Edited from the medical textbook "Handbook of Surgical Operations, U. S. A. Medical Department, 1863", (in this collection) written during the Civil War by Stephen Smith, M.D.:
The anesthetics in general use are sulphuric ether and chloroform.
Sulphuric Ether.- — This agent is liable to adulteration, by sulphurous acid, alcohol, volatile oils, and by oxidation; it may be rendered purer by agitation with lime water, and afterwards separating it by decanting.
Method of Administration.—The following practical remarks on the administration of ether were made by a Committee appointed by the Boston Society for Medical Improvement to investigate the alleged dangers from inhalation of ether :
Ether should never be given from any inhaling apparatus. The best medium of its administration is a bell-shaped sponge, large enough to cover in the nose, mouth, and chin; but it is difficult to find one of sufficient size and close enough in texture, or without such numerous apertures at the root as to admit too freely the atmospheric air. A sponge of this sort, moreover, being as expensive as rare, is seldom used outside of hospitals. A stiff towel, properly folded, may be substituted, and has the advantage of being always at hand; as it may be left behind, the surgeon does not carry away with him the annoying odor of an impregnated sponge. It is desirable that the towel should be a new one, and of pretty good size. It is to be taken just as it comes from the laundry, and not unfolded further than to display it in the dimensions of about ten inches by five; by folding down two of the corners in such a way that they shall lap over each other a little, and securing them by stout pins, a cone will be made which fits the face admirably. The thick layers of towelling will hold sufficient ether, and its texture will prevent a too free dilution of the anesthetic by the atmospheric air, provided the apex and seam of the cone are carefully and tightly closed, either by pins or the fingers. As the cone becomes collapsed by saturation, it should from time to tune be opened, and kept in shape by distending it with the hand. Unless these details are attended to, and especially the closure of the apex of the cone, the induction of anaesthesia will be uncertain and protracted.
In anything so porous as a towel or sponge, the difficulty is to exclude enough air; for while its adequate admission to the lungs during etherization is essential to the life of the patient, its too free entrance not only delays anaesthesia, but induces a condition of excitement, both mental and physical. The importance of excluding the air, as above stated, is a point not generally appreciated, but the necessity of it has long been known to those most accustomed to the use of ether, as shown by the " chemise" with which, in hospital practice, a too porous sponge is often covered to expedite the etherization of a rebellious patient. Ether should be poured lavishly on the towel or sponge, an ounce or two at a time, especially at the commencement of inhalation. Although it may be wasted, too much, as far as safety is concerned, cannot be used. A small quantity poured on hesitatingly and timidly, as is sometimes done, has the same effect as a too free dilution of the vapor with air, producing simply intoxication and its accompanying excitement without anaesthesia; whereas a large amount, though the cough and choking sensation which the greater volume of vapor produces may cause the patient to resist and struggle, is certain to bring about a satisfactory condition of insensibility.
Phenomena of Etherization.—A strong, full-blooded man is pretty sure to resist the approaches of anesthesia under any circumstances. This may sometimes be overcome by warning him beforehand of such a possibility, and inducing him to resolve not to struggle; the last impression on his mind influences him even in his stupor. The same thing is liable also to happen with almost all patients just before complete anesthesia takes place, but the ether rarely requires to be suspended. Occasionally the respiration becomes embarrassed during the period of excitement, partly from the struggle itself, and partly perhaps from the increased flow of saliva, which is a common phenomenon of etherization, or from the position of the tongue or head of the patient, and a condition may sometimes show itself characterized by lividity, rigidity, and convulsive motions of the extremities. Although alarming to the inexperienced, the state is in fact devoid of danger, provided the ether be momentarily suspended; this being done, the refusal to breathe soon gives place to a long-drawn inspiration, and in most instances complete insensibility immediately ensues. In such a case it is interesting to observe how readily the spasm yields, and how complete is the muscular relaxation which follows the free respiration of air unmixed with ether.
