I

GOLDEN RULES

OF

ANESTHESIA

BY THE SAME ATUTHOR.

A PRACTICAL GUIDE TO THE

ADMINISTRATION OF AN1ESTHETICS.

211 pp. Illustrated. 4s. 6d. Net.

LONGMANS, GREEN & CO.

''The writer of this book has set himself to instructstudents, and he has performed his task well .Dr. Probyn-Williams' book may be accepted as asuccessful solution of the difficult problem involvedin any attempt to marshal the facts of anaesthesia insuch a way that an average student can master themand apply them in practice."-Lacet.

"It is almost an ideal handbook of very moderatedimensions, for the use of the student and practi-tioner. The ' technique' of gas, ether, and chloroformanaesthesia are admirably described, and excellentillustrations of all necessary apparatus are provided.

'

-Edin. 1ied. Jouer.

GOLDEN RULESOF

ANIE STHESIA:

BY

R. J. PROBYN-WILLIAMS, M.D.,Senior Anaesthetist & Instructor in Anaesthetics atthe London Hospital, Lecturer on Anesthetics inthe London Hospital Medical College, Anesthetist

to the Royal Dental Hospital of London.

"GOLDEN RULES" SERIES, No. XIV.

1risto l:JOHN WRIGHT & CO.

Aonon:SIMPKIN. MARSHALL. HAMILTON, KENT & Co., Lim.

PREFACE.

THE following rules represent someof the principal points to which theattention of the student must bedirected during the practical part ofhis course of instruction in theadministration of anesthetics.

It is hoped that some of them mayalso be found helpful to those practi-tioners who are occasionally called onto give an anaesthetic.

As ethyl chloride is now again ontrial, and most text-books give noaccount of its use, a short account of

it has been added.

13, WELBECK STREET, W.

CONTENTS.

GENERAL RULES - 9

PREPARATION OF THE PATIENT - - - 10

EXAVIINATION OF THE PATIENT - - 11

POSITION OF THE PATIENT - - - - - 13

ADMINISTRATION OF THE ANESTHETIC - 16

RECOVERY FROM THE ANESTHETIC - - - 27

NITROUS OXIDE FOR DENTAL OPERATIONS - 29

NITROUS OXIDE IN GENERAL SURGERY - 36

NITROUS OXIDE AND OXYGEN - - - - 37

ETHER - - - - - - - - - 38

CHLOROFORM - - - - - - - - 4

MIlXTURES OF ETHER AND CHLOROFORM - - 50

DIFFICULTIES AND DANGERS OF ANIESTHESIA 52

ARTIFICIAL RESPIRATION - - 56

CHOOSING THE ANESTHETIC - 57

ETHYL CHLORIDE- -- - - - - 62

Golden Rules ofAnwstkesia.

GENERAL.

1.-Never give an anasthetic withouta third person being present.

2.- Never give any anaesthetic -unless it be nitrous oxide for a dentaloperation-without being prepared withanother in case the first one provesunsatisfactory.

3.-Never give any anasthetic with-out having at hand all the apparatuswhich may be required for the treat-ment of emergencies. These shouldconsist of mouth-props, a wedge to open

10 Golden Rules of

the mouth, a gag, tongue forceps, instru-ments for tracheotomy, a hypodermicsyringe--in working order-with strych-nine, brandy, or any other drugswhich you are in the habit of using.

4.-Always remember that emer-gencies may arise in patients who arefairly healthy, and require an immediateoperation on account of an accident, aswell as in the comparatively feebleand bed-ridden patients who have beenprepared for the administration.

PREPARATION OF THE PATIENT.

Remember that a patient who has beenproperly prepared for an anaesthetic,as a rule takes. it far better than one whohas not been so prepared.

Remember that the best possiblepreparation for a patient is to have alight supper, a long night in bed, the

Ancesthesia. 11

bowels and stomach empty, and thesurgeon ready to operate in good timein the morning.

When the patient is weakly thestarvation before the operation shouldnot be carried too far, and if the opera-tion may be severe it is a good plan togive an enema of beef-tea or coffee withan ounce of brandy about half an hourbefore; while if, much shock may beexpected, gr. A of strychnine should beinjected.

Smoking and alcohol should be dis-continued for some hours before theadministration of an anaesthetic.

EXAMINATION OF THE PATIENT.

Always take care not to frightenthe patient by your examination; andremember that both his respiration and

12 Golden Rules of

circulation will be affected by nervous-ness, and make due allowance for this.

While speaking a few words, watchcarefully the colour of the face andlook out for signs of breathlessness.Then listen to the chest for signs ofheart or lung disease.

If you discover an abnormal cardiacmurmur, look out for signs of want ofcompensation; but remember that incases of death from cardiac failure underan ancesthetic, the heart has often beenapparently normal before the adminis-tration, and no disease has been foundpost-mortem.

Always ask a patient to take a longbreath ;.and if you suspect some nasalobstruction, try whether the nose can beused freely for the purpose of respira-tion. If it is much blocked, you willfind a small prop attached to a stringplaced between the teeth most useful, as

Anesthesia. 13

this will ensure free breathing throughthe mouth.

