Chapter XVII

) but as long as the blood pressure within the brain, and especially the medulla, is maintained this effect is of secondary importance; but when the respiratory centres lack their natural stimulus, and respiration becomes irregular, then, as it were, the patient “bleeds into his own vessels.” It is under these circumstances that adrenalin produces its most marked and prompt effect.

The first effect of chloroform inhalations is to _raise blood pressure_, but this is soon followed by lowered tension. The _pupils_ may dilate slightly at first, but usually contract and remain contracted during anesthesia. _When they dilate suddenly means should be adopted to avert the danger threatened_, as the relaxation of the iris is the first visible relaxation of death. While the pupils react to light there is little danger.[8]

[8] Lehmann believes it is a bad sign when a patient who is taking an anesthetic keeps the eyes partially or completely open, or frequently reopens them after being under the influence of the drug. He holds it to be a premonitory symptom of more or less serious complications.

Death from chloroform usually occurs when it is assumed that no accident is likely to happen, as when it is given to an athlete, or to drunkards who are supposed to be secure from any reflex influences. Patients with weak hearts can be conducted safely through a prolonged anesthesia if there be time to prepare them. (See chapter on the Preparation of Patients.)

The after-dangers of chloroform are smaller than those of ether, due in part to the fact that a much smaller amount of the drug suffices; in other words--that it is the stronger.

After anesthesia has been produced and the patient is unconscious it requires but small additional amounts to maintain unconsciousness, as it is necessary to add only as much as may be required to replace what is lost by evaporation and exhalation. It is sometimes advantageous to commence with nitrous oxide gas, for there are fewer unpleasant reflexes, less salivation, and less disturbance of every kind. _Shallow breathing may be improved at almost any time with a few drops of ether._

Many anesthetizers have a habit of testing the degree of anesthesia by touching the cornea with their fingers. A piece of sterile gauze will prove equally effective and less irritating.

When the mask upon which chloroform or ether is given is held over the face free salivation will frequently be excited, and the patient will be tempted to swallow as well as inhale. In this way the vapor of the anesthetic is taken into the stomach as well as into the air passages, and when the stomach is empty this comes into direct contact with the gastric mucosa. This may produce not only irritation, but, in extreme cases, gastritis. It has been suggested that to allow the patient to drink a quantity of water at intervals before taking the anesthetic, and especially a half-pint or more immediately before beginning it, will be to permit of absorption and dilution of the anesthetic vapor without their causing this irritation.

[Illustration: FIG. 40

Harcourt inhaler.]

The simplest method of administering chloroform is upon an ordinary mask, the covering of which should be thin in order to permit of easy play of air. By this method a patient can always be anesthetized, but with a waste of the anesthetic and with absolute uncertainty as to the proportion of chloroform vapor in the inspired air. A variety of expedients have been suggested in time past, and chloroform inhalers of various patterns are constantly upon the market. The Junker inhaler, introduced some twenty-five years ago, was a great improvement upon its predecessors, but only recently has a really scientific measuring inhaler been placed before the profession. This is the one devised for and introduced by a committee of the British Medical Association, and is the result of the study and ingenuity of Prof. Vernon Harcourt. It has already been stated that more than 2 per cent. of chloroform vapor in the inhaled air is dangerous. The Harcourt apparatus consists of a two-necked bottle, nearly filled with chloroform, into which are dropped two colored glass beads, which serve to indicate when the temperature is between 55° and 59° F. If the temperature be below 55° F., both beads will float; if it be above 50° F. both will sink. If the former, the proportion of chloroform will be below that indicated by the pointer; if the latter, it will be greater. Inasmuch as during inhalation the chloroform is cooled by evaporation, it is necessary to occasionally place the warm hand over the bottle until the blue bead has sunk and the red bead is beginning to sink, indicating that the temperature is again approaching 59° F. A stopcock is so constructed that when the pointer is at one end of the arc the maximum amount of chloroform which may be taken up is 2 per cent.; when the pointer is at the opposite end, the patient breathes only pure air. There are valves which prevent the entrance of expired air into the apparatus, and which show whether the stopcock is working. They also show the character of the respiration. Administration is begun with the pointer at 0.2, and while it may require 2 per cent. of vapor to produce narcosis; _i. e._, the complete and final stage of anesthesia, it will take scarcely more than 1 per cent. to maintain it. The mouth-piece has an expiratory valve, and the apparatus can be held in any position, but should be kept nearly vertical. The mask is fitted with an air cushion, which can be molded in hot water so as to fit the patient’s face. Buxton, who is the leading authority on anesthetics in London, has abandoned all other apparatus for this. While he is a most skilled expert, he has shown that by means of this apparatus chloroform can be given with almost absolute safety.

Aside from the danger and discomfort pertaining to the use of chloroform in apartments lighted or heated with natural gas, there is another similar danger in connection with ordinary city illuminating gas. In the presence of a flame produced by the latter the vapor of chloroform is broken up not only into chlorine and hydrochloric acid, but into a carbon oxychloride, known also as _phosgene_, which is toxic and produces a sense of suffocation by producing decomposition within the blood. A fatal occurrence of this kind led to experiments on animals by an Italian observer, which showed that the substance produced rapid disintegration of hemoglobin, which fell rapidly to 40 per cent., and that accompanying this there was suppression of urine with convulsions.

