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Anaesthesia and Analgesia in Certain Medical Diseases with Complications or Associated Conditions Requiring Surgical Intervention, and, The Treatment of Certain Types of Convulsions by the Administration of Some of the Newer Drugs Used in Anaesthesia

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A dm inistrat i o n o f some o f the Newer Drugs used i n A n aesth esia
p re sen te d by
Andrew Kerr B oyle. M.B. Ch. B. ( G le e .).
fo r
The degree o f D octor o f M edicine
o f th e
PnlTC TllfT 9 f A m o t *
(P .C .P . and S . g pg,)
ProQuest N um ber: 13905566
All rights reserved
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a n o te will in d ic a te the d e le tio n .
uest.
P roQ uest 13905566
Published by ProQuest LLC(2019). C o p y rig h t of the Dissertation is held by the A uthor.
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T his t h e s i s h a s been com piled from o a se s p e rso n a lly
conducted by A.K. Boyle d u ring h is te rm o f o f f ic e
a s r e s id e n t a n a e s th e ti s t to St* Jam es' H o s p ita l,
Balham, London.
DESIDERATA
P re - o p e ra tiv e I n v e s tig a tio n s and P re p a ra tio n
At S t . Jam es’ H o sp ita l b e fo re an a n a e s th e tic o r a n a lg e sic i s
adm inistered to a n in door p a tie n t th e fo llo w in g f a c to r s a re determ ined
as a c c u ra te ly a s p o s s ib le .
I.
THE ANAESTHETIC TOLERANCE OF THE PATIENT
D eterm in atio n o f th e p a t i e n t ’ s to le ra n c e tow ards any form o f a n a e s th e s ia
o r a n a lg e s ia i s based upon 1* G eneral C r i t e r i a :
These in c lu d e ,
(1) In q u iry in to th e p a s t m edical h is to r y e s p e c ia lly in r e la tio n
to p re v io u s a n a e s th e s ia o r a n a lg e s ia and th e p a t i e n t 's re a c tio n
to i t .
Abnormal s e n s i t i v i t y , in d iv id u a l a n d /o r fa m ilia l to any
drug o r group o f drugs i s o f s p e c ia l im portance.
(2) Complete p h y sic a l exam ination w ith s p e c ia l re fe re n c e to "the
o ir c u la to r y , r e s p ir a to r y , u rin a ry and nervous system s.
The h e ig h t and w eight o f th e p a tie n t a re reco rd ed .
2 . S p e c ia l C r i t e r i a :
C e rta in c r i t i c a l t e s t s a re now a p p lie d (1) M oot's In d ex »
^ 9 ° P jeagarg
D ia s to lic P ressu re
x 100 * 3) approxim ately
i n normal p a t i e n t s .
M oot's index p ro v id es an approxim ate index to th e c a rd ia c re s e rv e .
I f i t i s below 25 o r above 75 th e c a rd ia c re s e rv e i s gravely
in a d e q u a te .
(2) B arash ’ s Energy In d ex - (S y s to lic + D ia s to lic Blood
P re s su re ) x P u lse R a te .
The num erals o f th e thousands c o n s titu te th e index whose normal
v a lu e i s 12- 18.
,
,
w ’ V -v
B arach’ s Energy Index p rovid es an approxim ate o f th e c irc u la to ry
re se rv e .
I f i t i s below 6 o r above 24 1he c irc u la to ry energy
i s g ra v e ly d e f ic ie n t .
(3) H enderson’ s B reath-H olding T est
I n t h i s t e s t th e p a t i e n t , a f t e r ly in g a b so lu te ly q u ie t f o r fiv e
m in u te s, ta k e s a m oderately deep b re a th and holdB i t f o r as long
a s p o s s ib le , having th e l i p s clo sed and th e n o s t r i l s pinched
to g e th e r .
H e n d erso n 's B reath-H olding T e st g iv es an approxim ate measure of
v i t a l o a p a c ity .
The normal s u b je c t should be a b le to hold h is
b re a th f o r some 45 seconds.
A perio d below 10 seconds im p lies
s e r io u s ly im paired v i t a l c a p a c ity .
