ANESTHETICS
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.
GENERAL ANESTHESIA
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 a body 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.
PREPARATION FOR GENERAL ANESTHESIA
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, take note
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.
CHLOROFORM
(_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.
[Illustration: FIG. 27.—SCHIMMELBUSCH DROPPING BOTTLE.]
[Illustration: 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 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. 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.
[Illustration: FIG. 29.—SCHIMMELBUSCH IMPROVED FOLDING MASK.]
[Illustration: 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 the vapor. 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 and soles. 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.
ETHER
(_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—the test 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.
[Illustration: FIG. 31.—ALLIS INHALER.]
[Illustration: FIG. 32.—FOWLER INHALER.]
[Illustration: 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. (See Fig. 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.
COMBINED ANESTHESIA
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 interchange of 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
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.
ETHYL BROMID
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 sixteen grams
of chloroform are required to keep up anesthesia for fifteen minutes. The
after-effects of chloroform are entirely overcome by the above method.
ETHYL CHLORID
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 preliminary to
other anesthetics, decreasing the time required for the production of
anesthesia and avoiding shock and discomfort to the patient.
LOCAL ANESTHESIA
ETHYL CHLORID
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. If _elastic constriction_ can 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 in hot sterilized water. More or
less redness of the skin will be noted even for some time after the
operation.
COCAIN
(_Methylbenzoylecgonin_)
(Gädeke, Nieman, Bennett, Koller.) Cocain is the alkaloid derived from
several varieties of _Erythroxylon 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:
Cocain murias 0.1
Morph. sulph. 0.025
Sodium chlor. 0.2
Aquæ sterilis. 100.0
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).
[Illustration: FIG. 34.—SIMPLEX SYRINGE.]
[Illustration: FIG. 35.—KOLLE IMPROVED PRAVAZ SYRINGE.]
[Illustration: 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 with finger rings to slip over the glass barrel, as
shown in Fig. 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.
BETA EUCAIN
(_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
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 ethyl chlorid. 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.
STOVAIN
(_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.