The position in which the patient is lying is of as much importance to the anæsthetist as to the surgeon. It is for the surgeon to say what he wants and for the anæsthetist to realise how his own work will be thereby affected.
This is the ordinary position and calls for no extended comment. The pillows must be so arranged that at no spot is the body acutely flexed or extended. Abdomen, thorax, neck, and head must all be roughly in a straight line.
Deep-chested subjects require a higher pillow than those with shallow chests, otherwise the neck is bent back and respiration obstructed.
The arms should either be folded and retained by a bandage or other device over the chest, or extended so that the hands can be slipped under the buttocks and retained there by the body weight. An arm which is allowed to hang over the side of the table is likely to show next day and for many months afterwards, the condition of drop-wrist from musculo-spiral paralysis.
This is an awkward position for the anæsthetist; there being a general tendency to respiratory embarrassment. Put a pillow under the upper part of the thorax, leaving the lower part and the abdomen as free as possible. Let the head project from the pillow, so that the face can be got at without undue rotation of the neck. The intratracheal method is a great help.
This may be called for either with or without the addition of a sand-bag or inflatable air-pillow to push the loin upwards. In either case, there is a tendency for the upper shoulder to fall forwards, the position then assimilating itself to the face-down position. This is best met by a support fixed to the table, upon which the upper arm may be rested. Failing such a convenience, a sand-bag may be pushed in to keep up the shoulder, or the assistance of a nurse may be required.
Slight tilting of the head end of the table downwards is often useful in assisting the return of bowel into the abdomen: in this position, the patient usually takes the anæsthetic very well. It must not be assumed until the third stage of anæsthesia is reached.
For many gynæcological operations, however, the full Trendelenburg position is required. Healthy subjects usually do quite well in it, but stout persons not uncommonly show a good deal of cyanosis. At the close of the operation it is essential to restore the table to the horizontal slowly: the physics of the circulation are profoundly modified, and if any serious degree of shock is present, rapid return to normal may initiate a collapse.
In the full position, the weight of the body should be taken by metal supports attached to the table against which the shoulders may rest. To hang the entire weight of the body upon the legs may cause a good deal of after-suffering to the patient.
The object of this position is to diminish venous engorgement and bleeding in operations requiring delicate dissection in the region of the neck. Prof. Alexis Thomson introduced the position into Edinburgh surgery: the author was at first rather nervous of it, but has found that with proper precautions the patients do uncommonly well. Beyond all doubt, the position is a great help to the work of the surgeon.
Not every surgical table is capable of giving the full position without the use of many pillows and sandbags. The head-piece of the table is tilted up at an angle of about 75° or even 80°, and the patient pulled up so that the flexion of the body occurs in the lumbar, not the dorsal spine. A small sand-pillow is placed behind the neck so as to produce slight extension. Another heavier one is placed under the thighs to prevent the body slipping down. A slight tilt downwards towards the head end may be given to the table as a whole with the same object.
Fig. 49.—Sitting-up posture for operations on the neck.
One should not in this position attempt to induce a deep chloroform anæsthesia. Weak C.E. mixture at most, but better simply open-ether is the method of choice. The induction is begun with the shoulders raised to a modified degree, and the full position assumed in a light third stage anæsthesia.
Intratracheal ether combined with this position is an ideal anæsthesia for the removal of goitre or extensive dissections in the neck for enlarged glands.
The author became acquainted with this useful position while acting as Anæsthetist at the Royal Herbert Hospital, Woolwich, where the Nose and Throat Department was under the charge of Major O’Malley, F.R.C.S. Major O’Malley was kind enough in a recent letter written by request to refresh the author’s memory of the details.
Fig. 50.—O’Malley’s posture for intra-nasal surgery.
With the patient lying as shewn in the photograph, every part of the interior of the nose can be easily inspected by the surgeon; the elevation of the head and shoulders prevents undue bleeding, and such hæmorrhage as does occur goes down the gullet, where it does no particular harm, instead of into the larynx. The degree of flexion of the head upon the neck is not so extreme as to interfere with respiration.
The details of O’Malley’s procedure are as follows:—
The interior of the nasal cavities are packed with gauze soaked in adrenalin and novocain a quarter of an hour before operation, and the patient receives a very small dose of morphia and atropine immediately before anæsthesis is induced; given in this way it does not complicate the induction with chloroform to the same extent as if given earlier. The patient lies with the top of the head level with the top of the table, and the head and shoulders (including the upper two-thirds of the shoulder blades) supported on the usual depth of pillow. Induction is by chloroform or mixture; a very light third stage only is aimed at. When it is attained the mouth is opened by a gag, and Phillip’s Oral Airway inserted (see Fig. 8). Strict oral respiration is essential to success. If air is passing in and out of the nose, blood is spluttered all over the surgeon, seriously interfering with the harmony of the proceedings. Junker’s chloroform bottle is ready, and the end of the supply pipe is passed into one of the side holes in the air way.
The head of the table is now elevated to an angle of 45°, and a small sand pillow slipped behind the occiput. The gauze is removed from the nose, and the operation can be performed with great comfort.
The circulation of the patient needs careful watching for the first minute or two after the table head has been elevated, but thereafter there is usually no special cause for anxiety. The area of operation is locally anæsthetised by the action of the novocain and a light chloroform sleep only is required.