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CURATIVE MEDICINE.

PART XIV.

ANESTHETICS AND SOPORIFICS.

Discovery of Anesthetics.—The victories of peace often far surpass in result the renown which they receive. Such was the achievement of Thomas G. Morton, a dentist, who, October 16th, 1846, for the first time produced complete anesthesia or insensibility to pain under a major surgical operation. This occurred in the clinic of the celebrated surgeon, Dr. John C. Warren, at the Massachusetts General Hospital. These men, by their discovery, not only wrought a revolution in surgery, but were victors over the horrible agony previously suffered at the hands of the surgeon. Their labors have brought to pass what Dr. Oliver Wendell Holmes has written: "The fierce extremity of suffering has been steeped in the waters of forgetfulness, and the deepest furrow in the knotted brow of agony has been smoothed forever."

Spread of the Discovery.—News of this remarkable discovery seemed to be carried by the winds, and soon anesthesia was used in the clinics of the world. The following year, chloroform was introduced by Sir James Simpson, of Edinborough. Such a boon to humanity is beyond estimation. The agony suffered under a severe surgical operation only the few courageous ones enduring it and yet surviving, can tell. Anesthesia now renders comparatively easy very many new procedures, especially those requiring the greatest delicacy of touch and accuracy in dissection of brain or amid vessels and nerves —procedures not possible in the haste necessary before the days of anesthesia. Then, too, the operations were formerly few; now relief is for the many. The numbers rapidly multiplied many fold. For example, in the Massachusetts General Hospital during five years previous to the introduction of anesthesia, only 184 persons were willing to submit themselves to the ordeal of an operation. In the five years following, 487 operations were done, and, in 1899, in the same hospital, 3700 operations were performed. Anesthesia is a benign alleviator of suffering, a merciful prolonger and saver of life.

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ANESTHETICS.

Anesthetics, artificial means of producing insensibility or loss of feeling, are general and local.

General Anesthetics.—The more common ones are ether, chloroform, nitrous oxide, and ethyl bromid[sic]. They are given by inhalation, and commonly more or less mixed with air or oxygen. The chief uses of general anesthesia are, to abolish the pain of labor and surgical procedures; to produce muscular relaxation in ruptures, fractures and dislocations; and to enable the physician to make examinations otherwise painful.

Preparation of Patient.—In emergencies, a patient sometimes must needs be given an anesthetic without previous preparation, but, when time affords, preparation should never be omitted. The dangers from an anesthetic are commonly magnified by the laity, yet a skilled anesthetizer, while not afraid, should have a wholesome respect for the complications which are always possible to arise. The better condition a patient is in at the time of giving an anesthetic, so much the less likely are serious results. Therefore the advisability of attention to the patient and his preparation previous to operation. The condition of lungs, heart, and kidneys is especially to be noted, the urine examined for albumen, casts and sugar. While the presence of the latter do not absolutely contraindicate the giving of an anesthetic, yet they may at least influence in the selection of the kind, and lead to special necessary precaution in its giving.

The Bowels.—The bowels should be freely emptied the day before or the morning of operation. This is well done by epsom or rochelle salts, one to two tablespoonfuls, supplemented, if need be, by an enema of soap-suds one quart, glycerin two tablespoonfuls, epsom salts two tablespoonfuls. The injection should be given a few hours before operation. The bladder should also be emptied immediately before operation.

Rest and Sleep.—The patient should rest for twenty-four hours previous, preferably in bed. He should have a general bath, that the skin may be active. Sleep should be secured the night previous; if there is nervousness, a warm bath at night may quiet, or it may be necessary to give a powder of potassium bromide, ten grains, or of trional, fifteen grains, in a little hot broth or hot tea; either may be repeated. The anxiety of the patient may interfere with digestion. At any rate, the diet for a day previous should be light, for example, broths, soups, soft eggs, bread and butter, toast. At the time of giving an anesthetic the stomach should be empty. If operation is to be early in the morning, no breakfast should be given. A small quantity of beef tea or of broth and a little brandy may be well. If operation is not until midday, a light breakfast of beef tea or of broth and toast or a roll had best be taken. Never give any food within three hours of operation, and only a very moderate quantity of water within the same time. Matter in the stomach induces vomiting, and this endangers the patient to the entrance of portions of food into the windpipe.