Unless chloroform be given by one familiar with its use, it is best given from a dropping bottle. If this be so arranged that it will discharge but one drop at a time, and the anesthetizer so administer it as to allow perhaps one drop to fall each second, the patient will at no time get an overdose, nor will there be struggling or choking. Irregularity of breathing is usually the result of insufficient air, and the mask should be at once removed, so that the patient may take one or two deep inspirations. When the cornea is insensitive the patient will stand almost any manipulation except, perhaps, stretching of the sphincters. When the sphincter can be stretched without provoking any effect except a prolonged inspiration, then the patient is, in all probability, completely relaxed and ready for any procedure. When the breath becomes stertorous the mask should be removed even though the cornea be sensitive. It will quickly lose its sensitiveness again within a few seconds. _Proper breathing must be maintained._ Free supply of air is important above all other things, and it is better that the surgeon should wait rather than the anesthetizer.

Additional safety in the use of chloroform may be afforded by the simultaneous use of oxygen gas, by which cyanosis is usually avoided and vomiting often prevented. It may be safely used with chloroform, but not with ether. If ozonized air be conducted into anhydrous ether it forms a thick liquid, probably ethyl peroxide, which explodes if heated (Hare). It is a mistake to so manage the administration of chloroform with oxygen that the patient receives no pure air. Oxygen is of great value, but it is not physiologically breathed in its pure state. When the gas is allowed to bubble through a bottle of chloroform, carrying with it the vapor, no idea can be formed as to relative percentages. A better way is to administer the chloroform upon a mask, and the oxygen by a tube from a wash-bottle filled with water and passed into the nostril under the edge of the inhaler (Hare).

Gwathmey has introduced a modification of the well-known standard Junker inhaler, by which oxygen and chloroform, or nitrous oxide and ether, may be given together, or by which any desired combination can be effected. Its special advantage is the same as the Harcourt apparatus, that the percentage of chloroform or ether vapor can be estimated or controlled. So far as the administration of chloroform with oxygen is concerned, Roth has shown that oxygen does not decompose the chloroform, but diminishes the danger of its administration.

Gwathmey refers to the advantage of keeping an open airway by turning the head a little to one side and pressing the jaw well forward; he also advises that when the anesthetic is removed from the face it is well to replace its odor by some other perfume, such as cologne or smelling salts, as it is presumed that the olfactory nerve is responsible for the initial symptoms of nausea and gastric distress.

In some States natural gas is used as fuel, usually in open fireplaces or stoves. When chloroform is administered in a room thus heated, or even lighted by natural gas, formaldehyde gas is the result of a mutual decomposition, and this is exceedingly pungent and irritating, and will soon produce violent coughing in all who are present in the room. It may be impossible to avoid this, but natural gas flames should be extinguished and some other source of illumination should be depended upon when practicable.

A. C. E. MIXTURE.

Under this term are known various mixtures of alcohol, chloroform, and ether, the intent being to counteract the depressing influence of chloroform by alcohol and ether. It may be said of every mixture of anesthetics that it is no less dangerous than its strongest constituent. Thus a mixture of chloroform and ether should be given with as much precaution as pure chloroform.

Mixtures of this kind should be made fresh for each administration, as the most volatile ingredient may evaporate in unknown amount and thus change the proportions. This is true of the mixture even after it is poured upon the inhaler, and the patient will thus be subjected to a chloroform mixture of varying strength.

The administration of ether for a few seconds during chloroform anesthesia will often prove beneficial in regulating or deepening inspiration, but it would be best to have the two drugs separate, and use the ether as it may seem called for, rather than to rely upon any such mixture. Moreover the vapor of alcohol is of itself irritating and undesirable.

ETHYL BROMIDE.

For operations of but short duration ethyl bromide offers some advantages, in that its effects quickly pass away and that there are few unpleasant sequels. Indeed, patients may take it for a few minutes with almost as little disturbance as is produced by nitrous oxide; nevertheless it cannot be regarded as being as free from danger as was originally claimed. Only a pure preparation should be used. When given as ether is usually given, upon a cone or mask, complete anesthesia may often be produced within one minute. It can hardly be relied upon to produce muscular relaxation and it frequently causes great congestion of the face and head, consequently it is not as convenient for short operations on the nasopharynx as its other good qualities might render it. It is not unpleasant to take, and ordinary ether anesthesia may well be begun with it.

METHYLENE BICHLORIDE.

For a number of years this anesthetic agent was in favor, especially in Great Britain, where it was warmly advocated by Spencer Wells. Its odor is agreeable, its action rapid, and recovery from its effects is usually prompt. But it proved to be unsafe, since it was found that the substance commonly used under this name was really chloroform diluted with one-fifth of methyl alcohol, while the genuine methylene bichloride was found by experiment to be a dangerous substance, and its use has been discarded.

ETHYL CHLORIDE.

This, like every other drug used for the purpose, should be used in perfectly pure form. While this can be obtained from manufacturers in this country, there seems to be a tendency to rely upon the imported preparation sold here under the name of Kelene. For certain short operations, such as those upon the eye, nose, and throat, and for children, it has many advantages and appears to be a reasonably safe drug for the purpose. Consciousness is quickly recovered after its use, and the after-effects are slight. It is in general use preparatory to one of the stronger anesthetics, like ether or chloroform, and affords a means of putting patients under the relaxing effect of either of these drugs. It should be administered upon a cone or mask, from which evaporation should not occur too easily, because it is extremely volatile. In the hands of one accustomed to its use, operations of considerable magnitude and duration may be successfully maintained. A special valveless mask has been devised for its use, consisting of a rubber mouth-piece which can be snugly fitted to the face, and a movable tube over which two or three layers of gauze may be stretched, upon which the ethyl chloride is allowed to drop or is ejected from the tube in which it is sold. Sometimes the expired air will freeze upon this gauze. This is of no disadvantage.

