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 Another Random Document on
Scribd Without Any Related Topics
The Project Gutenberg eBook of Practical
Points in Anesthesia
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
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under the terms of the Project Gutenberg License included with this
ebook or online at www.gutenberg.org. If you are not located in the
United States, you will have to check the laws of the country where
you are located before using this eBook.

Title: Practical Points in Anesthesia

Author: Frederick-Emil Neef

Release date: October 3, 2016 [eBook #53199]

Most recently updated: October 23, 2024

Language: English

Credits: Produced by The Online Distributed Proofreading Team at

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*** START OF THE PROJECT GUTENBERG EBOOK PRACTICAL

POINTS IN ANESTHESIA ***
PRACTICAL POINTS
IN
ANESTHESIA

By

FREDERICK-EMIL NEEF
B. S., B. L., M. L., M. D.
New York City

New York, U. S. A.
Surgery Publishing Company
92 WILLIAM STREET
1908
COPYRIGHT, OCTOBER, 1908
BY
SURGERY PUBLISHING CO.
NEW YORK
 PREFACE

I have tried to present some of my impressions on the correct use of

chloroform and ether and of a very useful combination of these—
anaesthol. No doubt, my observations and conclusions will have to
be modified in many details by the experiences of others. I have
merely voiced a simple and coherent working theory, which has
gradually forced itself upon me as my views on the practice of
anesthesia have become a little broader and more comprehensive.

FREDERICK-EMIL NEEF

941 Madison Avenue

New York
 CONTENTS

Preface, 5
The Induction of Anesthesia—The German Hospital System, 9
Cardiac Collapse, 12
Respiratory Collapse, 13
When Shall the Patient be Declared Ready for Operation, 15
Maintenance of the Surgical Plane of Anesthesia, 16
Some Important Reflexes, 22
Vomiting During Anesthesia, 23
Obstructed Breathing, 24
The Use of the Breathing Tube, 26
Indications for Stimulation during Anesthesia, 28
The Influence of Morphine on Narcosis, 30
General Course of the Anesthesia, 31
Awakening, 31
Recession of the Tongue after Narcosis, 33
Post-Operative Distress, 34
Morphine-Anaesthol-Ether Sequence, 36
Minor Anesthesia with Ethyl Chloride, 38
Intubation Anesthesia, 38
Cases Requiring Superficial Anesthesia, 43
Cases Requiring Anesthesia Of Moderate Depth, 44
Cases Requiring Profound Anesthesia, 44
Conclusion, 45
PRACTICAL POINTS IN
ANESTHESIA
 The Induction of Anesthesia.

I can spare the reader the ordeal of many words by beginning in a

concrete way with the outline of a system of anesthesia that is now
largely followed at the German Hospital, New York City.
The Mask The Schimmelbusch mask is used; this fits
the face and is large enough to include the
bridge of the nose and prominence of the chin. It is covered with a
piece of thin flannel, and, over this, impermeable cloth in the center
of which a lozenge-shaped fenestra (1½”×1”) has been cut. In the
upper half of this little window with the flannel pane, on the inside of
the mask, a small wad of gauze is fastened. The mask is then
complete and can be used for administering any anesthetic by the
drop method—chloroform, anaesthol or ether. In giving ether one
makes use of the upper half of the fenestra with its separate ether
pad; while chloroform and anaesthol are given to advantage through
the lower portion. The chin, cheek and bridge of the nose are
anointed with a little white vaseline at the line of contact with the
mask, and then the latter is allowed to rest lightly on the face of the
patient for a few moments, until he can reconcile himself to the
strange procedure, and resumes his normal breathing. There must
be absolute quiet. The anesthetist alone may speak when he deems
fit.
The Induction The beginning is made with anaesthol or
chloroform drop by drop. The slightest
objection on the part of the patient that the vapors are too strong
must be considered; irritation of the throat, slight coughing, all
merely emphasize that the introduction must be very gradual. If the
patient is solicitous about the efficacy of the anesthetic he should be
assured that there is no hurry, and he should be enjoined to take
deeper breaths, if he breathes too lightly. As long as the patient is
Primary Anesthesia conscious he will respond to the injunction
to take a deep breath; if he does not
respond to this request he has reached the stage of unconsciousness
—the state of primary anesthesia.
Sometimes a remarkable calm, a period of relative apnea, precedes
the stage of excitement. At other times, this stage ushers the patient
directly into the state of complete anesthesia. There need be no
stage of excitement at all. This is especially true if morphine has
been administered hypodermatically before narcosis, and if the
induction of the anesthetic is cautious and gradual.
Surgical Degree The surgical degree, the state of complete
anesthesia, is announced by the respiration
when it assumes the more or less well marked snoring character of
one who is fast asleep.
In the German Hospital system the patient, male or female, is given
a quarter of a grain of morphine sulphate hypodermatically half an
hour before narcosis. The anesthesia is always induced with
anaesthol or chloroform. Where much blood is lost or the operation
is of very long duration one may at any time make the transition to
ether by the drop method without changing the mask. As a rule, a
morphine-anaesthol narcosis is given with a few drops of ether now
and then (ether feeding), when a little stimulation is indicated. In a
small number of cases, among them choledochotomies and other
operations on the gall-bladder, particularly where there is jaundice,
the morphine-anaesthol introduction is followed by the ether drop
method.
 Cardiac Collapse.