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Temperature of Room.—The room should be warm, not less than 70 degrees Fahrenheit, and the patient protected with sufficient blankets. If a light in the room is necessary, it should be above and some little distance from the patient. Ether is inflammable, and the vapor explosive, but the latter sinks to the floor. The clothing should be loose, particularly about the neck and body. If a woman, the corsets should of course be removed to give opportunity, if only this once, for free breathing. The hair should be braided. A third party should always be present. The patient should lie upon the back with only a small pillow beneath the head. Take care that the limbs are not cramped or pressed upon. The lips and nose should be anointed with vaseline. Having spoken some cheerful, encouraging word to the patient, the anesthetizer examines the heart, notes the condition of the pulse and respiration, and, without fail, sees that any foreign bodies in the mouth, including false teeth, are removed. He is now ready for the administration of the anesthetic.

Giving Ether.—The writer desires to state, in most emphatic terms, that an anesthetic should, never be given by any but a skilled person or under the direction of such a person—one who can interpret danger signals, and can act promptly and intelligently. The limits of this work forbid giving detailed directions. Some of the salient points regarding the giving of ether may prove of benefit as well as of interest.

What the Operator Will Have in Hand.—The anesthetizer will have at hand stimulants—brandy, strychnine, atropine, digitalis and a hypodermic syringe in working order. He will have a mouth-gag and tongue forceps, and needs at hand two or three small towels. Ether is best given upon some simple inhaler, such as an Allis, but may be well given upon a towel folded into a cone, or, if the face be anointed, the folded towel may be placed flat over the patient's nose and mouth. Having gained the confidence of the patient, by assurances that he will give the anesthetic slow and will not choke him, the anesthetist says, "I want you to breathe through the inhaler a few moments to get used to it before I put any ether upon it. Now just a drop or two." So beginning, and continuing very slowly, "feeling" his way, the anesthetist may have reasonable hope that he will avoid any serious trouble in the stage of excitement. If choking or coughing occurs at first, proceed very gradually, giving a breath or two of pure air, and the throat will soon become accustomed to the drug which at first irritates. Vomiting thus early demands the withdrawal of the drug for a few moments, until the throat and mouth are freed from the vomitus.

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Pushing the Anesthetic.—After primary irritation ceases, the anesthetic may be "pushed," more and more being added, until, when the patient is in the second semi-conscious excitable stage, he may be getting a large quantity. "Pushing" the drug at this point will quickly send the patient over the period of disturbance into the quiet of complete anesthesia. If, however, very violent struggling with rigidity and great cyanosis, or blueness occurs at this time, it is, generally wise partially to withhold the anesthetic for a few moments.

Signs of Perfect Anesthetization.—A patient is known to be completely anesthetized by the loss of consciousness, loss of motion, relaxation of the muscles, loss of certain movements, e. g., that of winking when the eyeball is gently touched. The breathing should be regular and quiet. The anesthetizer not only observes the movements of the chest in respiration, but notes by touch and sound the rhythmical inflow and outflow of air. The breathing and circulation are especial indexes as to the condition of the patient. The regularity, rate, and strength of the pulse should be frequently noted. Any marked variation from the normal should receive immediate attention. Stimulation may be needed or withdrawal of the anesthetic demanded. The color of the patient is also a valuable index. Great pallor generally indicates failure in the circulation; cyanosis or blueness, that the inhalation of oxygen is insufficient. The latter generally calls for removal of the drug and a determination and correction at once of the cause of imperfect inspiration.