=Local Use.=--On account of its extreme volatility, chloride of ethyl affords a ready means of producing local anesthesia. It boils at 50° F., and when the tube containing it is held in the hands and its capillary tip is opened it issues in the form of a fine spray, which being directed upon the part to be desensitized first chills and then freezes it. Whether this part be skin or mucous membrane the effect is the same. As soon as the desired area is covered with a thin layer of small frozen crystals, looking like hoar-frost, the surface is anesthetized and the necessary instruments may be used. Blowing on the part to be anesthetized will favor evaporation and shorten the time necessary for the purpose.

The purposes to which this drug may thus be used are numerous and obvious. For instance, in dentistry it will do much to allay the pain of tooth extraction; in genito-urinary surgery such operations as incision of the prepuce, the cauterization of venereal ulcers, and circumcision may be done with little or no pain. The small operations required in various skin diseases, the incision of small abscesses, the use of caustics wherever they may be needed, may all be made easy under its effect; while in cases of neuralgia, stings, bites, etc., it will often alleviate the symptoms. The skin may also be anesthetized in this way before the introduction of the needle through which antitoxins are injected or hypodermoclysis practised. Before venesection or before exploratory puncture it may also be used.

=Somnoform.=--This agent, composed of ethyl bromide 5 parts methyl chloride 35 parts, and ethyl chloride 60 parts, was introduced by Rowland, of Bordeaux, as a convenient means of producing an analgesic condition, _i. e._, something between complete anesthesia and conscious sensibility. The dose is about 5 Cc., to be sprayed upon a tightly fitting mask. The patient should be told to breathe and swallow as naturally as possible, and the effect is obtained within a few seconds. The agent is so speedy in producing its effects that it is sometimes difficult to tell when the proper degree of unconsciousness has been secured. A patient may be directed to hold up an arm in order that when it drops the surgeon may proceed. There is neither cyanosis nor corneal reflex, and nausea does not usually occur. The essential point of administration is the exclusion of air. Twenty seconds of administration will give from one to two minutes of anesthetic effect, during which various brief operations can be performed. By proper management this period can be lengthened many times.

=Petroleum Ether.=--Petroleum ether was introduced by Schleich for the purpose of diluting chloroform. By itself it has a weak anesthetic power, and seems to possess some dangers of its own in the way of depressing the heart’s action and producing convulsions.

OTHER VOLATILE ANESTHETICS.

Schleich was among the first to demonstrate that the retention of an anesthetic within the body depends upon its boiling point. W. Meyer carried Schleich’s views still farther and showed the at least theoretical value of an anesthetic mixture whose boiling point was that of the normal blood temperature. If the evaporating point be much higher than the blood it is volatilized too easily, while if it be lower it reduces body temperature as it evaporates. After considerable experimentation Meyer recommended a mixture by volume of chloroform 3 parts, ether 2 parts, and ethyl chloride 1 part, and introduced this mixture under the name of _anesthol_. This composition does not seem to have met with great favor as yet, although it has theoretically much to commend it, as it seems slower in action and but little more satisfactory in other respects.

NITROUS OXIDE GAS.

This is by all means the most rapid general anesthetic in use. Patients can be placed under its influence in from twenty-five to sixty seconds. For a long time its employment was confined to dental practice, but it is now in general use by surgeons, as a preliminary to the use of ether or as the sole anesthetic agent. When managed properly patients can be kept for a half-hour or even an hour under its influence. Two disadvantages attend its administration: (1) It is difficult to completely relax the muscles and so maintain them that no difficulties are placed in the operator’s way, _e. g._, in certain operations upon the abdomen where muscle rigidity delays and makes difficult the operation. (2) The use of nitrous oxide alone so far impairs proper oxygenation of the blood that this fluid becomes dark or almost black and frequently obscures the field of operation. These difficulties, especially the latter, can be overcome by the skilful _simultaneous use of oxygen gas_, by which the blood is kept well oxygenated, and by which the deep stupor of nitrous oxide poisoning can be made so safe that it can be prolonged to the degree necessary to afford relaxation.

Nitrous oxide anesthesia is thus proved to be something more than mere asphyxia, or it would be completely counteracted by oxygen. Suitable apparatus can now be procured by which both gases can be blended together as desired; considerable experience, however, is necessary for their successful use. It is generally stated that nitrous oxide alone should not be given to persons with fatty hearts or atheromatous vessels. From a brief period of nitrous oxide anesthesia patients usually recover within a few minutes and without after-effects; still, relaxation of the sphincters may occur. After its prolonged use there may be considerable headache and vertigo.

THE CHOICE OF AN ANESTHETIC.

This will depend upon who is to be the anesthetizer as well as upon the actual condition of the patient. If an inexperienced person is to administer the anesthetic, ether is safer than chloroform, though slower. On the other hand, when given by an expert, and after due preparation of the patient, chloroform is ordinarily preferable. The latter is especially indicated in the young and aged, as well as in those who have bronchitis or chronic cough, and those who have advanced renal diseases or atheroma, because it is not likely to produce such high arterial tension.

Ether should never be given near an unprotected flame, and lamps or gas-jets should be held above the level of the operating table, as the vapor of ether is heavier than air and will tend to sink. The disadvantages of chloroform where natural gas is in use have already been mentioned.