Always remove all artificial teethwhich are not firmly fixed, and also re-member that very loose teeth maybecome detached and give trouble; andalways see that there are none whichare likely to be broken off if it isnecessary to use a gag.

Remember that a child has beenknown to retain a sweet in the mouth,and a man a plug of tobacco.

Remember that an inspection of theback of the mouth may give you muchuseful information as to the presence ofenlarged tonsils or adenoid growths;these may cause trouble during theadministration.

POSITION OF THE PATIENT,

Never give chloroform, or any mix-

14 Golden Rules of

ture containing chloroform, to a patientwho is sitting in a chair, or who ispropped up with many pillows on anoperating table.

There is no objection to this positionwhen gas, ether, or ethyl chloride isbeing given.

If chloroform is required throughoutthe administration, and the sitting posi-tion is necessary for the performanceof the operation, the patient should beancesthetised in a position as nearlyrecumbent as possible, and then graduallyraised to that which the operator desires.

When a patient is lying on his backsee that the head is turned wheneverpossible to one side., In this positionthe tongue will not fall back so readily,and mucus and saliva which may accumu-late will collect in the cheek and can beeasily removed,

When a patient is vomiting there is

Ancesthesia. 15

less chance of the vomited materialentering the larynx if he is turned on toone side. This position is very useful incases of persistent vomiting from intes-tinal obstruction, and the patient shouldbe turned as far over to one side as theoperator can allow.

When the operation is to be performedon the upper part of the body, alwaysremember to keep the head turned tothe opposite side, so that there can beno danger of contaminating the wound.

When during the operation the patientmust lie on one side, remember thatthe lung which is lowermost cannot doits work so well, and see that the upper,most lung is unhindered by assistantsleaning on the chest, etc.

A very good position may be obtainedby the use of Mr. Carter Braine's arm-rest, but if this is not available, careshould be taken to prevent the patient

16 Golden Rules of

rolling over on to his face, by proppingup the arm that is uppermost, and fixingit as much as possible.

ADMINISTRATION OF THEAN/ESTHETIC.

Always try to keep the room quiet,both when a patient is being anmsthe-tized and when he is recovering.

Never let the clothes, dressings, ormacintoshes be moved, or an examina-tion be made, while the patient is still inthe first stage of anaesthesia.

Always start the administrationgradually; a strong dose of the anms-thetic at first will probably make thepatient hold his breath, cough, or per-haps struggle.

Never try to get a patient underquickly.

A little encouragement at first oftencheers a patient, and makes him-breathemore freely.

When a patient holds his breath forsome time, be sure that he does not geta strong dose of the drug with his nextinspiration. This is of the utmostimportance in the administration ofchloroform, as it is generally at thesetimes that an overdose is given, but thesame remarks also apply to the adminis-tration of mixtures with ether.

When anaesthesia is obtained, thefollowing points must be carefullywatched :--Respiration, the pulse, thecolour of the face, the condition of thecorneal reflex, the size of the pupil, andthe amount of muscular relaxation.

Not one of these should ever be neg-lected.

Remember that your object is to give2

Anaesthesia. 17

18 Golden Rules of

just sufficient of the drug to produce itsdesired effect, and not to see how muchyou can give without endangering yourpatient's life.

RESPIRATION.

Always watch the ,respiration mostcarefully throughout the administration.When the breathing is at all shallow, itcan best be estimated by feeling it on theback of two or three fingers held in frontof the mouth and nose.

Never be content with watchingabdominal or thoracic movement, with-out at the same time feeling or hearingthe breath.

Always try to keep the respiration asregular as possible, both in rate anddepth.

Always listen to the breathing whenthe first incision is made. If there isno change in the character or rhythm,your patient is probably sufficiently

Ancesthesia. 19

under; but if the breath is held, it isbetter to give the patient a little inoreof the anasthetic.

Remember that in stretching thesphincter ani there will often be somespasm of the larynx, unless your patientis well under.

Remember that when the breath isheld during a state of light anesthesiait may often be started again by rubbingthe lips briskly with a towel.

Remember when, the nasal passagesare more or less blocked, and you keepthe mouth firmly closed by holding aface-piece tightly over it, that there isnot a very free channel for the purposeof respiration. If a patient cannotbreathe well through the nose, it is wiseto make sure that he has a good air-way through the mouth, and this is bestdone by placing a small prop betweenthe teeth either before the commence-

20. Golden Rules: of

ment of the administration or when thepatient is becoming unconscious.

The commonest obstruction to freebreathing is the dropping back of thetongue. If pressure behind the angleof the jaw is not sufficient to keep theair-way free you must draw the tongueforward with forceps; but never keepthe forceps on longer than necessary, asthey bruise the tongue and leave it sorefor some time afterwards.

Occasionally it may be necessary tokeep the tongue forward for some time,and then it is better to put a ligaturethrough it, as by this means it may bekept in a very good position with lessswelling and after-pain than would beproduced by the forceps.

Remember that frequent applicationsof the tongue forceps betray want of careor experience on the part of the anaes-thetist.