It should therefore be borne in mind, that when there is muscular rigidity with lividity, the suspension of etherization will transform this into the relaxation of anesthesia. Persons of intemperate habits succumb to ether slowly, and with greater reluctance and more opposition than persons unused to intoxication. The pulse should be watched by a competent person from the outset, and its failure, either in strength or frequency, lead to more cautious use of the ether. It must, however, be remembered, that in experiments with anesthetics upon animals, the heart has been found to be the ulttmum moriens; the respiratory movements, therefore, should not be forgotten or neglected, but any slowness or irregularity in the performance should at once receive attention. Ether is not to be withheld from a patient to be operated on, even in a state of collapse after severe accident, but great caution is demanded in its use with patients who are near death from chronic and exhausting disease, and who require operations.
The best test of complete etherization is the snoring of the patient; and no operation, unless slight, should be undertaken until this symptom presents itself. The relaxation of the muscles of the extremities may occur without insensibility. The important distinction between snoring and stertor is, however, to be borne in mind. Whilst the former is caused only by the relaxation of the muscles of the palate, the latter arises from spasm of the vocal cords and partial closure of the rima glottidis, and thus becomes the immediate forerunner of the train of symptoms already referred to as indicative of partial asphyxia. Stertorous respiration demands, therefore, a brief suspension of inhalation; one or two inspirations of fresh air will, as already mentioned, almost instantly dispel the symptom. Ether may be administered to persons of all ages, from the new-born infant to the octogenarian. There is, however, a condition prone to manifest itself with children, especially those who, are weak, strumous, or overgrown, which is due to its cumulative properties. It may show itself after almost any degree of etherization, and is characterized by a feeble pulse and slow respiration, not passing off with the readiness usually marking the phenomena of etherization. "With young persons a cautious inhalation of five minutes will often induce an anesthesia of half an hour, an effect wholly out of proportion to what the same amount of ether would produce in an adult. This state is not a dangerous one, and only requires time to dissipate its symptoms. Compression of the chest will expel the fumes of ether being eliminated from the pulmonary surface, and permit the entrance of a fresh supply of oxygen to stimulate the circulation. The inhalation should therefore be suspended at short intervals with children, and but little ether given at a time."
Chloroform: Chloroform may be adulterated with alcohol, oils, and ether. Alcohol can be added without being detected by the smell, but may be detected by dropping the chloroform into water, when it assumes a milky appearance. Oils are detected by strong sulphuric acid, which gives a yellowish or reddish brown color; the presence of ether is detected by its readily burning when exposed to a flame. Pure chloroform may be thus tested:—-When dropped on the hand it evaporates without leaving the least smell or moisture behind; it is free from color or opacity; it does not redden or bleach litmus paper; it does not become opaque when dropped into water; it does not coagulate the white of egg.
Administration: In the administration of chloroform great care must be exercised. The following judicious rules by Prof. Gross (System of Surgery) cannot be too carefully followed:
" 1st. During etherization the patient may sit up with impunity, but this is not the case during the inhalation of chloroform, owing, apparently, to the greater relaxation of the muscles, and consequently, to the greater difficulty in maintaining the circulation of the brain through the influence of the heart's action. Not only should the body be recumbent, but care should be taken to depress the head and shoulders, bringing them nearly to a level with the trunk.
" 2d. An empty state of the stomach is desirable for two reasons; first, because if chloroform be given soon after a hearty meal it will be almost certain to induce vomiting; and, secondly, because a crowded condition of the organ interferes materially with the movements of the diaphragm. Food must not be taken for at least four hours before the exhibition; but, on the other hand, the interval should not be too protracted, lest serious exhaustion result from »he want of the necessary stimulus.
" 3rd. Care must be taken, before the inhalation is commenced, that the patient's clothes are sufficiently loose to prevent constriction of the chest and abdomen. Any compression from this source would necessarily impede the action of the diaphragm, and might thus become a cause of mischief.
"4th. The importance of having an abundance of atmospheric ah- during the inhalation of an article so potent as chloroform, is self-evident; in etherization this is of comparatively little consequence, but in the exhibition of chloroform for surgical and obstetrical purposes, it is absolutely indispensable to the safety of the patient.
" 5th. The inhalation must be effected gradually, not hurriedly, time being allowed to the system to accommodate itself to the influence of the remedy, thus avoiding the shock which might otherwise result to the heart and brain. From six to eight minutes should usually be spent in producing the full effects of the anaesthetic.
