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.

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.

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]

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.

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:

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:

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.

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]