Complications.—Irritation apt to arise early in the administration has been alluded to. If vomiting occurs, the head is always to be turned to one side and the mouth wiped out. In a large majority of cases vomiting may be stopped by increasing the quantity of the anesthetic.

The Respiration.—Before complete anesthesia occurs the patient may "forget" to breathe; the word "breathe" spoken loudly into his ear will generally arouse him to efforts of respiration. If after complete anesthesia the respiration is abnormal, the immediate determination of the cause and its correction are imperative. A muscular movement at such time will generally indicate recovery from the anesthesia and the necessity for an increased quantity of the drug. Otherwise, the anesthetic should be stopped, the mouth gagged open, the tongue pulled forward with forceps or towel, and mucus collected in the throat wiped out. This will generally be sufficient to restore breathing and to relieve the cyanosis, allowing the administration soon to be resumed. Should these means fail, artificial respiration should be instituted (which see below). The foot of the bed should be raised; fresh air admitted to the room, the patient well protected and surrounded by hot-water bottles. Meanwhile, various means of stimulation should also be used—hypodermic injections of strychnine, atropine, digitalis, ammonia; injections into the bowel of hot black coffee and brandy; a mustard plaster applied over the heart.

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Artificial Respiration.—Laborde's Method. The jaws are held apart and the mucus wiped from the mouth and throat. The tongue is grasped with forceps or the fingers covered with a towel, and is drawn every four seconds, strongly and quickly forward, and each time allowed to go gradually back.

Sylvester's Method.—The former method should be used in conjunction with this. The patient is in a recumbent posture. The operator grasps both the patient's arms near the elbow and draws them gradually outward and upward until they nearly touch the patient's head. They are thus held for two seconds, while air enters the lungs. The arms are then gradually lowered and pressed firmly against the side and front of the chest for two seconds, thus forcing air out of the lungs. The movement of elevation and depression should be made not more than fifteen or eighteen times a minute.

Giving Chloroform.—Ether is a safer anesthetic for most purposes than chloroform. The latter is preferable, however, in a few conditions, e. g., in infants and the very old; in serious lung and kidney trouble chloroform, because of the less quantity required, is less irritating. In certain operations about the face the patient can better be kept anesthetized by chloroform, and it is often better suited for employment in labor, because more quick in action and more relaxing.

Giving Ether.—The general principles for giving ether apply to the giving of chloroform. However, because chloroform is quicker in action, it should be given with greater care. Ether, like alcohol, is a stimulant to the heart, and is therefore generally preferred in heart disease. Chloroform has clinically a distinct depressant action upon that organ.

How to Give Chloroform.—Chloroform may be well given upon a folded towel or napkin, or piece of cheese-cloth. The object from which the chloroform is inhaled must not be held in contact with the face but an inch or more above the nose so that the vapor may be freely mingled with air. Chloroform should be given drop by drop, cautiously, and particular watch-care given for danger signals. If struggling occurs it is imperative that the drug be not "pushed" lest, at this time, when breathing deeply, the patient inhales at a few breaths an overwhelming quantity. Eternal vigilance is the price of safety in anesthesia and especially so in the giving of chloroform.

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Nitrous Oxide.—Nitrous oxide or laughing gas is perhaps the safest general anesthetic. Its action is rapid, anesthesia resulting in one minute. But its effect is fleeting, lasting less than one minute, thus rendering it unfit for major operations. It is much used by dentists for the extraction of teeth and has been used with advantage in minor surgery, such as opening an abscess. The gas (a liquid under pressure in steel cylinders) is bulky and not readily carried by the surgeon; the apparatus necessary for its use together with other agents is complicated, so that this drug is not likely soon to become popular in surgery.