(4) R ead’ s and T a l e 's Formula
I n d i r e c t e s tim a tio n o f th e b a sa l m etabolic r a te may be made from
R e a d 's Formula
Y a le 's Formula
B.M.R. - 0 .6 8 3 (P.R. + 0 .9 P .P .) - 7 1 .5 .
B.M.R.- P .R . + P .P . - 111*
Where P .R . re p re s e n ts th e p u lse r a t e p er m inute and P .P . th e
p u lse p re s s u re .
D ire c t e s tim a tio n i s alw ays employed i n th y ro to x ic p a tie n ts
except when they a r e c r i t i c a l l y i l l and l i k e l y to be exhausted
by th e p ro ced u re.
The b a sa l m etab o lic r a t e may n o t g iv e much a d d itio n a l help
i n e stim a tin g th e o p e ra tiv e r i s k , but i t i s o f a s s is ta n c e in
gauging
th e approxim ate oxygen re q u ire m e n ts.
T his i s a
c o n s id e ra tio n o f im portance where gas a n a e s th e s ia i s contem plated
f o r f e v e r is h p a tie n ts and p a tie n ts s u ffe rin g from th y re o to x ic o s is .
(5) E x e rc is e T olerance T est
I n cases o f c a r d io -v a s c u la r d is e a s e e x e rc is e to le ra n c e d e term in atio n
is e s s e n tia l.
I t w i l l be r e a lis e d -that, in many c a s e s, th e p a tie n t i s so
d e s p e ra te ly i l l and th e o p e ra tio n one o f such urgency, th a t
d e ta ile d in v e s tig a tio n s i n advance a re im p o ssib le .
The A n a e s th e tic T olerance i s deduced from th e maximum o f in fo rm atio n
o b ta in a b le .
By c o n s id e ra tio n o f such in fo rm atio n each p a tie n t i s
c la s s if ie d a s o f Ample a n a e s th e tic to le ra n c e .
P robably adequate a n a e s th e tic to le ra n c e
or
In a d e q u ate a n a e s th e tic to le ra n c e .
H,
THE ANAESTHETIC RISK OF THE PATIENT
From th e above g e n e ra l and s p e c ia l c r i t e r i a and from th e n a tu re o f th e
proposed o p e ra tio n , th e a n a e s th e tic r i s k p resen ted by th e p a tie n t i s a sse ssed .
4 convenient c l a s s i f i c a t i o n i s th a t suggested by th e In te rn a tio n a l A naesthesia
Besearch S o c ie ty .
"A" R isk : Minor o p e ra tio n upon a h e a lth y s u b je c t, i . e . a s u b je c t in
whom a l l th e above c r i t e r i a a re e n tir e ly s a tis f a c to r y .
"B" R isk : Major o p e ra tio n upon a h e a lth y s u b je c t, o r An o p e ra tio n not dangerous to l i f e upon an unhealthy s u b je c t,
i . e . a s u b je c t i n whom im paired a n a e s th e tic to le ra n c e i s
in d ic a te d by th e above c r i t e r i a .
"Cn R isk : S e rio u s o p e ra tio n upon a p a tie n t p re se n tin g some grave
p a th o lo g ic a l c o n d itio n .
"Drt R isk : A p a tie n t i n u rg e n t danger o f d eath from s u r g ic a l d ise a se
o r from some c o m p lic atio n .
III.
THE SAFEST and most SUITABLE ANAESTHETIC o r ANAIGESIC AGENT and TECHNIQUE
The c h o ice o f th e a g en t and techniq u e in v o lv e s a b alan cin g o f four
fa c to rs The A n a e s th e tic T o leran ce and R isk p resen ted by th e p a tie n t .
The T o x ic ity o f th e A gent.
The convenience o f th e surgeon.
The p h y sic a l r e a c tio n s o f th e p a tie n t .
I t i s in flu en c ed by c e r t a i n p a th o lo g ic a l f a c to r s , f o r example, shock and
haemorrhage, grave s e p s is , k e t o s i s , d is e a s e s o f th e v a rio u s system s, by
reg io n al f a c to r s such a s c r a n ia l s u rg e iy , rh in o -la ry n g o lo g ic a l surgexy, th o ra c ic
surgery, e t c e te r a , and by th e extrem es o f ag e.
P o ssib le r i s k o f f i r e and e x p lo sio n i s an im portant c o n sid e ra tio n in
the s e le c tio n of th e a g en t and tech n iq u e.
