POSTURE OF THE PATIENT.
The position in which the patient is lying is of as much importance to
the anæsthetist as to the surgeon. It is for the surgeon to say what
he wants and for the anæsthetist to realise how his own work will be
thereby affected.
Dorsal Decubities.
This is the ordinary position and calls for no extended comment. The
pillows must be so arranged that at no spot is the body acutely flexed
or extended. Abdomen, thorax, neck, and head must all be roughly in a
straight line.
Deep-chested subjects require a higher pillow than those with shallow
chests, otherwise the neck is bent back and respiration obstructed.
The arms should either be folded and retained by a bandage or other
device over the chest, or extended so that the hands can be slipped
under the buttocks and retained there by the body weight. An arm which
is allowed to hang over the side of the table is likely to show next
day and for many months afterwards, the condition of drop-wrist from
musculo-spiral paralysis.
Face-down Position.
This is an awkward position for the anæsthetist; there being a general
tendency to respiratory embarrassment. Put a pillow under the upper
part of the thorax, leaving the lower part and the abdomen as free as
possible. Let the head project from the pillow, so that the face can be
got at without undue rotation of the neck. The intratracheal method is
a great help.
Lateral Position.
This may be called for either with or without the addition of a
sand-bag or inflatable air-pillow to push the loin upwards. In either
case, there is a tendency for the upper shoulder to fall forwards, the
position then assimilating itself to the face-down position. This is
best met by a support fixed to the table, upon which the upper arm may
be rested. Failing such a convenience, a sand-bag may be pushed in to
keep up the shoulder, or the assistance of a nurse may be required.
The Trendelenburg Position.
Slight tilting of the head end of the table downwards is often useful
in assisting the return of bowel into the abdomen: in this position,
the patient usually takes the anæsthetic very well. It must not be
assumed until the third stage of anæsthesia is reached.
For many gynæcological operations, however, the full Trendelenburg
position is required. Healthy subjects usually do quite well in it, but
stout persons not uncommonly show a good deal of cyanosis. At the close
of the operation it is essential to restore the table to the horizontal
_slowly_: the physics of the circulation are profoundly modified,
and if any serious degree of shock is present, rapid return to normal
may initiate a collapse.
In the full position, the weight of the body should be taken by metal
supports attached to the table against which the shoulders may rest. To
hang the entire weight of the body upon the legs may cause a good deal
of after-suffering to the patient.
The Sitting-up Position. (_See_ Fig. 49.)
The object of this position is to diminish venous engorgement and
bleeding in operations requiring delicate dissection in the region of
the neck. Prof. Alexis Thomson introduced the position into Edinburgh
surgery: the author was at first rather nervous of it, but has found
that with proper precautions the patients do uncommonly well. Beyond
all doubt, the position is a great help to the work of the surgeon.
Not every surgical table is capable of giving the full position without
the use of many pillows and sandbags. The head-piece of the table is
tilted up at an angle of about 75° or even 80°, and the patient pulled
up so that the flexion of the body occurs in the lumbar, not the dorsal
spine. A small sand-pillow is placed behind the neck so as to produce
slight extension. Another heavier one is placed under the thighs to
prevent the body slipping down. A slight tilt downwards towards the
head end may be given to the table as a whole with the same object.
[Illustration: FIG. 49.--Sitting-up posture for operations
on the neck.]
One should not in this position attempt to induce a deep chloroform
anæsthesia. Weak C.E. mixture at most, but better simply open-ether is
the method of choice. The induction is begun with the shoulders raised
to a modified degree, and the full position assumed in a light third
stage anæsthesia.
Intratracheal ether combined with this position is an ideal anæsthesia
for the removal of goitre or extensive dissections in the neck for
enlarged glands.
O’Malley’s Position for Nasal Surgery. (_See_ Fig. 50).
The author became acquainted with this useful position while acting as
Anæsthetist at the Royal Herbert Hospital, Woolwich, where the Nose
and Throat Department was under the charge of Major O’Malley, F.R.C.S.
Major O’Malley was kind enough in a recent letter written by request to
refresh the author’s memory of the details.
[Illustration: FIG. 50.--O’Malley’s posture for
intra-nasal surgery.]
With the patient lying as shewn in the photograph, every part of the
interior of the nose can be easily inspected by the surgeon; the
elevation of the head and shoulders prevents undue bleeding, and
such hæmorrhage as does occur goes down the gullet, where it does no
particular harm, instead of into the larynx. The degree of flexion
of the head upon the neck is not so extreme as to interfere with
respiration.
The details of O’Malley’s procedure are as follows:--
The interior of the nasal cavities are packed with gauze soaked in
adrenalin and novocain a quarter of an hour before operation, and the
patient receives a very small dose of morphia and atropine immediately
before anæsthesis is induced; given in this way it does not complicate
the induction with chloroform to the same extent as if given earlier.
The patient lies with the top of the head level with the top of the
table, and the head and shoulders (including the upper two-thirds of
the shoulder blades) supported on the usual depth of pillow. Induction
is by chloroform or mixture; a very light third stage only is aimed
at. When it is attained the mouth is opened by a gag, and Phillip’s
Oral Airway inserted (_see_ Fig. 8). Strict oral respiration is
essential to success. If air is passing in and out of the nose, blood
is spluttered all over the surgeon, seriously interfering with the
harmony of the proceedings. Junker’s chloroform bottle is ready, and
the end of the supply pipe is passed into one of the side holes in the
air way.
The head of the table is now elevated to an angle of 45°, and a small
sand pillow slipped behind the occiput. The gauze is removed from the
nose, and the operation can be performed with great comfort.
The circulation of the patient needs careful watching for the first
minute or two after the table head has been elevated, but thereafter
there is usually no special cause for anxiety. The area of operation
is locally anæsthetised by the action of the novocain and a light
chloroform sleep only is required.