Efforts should be made to prevent struggling, as in the violence of this unconscious act an overtaxed heart might yield, or at least undergo dilatation. Chloroform is notably less likely to be followed by nausea and vomiting than ether, and yet nausea cannot always be prevented. There can be no doubt that morphine, alone or with atropine, may be given with advantage to most patients before administration of a general anesthetic. The treatment of postanesthetic nausea has been referred to in the chapter on the Preparation and After-care of Patients. By general consent, chloroform is the anesthetic of choice during labor.

THE DANGERS OF AND ACCIDENTS FROM ANESTHETICS.

The principal dangers from any of the volatile anesthetics come from interference with circulation and with respiration. The heart may give rise to alarm by gradual _failure in strength_, while the pulse becomes more rapid and irregular, or by sudden and apparently complete _cessation of activity_. _When the pupils suddenly dilate_ and do not react to light danger is close at hand, if it have not already manifested itself, and then is the time to discontinue the anesthetic and resort to vigorous methods, which may include artificial respiration, but must include attention to the heart. It is customary to use injections of strychnine, which are often too weak or too small to be of service, nothing less than ¹⁄₂₀ Gr., which may be repeated in a few moments, will be of any service. If ¹⁄₁₅₀ to ¹⁄₁₀₀ Gr. of atropine be given with the strychnine it will prove a much more effective stimulus. It is right and proper to administer these drugs in this emergency, but still more reliable measures are at hand.

_Sudden stoppage of the heart_, being the most disastrous accident during or after anesthesia, has attracted no small amount of attention on the part of experimenters. An active _massage of the heart_ seems to furnish the basis for all the newer methods of treating it, all of which are accompanied by artificial respiration. Some of Crile’s work in this connection was alluded to in the chapter on Blood Pressure and Shock.

[Illustration: FIG. 41

Showing how proper traction on the tongue pulls on the epiglottis. (Hare.)]

Numerous investigators have revived the hearts of experimental animals by massage and saline injections, and Crile has shown the advantage of adding adrenalin to the latter. It is better to begin the efforts while the heart is still feebly beating than to wait until it has ceased. Ordinarily this massage should be made through the intact thorax, but the time is coming when it will be esteemed life-saving either to open the abdomen and massage the heart through the diaphragm, or to open the thorax and do it directly. The former can be done during almost any abdominal operation. The greatest obstacle to success has been the formation of clots in the cardiac cavities. These are formed within a few moments after the heart has ceased to act.

_Massage of the heart, coupled with the use of adrenalin_, will prove of service.

_Approaching cardiac weakness_ is always indicated by failure of capillary circulation, which may be easily and instantly estimated by making pressure upon the finger-nails. The rapidity with which the blood will return to give them a natural appearance, after such pressure is made, will be the index as to whether or no stimulation is necessary. Tardiness in return of color, or absence, is a better indication of the approach of shock than is coldness of the nose or moisture of the skin. It often precedes acceleration of the pulse.

_Respiration may be interfered with by a variety of causes._ Not infrequently the tongue is allowed to drop backward into the pharynx as the patient lies upon his back, which, by its pressure, causes the epiglottis to fall backward upon and close the glottis. The indication here is to lift the tongue forward and carry the epiglottis upward so as to restore the air channel. Extension of the head and neck will accomplish much in this direction, as well as holding the lower jaw forward and upward by well-regulated pressure exerted behind the angle and at the same time by upward and forward traction upon the hyoid bone. But when it is necessary in cases of emergency to carry out this maneuver forcibly and extensively, then the _tongue should be drawn upward and forward_ in the direction indicated in Figs. 41 and 42.

Tongue forceps are often resorted to for this purpose, and can be procured in various forms and shapes. To the writer their employment has always seemed far more barbarous than the much simpler expedient of passing a curved needle, armed with silk, through the tongue in either direction, 3 to 5 Cm. back of its tip. The suture thus drawn through is knotted and made into a loop, and may be employed through a long operation to make all the traction that will be required. This really makes the tongue less sore and produces _less swelling and after-discomfort_ than does the use of forceps.

[Illustration: FIG. 42

Showing how dragging the tongue over the teeth fails to pull on the epiglottis. (Hare.)]

Respiration may also be impeded or suddenly checked by the presence of a foreign body. This may possibly be a plate which the anesthetizer has failed to require the patient to remove, or it may be material ejected from the stomach; this latter is especially likely to happen when emergency has required anesthesia without due preparation. When this happens the fingers should be passed behind the epiglottis and the obstructing body removed. In rare instances some portion of food may have been so impacted in the glottis as to completely obstruct it. If such an emergency arise the trachea should be opened and relief thus afforded. Only in this way can life be saved. Embarrassment of respiration is caused at other times by the patient apparently “forgetting to breathe” or by his taking such shallow inspirations that nothing is accomplished. This may be combated in several ways. In the former instance the use of ether or injections of atropine will frequently afford the necessary stimulus to the respiratory centres. In the latter class of cases especially the most valuable expedient is the _dilatation of the sphincter ani_, which may be stretched with a speculum, or with the fingers. Long-drawn, even gasping inspirations may follow this expedient.

Finally in certain cases artificial respiration will be required, combined with rhythmical traction upon the tongue. The tongue should be grasped, or controlled by a suture, and _retracted from the mouth at the rate of at least sixteen times a minute, while the chest is compressed at the same rate_, the traction being made at the moment of relaxation of chest pressure. Tongue traction alone will sometimes renew respiratory movements in extreme cases.[9] Figs. 43 and 44 from Hare, show the combined manipulation of inverting the patient in order that the brain may not lack for blood supply, and carrying out artificial respiration.