Ancesthesia. 21

Do not push the jaw forward whilethe patient is quite conscious.

Remember when keeping the jawforward for a long time, to bruise theskin as little as possible.

Remember that besides pushing thejaw forward with the fingers of one hand,a good deal may be done to help bypulling the chin forwards and upwardswith fingers of the hand which isholding the inhaler.

At the same time care should be takenthat the lower teeth are not lockedbehind the upper.

CIRCULATION.

Remember that it is even moreimportant to keep a watch on the circu-lation when chloroform or one of itsmixtures is being administered, thanwhen ether is the anvesthetic.

22 Golden Rules of

The most convenient pulse is thefacial artery, as it passes over the lowerjaw; you can feel this with one fingerwhile you are keeping the jaw forwardwith another.

Remember that the amount ofshock which an operation produces in apatient will be indicated in the pulse,and in the colour of the skin.

When a pulse is steadily gettingfaster and weaker in spite of all yourefforts to improve it by giving moreair, or a more stimulating anesthetic, itis your duty to warn the surgeon thatthe patient is not doing well, so that hemay, when possible, hasten the opera-tion.

Remember ihtt when a patient is toolightly under and about to vomit, thepulse may become feeble. This conditionmust not be confused with the stage ofoverdose. In both cases the pupil may

Ancesthesia. 23

'be large, but in the case of too lightanesthesia the corneal reflex will be-present.

Always keep a careful watch on thepulse of a patient who is recovering froma prolonged administration.

COLOUR OF THE FACE.

Always try to prevent your patientbecoming cyanosed, and try differentpositions of the jaw and tongue, etc., tillyou are satisfied that you cannot dobetter.

Remember that the colour is wellshown in the lips and ears.

Remember that when your patient iscyanosed, the seat of operation will alsobe full of dark blood, which will makethe surgeon's work more difficult.

Remember that cyanosis or pallor issometimes caused by allowing the patient

24 Golden Rules of

to come round too much, and as a resultto hold his breath and strain. In thesecases the lips should be rubbed brisklywith a towel to start the breathing again,and rather more of the anasthetic shouldbe given.

But on the other hand pallor may bepart of the result of an overdose of theanaesthetic; and then more air must begiven.

CORNEAL REFLEX.

Never try to obtain the corneal reflexwhile a patient is moving or beingmoved, as you may then do damage tothe cornea.

Never try to obtain a corneal reflexwhile you can feel resistance in theupper lid when you attempt to raise it.

When trying the corneal reflex alwaysraise the lid with one finger and touchthe cornea with another.

Ancesthesia. 25

Frequent attempts to obtain the reflexin one eye will deaden the sensitive-ness of the cornea in that eye; and inthese cases it is wiser when possible touse the eyes alternately.

In infants, the corneal reflex is notsuch a reliable sign of anasthesia as inadults. In these little patients pinchingthe skin may provoke a response in theform of movements of the limbs, oreven cries, when the corneal reflex isapparently lost.

The corneal reflex should never beabolished during tracheotomy and op-erations on the thyroid, or those forempyema.

LIGHT REFLEX.

The pupils as a rule should reactreadily to light. If a pupil is dilating,and at the same time the reaction tolight is becoming sluggish, you will

26- Golden Rules of

generally find that less anasthetic isrequired.

SIZE OF THE PUPIL.

When a patient is becoming anms-thetized the pupil is generally dilated,and it is at this stage, before the cornealreflex is lost, that most operations undergas are performed; but as more of thedrug is given and the patient becomesmore fully under its influence, the pupilagain contracts.

During an operation the pupil shouldbe of a medium size., If too much ofthe anaesthetic is given it will graduallydilate (dilatation from paralysis), thelight reflex becoming sluggish, with thecorneal reflex also abolished.

If too little of the anaesthetic is giventhe pupil will also dilate (reflex dilata-tion), with a brisk reflex to light, and alid-reflex to touch.

Anacsthesia. 27

As a rule the average size of the pupil;of a patient under ether, is larger thanthat of one under chloroform. This is inpart due to the use of a closed apparatusfor the administration of ether.

Remember that a very small pupil,the so-called " pin-point " pupil, isoften a sign of light anmsthesia, and aprecursor of vomiting.

RECOVERY FROM THEAN ESTHETIC.

Coughing and vomiting are the twomost common of the after-effects of ananmsthetic.

Coughing may to a great extent berelieved, and the risk of more seriousrespiratory trouble diminished, by kaep-ing the room thoroughly warm till thepatient has quite recovered from theeffects of the anwsthetic.

98 Golden Rules of

Vomiting is often caused by givingfood too soon. As a rule about fourhours should elapse before the first liquidshould be , given, which may consist ofsome weak tea. Milk should be avoided,and no solid food should be given untilliquids are retained without any dis-comfort.

Sipping very hot water, or Suckingsmall pieces of ice will sometimes be ofservice, and if the vomiting is severe itmust be treated on general principles.

Remember that vomiting is morelikely to occur after ether than afterchloroform, but that in the former caseit occurs as a rule before the patient isconscious, and consists of the removalof saliva and mucus which has beenswallowed; but if vomiting occurs afterchloroform it is generally when thepatient has become conscious, andoften after the first food has been taken.