Cardiac collapse is fortunately uncommon. It usually occurs during

the induction of anesthesia. Suddenly there is a marked pallor of the
face and the pulse becomes weak. It happens in chloroform, and
occasionally in anaesthol narcosis. When such a tendency is
discovered ether should be given by the drop method.
Gradual induction of anesthesia until the patient’s tolerance to
chloroform is ascertained, is of cardinal importance.
 Respiratory Collapse.

Obstructed breathing developing during the induction of narcosis is

apt to be due to crowding. If obstructed breathing becomes manifest
later, that is, during the course of the operation, it may be due to
inhibitory reflex elicited by the surgeon. Traction on the gall bladder
or mesentery will sometimes evoke a peculiar noisy breathing which
does not mean that the patient is insufficiently under the influence
of the anesthetic. The breathing becomes normal and unrestrained
as soon as the surgeon desists from these vigorous manipulations.
Crowding Probably the most common of mistakes is
crowding the anesthetic. The anesthetist
becomes aware of faint, high pitched notes in the breathing—the
beginning of obstructed respiration. He examines the lid and corneal
reflex and these convince him that the patient is in the state of
superficial anesthesia. Naturally, he gives more of the anesthetic. To
his great chagrin the breathing becomes progressively more
stertorous. The cyanosis which was at first slight, deepens. The
noisy breathing attracts the surgeon’s attention. The perspiring
anesthetist is enjoined to push the jaw forward; but the spasm of
the muscles is too great. The teeth are pried apart, barbarous
instruments are brought into play to pull the tongue forward. The
patient has not received sufficient air all this time—his face is slate-
Respiratory colored. The nasal or pharyngeal tube,
Collapse tongue traction, oxygen, artificial respiration
with rhythmic chest compression, stretching of the sphincter ani, all
follow in an illogical onslaught, until finally a long deep breath is
induced and the victim is resuscitated. The condition was one of
respiratory-collapse. The cause was crowding of the anesthetic.
 When Shall the Patient be
Declared Ready for Operation?

As soon as the first, unimpeded, snoring respirations are heard, the

cleansing of the field of operation may begin. If the cleansing
manipulations do not disturb the rhythm of the snoring respiration,
the rate of the pulse does not increase and the patient makes no
defensive movements, he is very likely already in the proper plane of
anesthesia. Note is at once made of the state of the pupil and lid
corresponding to this plane.
Initial Incision When the surgeon makes the initial incision
observation is again made as to whether
the rhythm of the respiration and the rate of the pulse remain
undisturbed and whether the patient continues to be passive; if this
is the case, the patient is considered to be in the correct plane of
anesthesia—the plane in which he must be kept throughout the
operation.
Awakening Stimuli Of course, it is clear that the depth of the
narcosis must, in a measure, be
proportionate to the magnitude of the awakening impulses set up by
the surgeon’s manipulations. In abdominal work these impulses are
more intense near the solar plexus of nerves, that is, in the upper
part of the abdomen. Traction on the mesentery or the introduction
of long gauze tampons into the abdominal cavity for “walling off”
sets up powerful awakening stimuli.
 Maintenance of theSurgical Plane
of Anesthesia.