Ethyl Bromide.—This, a colorless agreeable liquid, has not been widely used, but not a few, notably Dr. E. E. Montgomery and Dr. Wilmer Krusen, praise it highly where anesthesia of short duration is desired. In giving it to an adult it is well to pour from four to six teaspoonfuls, the whole amount to be given, upon a folded towel, and to apply the saturated surface directly to the nose of the patient, pressing the edges of the towel down upon the face to exclude the air. Unconsciousness is obtained in about half a minute. The anesthesia is rapidly recovered from, and after ill-effects are almost nil. This agent is adapted to cases needing anesthesia for examination, to the incision of abscesses, and for the relief of suffering in labor. It is considered comparatively safe by those who have used it. The favorite general anesthetics have been referred to. Space forbids the mention of others less popular and less reliable.

Care of Patient After Anesthesia.—The patient must be carefully watched until he regains complete consciousness. He should, of course, remain recumbent. The erect attitude might result in heart failure. The head should be higher than the body. He should be warmly covered and perhaps be surrounded by hot water bottles. The inhalation of oxygen is best, but an inhalation of vinegar is an excellent procedure to prevent nausea and vomiting. If the latter occurs, the head should be turned well to one side, the vomitus caught in a towel or basin. Food should not be given for several hours and if water is allowed it should be given only in teaspoonful doses quite hot, frequently repeated. If vomiting continues a mustard plaster should be put over the stomach, fresh air admitted to the room and a little hot black coffee given.

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Local Anesthetics.—The chief ones are ethyl chloride, ether and rhigolene sprays, ice and salt, carbolic acid, eucaine and cocaine.

Freezing Agents.—These agencies are employed in the lesser operations, and occasionally when there is some complication preventing a general anesthetic.

Ice and Salt.—If one-quarter pound of ice be broken into small bits, and one-eighth pound of common salt added and the mixture be put in a thin bag and laid upon the skin surface, the area will become anesthetic in ten or fifteen minutes.

Ether, Rhigolene and Ethyl Chloride directed upon a part in a fine spray produce anesthesia by their cold effect. The latter is put up in a convenient glass tube with a metal cap. A part touched with pure carbolic acid becomes blanched and anesthetic.

Cocaine Hydrochlorate in a watery solution is quite commonly used for injecting into the skin, for applying to the mucous membrane, the latter absorbing it. It is applied to the nose, mouth or throat by a spray or swab, or dropped into the eye. For injection a two per cent. solution is generally sufficient. For application to the eye a four per cent. solution may be necessary, and for the nose and throat a ten or even twenty per cent. solution may be cautiously used. Da Costa says that never more than two-thirds of a grain should be painted upon a mucous surface and never more than one-third of a grain should be injected into the tissues. Examples of useful purposes to which cocaine may be put are, for instance, the removal of a wen, or a wart, the correction of a small deformity of the bones of the nasal cavity. A finger or toe can be comfortably amputated by its use, a constricting band meanwhile being placed about the root of the part to prevent the absorption of too great a quantity of the drug. The whole area supplied by a large nerve may be anesthetized by injecting cocaine about the nerve trunk.

Eucaine Hydrochlorate.—Eucaine hydrochlorate has practically the same action and may be used in the same way as cocaine.

Infiltration Anesthesia.—Infiltration anesthesia, commonly called Schleich's method, is produced by injecting into a part several ounces of a weak table salt solution to which a minute quantity of cocaine, morphine and carbolic acid has been added. The method is very efficient and has been successfully used for major operations. The anesthesia is partly due to the pressure upon the tissues, especially the nerves, by the injected fluid.

Spinal Anesthesia.—A method lately much talked about and one practiced considerably in France, is one in which a small quantity of a one-half or one per cent. solution of cocaine is injected by a syringe through, a hollow needle into the spinal canal. In about five minutes loss of sensibility occurs in the parts supplied by nerves given on below the point of injection. All of the body below the diaphragm can thus be rendered anesthetic. Anesthesia lasts about forty-five minutes. It has been employed successfully in labor and in various grave operations. But it is not without its dangers, and, though relieving pain, it does not remove the horrors of an operation which consciousness must give. This method will probably never supplant general anesthesia. The ideal anesthetic is one without danger which abolishes both consciousness and sensation, thus giving the surgeon the absolute control of his patient—a condition essential to the accomplishment of the best result. May the twentieth century see the discovery of the ideal anesthetic.