&Ancisthesia. 29

It. is more likely to recur than the vomit-ing after ether, and to be accompaniedby more discomfort.

When the operation is completed, seethat the patient is carefully laid in bed,and not dropped into it.

If the nature of the operation willallow it, a patient recovering from ananwsthetic will be more comfortablelying on one side, and in this positionboth coughing and vomiting, if theyoccur, can be more easily accomplished.

ADMINISTRATION OF NITROUSOXIDE FOR DENTAL OPERA-

TIONS.

Whenever possible try your gas cylinderbefore the patient enters the room, or atany rate be careful that you do not alarman already nervous individual by violentrushes of gas from the cylinder.

80 Golden Rules of

Always see that the valves are actingwell before applying the face-piece.

Remember that it is easy to let outair from a distended pad of a face-piecewhen applied to the face, but it isimpossible to fill the pad again withoutremoving it.

Never have your bag so distendedwith gas that when you turn the tap forthe first time the patient gets a puff ofgas into his mouth.

Remember that you will as a rule beout of the operator's way if you stand atthe left of the patient, or behind thechair.

Before you begin the administration,always see that your patient's head is ina good position, that is to say as nearlyas possible in the same axis as thebody; the chin should not be pushedforwards, or upwards.

Ancesthesia, 31

Always ask your patient to take along breath, and watch to see whetherthere is any sign of constricting clothing.

Be careful to place the prop on asound tooth; and if the gag is to be usedlater on' for the other side, see where itshould rest while you are inserting theprop.

Never use any form of prop unless itis attached to another one by silk orcatgut, etc., so that there can be nodanger of the patient swallowing it.

When a patient is not able to openthe mouth sufficiently wide for a suita-ble prop to be placed on the opposite sideof the mouth, be sure that you get somesort of prop between the teeth on thesame side as the tooth to be extracted,and when the patient is fully anes-thetized, open the mouth widely bymeans of a Mason's gag placed on theopposite side.

32 Golden Riles of

: Remember to insert the prop as thelast preliminary, and do not leave themouth propped widely open for sometime while you are making other pre-parations.

Remember that a face-piece willgenerally fit better when held in positionas lightly as possible. Pressing it toofirmly against the face hurts the patient,and spoils the shape and fitting of theface-piece.

Remember when applying the face-piece to keep one or two fingers underthe chin. By doing this you can oftenkeep a better air-way, and by a littlepressure you can prevent a nervouspatient from opening the mouth toowidely and so displacing the prop.

Always keep the room as quiet aspossible when administering nitrousoxide.

Never let your bag get less than halffull, for if both cylinders are then empty,you may not have enough gas to obtainanesthesia by re-breathing.

Do not allow re-breathing unlessyour supply of gas is running short, oryou are going to change to ether. Re-breathing is generally followed by moreheadache or giddiness than when thevalves are used throughout.

When giving gas without air alwaystry to remove the face-piece justbefore the first appearance of jactitation,as otherwise the operator will be muchinconvenienced.

Remember that in all patients exceptvery vigorous or alcoholic men you canget a better and quieter anaesthesia bygiving a suitable supply of air or oxygenwith the nitrous oxide.

Remember that the best sign of3

Aneasthesia. 33

S3 Golden Rules of

anaesthesia when giving gas and air, orgas and oxygen, is the deep, regularbreathing, which is often accompaniedby some snoring. You should alwaystry to work by this sign rather than byrelying on the absence of the conjunc-tival reflex, as good anesthesia may beobtained without this being established.It is very unpleasant for a patient whenpartly conscious to feel a finser touchingthe eye.

While the operation is going on alwayskeep the head as still as possible,and in the most suitable position.

When the operation is on the lower

jaw, support should be given to preventdislocation.

Remember that when the operationis on the lower jaw, the operator willsometimes press the tongue so far backthat respiration is impeded. The anms-thetist should see that this is not carried

Anesthesia. 35

too far, and should push the jawforward when necessary.

Always watch for teeth, or fragmentsof teeth, left in the mouth, and whenpossible help the operator by removingthem. If in spite of your endeavours toprevent it a tooth gets to the back of themouth, try to remove it by passing afinger along the tongue, and if thepatient has come round, make him leanwell forward in the chair with the headbent down, tell him to cough, and slaphim on the back. Before inverting thepatient, which is sometimes necessarywhen spasm is set up by the presence ofthe foreign body in the larynx, alwaysbe prepared to perform laryngotomy.

Always watch the respiration of apatient under the influence of nitrousoxide, and if you notice that as theoperation proceeds the colour instead ofimproving becomes worse, and respira-

36 Golden Rules of

tion is not satisfactorily performed, stopthe operation, pull the tongue forward,and compress the chest. If thesemeasures are insufficient, lift the patientfrom the chair on to the floor, hold histongue forward with tongue forceps, andperform artificial respiration till hebreathes naturally and regularly byhimself.

NITROUS OXIDE IN GENERALSURGERY.