When the patient is very feeble, or pale and.timid, it will be advisable to give him, immediately before the operation, from half an ounce to an ounce of brandy; and the dose may afterwards be repeated, if the effect is obliged to be maintained for an unusual length of time, sufficient consciousness being permitted for the performance of deglutition. The best mode of administration of chloroform is to pour the fluid upon a napkin or handkerchief previously folded into a kind of cup-shaped hollow, and held securely in the hand. Or, instead of this, a small, hollow sponge may be used. As to the various inhalers that have been devised for the purpose, they are all objectionable on account of their inconvenience and the difficulty of obtaining a sufficiency of atmospheric air. The patient having taken his place upon the table, and emptied his lungs by a deep and protracted expiration, the napkin, impregnated with a drachm of chloroform, is held over the mouth and nose, at a distance of about two inches, being gradually brought nearer and nearer until it is within half an inch, beyond which it should not be carried, the chest being at the same time regularly and powerfully distended. On no account should the liquid be permitted to come in contact with the surface, as it might thus cause vesication.
All unnecessary conversation is avoided, lest the attention of the patient should thereby be unduly distracted. The assistant having charge of the administration gives it his earnest and undivided care; wetting the napkin from time to time with the fluid, and seeing that the patient gets an abundance of air, his vigilance increasing as the effects of the medicine become more and more apparent. As soon as the sensibility is completely abolished, the operation is commenced, a return to consciousness being prevented by holding the napkin, wet with a small quantity of the vapor, occasionally before the nose; and thus the impression is maintained, steadily and cautiously, not only until the knife has fully accomplished its object, but until the principal arteries have been secured, and, in some cases, even until tht dressings have been applied.
As soon as the inhalation has been fairly entered upon, one of the attendants should sedulously watch the state of the pulse, of the respiration, and of the countenance. Any sudden failure in any one of these should at once create alarm, and induce a suspension of the operation, or provision for the admission of a greater quantity of atmospheric air. I do not deem it necessary that a finger should be constantly kept upon the pulse; for the color of the face and the nature of the breathing will always sufficiently indicate the effects which the anesthetic is exerting upon the system, and thus afford abundant opportunity for preventing any unpleasant occurrence.
The quantity of chloroform required during an operation, and the time during which its effects may be safely maintained, must, of course, vary according to the exigencies of each particular case. In general, from half an ounce to an ounce may be regarded as a fair average^ but very frequently it takes three or even five times that amount, depending upon the severity and duration of the operation, and the susceptibility of the individual. In some instances almost an incredibly small portion answers the purpose. Children usually require comparatively little; and it is well known that women are, as a general rule, more susceptible to its influence than men. Persons exhausted by hemorrhage are very easily affected by it, owing to the rapidity of its absorption, and hence it should always be administered to them with unusual care."
Dr. Simpson has advised that chloroform be given by laying a handkerchief over the face, and letting the chloroform fall on it drop by drop.
Resuscitation: The towel or inhaler being removed, the patient's tongue should be drawn forward with forceps or a tenaculum, fresh air admitted from the door or windows, or induced by a fan, and artificial respiration instituted. Stimulating applications to the surface, cold douche to the head, and stimulating injections may be added. The main reliance is on artificial respiration, and this is best kept up by Marshall Hall's method as follows: " Turn the body gently, and completely, on the side and a little beyond, and then on the face, alternately; repeating these measures deliberately, efficiently, and perseveringly, fifteen times in a minute, only [when the patient reposes on the thorax, this cavity is compressed by the weight of the body, and respiration takes place; when he is turned on the side, this pressure is removed and inspiration occurs]. When the prone position is resumed, make equable but efficient pressure along the spine ; removing it immediately before rotation on the side [the first measure augments the expiration, the second commences inspiration]." As soon as the patient can swallow, give brandy and ammonia. Efforts at resuscitation should not cease until death is evident.
A method of producing artificial respiration has been introduced by Dr. Sylvester; it consists in laying the patient on his back, drawing the tongue forward, then carrying the arms slowly upwards over the head, thus elevating the ribs by means of the pectoral muscles, and inducing respiration; the arms are then brought down to the side of the chest and slightly compressed against it; these movements are to be repeated slowly as by the other method.
If a galvanic battery is at hand it should be resorted to among other possible means of restoring animation.