IV. THE NECESSARY TRELDfllNAKY PREPARATION OF THE PATIENT
The p re lim in a ry p re p a ra tio n of th e p a tie n t - h y g ie n ic , psychic and
medical - w i l l depend upon th e c o a litio n s and circum stances p re sen t in the
p a rtic u la r c a s e .
The o b je c t o f th e m edical treatm en t o f the p a tie n t about
to undergo an o p e ra tio n i s to r e s to r e as com pletely and as ra p id ly as
possible h i s re s o u rc e s and to provide him w ith any necessary o r d e sira b le
prelim inary m e d ic a tio n .
The p re -a n a e s th e tic am nesic, h y p n o tic o r n a rc o tic
drug, and th e dose to be employed, are determ ined from a c o n sid e ra tio n of
the age, s e x , body w e ig h t, h a b its o f l i f e and s t a t e o f h e a lth o f the
P a tie n t and o f th e advantages and d isad v an tag es, in d ic a tio n s and c o n tra -
in d ic a tio n s , dangers and methods o f a d m in is tra tio n of th e drug,
V.
THE EOSSIBLE ACCIDENTS o f th e proposed ANAESTHESIA o r ANAIGESIA
The p ro p h y la x is o f c o m p lic atio n s d u rin g a n a e s th e s ia o r a n a lg e s ia
demands a knowledge o f t h e i r p o s s ib le o ccu rren ce and o f th e p rev en tiv e
measures to be a p p lie d , th e prompt and e f f i c i e n t tre a tm e n t o f them
adequate s k i l l and f a c i l i t i e s .
A ll m echanical a p p a ra tu s i s te s t e d p e rs o n a lly by th e a n a e s th e tis t
before u s e ,
i
<xX)jj-o ^
OBSERVATIONS d u r i n g OPERATION
A t i n te r v a ls o f f i v e m inutes throughout a n a e s th e s ia re a d in g s o f The p u lse r a t e and c h a r a c te r .
The r a t e and c h a r a c te r o f r e s p ir a tio n .
The s y s to li c and d i a s t o l i c blood p re s su re s are re c o rd ed .
The p a t i e n t ’ s c o lo u r i s c o n s ta n tly observed.
A ccurate c h a r tin g p la c e s th e a n a e s th e t i s t i n a p o s itio n to a s s e s s the
degree of o p e ra tiv e shock a t any s ta g e o f th e o p e ra tio n , to inform the
surgeon, i f re q u e s te d , w hether f u r th e r s u r g ic a l procedures a re o r a re no t
p erm issible, to su g g est
the
speedy com pletion o f th e o p e ra tio n , i f
p a t i e n t 's c o n d itio n w arrant i t and to d i r e c t th e immediate
changes in
in s titu tio n
of such r e s t o r a t i v e m easures a s a re n e ce ssa ry to combat profound shock*
I n o ases o p e ra ted upon under l o c a l o r s p in a l a n a lg e s ia w ithout
adjuvant in h a la tio n a n a e s th e s ia , however, a q u ie t com fortable p a tie n t i s
disturbed by fre q u e n t blood p re s su re re a d in g s.
S u f fic ie n t in fo rm atio n can
u sually be o b ta in e d by o b s e rv a tio n s of h i s co lo u r and o f th e c h a r a c te r is tic s
of h is p ils e and r e s p ir a tio n .
P rogress n o te s and
conments a re made.
I n th e case o f gas
a n a e s th e s ia , oxygen percentage and d e ta i ls o f
reb reathing a re s im ila r ly re c o rd ed .
The t o t a l q u a n tity o f th e ag en t o r a g en ts used and th e d u ra tio n of
the a n a e sth e sia o r a n a lg e s ia a re c h a rte d .
IQST-OPERATIVE MANAG0IENT
Competent c a re o f th e p a tie n t a f t e r o p e ra tio n i s o f th e g re a te s t
importance.
S u ita b le p ro p h y la c tic m easures w i l l a v e r t many o f th e
com plications o f a n a e s th e s ia and a n a lg e s ia ;
early i s extrem ely e f f e c t i v e .
proper tre a tm e n t s ta r te d
I t i s e s s e n t i a l th a t th e a n a e s th e tis t
be cognisant o f a l l th e s e r io u s sequelae which may occur and th a t he be
thoroughly conversant w ith th e p re v e n tiv e and c u ra tiv e th e ra p ie s to
be a p p lie d .