[9] Freudenthal has called attention to the extreme irritability of both surfaces of the epiglottis, and advises to pass the index finger down upon it, irritating it by friction. This causes a powerful reflex effect, as the glossopharyngeal supplies its anterior surface and the inner branch of the superior laryngeal its posterior surface.

While these measures are to be regarded as emergency expedients, they will often need to be supplemented by others, the use of adrenalin and of salt solution, either beneath the skin or in the veins, and the use of the Crile pneumatic rubber suit described in the chapter on Shock.

[Illustration: FIG. 43

Showing inversion of patient and method of performing artificial respiration simultaneously. (Hare.)]

[Illustration: FIG. 44

Same as Fig. 43.]

There is a delay in the management of the patient after the conclusion of an operation which is too often neglected--namely, prevention of such exposure as shall produce a sudden checking of perspiration. The patient should be wrapped in several thicknesses of blanket, leaving only the face exposed; and only when fully conscious should he be uncovered gradually and well dried with a bath towel. Such procedure takes away much of the danger of congestion of the lungs, or of the kidneys, which may cause serious disturbance should they occur.[10]

[10] The following is quoted from a recent journal article by an unknown writer:

_Acid Intoxication after Anesthetics._--Occasionally some surgeon reports a case of peculiar rapid fatal toxemia after a prolonged operation, the cause of which is obscure. We have also heard of this trouble after parturition, during which chloroform was given for a prolonged period, and the ultimate cause of the violent symptoms has been unknown. Now we are beginning to believe that anesthetics, especially chloroform, can produce a destructive effect on the liver and kidney cells very similar to phosphorus poisoning. In many cases a peculiar idiosyncrasy seems necessary to explain the toxic effect, but certain predisposing causes have been noted, _e. g._, hemorrhage. The symptom-complex makes its appearance from a few hours to a few days after the anesthesia, and consists of vomiting, restlessness, delirium, convulsions, coma, irregular breathing, cyanosis, and icterus in varying degree. The disease as described by Bevan and Favill is a hepatic toxemia, resulting from acute fatty degeneration of the liver, and seems to be a clinical entity. It is characterized by an acid intoxication, acetone, diacetic acid, and beta-oxybutyric acid being found in the blood and urine. Several clinical varieties must receive renewed interest in the light of this investigation. First is acute yellow atrophy of the liver, many cases of which occur after chloroform anesthesia. Next, the rapid death after abdominal operations, which have hitherto been attributed to intestinal toxemia; and lastly, certain fatal cases of nephritis after operation need a more careful study.

ARTIFICIAL RESPIRATION.

All foreign bodies should be removed from the mouth and pharynx. If the patient have been in water he should be suspended head downward, in order that the water may escape by gravity from the lungs. In all of these methods _rhythmical traction_ upon the tongue will be found a valuable aid in the procedure.

_Sylvester’s method_ utilizes the arms as levers by which to expand the thorax, by means of the muscles which pass between them and the chest. The patient is laid on his back, the shoulders somewhat elevated and the head thrown backward. The forearms are seized just below the elbows and carried upward over his head, by which movement the chest is expanded; here they are held about two seconds, and then brought down to the side of the chest and actual compression of the thorax made with them, for the same period of time. When the chest is compressed, an assistant may also press the liver upward and thus help to empty the lungs. The intent is to make from sixteen to eighteen of these movements in a minute. In children the movements are made more rapidly, and in infants considerably more. It is usually necessary that traction be made upon the feet to prevent pulling the body upward when the arms are moved to expand the thorax. If the manipulations can be carried out upon a table whose feet can be somewhat elevated this will also help, as the blood is thereby induced to enter the cranium.

_Marshall Hall’s method_ is to roll the patient from his back on to his side, the uppermost arm being utilized to make pressure upon the side of the thorax in order to expel air. Then the body is rolled over on to the back, by which movement the chest is expanded. This method is not nearly as efficient as that mentioned above.

[Illustration: FIG. 45

Fell’s apparatus for forced or artificial respiration.]

In case of drowning _Howard’s method_ is quite applicable. The maneuvers are as follows:

1. Turning the patient upon the face, with a large firm roll under the stomach and chest, and protecting his mouth from the surface upon which he is lying, press with full weight two or three times, for four or five seconds, each time upon his back, so that the water is expelled from his lungs and stomach.

2. Then quickly turn him face upward with the roll beneath his back, with his head hanging downward and his hands above his head. The operator then kneels astride over the patient, with the hips between his knees, and grasps the lower part of the patient’s chest firmly, bracing his own hands with his elbows firmly against his own hips. With his full weight he then makes pressure upon the patient’s chest, compressing it laterally for two or three seconds, gradually leaning forward while doing this, and then with a sudden jerk pushing himself backward. The intent here is to imitate the ordinary respiration rate as above, or perhaps a little less often. This may be continued for a half-hour or even for an hour, sometimes with eventual success.

There should be also massage of the heart, in addition to traction upon the tongue. Artificial assistance should not be discontinued until the patient is breathing regularly and sufficiently without help. In Fig. 45 is represented the Fell apparatus for making forced artificial respiration, this being a great improvement on the so-called mouth-to-mouth inflation. The essential feature of it is a bellows, by which the air is forced into the lungs, through a mouth-piece made to fit tightly over the face, or through a tracheotomy tube. In accident cases other measures, such as artificial warmth, etc., should be employed.

