HANDBOOK OF
ANÆSTHETICS
BY
J. STUART ROSS, M.B., CH.B., F.R.C.S.E.
LECTURER IN PRACTICAL ANÆSTHETICS, UNIVERSITY OF EDINBURGH;
HONORARY ANÆSTHETIST EDINBURGH DENTAL SCHOOL;
ANÆSTHETIST, DEACONESS HOSPITAL; INSTRUCTOR
IN ANÆSTHETICS, EDIN. ROYAL INFIRMARY
With an Introduction
BY
HY. ALEXIS THOMSON, C.M.G., M.D., F.R.C.S.E.
PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH
AND CHAPTERS UPON
Local and Spinal Anæsthesia
BY
WM. QUARRY WOOD, M.D., F.R.C.S.E.
LATELY TEMPORARY ASSISTANT SURGEON, EDINBURGH ROYAL INFIRMARY
AND UPON
Intratracheal Anæsthesia
BY
H. TORRANCE THOMSON, M.D., F.R.C.S.E.
ANÆSTHETIST TO THE LEITH HOSPITAL
EDINBURGH
E. & S. LIVINGSTONE, 17 TEVIOT PLACE
1919
CONTENTS
CHAP. PAGE
INTRODUCTION BY PROFESSOR ALEXIS THOMSON ix
PREFACE xi
I. PHYSIOLOGICAL ACTION OF ANÆSTHETIC DRUGS 1
II. SHOCK AND ANÆSTHESIA 5
III. ASPHYXIA OR ANOXÆMIA 15
IV. METHODS OF ANÆSTHETISING 28
V. THE CLINICAL OBSERVATION OF THE PATIENT 31
VI. THE PREPARATION OF THE PATIENT 42
VII. NITROUS OXIDE 46
VIII. NITROUS OXIDE AND OXYGEN 60
IX. ETHER 74
X. INTRATRACHEAL ETHER 96
XI. CHLOROFORM 109
XII. ETHYL CHLORIDE 122
XIII. MIXTURES OF NITROUS OXIDE AND ETHYL CHLORIDE 128
XIV. MIXTURES OF CHLOROFORM AND ETHER 134
XV. SEQUENCES 137
XVI. THE ACCIDENTS OF ANÆSTHESIA 140
XVII. THE SEQUELÆ OF ANÆSTHESIA 151
XVIII. POSTURE OF THE PATIENT 157
XIX. THE CHOICE OF THE ANÆSTHETIC 162
XX. LOCAL ANÆSTHESIA 171
XXI. SPINAL ANÆSTHESIA 193
APPENDIX 201
INDEX 209
LIST OF ILLUSTRATIONS.
FIG. PAGE.
1. Shock (Grey and Parsons) 6
2. Shock (after Crile) 8
3. Diagram to Illustrate Anoci-Association (after Crile) 11
4. Apparatus for Lane’s Saline Infusion 13
5. Diagram of the Vicious Circle of Asphyxia 20
6. Hewitt’s Mouth Props 22
7. Bellamy Gardner’s Mouth Props 23
8. Phillips’ Modification of Hewitt’s Artificial Air-way 23
9. Silk’s Nasal Tubes 23
10. Tongue Forceps and Glossotilt 24
11. Apparatus for Opening Clenched Jaws 25
12. Frame for Adapting Vertical Cylinders to Foot Use 47
13. Nitrous Oxide Cylinders (upright and angle) 48
14. Complete Nitrous Oxide Apparatus 49
15. Barth 3-way Nitrous Oxide Tap 50
16. Hewitt’s Wide-bore Nitrous Oxide Valves 50
17. Ash’s Modification of Paterson’s Nasal Gas 58
18. Hewitt’s Apparatus for Nitrous Oxide and Oxygen 63
19. Diagram to Illustrate Action of Hewitt’s and Teter’s
Gas-Oxygen Methods 67
20. Details of Clark’s Expiratory Valve 68
21. The Clarke Gas-oxygen Apparatus 69
22. Marshall’s Sight-feed Gas-oxygen Apparatus 70
23. Clover’s Ether Inhaler, with Nitrous Oxide Attachment 77
24. Clover’s Inhaler, Diagram of a Vertical Section 78
25. Hewitt’s Wide-bore Ether Inhaler 80
26. Ormsby’s Ether Inhaler 81
27. Bellamy Gardner’s Mask and Ether Dropper 83
28. Four Photographs to Illustrate the Administration of Open
Ether 84–5
29. Shipway’s Warmed Ether Apparatus 91
30. Diagram of Intratracheal Apparatus 98
31. Electric Blower for Intratracheal Method 99
32. Kelly’s Intratracheal Apparatus 100
33. Shipway’s Intratracheal Apparatus 102
34. Hill’s Direct Laryngoscope 104
35. Diagram of Blood-pressure Curves Obtainable with
Chloroform 110