In considering the advisability ofgiving gas with air or oxygen for asurgical operation remember :-

1.-That it is very useful from thefact that no elaborate preparation ofthe patient is necessary, and recoveryis generally rapid and unaccompaniedby unpleasant symptoms, such asvomiting, etc.

Anesthesia. 37

2.-That it should be reserved forthose operations which do not takemore than ten minutes, and in whicha very profound ancesthesia is notrequired.

3.-That when the administrator isaccustomed to the more complicatedapparatus, more satisfactory ances-thesia can generally be obtained forthese cases with gas and oxygenthan with gas and air.

4.-That the rapid recovery is some-times a drawback; as for instance inthe breaking down of adhesions, whenthe patient recovers from the effect ofthe gas so quickly that most acutepain is often felt.

NITROUS OXIDE AND OXYGEN.Remember that as a rule you can get

a longer and quieter anaesthesia whenair or oxygen is given with nitrous oxide.

38 Golden Rules of

When giving it see that your face-piece fits accurately, and that the twobags are kept equally distended.

For a dental operation the best signof anaesthesia to work by is the deepregular breathing, accompanied generallyby faint snoring; but for short surgicaloperations the corneal reflex may bekept abolished.

ETHER.

When giving ether with a Clover'sinhaler, remember the followingpoints:-

Select a face-piece, and then fix itsecurely to the body of the inhaler.

Pour out a measureful of ether, andsmell it to make sure that it is reallyether.

Turn the indicator to 2 and pour theether in.

Ancesthesia. 39

Turn the indicator back to 0, and blowthrough the face-piece and inhaler toremove all smell of ether.

Now fit on the bag, and holding theinhaler in the right hand tell the patientto take a good breath and then to blow itout into the bag, at the same time apply-ing the inhaler so that the bag becomesdistended.

Remove the inhaler during inspiration,and let another expiration be caught inthe bag.

Never distend a bag into which apatient is going to breathe with yourown expired air.

When the bag is distended to abouttwo-thirds of its size, keep the face-pieceapplied continuously.

Always allow five or six respirationsto be taken with the indicator at 0, andthen slowly turn towards 1.

40 Golden Rules of

Remember that you can hardly starttoo slowly. If you give ether verygradually you may anaesthetize thepatient without his noticing the etherto any disagreeable extent. By turningon the ether too quickly, you will causeyour patient to hold the breath, cough,or else struggle, and it may be sometime before a tranquil anaesthesia isobtained.

Never increase the strength of thevapour while the patient is holding hisbreath; but wait till natural breathingbegins again.

If the patient coughs at the beginningof the induction give a weaker vapour fora few breaths, and then increase thestrength again very gradually ; but if thecoughing does not begin till the patientis almost anaesthetized, you may stop itby pushing the ether till anesthesia iscomplete.

A ces thesia. 41

Remember that a full strength ofether is seldom required, except forvery vigorous or alcoholic men. For mostwomen you need not go beyond 2, andfor children 1 or 14 is quite sufficient.

Whenever possible the head should beturned to one side during the adminis-tration of ether, on account of the amountof mucus and saliva which is oftensecreted. In this pcsition much of theliquid will collect in the cheek which isresting on the pillow, and may be easilyremoved. If the secretion is thin, it is agood plan to place a corner of a towel inthe cheek, and much of the liquid willthen be gradually absorbed.

The stimulating effects of ether aremost beneficial during the inductionperiod and for the earlier stages, and forshort operations; but the inhalation ofether for long periods and in strongdoses may produce bronchitis or even

42 Golden Rules of

pneumonia, unless special care is takenduring the stage of recovery.

Whenever possible induce anaesthesiawith ether, and if the operation is to bea long one, change at the end of half anhour, or sooner if necessary, to a mixturewith chloroform, or in some cases chloro-form itself for the rest of the time. Inoperations on the chest and abdomen,after which it is important that thereshould be as little coughing or vomitingas possible, it is wiser to change fromether earlier, say after about 10 to 15minutes.

Remember that the stimulating effectof ether is especially desirable in alloperations which are likely to producemuch shock, such as operations on largejoints, on sensitive parts, as the genera-tive organs, on the anus, etc., and forextensive operations for cancer of thebreast, etc.

Anaesthesia.. 43

When ether has been given during along operation, remember that besidesthe special care which should be takento prevent bronchitis, it is important towatch the pulse while the patient isrecovering. The stimulating effect ofthe ether will gradually be lost, and theshock produced by the operation willbecome more apparent. In these casesit may be necessary to give strychninefreely.

When it is necessary to change fromether to a mixture or pure chloroform,this should be done whenever possibleduring light anresthesia, that is to saywhile the corneal reflex is present.Chloroform should be given sparinglyat first, as on account of the deeprespirations established by the ether, toolarge a dose might soon be absorbed.

When trouble is caused by mucus inthe larynx, it is advisable to allow the

44 Golden Rules of

patient to cough it out before changingthe anaesthetic, if this will not interferewith the operation.