MORPHINE AND SCOPOLAMINE.

Morphine offers no little aid in the production of anesthesia in many cases. Those patients who are terrified by the thought of operation, and who are in a semihysterical state when anesthesia is begun, may be greatly tranquillized by a hypodermic injection of 0.01 to 0.015 of morphine, fifteen or twenty minutes previously. Given in this way it acts as a heart tonic and general equalizer to the circulation. If a small dose of atropine be added the effect upon the respiratory centres is much enhanced. Again, in those cases where anesthesia is begun without it, and patients prove very rebellious, it will have the same happy effect. The only objection to its use is the nausea which may thereby be produced. There is no way by which to dissociate this from the nausea due to the anesthetic, elsewhere considered under the heading of the After-care of Patients.

Patients can rarely be so completely put under the influence of morphine as to justify its use alone.

=Scopolamine.=--The Germans sell under this name an alkaloid made from the Solanaceæ, which seems to be identical with the _hyoscyamine_ of the U.S. Pharmacopœia. Schneiderlin, in 1900, published a method of producing anesthesia with little discomfort by using it combined with morphine. The mixture seems more effective than either alkaloid alone, but is rather slow in action. On the day preceding the operation a trial dose of 0.02 of morphine and 0.008 to 0.01 of scopolamine may be given. This will demonstrate the susceptibility of the patient to the mixture. One hour and a half before the operation this dose, or a larger one, should be administered, and, if necessary, another one of smaller size fifteen minutes before the time of operation.

According to this method an interval of sixty to eighty minutes should elapse between the first dose and the operation itself. When anesthesia is thus produced it lasts from three to several hours. Others have advised to divide the dose into three injections, giving the first about two and one-half hours, the second one and one-half hours, and the third one-half hour before operating. In some cases this has produced complete and satisfactory anesthesia; in some it has not been complete, while in others serious symptoms have been produced. The statement that each alkaloid counteracts the dangerous effects of the other is not substantiated; it is probable that the combined effect is greater than would be that of either used alone. This mixture should rarely be used, save in those cases where general anesthesia is inadvisable, and where there are difficulties, even about the employment of local anesthetics.

LOCAL ANESTHESIA.

The use of ethyl chloride, as the most volatile of the ordinary drugs, by which chilling or freezing of the skin may be produced, has been already mentioned. Other agents which chill or freeze may be used, _e. g._, a spray of common ether or of rhigolene, or the local application of ice and salt.

=Liquid Air.=--Liquid air, when available, affords an excellent means of benumbing sensibility, since one or two very light applications, two or three minutes apart, admirably serve the purpose. It is, however, rarely available and should be used with great caution.

=Cocaine.=--Of the local anesthetics _cocaine_, or some of its compounds or substitutes, will give the best results; although it is said that injections of pure water, if sufficiently bulky, will also answer the purpose of a local anesthetic. Cocaine has marvellous properties upon mucous surfaces or in the tissues, but none upon the unbroken skin. Where the parts to be operated are covered with skin it is necessary to inject the drug with a hypodermic syringe, as in the case of all deeper tissues. About the eye, the drug is used in from 1 to 4 per cent. strength; in the nasopharynx, from 2 to 4 for ordinary purposes; about the genitals, 2 to 5 per cent.; beneath the skin, ordinarily in strength of 1 to 2 per cent. In operations upon the nasopharynx and larynx it is often advisable to make a local application of a small amount of an almost saturated solution, by which a more complete effect is gained.

_Cocaine is not without dangerous toxic properties_, to which some persons are peculiarly susceptible. It will seriously disturb heart

## action in some; in others produce vertigo and mild delirium, and in

still others peculiar erotic symptoms. Warm solutions are more quickly absorbed than cold ones. The use of more than 0.06 (1 grain) should be avoided.

When the skin alone is to be anesthetized the injection should be made into and not beneath. The nearer the cocaine solution is deposited to the principal nerve trunk or branches the more promising will be its effect.

The use of cocaine in operations, under general anesthesia, for the prevention of those depressing influences which cause lowered blood pressure and shock, has been alluded to in the chapter on Shock. For instance, it is well to spray the larynx after opening it and before making further operation upon it; while in all major operations in which large nerve trunks are exposed or divided, _e. g._, amputations, etc., the injection into the nerve trunks of a few drops of 2 or 3 per cent. cocaine solution prevents this kind of disturbance.

For small and localized operations the direct injection of cocaine into and around the area involved will prove sufficient. It is rarely necessary to use for this purpose a solution stronger than 1 or 2 per cent., especially if it is deposited drop by drop around the entire margin of the area and if the part have been previously made bloodless by pressure, as by the Esmarch rubber bandage. But when extensive operations are to be undertaken the method of “_blocking_,” so called, should be carried out. This consists in cocainizing the principal nerve trunks which supply the part, for which purpose an accurate knowledge of regional neural anatomy is necessary, with the intent to inject into or closely around the nerve trunks a few drops of a 1 or 2 per cent. solution. Working in this way by combination of injection, then of incision, by which the nerve trunks are better exposed and more fully protected in order to be more completely injected, and then proceeding farther with the operative part, extensive operations have been and may be done; such for instance as amputations, not alone of the limbs but even of the shoulder girdle, removal of large tumors, etc. In this way, for example, Kocher now removes most of the goitres which he attacks. The essential feature of this work is to first get the cocaine inside of the nerve sheaths. In this way a minimum of the drug is used with a maximum of effect. Nevertheless when a large nerve trunk is thus to be paralyzed temporarily it is best to inject the solution directly _into it as well as around it inside the sheath_. Cocaine is a temporary protoplasmic poison, and for the time being shuts off the afferent power of the nerve. One advantage of this method is the avoidance of shock as well as of pain. Another method, devised by Schleich, is to be preferred. He uses three different solutions, of which the second is commonly used. Tablets for making these solutions can now be obtained. In order to secure the best effect with them the parts should be made bloodless. The solution is deposited subcutaneously in a series of drops around the margin of the area, and then massage may be made to distribute the fluid more uniformly in the tissues. When the tissue to be operated upon is inflamed the injections should be made first into the healthy area on the proximal side.