36. Vernon Harcourt’s Percentage Chloroform Inhaler 115
37. Chloroform Mask 116
38. Chloroform Drop Bottles 117
39. Junker’s Chloroform Apparatus 119
40. Tube of Ethyl-Chloride 122
41. Ethyl-Chloride Inhaler 124
42. Guy’s Gas and Ethyl-Chloride Inhaler 128
43. Details of Guy’s Inhaler 129
44. Diagram of Gas-Oxygen Method Introduced by Dr Guy and
the Author 130
45. The Guy Ross Gas-Oxygen Instrument 131
46. Rendle’s Cone 135
47. Clover Inhaler adapted for the Ethyl Chloride-Ether
Sequence 139
48. Two Photographs illustrating Sylvester’s Artificial
Respiration 146–7
49. Sitting-up Posture for Operations upon the Head and Neck 159
50. O’Malley’s Posture for Intra-nasal Surgery 160
51. All-metal Syringe for Infiltration Anæsthesia 176
52. Infiltration of the Brachial Plexus 183
53. Needle and Syringe for Spinal Analgesia 194
54. Position of the Patient for Spinal Analgesia 196
INTRODUCTION.
The securing of a safe anæsthesia during operations is more important
than ever before, partly because of the mere number of operations,
and partly because of the greater extent to which other operative
risks--hæmorrhage, shock and infection--have been overcome. The risk
from the anæsthetic is now so very small that the joint aim of the
surgeon and anæsthetist to abolish it altogether is not far from
being accomplished. The author of this volume has done a good deal to
accomplish this end, and it is a matter of congratulation that he has
now published an account of his methods, so that a larger circle may
benefit from his teaching and his experience.
The author very properly goes further and maintains that anæsthesia
must not only be safe but must also be good; good anæsthesia is
absolutely vital to good surgery. Only a generation back many surgeons
professed to see no difference as to who gave the anæsthetic; at the
present day no one willingly embarks upon a difficult operation without
the aid of a skilled anæsthetist.
In various parts of the book the author has very rightly laid great
emphasis upon the influence which the work of the surgeon has upon
that of the anæsthetist. The latter may learn much from an occasional
glance at the field of operation. He should not interest himself in the
details of operative procedure to the distraction of his mind from his
own responsibilities; but he can, in abdominal surgery, see for himself
whether the muscles are properly relaxed, and observe the state of
operation, so that he can when necessary deepen the anæsthesia in good
time, while not maintaining deep anæsthesia when a light one would
suffice. Finally, he can check his other sources of information as to
the condition of the circulation by noticing the force with which cut
arteries spout, the colour of the blood and the size of uncut veins.
Like other branches of medicine, adequate study as well as practical
experience is required in order to master the art of administering
anæsthetics, and that a reliable manual of instruction is essential,
goes without saying; I feel on perfectly safe ground in recommending
this book as such both to the student and the practitioner.
ALEXIS THOMSON.
PREFACE.
