also the stomach, should be evacuated before the operation. If the time for
174
SURGICAL TECHNIC
an anaesthesia can be previously set the hours of the forenoon are decidedly
preferable, because the stomach of the patient is then empty ; hence vomit-
ing occurs more rarely and the after effects of anaesthesia are less unpleas-
ant. Weak patients may sometimes receive a small glass of strong wine
about half an hour before anaesthesia to stimulate the heart's action. If the
operation must be performed without these preparations (in case of acci-
dent) all precautionary measures on p. 182 must be especially observed, since
vomiting nearly always occurs.
The ancestJietizcr should attend only to the narcosis, and should pay
special attention from the beginning of anaesthesia to the pulse and the res-
piration. He must keep within reach, in addition to the chloroform appa-
ratus, a mouth-gag, tongue forceps, towel, sponge provided with a handle,
and a pus basin. Care must be taken that perfect quietude prevails in the
room. All talk should cease, and especially with the patient, likewise all
running to and fro. Previous to every anaesthesia the anaesthetizer should
carefully examine the heart and lungs of the patient in order that special
precautionary measures may be taken in case the heart or lungs of the
patient are diseased. Patients having a serious defective cardiac action or
a severe affection of the lungs should not be anaesthetized with chloroform.
During every narcosis, several persons in addition to the surgeon should be
present, partly as assistants, in accidents which suddenly occur, partly as
witnesses for the defence, to testify against the hallucinations sometimes
represented by patients as facts.
Fig. 313. Von Esmakch's Chloroform Apparatus
Concentrated chloroform vapors cause, after a very short time, cessation
of respiration and of the heart's action. Hence, the administration of chloro-
THE TREATMENT OF WOUNDS
175
form on a dense cloth or a saturated sponge, held in close contact with the
mouth and the nostrils, is dangerous. Chloroform vapors used for inhalation
should be ivell diluted zuitJi air. A very common method of inhalation is by
means of Skinner' s apparatus, sim-
plified by the author, and consisting
of a wire frame, covered with wool-
len tricot (mask), and a dropping
bottle (Fig. 313). It can easily be
carried in the pocket together with
forceps for holding the tongue (Fig.
320), packed in a leather or a metal
case (Fig. 314). Since the mask oc-
casionally becomes soiled with blood,
mucus, or vomited matter, it is well
to renew the tricot cover before
each anaesthesia ; this can easily be
done with SchininielbnscJi s aseptic mask (Fig. 315). Likewise, during a
prolonged anaesthesia it is well to change the tricot cover, whenever it has
become moist from the expired air.
Sufficient air is inspired with the chloroform vapors through the tricot
cloth during each inspiration. Pour at first only a moderate quantity of the
anaesthetic (10-20 drops) upon the mask, hold it lightly before the mouth
and the nose, and instruct the patient to take full, deep inspirations, secur-
FiG. 314. Chloroform Apparatus packed
IN Case
Fig.
315-
Schimmelbusch's ChloroF(jk.m Mask
ing at the same time his confidence by assuring and encouraging remarks.
It is altogether a great mistake to pour at once upon the mask so much of
the anaesthetic that it trickles down from the inner surface. Aside from the
violent irritation of the air passages, indicated by coughing, dyspnoea, and
restlessness, inflammation of the skin of the face and especially of the
176
SURGICAL TECHNIC
eyelids is to be apprehended from this moistening with chloroform. The
skin is protected from this inflammation by brushing it with vaseline or
some similar demulcent. In the easiest manner, however, and with a very
small quantity of chloroform, anaesthesia may be produced and the patient
be kept under its influence for several hours without much danger, if, from
the beginning, chloroform is administered only by the drop method (drop
narcosis). From an ordinary dropping bottle, allow one drop to fall upon the
mask every 5 to 10 seconds. Anaesthesia is often produced in 8 to 10 min-
utes, provided a complete quietude prevails in the room while the chloroform
is administered and the patient is
not touched, for instance, for the
purpose of rendering aseptic the
field of operation ; nearly all un-
pleasant symptoms are absent when
anaesthesia is thus gradually in-
duced. After anaesthesia has been
fully induced it will suffice to admin-
ister one drop of the anaesthetic
upon the mask every ten seconds
until the end of the operation. The
quantity of chloroform used is about
25 to 30 grams an hour. In excep-
tional cases the anaesthetizer may
at times be obliged to administer
chloroform more rapidly for the
purpose of effecting and maintain-
ing: full anaesthesia.
