleich’s solution being well known. It is composed as follows:

Gauthier suggests the addition of one drop of a one-per-cent solution of nitroglycerin to the quantity injected and repeated to prevent the unfavorable after effects.

Solutions of cocain are to be made up fresh each day, as they become moldy on standing. They cannot be sterilized, for the reason that a temperature of 213° F. renders them useless. The solution is most active at 50° F. (Costa).

For hypodermic purposes two- to ten-per-cent solutions are employed, the four per cent being more generally used, not more than 0.1 gram of the agent being introduced (Hänel, ano).

Fig. 34.—Simplex Syringe.Fig. 35.—Kolle Improved Pravaz Syringe.

Fig. 34.—Simplex Syringe.

Fig. 35.—Kolle Improved Pravaz Syringe.

Fig. 36.—“Sub-Q” Syringe.

For the introduction of the solution the ordinary Pravaz syringe can be used, a modification of which being known as the “Simplex” (Fig. 34). It is a glass instrument, without screw threads within the needle base, and has a sterilizable fiber piston. The only disadvantage offered by this syringe is the lack of finger rests. The author has added a removable nickel-plated sleeve withfinger rings to slip over the glass barrel, as shown inFig. 35. The advantage of this modification will be appreciated when injections are made into dense or cicatricial tissue where considerable pressure is necessary for the introduction of the solution.

Another excellent syringe for the purpose is the metal-cased instrument known as the “Sub-Q” (Fig. 36); the barrel and piston in this are of glass, an asbestos packing being wound over the piston head.

Metal needles with large thread or smooth ends are employed. As the asbestos packing contracts in drying, the piston should be removed from the barrel and cleansed immediately after use, and not be introduced into the barrel until both the asbestos windings and the inside of the barrel have been moistened with warm sterile water. This precaution prevents the cracking of the instrument through undue pressure exerted on the end of the piston rod at the time of use.

To render the primary introduction of the needle painless the area might be sprayed for a moment with ethyl chlorid. After carefully preparing the site of operation, the subcutaneous injections are made in a somewhat oval or circular manner, the first infiltration of the cocain rendering the succeeding points analgesic.

It will be noted that the skin becomes whitened and is raised in little tumors, with the point of puncture as a center. The various punctures are so placed that the borders of these tumors meet, the entire site becoming edematous. If by constriction the part can be rendered ischemic, the analgesic effect is prolonged, reducing the systemic absorption to a minimum.

The subsequent nausea often following may be promptly overcome by the use of a mixture of creosote, four drops in limewater. For mucous surfaces the anesthetic may be applied with absorbent cotton and allowed to remain about five minutes. In deeper wounds than those involving skin, deeper injections must be made.

The effect of the anesthetic as above employed is practically immediate, and the operation can proceed at once. Its duration is from fifteen to twenty minutes for subcutaneous surgery, but where the deeper structures are involved subsequent injections must be made to control the pain.

(Benzoylvinyldiacetonalkamin)

(Merling, Vinci.) White powder, soluble in 33 parts of water. While the effects of eucain are immediate and produce anesthesia as thoroughly as cocain, it has the objection of producing local hyperemia and increased edema of the parts injected. This often interferes with the successful outcome of the first operation, as will be later shown. The advantage over cocain, however, is that a solution of eucain can be sterilized by boiling without reducing its usefulness, which in itself is an item, since both are expensive, and if we must prepare a cocain solution fresh for each day we must discard all that has not been used, while with eucain the same preparation can be safely used over and over, after proper sterilization.

The two- and three-per-cent solutions are most employed to the extent of from 10 to 60 minims. Its subcutaneous effect is immediate, lasting from ten to twenty-five minutes. When applied locally to mucous membranes, the five-per-cent solutions are used.

Principally it may be said that eucain does not exhibit the toxic properties of cocain, the author having employed it in over 5,000 cases with no untoward effect.

Liquid air is suggested as a means of local anesthesia by A. C. White. He recommends its intermittent application instead of freezing the part as with ethylchlorid. It is sprayed on the parts and produces immediately anemia and insensitiveness. There is no hemorrhage during its use, so that dressings may be applied before the parts assume their circulatory function; an advantage of considerable value in plastic surgery. No untoward results follow its use.

(Benzoyl-ethyl-dimethylamin-opropanol hydrochlorid)

(Fourneau.) This is the latest preparation advocated for local anesthesia. It is a synthetic product, derived from tertiary amyl alcohol. It is less toxic than cocain, and has been used more or less in the past years experimentally, but the consensus of opinion seems to be against its use. Jennesco has used it extensively in conjunction with strychnin in spinal anesthesia, but the surgeon in general has not taken kindly to it. In plastic surgery, as used locally, it has been little employed, eucain being the most serviceable for the purpose.

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