This little book is an attempt to present to the student and
practitioner a condensed account of modern anæsthetic views and
practice. In choosing a general scheme I have tried to lay emphasis
upon the relation of anæsthesia to general medical science rather than
upon elaborate descriptions of anæsthetic apparatus and methods which
a few years hence may be superseded. I have therefore devoted the
first four chapters to an account of the various forces which modify
the physiology of the patient during an operation under a general
anæsthetic, in so far as we at present understand them. I trust that
they will prove not only a sound basis for the information given in
the rest of the book but also a help towards forming a judgment upon
new methods and appliances as and when they meet the attention of the
reader.
In making a selection of drugs and appliances for description, I have
eliminated those which do not appear to me to have any real sphere of
usefulness.
The account of nitrous oxide and oxygen has been given in some
detail. Both the profession and the lay public have arrived, through
the experiences of the war, at a more just appreciation of the
possibilities of this combination than was at all general before
the year 1914. At the present day, no one who proposes to engage in
anæsthetic work can afford to remain unpractised in its administration.
I have an apology to make to my women readers. Throughout the book,
when speaking of the anæsthetist, I have presumed the male sex. Such
phrases as “his or her” and “he or she” are tedious and inelegant, and
their omission must not be taken as forgetfulness on the author’s part
that women frequently make very good anæsthetists.
Professor Alexis Thomson has added to the many kindnesses I have
received at his hands by writing the Introduction which immediately
precedes this Preface, and I wish to express my sincere thanks to him
for such a valuable addition to the book.
From Mr David Wallace, F.R.C.S.E., I have received much valuable help
and guidance in anæsthetic matters. It was largely due to his kindly
assistance and moral support that I was encouraged to persevere with my
early attempts to use nitrous oxide and oxygen in major surgery. The
hints which are given in connection with Genito-Urinary Surgery are
also derived from him.
The chapters upon Local and Spinal Anæsthesia are entirely the work of
Mr Wood, to whom I must express my gratitude for the admirable way in
which he has done the work.
I must also thank Dr Torrance Thomson most sincerely for his useful
contribution in chapter X, which constitutes a complete
monograph upon Intratracheal Anæsthesia.
To Dr Wm. Guy I am indebted for the photographs which appear in the
book, and I must express my sincere gratitude to him for the trouble he
has taken in the matter.
Much thanks are also due to the following firms who have been kind
enough to lend illustrative blocks:--Messrs Claudius Ash & Co. Ltd., G.
Barth & Co., De Trey & Co., J. Gardner & Son, Allen & Hanbury’s Ltd.,
Meyer & Phelps, Coxeter & Son, Down Bros., Ltd., Krohne & Sesemann, and
Mr J. H. Montague.
Lastly, I must express my high appreciation of the courtesy which the
publishers have shown to me, and of their generosity in the matter of
illustrations.
J. STUART ROSS.
_October 1919._
Handbook of Anæsthetics.
CHAPTER I.
PHYSIOLOGICAL ACTION OF ANÆSTHETIC DRUGS.
Every anæsthetic drug has certain pharmacological peculiarities of its
own, but all have much in common, and it is to these common features we
shall first direct our attention.
Reaching the blood stream by absorption from the lung alveoli, the drug
enters into loose combination with the red blood corpuscles; a small
proportion only is carried in the plasma. Within the corpuscles it
must of necessity displace a certain proportion of the oxygen normally
carried: this factor is of great importance only in the case of nitrous
oxide gas, which readily displaces the larger part of the normal oxygen
content. In the case of other anæsthetics, the same process occurs; but
to a less extent. Detailed figures of the extent to which the blood
gases are altered in various stages of chloroform anæsthesia will be
found in Appendix III.