Fig. 316. Junker's Chloroform Api'ar.\tus
For the purpose of diluting the chloroform vapors at a like proportion
by the admixture of zir, Junker s apparatus may be used (Fig. 316). Since
the chloroform cannot evaporate in the air with this apparatus, its adminis-
tration is more economical. The apparatus consists of a graduated bottle,
half filled with chloroform, from which, by means of an atomizer, {a) the
vapors mixed with air are forced into the mouthpiece, {b) held before the
mouth and the nose of the patient. Kappelcr s apparatus of a similar con-
struction can also be recommended.
COURSE OF CHLOROFORM ANAESTHESIA
After 'CciO. first inspirations, patients have subjective sensations, mostly of
a pleasant nature; respiration somewhat increases, the pulse becomes fuller
THE TREATMENT OF WOUNDS 1 77
and more rapid, and the eyes are filled with tears. An erythema resembling
measles appears on a delicate skin on the neck and the upper portion of the
thorax. The patients often cease breathing ; the ansesthetizer should then
request them to inspire. Sensibility may have been decreased to such a
degree that certain minor momentary operations can be performed without
any reflex movements. With many patients, this moment has been reached
when the arm, held in a vertical position, slowly sinks down. With feeble
patients, men of good habits, women, and children, full narcosis and com-
plete relaxation of the muscles will at once set in. In most cases, how-
ever, it is preceded by a stage of excitation. Clonic and tonic contractions
of the muscles occur ; the patient screams, sings, fights, and makes attempts
to run away. This state is especially well marked in vigorous patients and
in intemperate persons. To control the excitement from the beginning, it
is well, about 15 to 20 minutes before the anaesthesia, to administer an
injection of morphine (o.oi), whereby anaesthesia takes a considerably more
tranquil course and is more rapidly completed.
If the anaesthesia is now continued uninterruptedly, by administering
chloroform by the drop method, this state of excitation gradually decreases,
and, under deep, often stertorous, respiration, complete anaesthesia — relax-
ation of all the muscles, arrest of all reflex movements (period of tolerance)
— sets in. Last of all the cornea reflex disappears, as well as that of
the mucous membrane of the nose and upon the inner side of the thigh.
The pupil, which before relaxation was somewhat dilated, contracts, the
eyeballs make asymmetric movements, the pulse becomes smaller and
weaker, the body heat and the blood pressure become lower, the respira-
tory movements quicker and shallower, and metabolism is retarded. If
still more chloroform is inspired, the paralyzing effect may extend to
the medulla oblongata and the motor ganglia situated in the heart it-
self, and with a sudden dilatation of the pupil, cessation of the respiratory
movements and of the heart's action may ensue. This dangerous stage
can be avoided, if the patient is kept anaesthetized only to such a degree
that the coimea reflex is Just extinct ; chloroform should then be ad-
ministered by the drop method at greater intervals, and for some time not
at all ; only on the return of the reflex should a few more drops be ad-
ministered. Hence, a frequent test for tJie cornea reflex is necessary. Raise
the upper eyelid with the third finger, and touch the cornea gently with
the forefinger. If the pupil becomes dilated — complete relaxation of the
muscles not having set in — it is a premonitory stage of vomiting, which at
times may be prevented by administering drops of chloroform more rapidly.
178 SURGICAL TECHNIC
With this careful and gradual method of using chloroform, threatening
symptoms only rarely occur during anaesthesia. They are most to be
apprehended in very excitable patients (hysteria) ; in feeble and anaemic
and in stout persons (fatty degeneration of the heart); and in patients subject
to pulmonary or heart disease ; in inveterate smokers and drinkers (alcohol,
morphine, chloral); likewise, in patients having a diseased liver or kidneys,
diabetes, diseases of the lymphatic glands, and thymic asthma (status
thymicus). Whether an anaesthesia will take a normal course may be recog-
nized after the first inspirations from the fact that the eyes close peacefully ;
if the upper eyelid does not close entirely, or if the eyes remain half open,
the surgeon must be prepared for unpleasant accidents.