In order to conduct a narcosis scientifically one must know the signs

of sufficient anesthesia and the signs of awakening.
Respiration The respiration is studied by watching the
movements of the chest or abdomen, by
placing the hand in the vicinity of the nostril to feel the respiratory
current of air, or, best of all, for the respiration is rarely noiseless, by
listening to the breathing. The quality of the breathing is noted. The
faintest indication of a snoring respiration means that the surgical
degree has been reached. Any change in the quality of the breathing
compels the questions “Has the patient escaped from the proper
surgical plane?” “Is the anesthesia too deep or too superficial?” or
“Is the change simply a respiratory reflex induced by the surgeon’s
manipulations?”
Color The color of the ear is a most useful guide.
This does not hold good of the color of the
forehead. The forehead in some individuals becomes cyanotic with
slight changes of posture. The ear is not so subject to postural
influences and is therefore a less misleading indicator of the venous
condition of the blood. Even a slightly bluish tinge of the ear
demands attention. Usually, crowding is the cause, and a little more
air allows the normal red flush to return. Slight pallor developing
during the course of the narcosis should always be regarded as a
danger sign. It means that the patient is in profound anesthesia, and
that the heart is threatening collapse. The mask should be removed
promptly and the patient allowed to breathe pure air. As long as the
pulse is not weak or irregular one need not worry about the
outcome.
Pulse There are some advantages in choosing the
temporal pulse as the guide, instead of the
radial pulse, which is ordinarily followed; occasionally the temporal
can still be felt when the radial has become impalpable. The
pulsation of the temporal artery is best felt by placing the index
finger flat over the tragus into the depression at the root of the ear.
The pulse is important because it tells how the heart reacts towards
the anesthetic and the surgeon’s manipulations. The frequency is not
very important. Exceptionally, it may be 120 or 130 during the
greater part of an anesthesia without vital significance, if the quality
is good. A diffuse and weakening pulse is a signal that the narcosis
is too profound and that the heart is in danger of collapse. A
somewhat irregular pulse may immediately precede or accompany
the act of vomiting, and it is not a cause for alarm.
Accessory to the respiration, color and pulse, but of lesser
significance, are the pupil, the cornea and eyelid, and the secretions.
Pupil In patients who have not received morphine
before narcosis the pupil is, as a rule, a
guide of some importance. If the pupil is narrow, examination of its
reaction to light is generally superfluous. A wide pupil, however,
often means one or the other extreme of narcosis. A wide pupil
which reacts promptly to light indicates superficial anesthesia; the
patient may need more of the anesthetic. A wide pupil which reacts
to light sluggishly or not at all means that the danger line has been
overstepped; the anesthesia is too deep; the patient must have air.
Without knowledge of the reaction, every markedly dilated pupil
should be looked upon as prognostic of danger.
Cornea To touch the cornea repeatedly with the
finger for the purpose of obtaining the
corneal reflex, is a bad habit. The reflex can be tested just as
satisfactorily by shifting the eyelid gently across its surface.
A point worth remembering is that in the morphine-anaesthol (or
morphine-chloroform) anesthesia the corneal reflex may remain
quite active, while with ether it soon becomes feeble or extinct.
Eyelid A useful indicator of the degree of muscular
relaxation is, I believe, the tonicity of the
eyelid. The usual arm test is very misleading. Flexing the elbow once
or twice may give the impression that the muscles are thoroughly
relaxed, and yet, on repeating the manipulation five or six times one
may be surprised to obtain a sudden, powerful contraction of the
biceps, showing that the patient is still not fully under the influence
of the narcotic.
Normally the upper lid has a certain tonicity. If it is lifted gently by
means of the superimposed ball of the finger it springs back to its
natural position promptly. When the patient is fully under the
influence of the anesthetic, this tonicity is partly or completely lost
and the lid returns sluggishly to its natural position, or not at all. The
patient can sometimes be kept in a proper surgical plane by giving a
few drops of the anesthetic each time as the tonicity returns, and
ceasing when relaxation of the eyelid is obtained.
Secretions When the patient is under anesthesia to the
surgical degree the activity of the salivary,
sweat and tear glands ceases. The accumulation of mucus in the
mouth, the appearance of a tear in the eye, beads of perspiration on
the brow all mean that the anesthesia is becoming superficial, that
Individual more anesthetic is required. It is worth
Idiosyncrasy bearing in mind that these indicators of the
depth of narcosis do not, in all individuals, react in exactly the same
way. While initiating the narcosis the anesthetist can get his bearings
in regard to this point, and watch for any individual idiosyncrasy
which may exist.
It is unsafe to concentrate the attention on one sign, lest the general
aspect of the patient be overlooked.
The anesthetist watches constantly the rhythm and quality of the
breathing, the color of the ear and the character of the pulse. From
time to time, only as occasion demands, he refers to the accessory
signs for confirmation. Should he, at any time, be in doubt about the
depth of the narcosis, the first step is always to desist from giving
more of the anesthetic until he has regained his bearings or the
signs of awakening are recognized.
 Some Important Reflexes.

Pharyngeal Reflex (1) Pharyngeal reflex. Coughing does not

necessarily indicate awakening. It usually
means that the vapor of the anesthetic is too concentrated and
irritates the air passages. “Holding the breath” occurs even in fairly
deep narcosis and has the same significance. The treatment is to
dilute the anesthetic by admitting air.
Ano-respiratory (2) Ano-respiratory reflex. The crowing
Reflex inspiration heard during operation on the
perineum or rectum, does not indicate that the patient should have
more anesthetic.
Splanchnic Reflex (3) The reflex produced by traction on the
gall bladder or mesentery is similar in its
significance to that of the ano-respiratory reflex.
 Vomiting During Anesthesia.

Vomiting It may happen to the conscientious

anesthetist, who desists from giving more
of the anesthetic until he has regained his bearings, that the patient
suddenly shows signs of awakening, and vomiting begins. This is a
disagreeable, but generally not a serious interruption. The
anesthetist is absolute master of the situation. Although the patient’s
face turns somewhat blue during the vomiting efforts, the
anesthetist should not attempt to push the jaw forward or exert
traction on the tongue. The face is merely turned to the side and
kept in position by placing the hand on the cheek. The mouth and
pharynx are cleansed gently with a piece of gauze and the
anesthetic is continued, drop by drop. It is often surprising in such
cases how rapidly the patient can be brought back into the proper
plane of anesthesia. There need be no fear that the patient will fully
awake.
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