Schleich’s formulas are as follows:

No. 1. Cocainæ hydrochloridi .200 (gr. iij). Morphinæ hydrochloridi .025 (gr. ²⁄₅). Sodii chloridi .200 (gr. iij). Aquæ destillatæ ad 100.000 (f ℥ iiiss).

No. 2. Cocainæ hydrochloridi .100 (gr. iss). Morphinæ hydrochloridi .025 (gr. ²⁄₅). Sodii chloridi .200 (gr. iij). Aquæ destillatæ ad 100.000 (f ℥ iiiss).

No. 3. Cocainæ hydrochloridi .010 (gr. ¹⁄₆). Morphinæ hydrochloridi .005 (gr. ²⁄₅). Sodii chloridi .200 (gr. iij). Aquæ destillatæ ad 100.000 (f ℥ iiiss).

Various substitutes for cocaine are now on the market. Some of these are soluble and some insoluble. _Eucaine_ is most commonly used, especially in form known as _eucaine B._, or _beta-eucaine_. It is weaker than cocaine, especially so in toxic properties, and solutions of twice the strength can be used, often with satisfaction, and almost always without danger. For urethral and eye work, _e. g._, it answers the purpose; nevertheless, it will sometimes prove disappointing. _Orthoform_ is a crystalline, sparingly soluble artificial product, which is too light and too coherent to be generally serviceable. It often gives satisfaction mixed with other powders or in ointments, and it is usually free from toxic properties. _Nervanin_ is another laboratory product, not equal in activity to cocaine, but almost free from unpleasant properties. _Anesthesin_ is another similar product, which is practically free from physiological properties save that it acts as a local anesthetic. The latter may be employed for infiltration anesthesia in the following proportion, recommended by Dunbar:

Anesthesin hydrochloride 0.250 Sodium chloride 0.150 Morphine hydrochloride 0.005 to 0.015 Water 100.000 Cc.

_Stovaine_ and _alypin_ are among the latest synthetic substitutes for cocaine. The latter seems to offer promise of usefulness.

Adrenalin may be added to any of these solutions in proportion of 1 per cent. of a 1 to 1000 solution, and will have a beneficial effect in all cases.

INTRASPINAL COCAINIZATION.

The intraspinal injection of remedies was first suggested by Corning, of New York, in 1885; it remained, however, for Bier to perfect the technique in 1899, and to make it so popular that the same maneuver has been practised for various other purposes; as, for instance, for withdrawal of cerebrospinal fluid in cases of hydrocephalus, etc., or the injection of tetanus antitoxin. (See chapter on Tetanus.)

The intent in this use of cocaine is to spread the solution over the surface of the cord and beneath the arachnoid. For this purpose a needle about 4 inches in length, with a point not too sharp, preferably gold or platinum plated, is used; with this also a syringe which will hold 2 to 4 Cc., which can be firmly, yet easily, attached to the needle. The accompanying illustration (Fig. 46) will give an idea of the technique. The patient should be seated leaning forward so as to curve the back and open the intervertebral spaces. A sterilized towel is stretched tightly across the back from one iliac crest to the other; its upper edge should then pass just over the spinous process of the fourth lumbar vertebra. The injection is usually practised between the second and third lumbar spines, or between the third and fourth; the latter having been identified, the former are easily made out. The needle is entered about 1 Cm. to the right of the middle line and passed forward, inward, and upward, to a depth of 7 or 8 Cm. in the ordinary adult, until the resistance offered by the tissues is felt to have been passed and the point to have entered a cavity. If the needle has been passed alone the escape of a drop or two of cerebrospinal fluid will indicate that the spinal canal has been entered; if the syringe is attached to the needle the piston should be withdrawn in order to show the same result. It is possible to practise this operation with a patient in the recumbent position, but it is done more easily as above outlined. The skin may be frozen by the freezing spray, or may be anesthetized by the local injection of cocaine solution with the ordinary hypodermic syringe.

It is astonishing what beneficial effects can be gained from the use of a small amount of cocaine. It is rarely necessary to use more than 0.03 (¹⁄₂ grain) of pure cocaine in order to procure analgesia of the entire lower part of the body.