THE AWAKENING FROM AN/ESTHESIA VARIES
The patient should never be roused from it by calling, shaking, or by
beating his chest, etc. After anaesthesias of short duration, in which, however,
the stage of fullest tolerance had been reached, the patients often rise sud-
denly, are able to walk, and have no after pains. Still in most cases vomit-
ing occurs sooner or later. If the patient must be put to bed, as it happens
in by far the majority of cases, he should be placed comfortably, and con-
tinued quietude should prevail, in the slightly darkened room. Only one
person may watch at his bedside. Sometimes anaesthesia is followed by a
natural sleep of varied duration. The longer the sleep lasts the milder are
the sequelae of chloroform narcosis. In the majority of cases, however, the
patient is disturbed in his slumber by vomiting or spasmodic efforts to vomit
(nausea). At once turn the head well to one side and hold a folded napkin
or a basin at the side of the mouth. Vomiting can become very obstinate and
continue for days. The patient is relieved most rapidly, if not a drop of any
fluid is given to him in spite of his most imploring entreaties. If his request
is fulfilled vomiting will undoubtedly occur again. Should, however, circum-
stances make it justifiable to accede to his request, to quench his thirst, it is
well to give him small pieces of cracked ice, to place a slice of lemon on his
tongue, or to administer a few teaspoonfuls of champagne. Injections of
caffeine are also recommended against nausea. Lcivin warmly recommends
covering the face of the patient with a cloth saturated with vinegar. This
should be applied immediately at the end of anaesthesia over the mask, and
the latter be removed from under it, so that no pure air is inspired. The
cloth remains in position for several hours. As a rule this crapulence-like
condition (" Katzenjammer "), similar to that resulting from the intoxication
THE TREATMENT OF WOUNDS 179
of alcoholic drinks, is over on the following morning, and after a day of fast-
ing the first meal is greatly relished.
Unpleasant occurrences during the next few days are the following :
Superficial inflammation of skin (eyes, chin) from chloroform having trickled
down from the mask ; contusion of the tongue if it has been held for a long
time with forceps, pain and swelhng in the region of the parotid gland,
caused by an awkward and prolonged lifting of the lower maxilla ; lameness
of one arm from having been raised forcibly in a lateral direction during
anaesthesia, — the clavicle, having been turned around its longitudinal axis,
contused the brachial plexus against the first rib {ErFs paralysis;, or the
arm was carelessly pressed against the edge of the table or bed in taking
the pulse (radial paralysis). Likewise similar symptoms may occur on the
legs from pelvic high position.
Chloroform as well as ether anaesthesias cause a considerable decrease of
urinary excretion and albuminuria, the degree of which seems to depend less
on the duration of anaesthesia and the quantity of the anaesthetic than on the
individual sensibility of the patient (Drencke).
Unpleasant accidents during anaesthesia are especially : —
1. Disturbances of respiration. Soon after the first few inspirations,
many patients suddenly cease breathing, and must be urged to do so either
by encouragement or command. With others, obstinate coughing occurs,
which, however, generally ceases after a few very deep inspirations. Pa-
tients with bronchial catarrh or asthma are afflicted most frequently by
distressing cough.
Long-contimied expiratioti {singing) interrupted only by short superficial
inspirations becomes especially unpleasant because it prolongs anaestheti-
zation. By addressing the patient or by a light blow upon the chest he
often resumes the natural mode of breathing.
2. Vomiting may occur during partial as well as complete anaesthesia ;
especially when the stomach is not empty, and when the mask for some time
had been removed from the face and chloroform was again administered be-
cause the patient showed signs of reaction. Even when the stomach is
empty, patients are sometimes forced to vomit during the beginning of
anaesthesia, on account of swallowing the saliva, which flows profusely and
is mixed with chloroform vapors. In such a case, turn the patient's head at
once well to one side, in order that the vomited matter may not be aspirated
into the air passages ; next, the mucous membrane of the stomach must be
rendered less sensitive by a more complete anaesthesia. Experiments have
also been made to produce an immediate effect upon the pneumogastric and
l8o SURGICAL TECHNIC
the phrenic nerves by finger pressure directly behind the sternal end of
the clavicle {Joes).
When vomiting has ceased, the buccal cavity must be carefully cleansed
with a sponge provided with a handle, or with a cloth.