The actions of individual drugs upon the circulatory, respiratory,
and excretory systems differ so considerably that a small section
has been devoted to this subject in each of the chapters devoted to
nitrous oxide, ether, and chloroform respectively. One feature is,
however, dependent upon the _state of anæsthesia_ rather than
the action of the particular drug, and that is a certain slight fall
of blood pressure. This phenomenon is seen even in natural sleep, and
is presumably due simply to lack of normal stimuli such as tactile,
visual, and auditory impressions which in the ordinary circumstances of
life, help to maintain the tone of the vasomotor system. That such a
fall is due to the _state_ of anæsthesia admits of little doubt,
but the fact is not always easy to demonstrate since each of the drugs
themselves have a marked influence upon the B.P., which masks the pure
effect of the anæsthetic sleep.
Action upon the Nervous System.
It is in this system, of course, that we look for the characteristic
action of anæsthetics, since if we had a choice, it is the brain
only which we should desire to influence by our drug. It used to be
said that anæsthetics paralyse the brain from above downwards, but
that is only approximately true. More correctly we may say that the
more highly developed parts of the brain are earliest affected, and
that those portions, such as the vital medullary centres, which man
shares in common with his humbler zoological relatives, maintain
their activity until the last. Moreover, it must be remembered that
before any brain centre succumbs, it passes through a preliminary
stage of _excitement_, varying in intensity with varying drugs
and also with different types of patients. Those who are accustomed
to administer to their nervous centres repeated large doses of such
nerve poisons as alcohol and tobacco, may show very evident signs of
this preliminary cerebral irritation during the process of induction
of anæsthesia; so do also the unhappy possessors of nervous systems
deranged from other causes such as epilepsy.
_The first centres to be attacked are those of thought and perception._
The patient is incapable of coherent reasoning, and loses touch to
some extent with impressions from the outside world. _Muscular sense
and co-ordination next become affected._ Although still able to move
the limbs or the head, movements are incoherent, and if at this stage
the patient were put upon his feet, he would stagger as he does in
alcoholic intoxication. By this time _sensation_, both tactile and
special, begins to be affected. The patient is no longer cognisant of
pain,--if cut he would at any rate not have a remembrance of pain.
_The special senses_ are at this stage also lost, one of the last to
go being the auditory sense, a point which is sometimes forgotten by
those inclined to talk while anæsthesia is being induced. _Muscle tone
is the next function_ to be lost, and at this stage all movements on
the part of the patient should cease except those of respiration. _The
reflexes_ disappear at varying stages: the spinal reflexes, _e.g._
the knee-jerks, disappear fairly early, probably before muscle tone
is entirely abolished, but certain other reflexes persist to a later
stage. Those which are of most interest to the anæsthetist are the
conjunctival, corneal, and pupillary reflexes of which he will find
full details in Chapter V.
Lastly the _vital medullary centres_, respiratory, vasomotor, and
cardiac are overcome, and at this stage we have passed beyond the
stage of a proper anæsthesia into that of over-dosage. In passing it
may be observed that the level at which one endeavours to work is that
indicated by the loss of muscle tone and of some of the reflexes and
the full activity of the medullary centres, and that an anæsthetic is
good or bad according as it gives a wide or narrow margin between these
two events.
Upon the _peripheral nerves_, anæsthetics have much less effect than
on the central nervous system. Faradisation of a _motor nerve_ will
in the deepest anæsthesia still cause immediate contraction of the
muscles supplied by it, showing that the conductivity of the nerve
is unaffected. Of far more importance, however, is the fact that
the _sensory nerves_ are not paralysed. That pain is not felt by
the patient is due simply to the loss of function of the cerebral
sensory centres; _injury to the nerve still causes an impulse to be
transmitted to the brain_. Since no operative procedure can be carried
out without more or less trauma (injury) to sensory nerves, we may
picture the brain of the patient undergoing a surgical operation while
under a general anæsthetic, as being constantly bombarded by sensory
stimuli, which though not consciously appreciated by the sleeping
patient, are yet capable of producing reflex effects of a definite
character, the importance of which to the work of the surgeon and
anæsthetist it is difficult to exaggerate, and of which a condensed
account will be found in the succeeding chapter.