When giving gas before ether,especially when using a single bagful,be sure that the face-piece fits accu-rately, and till the patient is anms-thetized do not remove it to admit air,unless it becomes necessary on accountof cyanosis or spasm. It is unpleasantfor the patient to have an interval ofsemi-consciousness between the effects ofthe nitrous oxide and those of the ether.

If you have ethyl chloride at hand,remember that three or four minims willmake a very good substitute for gasbefore ether.

Remember that you cannot be toocareful in looking after your etherapparatus, and cleaning and drying itafter each administration. The metalreceiver is best cleaned with alcohol. A

Anacsthesia. 45

weak antiseptic solution either of car-bolic (1 in 60) or perchloride of mercury(1 in 2000) will be the best for washingout the bag, and if an Ormsby inhaler isused the bag may be turned inside out.

All rubber bags and tubes, unlessin frequent use, should be warmedoccasionally to prevent the rubber fromperishing.

CHLOROFORM.

Always remember to start theadministration with a very weak vapour,and never be in a hurry to get a patientunder quickly.

Always keep a most careful watch onthe respiration, and if you are not quitesatisfied with the sound of it, the breathshould be felt by some of the fingers heldnear the face of the patient.

Remember that any obstruction to

46 Golden Rules of

respiration will greatly increase thedanger of the absorption of an overdose.

As chloroform is a depressant to thecirculation, remember that a muchmore careful watch should be kept onthe pulse and on the colour of the facethan is necessary when ether is beinggiven.

Never attempt to push the adminis-tration when the patient is holding hisbreath or struggling; but on the otherhand remove the lint or mask furtherfrom the face, and try to re-establish thenatural breathing by rubbing the lipswith a towel, and when the breathinghas become freer and more regular, then,and not till then, give more of thechloroform.

Contraction of the pupil and fixityof the eyeball are more useful signs ofanoesthesia with chloroform than withether.

Ancesthesia. 47

Remember that a condition of sleepinstead of true anesthesia may be pro-duced by too small a dose of chloroform,and be sure that your patient is reallyunder, before the surgeon makes thefirst incision. This condition of falseanaesthesia is more likely to occur withinfants and small children than withadults, and in their case the cornealreflex may even be abolished withoutreal anesthesia being established. It iswiser in these instances, when theoperation is an important one, say anabdominal section, to make sure thatthe patient is really anaesthetic bypinching the skin or some other meansof provoking a reflex.

Remember that the path of safetybetween too much and too little of theanaesthetic is narrower with chloroformthan with ether.

When children breathe badly or begin

48 Golden Rules of

to show signs of an overdose, they mayoften be quickly restored by holdingthem up by the feet with the head justresting on the table, at the same timeplacing a finger in the mouth to keepthe tongue forward, and rhythmicallycompressing the chest as a form of arti-ficial respiration.

Anasthesia with chloroform may beinduced and maintained very satisfactorilyby means of a Junker's inhaler, with aface-piece made either of glass or flannelstretched over wire. This method isspecially useful during operations on thehead and neck, when the anaesthesia maybe kept up without bringing a bottlenear the face to drop more chloroformon the lint or a mask.

Remember too that the Junker'sinhaler is the most suitable apparatusto keep up a light anaesthesia such as isrequired in all operations on the thyroid,

Ancesthesia. 49

When using a Junker's inhaler alwaysremember :-

1.-That it is better not to havemore than about six drachms of chloro-form in the bottle,

2.--That great care must be takenwhen using the older form of theapparatus with two separate tubes to

see that they are attached to their

corresponding tubes on the bottle, and

always make sure that the apparatusis working properly before you attemptto give any of the vapour to your

patient, and so avoid the deplorable

accident of pumping liquid chloroform

on to your patient's face, or even intohis mouth.

3.-That you will get more chloro-

form vapour through the inhaler by

regular contractions of the bellows,than by hurried pumping with the

bellows only partly contracted.4

50 Golden Rules of

4.-When using a mouth or nasaltube with Junker's inhaler, see thatthe bore is sufficiently wide to allowa free stream of chloroform vapour.

As chloroform easily decomposes, it isa good plan to buy it in small bottles,and to keep it away from heat and light.

MIXTURES OF ETHER ANDCHLOROFORM.

Always regard mixtures of ether andchloroform as practically weak forms ofchloroform, and consequently be carefulin their use as you would be with themore powerful drug.

Never adminster them from a closedinhaler such as Clover's ether inhaler.

Always be careful not to burn theface of your patient. If the mixture isgiven from a flannel mask or lint, and

Aiesthesia. 51

large quantities of the mixture arenecessary to produce and maintain anes-thesia, it is a good plan to smear theface with vaseline or lanoline to preventthis occurrence. If a Rendle's mask isused, be careful to pour the mixture onto the sponge, and not on to the flannelbag.

When using a Rendle's mask, alwayskeep it as far away as possible from thepatient's eyes, as if this is not done someconjunctivitis may follow.

If you are not giving anesthetics fre-quently, it is better to make a freshmixture of chloroform and ether foreach occasion.

A good form is the C. E. mixture, thatis, two parts of chloroform to three ofether, or the A.C.E. mixture without thealcohol: but remember that it is slightlystronger than A.C.E., as the chloroform

52 Golden Rules of

is in the proportion of .2 to 5, insteadof 2 to 6.