3. A sudden eessation of the respiratory movements, which in the begin-
ning of anaesthesia can generally be restored by encouraging the patient,
may later on produce symptoms dangerous to life (reflex inhibition of
the pneumogastric nerves by irritation of the trigeminus branches upon
the mucous membrane of the mouth and the Schneiderian membrane of the
nose). After a few stertorous inspirations and after violent spasmodic
movements of the muscles, the glottis is closed by the muscular spasms ;
the abdominal wall makes a few more inspiratory movements, then retracts
and becomes as hard as a board; the jaws are iirmly pressed together; the
tongue is drawn backward and upward, so that the passage to the larynx is
obstructed. The face becomes flushed ; the lips bluish ; the veins swell ;
the pulse at first becomes slow, then imperceptible. This state of asphyxia
is caused by the spasms of the muscles of the larynx and the tongue
(spastic asphyxia). Prompt action is now imperative to free the upper
entrance to the larynx. The set jaws must be separated, the tongue must
be drawn well out of the mouth; if this prove successful, respiration is often
restored without further assistance, if not, artificial respiration should be
made (see below). Relaxation of the rigid muscles is effected by adminis-
tering more chloroform. In old people and children, during inspiration, the
closed flaccid lips are sometimes drawn like valves toward the toothless jaws
and the thin alae of the nose against the septum, preventing the entrance
of air. To prevent the injurious reflex from the trigeminus of the mucous
membrane of the nose upon the heart's action, Giierin had the chloroform
vapors inspired only by the mouth (the nostrils having been occluded with
clamp forceps or cotton). More recently Rosenberg recommends — as a pre-
vention of asphyxia — to anaesthetize the ramifications of the trigeminus of
the mucous membrane of the nose. With a spray he atomizes into the nos-
trils at two different tempos 6 eg. of a xo'p cocaine solution a few minutes
previous to general anaesthesia.
4. In XkiO. stage of tJie fullest tolerance, during the complete relaxation of
all the muscles, the tongue, following gravitation, not rarely falls back and
comes to lie upon the posterior pharyngeal space, thereby obstructing the
upper entrance to the larynx (paralytic asphyxia). These accidents are
the more dangerous because the symptoms of asphyxia do not occur in so
violent a manner ; but, in a short time, the blood becomes subcharged with
THE TREATMENT OF WOUNDS l8l
carbonic acid. The respiration becomes heavy and stertorous ; or even re-
spiratory retractions ("Einziehung") set in, the face becomes blue, the blood
dark, and the pulse irregular and weak. With sufficient attention, these
symptoms can be easily removed, by raising the lower jaw and by drawing
out the tongue.
5. Disticrbmices of the circulation. The most dangerous accident that
can occur in all the stages of chloroform anaesthesia is the sudden paraly-
sis of the Jieart, which can produce death (syncope). The face very sud-
denly turns as pale as death ; the pupil becomes dilated and fixed ; the
cornea reflex disappears; the lower jaw falls as in a corpse; the pulse
becomes rapidly imperceptible ; the heart beats are no longer audible ; the
hemorrhage from the operating wound ceases. Respiratory movements
may continue still for some time, although superficial and irregular, until,
after a few short inspiratory efforts, they cease as in the dying. Fortu-
nately, this distressing state very rarely occurs, and then mostly in
anaemic persons and in those who are suffering from heart disease. Still,
even robust persons in perfect health may become subject to it, especially
when they have manifested great fear and excitement before the operation.
If the cardiac function cannot be restored by artificial respiration and mas-
sage, death ensues. The mortality from chloroform is about one in every
ten to twenty thousand persons anaesthetized, and undoubtedly death from
this cause is becoming more and more infrequent. Many fatal cases from
chloroform are of course kept secret or reported as resulting from other
causes. The cases heretofore published occurred especially during minor
operations, which were to be performed rapidly with imperfect precaution
and insufficient preparation. Likewise, all those cases of fatal shock during
operations, which were observed before the discovery of chloroform, must
be considered here. Fatal accidents from anaesthesia may happen in the
practice of any surgeon with any patient ; and the blame should not be
attached to the surgeon, provided he is familiar with and has followed all
precautionary measures.
Note. — According to the statistics collected by Gurlt and communicated to the last
Surgical Congress, of 327,593 persons anaesthetized 134 deaths occurred ( i : 2444). Of
the several narcotics, chloroform was fatal at the ratio of i : 2039 ; chloroform with ether,
at I : 5090; ethylene bromide, at i : 5228; pental, at i : 199. With pure ether, no death
occurred in 14,506 anaesthesias, and the same freedom from danger was observed with the
mixture of chloroform, ether, and alcohol recommended by Billroth., at i : 3870, ether and
chloroform, at i : 7594.