The immediate p o s t-o p e ra tiv e tre a tm e n t o f th e p a tie n t s u ffe rin g from
such d ise a se a s d ia b e te s m e llitu s »nd th e r e s u s c it a ti o n o f "the newly-born
ch ild , not in f r e q u e n tly f a l l i n g to th e l o t o f th e a n a e s th e tis t, demand th e
re q u is ite knowledge and s k i l l .
ANAESTHETIC RECORDS
A com plete re c o rd i s k ep t o f th e p re -o p e ra tiv e in v e s tig a tio n s and
p rep aratio n c a r r ie d o u t, o f th e o b s e rv a tio n s made and r e s to r a tiv e
measures employed d u ring o p e ra tio n , and o f th e d e t a i l s o f p o s t-o p e ra tiv e
management in ev ery c a s e .
I t fu r n is h e s d a ta o f g re a t value should th e
p a tie n t re q u ire subsequent a n a e s th e s ia o r a n a lg e s ia , and provides m a te ria l
fo r s t a t i s t i c a l purposes and re s e a rc h .
ANAESTHETIC RECORD.
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ANALYSIS o f INDIVIDUAL FATALITIES
E very a n a e s th e tic and a n a lg e s ic f a t a l i t y i s s u b je c te d to in q u ir y
by an a p p ro p ria te consnittee o f th e m edical s t a f f .
a r e c i r c u la t e d among a l l concerned.
Autopsy f in d in g s a re s e t down i n d e t a i l .
The le s s o n s l e a r n t
D uring th e p e rio d from Ja n u a ry 1 s t , 1938, to F eb ru ary 4 th , 1939,
tW B nty-six c a se s o f meta-pneumonic empyaema were o p e ra te d upon a t
S t . Jam es' H o s p ita l.
The ty p e s o f o p e ra tio n perform ed w ere th e fo llo w in g :
Type o f O p e ra tio n
Number
I n t e r c o s t a l d ra in a g e .
7
P a r t i a l r e s e c tio n o f r i b .
16
I n t e r c o s t a l d ra in a g e w ith subsequent p a r t i a l
r e s e c tio n o f r i b
3
The a n a e s th e tic r i s k s were c l a s s i f i e d aB:
"B" R is k f o r i n t e r c o s t a l d ra in a g e ,
"Cn R isk f o r p a r t i a l r e s e c tio n o f r i b .
The m ethods o f a n a e s th e s ia and a n a lg e s ia employed were a s fo llo w s
Method o f A n a e sth e sia o r A n a lg e sia
Local a n a lg e s ia
Number
16
In h a la tio n a n a e s th e s ia
6
In trav e n o u s a n a e s th e s ia
2
Combination o f in tra v e n o u s w ith in h a la tio n a n a e s th e s ia
2
M o rta lity :
One o f th e p a t i e n t s h a s d ie d .
The o th e rs have e n t i r e l y h e a le d .
The m o r t a lit y , th e r e f o r e , h as been 3.84%.
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All hypodermic in je c tio n s were given th r e e - q u a r te r s
of an hour before o p e r a tio n ,
5$ a Pentothal Sodium 5% Aqueous Solution (A b b o tt).
0.5 gm. Pentothal Sodium in 10 cc. s te rile d is tille d w a te r.
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R e c o v e ry
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R e s u lt
Commentary on th e Methods o f A n a e s th e sia and A n a lg e s ia employed.
LOCAL ANALGESIA:
A lthough a method o f c o n s id e ra b le imm ediate s a f e t y , and one
p r a c tic a b le by th e surgeon h im s e lf , lo c a l a n a lg e s ia was u n s a ti s f a c to r y in
c h ild re n on account o f t h e i r r e s t l e s s n e s s , n o n -c o o p e ra tio n an d p s y c h ic a l
in s ta b ility .
Subsequent i n f e c tio n o f th e c h e s t w a ll, alw ays l i a b l e to
occur a f t e r p re lim in a ry p a ra c e n te s e s an d p a r t i c u l a r l y l i a b l e to co m p licate
i n f i l t r a t i o n a n a lg e s ia , was a m ost s e r io u s o b je c tio n i n b o th c h ild r e n and
a d u lts .