DIFFICULTIES AND DANGERSOF AN/ESTHESIA.

Remember that with gas, ether, andapparently with ethyl chloride, respira-tion will fail before circulation; butwith chloroform or its mixtures, eitherfeeble breathing, a bad colour, or a fail-ing plulse may be the first sign of danger;

Remember that undesirable effectsmay be obtained with ether in three:different ways :-

1.-By giving too strong a vapourat first. The patient coughs violently,or holds his breath, becomes cyanosed,and probably struggles.

The remedy for this is obviously pre-ventive, and care should always be taken

Ancesthesia 53

that a.weak vapour is presented to thepatient at first,

2.--By continuing it in too strong aproportion, or by giving it for toolong a time, so that the soft partsbecome much congested, and a largeamount of mucus and saliva issecreted. This is shown by the noisybreathing, accompanied by moistsounds, and by gradually increasingcyanosis. The pupil dilates, but thepulse, though quickened, may remaingood for some time. If this conditionis neglected, the breathing becomesshallow, and the patient may pass intoa serious state.

The appropriate treatment is either togive the vapour in a more dilute form,or if the obstruction to respiration ismarked, or the amount of secretion islarge, the anaesthetic should be changedto chloroform or one of its mixtures.

54 Golden Rules of

The patient's head, and in seriouscases his body, should be turned over toone side, and as much as possible of thesecretion should be removed by carefulsponging of the mouth and pharynx.

3.-Though a patient may be takingether perfectly, that is to say, breath-ing well without any abnormal amountof secretion, he may yet be placed ina dangerous condition by over-stimulation through an overdose ofthe drug.

In this state the breathing graduallybecomes faster and faster, and finallyvery shallow and "catchy" in char-acter; the pulse becomes faster andgradually weaker; the pupil dilates, andremains insensitive even to light.

Such a state demands a free supply ofair, and careful watching before anymore anesthetic is given; and if any

Anesthesia. 55

is required, the A.C.E. mixture willgenerally be found to be the best,

Remember that failure of the circu-lation which occurs with chloroform maybe of two kinds :-

1.-The sudden form, or syncope,in which the patient is dead almostbefore anything unusual is suspected.

2.-The gradual failure whichoccurs during an operation, either fromshock, excessive haemorrhage, or froman overdose of chloroform. In thisform the breathing gradually becomesfeebler and feebler, and finally stops;the pulse becomes smaller and faster ;marked pallor is observed, with adilated pupil, and no corneal reflex.

The treatment of both these forms isthe same, though unfortunately in thefirst it is often unsuccessful. It consistsof lowering the head, pulling the tongue

56 Golden Rules of

forward, performing artificial respiration,and injecting hypodermically strychnine(grain 1/30) or brandy (51). Furthertreatment may consist of transfusion,which is specially for use when there hasbeen hemorrhage, electrical stimulationof the heart, or manual compression.

ARTIFIOFAL RESPIRATION.

In performing artificial respiration,always remember:-

1.-That it is useless unless theair-way is clear; so let an assistantalways keep the tongue forward whileyou are doing the movements.

2.-Always start with compressionof the chest, so that no more chloro-form is sucked in.

3.-Careful movements-not more

Ancesthesia. 57

than 20 a minute-are of far morevalue than rapid and hurried ones.

4.-Be patient, and do not give upthe movements, though you' seem tobe doing little good at first, as a patienthas been restored by this means aftera considerable period.

CHOOSING THE AN/ESTHETIC.

Remember that you owe it to yourpatient to consider which will be for himthe most safe of the anaesthetics com-monly used. First comes nitrous oxide,then ether, then mixtures of ether andchloroform, and lastly chloroform itself,which may be shown by statistics to bemore than five times as dangerous asether.

Ethyl chloride, which is now being

58 Golden Rules of

tried again, seems as though it will rankbetween nitrous oxide and ether.

Remember that though it may oftenbe necessary to change to a mixture, oreven pure chloroform, you should alwaysconsider whether it is not possible toanesthetize the patient with ether, andthus get over the period which is mostdangerous when chloroform is used fromthe beginning of the induction.

When the time required by the surgeonis short, and the depth of the anaes-thesia not profound, always considerthe advisability of using nitrous oxideor ethyl chloride.

If after consideration, both these drugsseem insufficient, then consider thepossibility of ether.

Never give nitrous oxide or etherwhen a patient has any difficulty of

Ancesthesia. 59

respiration due to goitre, angina Ludo-vici, swollen tongue, etc.

Remember that ether may be contra-indicated by (a) the condition of thepatient, (b) the necessities of theoperation.

(a). Ether is often unsuitable at theextremes of life, in patients with aneurysmor markedly diseased arteries, in thosewith an inflamed or narrowed respiratorytract, and those suffering from severealbuminuria.

(b). Chloroform is to be preferred:-

1.-When it is specially desirable thatno congestion should be produced bythe anaesthetic as in operations onthe brain and cranial nerves, thethyroid gland, etc.