(The statistics quoted by the author refer only to deaths resulting from the immediate
effects of the anesthetic. The mortality would be much greater if all the fatal cases were
1 82
SURGICAL TECHNIC
reported, and more especially if it would include deaths resulting from secondary compli-
cations caused by the anzesthetic ; if this were done the dangers from ether anzesthesia
would become more apparent.) Death from chloroform must be considered an accident for
which every surgeon ought to be prepared if he uses chloroform. The statistics quoted
show that this accident occurs rather frequently, even though some surgeons for years and
tens of years had no fatal case during anaesthesia. Death from chloroform (poisoning) may
even occur subsequently (after several days), especially after a very prolonged full and often
repeated anccsthesia, from which the patient completely recovered. In such cases frequent
vomiting, heematuria, icterus, albuminuria, weakness of the cardiac action, collapse, occur.
Frequently these cases resulting from the after effects of chloroform are not rightly diag-
nosed as such.
The action of the surgeon during serious accidents is of the very greatest
importance, since upon it often depends the life of the patient. He should
see to it that the air can enter freely and that respiration not only does not
cease, but, if necessary, is maintained artificially. The chloroform mask, of
course, must be removed ivwiediately whenever grave symptoms make their
appearance.
Care for unobstructed respiration. Displacement of tJie entrance of the
larynx occurs most frequently during full anaesthesia; in consequence of
relaxation of the vinsclcs, the tongue falls toward the posterior pharyngeal
wall, and the epiglottis closes the upper entrance to the larynx. This con-
dition can easily be corrected by : —
Lifting of the lower jaw. Standing behind the patient, apply both hands
flat to the neck in such a manner that the forefingers come to lie behind
the ascending rami of the
lower maxilla ; push the
whole lower maxilla for-
ward until the lower row
of teeth projects beyond
the upper (subluxation.
Fig. 317). By means of
this manipulation, the
muscles at the root of
the tongue attached to
the lower maxilla, to-
gether with the epiglot-
tis and the hyoid bone,
Fig. 317. LiKHNG the Lower Jaw ^^^ ^^^^^^ forward in
such a manner that the upper entrance to the larynx becomes free. The
same effect is obtained also in the following manner : Stand before the
THE TREATMENT OF WOUXDS
183
patient; place the forefingers of both hands, hook-like, behind the angle
of the jaw and draw it forward {Kappele}-). Do not open the mouth too far
during these manipulations, else the base of the tongue is not lifted forward
but only upward.
The operator should proceed very gently in lifting the lower maxilla,
especially when the process must be continued for some time ; else, during
the following days, violent pains occur in the temporo-maxillary articulation,
together with swelling of this region, especially of
the parotid gland, which causes greater trouble to
the patient than the operation itself. For this
purpose, Giitsch has mentioned a lower maxilla
holder, with which the lower maxilla can be drawn
forward permanently and easily (Fig. 318;. The
rubber pad is placed behind the lower row of
teeth, the wire ring under the chin ; the clasp
is closed, and then the lower jaw is drawn forward by means of the ring.
If, however, an obstruction to the respiratory passage occurs in conse-
quence of spastic contraction of the muscles of the larynx, whilst also the
other muscles of the body are forcibly contracted, the operator will not
succeed in pushing forward the lower maxilla in the manner indicated ; in
such a case the jaws must be separated {Heisters or Rosers gag — see
Figs. 1 135, 1 1 36), the tongue must be grasped with the fingers or with
Fig. 318. Gutsch's Lower
Maxilla Holder
Fig. 319. Protraction of Tongue with Forceps
tongue-holding forceps (Fig. 320; and drawn out of the mouth as far as pos-
sible (Fig. 319). As after a long use of the forceps sometimes a consider-
able contusion of the tongue is produced, it is better to employ a tenaculum
1 84
SURGICAL TECHNIC
forceps (Fig. 321), as its use is attended by less injury to the tongue. In
case of necessity, a strong thread may be drawn through the tongue with
a large needle and used as a substitute for forceps. If the jaws are set very
tightly, Kappelo' recommends to grasp the Jiyoid bone with a little sharp
hook from the outside and to draw it forward ; by this means the base of
the tongue and the epiglottis yield to the traction.
Fig. 320
Von Esmarch's Tongue
HOLDING Forceps
Fig. 321
Championniere's Hooked
Tongue-holding Forceps
Fig. 322
Sponge Holder
If respiration still remains labored and stertorous, it is possible that this