_Beta-cocaine_ or _tropacocaine_ may be used for the same purpose, in double this amount, but they do not give as reliable results. Morton, of San Francisco, has suggested that ¹⁄₂ Gr. powders of cocaine be wrapped in such a way that they can be repeatedly sterilized by a heat of 200° F., and that one of these be dropped into the syringe barrel, that this be attached to the needle, and the cocaine itself be dissolved in the cerebrospinal fluid withdrawn through the latter, and then thrown back again. This is probably the neatest and most serviceable method yet devised, and its originator has assured the writer that with 1 Gr. of tropacocaine used in this way, thrown into the spinal canal with considerable force, _i. e._, in such a way as to more completely distribute it, he has been able to practise operations even upon the tongue with little or no pain to the patient. The solution used for this purpose should be sterilized, also the needle, the syringe, the patient’s skin, and the operator’s hands. The water with which the cocaine solution is made should be first pure, then measured, and the solution made in such strength that not more than the amount indicated above will be used. This should then be again heated, but not quite to the boiling point, since cocaine solutions are impaired by too much heat.

[Illustration: FIG. 46

Technique of intraspinal injection.]

The advantages of intraspinal anesthesia are many and obvious, and were it not for disadvantages this method would have supplanted all others for certain work. It is, however, by no means free from danger, both from the maneuver and from the drug itself. Carelessness in its introduction may lead to septic meningitis, while the drug itself may produce considerable and even serious or fatal disturbance, though these cases are rare. It has been claimed that 2 per cent. of the cases in which this method has been employed have, in consequence, terminated fatally. The immediate effects are largely confined to the stomach and the nervous system, and include nausea, intense headache, and profound depression. The remote effects are less positive, but have been stated to include serious changes in the cord itself. It is often a disadvantage to have the patient mentally conscious of what is going on, even though oblivious to pain. Inasmuch as cocaine produces analgesia rather than anesthesia, nervous patients will be likely to mistake the general sensation of lifting a limb, or manipulating it, for actual pain. There are not a few cases where chloroform and ether are so plainly contra-indicated that if it were possible to use any other agent with safety this would offer a valuable substitute.

The effect desired is not produced immediately, but comes on slowly, after the expiration of ten to twelve minutes. As ordinarily used, anesthesia of the surface will be produced up to the height of about the waist. Should it be desired, however, to increase or enhance the effect the solution might be injected between some of the dorsal vertebræ, although at this point it will require more skill to introduce the needle, and the operator should be cautious not to injure the cord. Below the second lumbar vertebra the cord breaks up into its segments and the patient would be almost exempt from this danger. It is occasionally necessary to tranquillize the patient’s fear by using morphine subcutaneously at the same time. It is a question whether this can be safely combined with cocaine for the subarachnoid injection. Failing in this it may be necessary to supplement the use of cocaine with ether or chloroform.

The intraspinal injection of normal saline solution, or even of pure water, has been shown by Eden to be almost as effective in some cases as the cocaine solutions. Bier has largely modified his statements about the value of intraspinal cocaine injections, and speaks of them as more dangerous than he had first appreciated.[11]

[11] _Magnesium Salts as Local Anesthetics._--Six years ago Meltzer discovered that magnesium salts have the property of inhibiting functional activity in nerve tissue, and in December, 1899, he announced that the intracerebral injection of magnesium sulphate in a rabbit caused paralysis without previous convulsions. He has recently announced the local anesthetic effect of small doses of a 25 per cent. solution of magnesium sulphate, an effect which lasts from one to two hours. It is the magnesium “ion” which possesses the anesthetic property, since the chloride and the bromides give the same effects.

These salts have this advantage over other local anesthetics that there is no primary period of excitation. Moreover, applied locally to nerve trunks they have the effect of “blocking” them; and when applied to the sciatic, pneumogastric, and other nerves, temporarily abolish their power of conducting influences, either motor or sensory. This effect is apparently due to the fact that the magnesium normally present in the tissues constantly exercises an inhibitory power over them, and that when thus applied from without they merely exaggerate the condition already present; thus, if this be true, affording an ideal anesthetic.

In December, 1905, Meltzer read a paper before the New York Academy of Medicine, announcing success with intraspinal injection of magnesium sulphate in 25 per cent. strength. Blake, of New York, promptly made use of the suggestion in a child with tetanus. Two injections of antitoxin had been made into the cervical cord on successive days, with apparently no effect. He then made lumbar puncture and a subdural injection of magnesium sulphate, giving 1 Cc. of 25 per cent. solution for every twenty-five pounds of body weight, administering it every thirty-six hours, employing four doses. The effect was marked, in immediate control of convulsions, which, however, was not permanent; hence the repetition of the doses. How much influence the previous antitoxin had produced does not appear.

Meltzer suggests that the best time for an operation is three or four hours after a spinal injection. He reports four cases thus operated, in one of which, after the operation, the patient passed into a period of deep general anesthesia, in which he remained for five hours, the pulse keeping up, the respirations falling to ten per minute. In this case another spinal puncture was made, some of the spinal fluid let out, and the spinal cavity treated by repeated irrigations with sterile salt solution.

Meltzer’s few but important experiences indicate that at least three or four hours should be allowed to elapse after the introduction of the magnesium solution. He advises 1 Cc. for every twenty-five pounds of body weight, for intraspinal injection, which causes not only _analgesia_ but temporary paralysis of the legs, sensation and motion returning in from eight to fourteen hours, with possible retention of urine for a day or two, requiring the use of the catheter.

Doses a little larger than the above, he thinks, would permit the performance of extensive operations in the abdominal cavity, or even higher up, without the aid of a general anesthesia. He is inclined to think that it would be preferable not to wait four hours, but to operate within about two hours after injection, with the aid of a small amount of chloroform, the operation to be followed by another puncture, with the removal of at least as much fluid as was introduced, and irrigation with sterile salt solution, finally leaving some of it within the canal.

## PART IV.

INJURY AND REPAIR.

##