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SOPORIFICS OR HYPNOTICS.

The Sleep Producers.—The class of remedies so-called are sleep producers. They may be divided into those which not only cause sleep but also relieve pain and those which have no pain-relieving properties. Of the former opium is the best example, and should be given where sleeplessness is due to pain, whereas, if due to other causes opium should never be given.

Insomnia.—Insomnia is such a distressing experience that people will go to extremities to relieve it, sometimes being led to use carelessly the most powerful and harmful remedies. The warning cannot be too emphatic to the laity against such a practice, for this class of drugs should rarely be taken except by the advice and under the direction of a skilled physician. The physician himself should be keenly alive to the especial danger of most direful drug habits. For the treatment of insomnia diligent search should be made for the cause and the latter removed. If due to coffee-drinking at night the habit should be abandoned. If to nervousness because of overwork or excessive social duties proper rest from such strain will probably relieve. If weariness or exhaustion be the cause, moderate stimulation with some hot drink, a little coffee or a small quantity of brandy, will help. A warm bath before retiring is sometimes efficacious. Some quieting occupation before retiring; e. g., the perusal of some light but interesting book will often suffice.

Insomnia from Pain.—However, insomnia from pain must be relieved by opium or some of its derivatives, codeine, morphine or heroine[sic]. Long continued administration of opium, except in hopelessly incurable cases, is to be strongly condemned. The cause of pain should be removed, then the need of a hypnotic is gone. In emergency, for the relief of severe pain, there need be no hesitancy in giving to an adult one-fourth to three-fourths of a grain of opium, one-sixth of a grain of morphine, or ten drops of the tincture of opium (laudanum), repeating either dose in an hour if relief is not obtained. Meanwhile a physician should be summoned. When opium is given, it should be with the clear understanding of the probable ill-effects of mental depression, and of nausea and vomiting, and the danger of the habit ever in mind.

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Chloral.—Chloral is perhaps the purest soporific. It is poisonous, however, when taken in excessive dosage, causing weakness of the heart or even heart failure. When insomnia is due to nervousness Hare recommends the following: 

                LATIN.

Rx.---Chloralis ............1 or 2 drachms 
      Potasii bromid ........... 2    "
      Syr. pruni virginiae...... 1 fluid ounce
      Aquae q. s. ad............ 3 fluid ounces
        M. et S.  A dessertspoonful at
    night.

                ENGLISH.

      Take of
      Chloral ..............1 or 2 drachms
      Bromide of potassium...... 2    "
      Syrup ot wild cherry...... 1 ounce
      Water sufficient to make.. 3 fluid ounces
          Mix. Directions: Take a dessertspoon-
    spoonful in water at night.

Sulphonal.—Sulphonal has sleep producing powers perhaps not equal to those of chloral. It finds its chief usefulness in nervous insomnia and especially in that occurring with those of unsound mind. It is commonly given in powder, twenty grains to a dose. As it is insoluble in cold water it should be given in hot water or hot milk. The drug is slow in effect and therefore should be taken two or three hours before retiring.

Trional and Tetronal.—These are closely related to sulphonal and are almost identical with that drug in their action. Their effect is felt in thirty minutes or less. The dose of each is fifteen to thirty grains agreeably given in hot broth or tea.

The Bromides.—The bromides of potassium, of sodium or of ammonium, the three being practically identical in action, are drugs very commonly used as quieters and sleep producers. The former is most frequently used. It is indicated where there is undue excitement of the nervous system, but never where the nervous symptoms are due to depression. It is a useful remedy for hysterical women, for the disagreeable nervous symptoms often accompanying the climacteric, and is a soporific for the over-worked and nervous, provided it is not long continued. It is useful in neuralgias and nervous headaches and frequently quiets the excessive nervousness of drunkenness. The dose of either is ten to thirty grains taken with water in powder, or dissolved in water.

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