2.-When an excessive secretion ofmucus or saliva would increase thedifficulties of the operator, as in the

60 Golden Rules of

removal of growths from the larynx,and other operations in the mouthand throat.

3.--In many operations on the faceor mouth where it would be impossibleto keep an ether inhaler in position,though in some of these it will bepossible to ancesthetize the patientwith ether, and then change to amixture or pure chloroform.

4.-When a cautery has to be usednear the mouth.

5.--When a very light anaesthesia isrequired, as in cases of painful labour,eclampsia, and when relieving thespasms of tetanus. In all these caseschloroform may well be given with aJunker's inhaler.

6.-In some operations on, theabdomen, when absolute relaxation of

Anaesthesia. 61

the muscles is required, with veryquiet breathing.

The age of the patient is an impor-tant factor in choosing an anmsthetic,and the following limits may be taken asa rough guide:-

From infancy to 2 or 3 years-Chloroform is the best anresthetic.

From 3 to 6 A.C.E. mixture.

From 6 to 10--Ether, preceded by alittle A.C.E. mixture.

From 10 to 50 or 60-Ether, pre-ceded by nitrous oxide, or by ethylchloride.

When the age of the patient is morethan 50, the choice depends entirely onhis general condition. If it is decidedto give ether, it is better to precede itwith some A.C.E. mixture rather thanwith nitrous oxide, and in many cases

62 Golden Rules of

chloroform or a mixture will be foundthe best agent throughout.

When a patient is suffering frommarked cardiac disease, a mixture ofether and chloroform should be slowlyand carefully given. When a cardiacmurmur is heard, and there are no signsof want of compensation, ether may begiven ; but the colour of the face shouldbe carefully watched, and a good supplyof air allowed.

ETHYL CHLORIDE.

This drug has recently been againtried to some extent, and may in a sensebe regarded as a substitute for nitrousoxide.

As an anesthetic for prolonged opera-tions it does not possess any advantagesover those usually employed; but for

Anaesthesia. 63

those which are as a rule done undergas, ethyl chloride has the advantage ofbeing easily portable, and not requiringany very elaborate apparatus, while theanaesthesia obtained by a single applica-tion is on the average longer than thatwith nitrous oxide, and unaccompaniedby cyanosis.

The drawback to its use is that therecovery is not so good as after gas,vomiting, headache, and giddiness beingmuch more common. Occasionally thepatient is quite collapsed for some time,and this is a great drawback to its usein the consulting room of a dentist orsurgeon.

Ethyl chloride is best administeredby means of some form of closed inhalerconsisting of a face-piece and india-rubber bag. An Ormsby inhaler isperhaps the best, but the face-pieceof a Clover inhaler attached to the bag,

64 Golden Bules of

without the metal reservoir for the ether,will answer very well.

The average dose for adults is 5 cc.,but for children this may be decreased to3 cc. It is generally well taken, and itis easy to obtain a good anesthesia ratherlonger than that which results from asingle administration of gas and air, orgas and oxygen. The absence of cyanosisis obvious, indeed the patient's face oftenbecomes flushed. Circulation is some-what stimulated, and the only dangerappears to be from any interference withfree respiration.

For a short operation, the face-piecemay be removed as soon as the breathingbecomes deep and snoring; but if as longa time as possible is desired, the anaes-thetic may be pushed till the cornealreflex is abolished.

The anesthesia obtained is just that

Ancesthesia. 65

required for a rapid removal of tonsilsand adenoids, the reduction of somedislocations, or for the removal of oneor two difficult teeth, etc.

Another good way of giving ethylchloride is to place 5 c.c. in a test-tube;then fill with nitrous oxide the ordinarybag of Hewitt's gas apparatus, and detachit as if it were to be used to precedeether in a Clover's inhaler. Now attachthe test tube containing the ethylchloride to the vulcanite tap of the gas-bag by means of a short india-rubbertube.

The administration of the gas is startedin the usual way, the patient breathingair through the valves till it is seen thatthey are working well; the gas is thenturned on, and the upper tap is quicklyturned so that re-breathing takes place.The vulcanite tap at the bottom of thebag is then turned and the ethyl chloride

66- Golden Rules of

admitted to the gas-bag by tilting up thetest tube.

Very good anaesthesia may be obtainedin this way, and it is specially suitablefor nervous patients who do not breathewell at the beginning of the administra-tion.

As mentioned above, another use ofethyl chloride is to precede ether inthe place of nitrous oxide. To do this itis only necessary to spray 4 or 5 c.c. onto the sponge in an Ormsby inhaler orinto the Clover bag, and let the patienthave a few breaths before giving theether. The result is generally very satis-factory; even stout vigorous men, whosometimes give trouble with gas andether, being quickly and easily anas-thetized without any marked cyanosis.

Ethyl chloride of British manufactureis as good as any other; and the various

Ancesthesia. 67

forms of special inhaler which are adver-tised are quite unnecessary.

The above remarks may be applied toSomnoform, a mixture of 60 % of ethylchloride with methyl chloride and ethylbromide, though this mixture is probablyless safe than pure ethyl chloride.

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