When an ex p erien ced a n a e s th e ti s t was a v a ila b le g e n e ra l a n a e s th e s ia
was p r e f e r a b le t o l o c a l a n a lg e s ia .
INHALATION ANAESTHESIA:
F o r i n t e r c o s t a l thoracotom y and p a r t i a l r e s e c tio n o f r i b i n a l l
p a tie n ts in h a la tio n a n a e s th e s ia w ith C yclopropane-oxygen, c lo se d c i r c u i t
technique w ith t o t a l re b re a th in g and carb o n d io x id e a b s o rp tio n , was th e
most d e s ir a b le m ethod.
A d m in is tra tio n by means o f a fa c e -p ie c e and
r e te n tio n - h a m e s s was a l l t h a t was n e c e s s a ry .
f u l l o x ygenation was a ffo rd e d ;
V ery q u ie t r e s p i r a t i o n w ith
blood p re s s u re was s l i g h t l y r a i s e d .
With
a slow r a t e o f flow o f Cyclopropane a d m in is tra tio n d u rin g in d u c tio n 300 to 33) c . c . per m inute - no untow ard s ig n s such a s r e s p i r a t o r y a r r e s t o r
to x ic e f f e c t s on c a r d ia c m u scu latu re w ere o b se rv e d .
oozing ceased w ith th e te rm in a tio n o f a n a e s th e s ia ;
In c re a s e d c a p il la r y
o o c u rrin g a s i t d id from a
s n a il wound and f o r a s h o r t p e rio d i t was o f no moment.
A hypodermic
in je c tio n o f a tro p in e i n th e c h ild and o f Omnopon and a tro p in e o r hyoscine in
th e a d u lts was g iv e n p r e - o p e r a tiv e ly .
I n h a la tio n n itr o u s oxide-oxygen w ith
minimal d i- v i n y l e th e r was a good s u b s tit u te f o r Cyclopropane-oxygen.
D i-v in y l e t h e r , devoid o f th e to x ic e f f e c t o f ch lo ro fo rm and th e r e s p ir a to r y
i r r i t a n t e f f e c t o f d i - e t h y l e th e r , added i n m inim al q u a n tit ie s to th e n itr o u s
o x id e-o xygen made i t p o s s ib le to m a in ta in ad eq u ate o x y g en atio n and
s a t i s f a c t o r y a n a e s th e s ia a t th e same tim e i n p a t i e n t s w ith oxygen
re q u ire m e n ts g r e a t e r th a n norm al.
th e method o f p a r t i a l r e b r e a th in g .
A c lo se d c i r c u i t was p r e f e r r e d to
P re lim in a ry p re m e d ica tio n w ith a tro p in e
was n e c e ssa ry to o b v ia te th e e x c e s siv e s a li v a t i o n consequent upon d i- v in y l
e th e r a d m in is tr a tio n .
INTRAVENOUS ANAESTHESIA:
In tra v e n o u s a n a e s th e s ia w ith p e n to th a l sodium , 5 p e r cen t aqueous
s o lu tio n , was used i n th e two a d u lt c ases f o r i n t e r c o s t a l d ra in a g e and
subsequent p a r t i a l r e s e c tio n o f r i b .
of "gas".
Both th e s e p a t i e n t s ex p ressed a d i s l i k e
P e n to th a l sodium was chosen i n p re fe re n c e to ev ip an sodium , th e
o th e r b a r b itu r a te i n common u se f o r in tra v e n o u s a n a e s th e s ia , f o r th e fo llo w in g
re a so n s:
re c o v ery .
th e r a t h e r sm oother in d u c tio n o f a n a e s th e s ia and th e more ra p id
The te ch n iq u e u sed was th e s in g le -d o s e m ethod, th e r a t e o f
in trav en o u s i n j e c t i o n n o t exceeding 1 c . c . i n 33 seco n d s.
A tro p in e was
ad m in istered hy p o d erm ically th r e e - q u a r te r s o f an hour p re v io u s ly ;
th e
s a liv a tio n n o t in f r e q u e n tly encountered i n in tra v e n o u s p e n to th a l a n a e s th e s ia
was th u s a v o id ed .
The e n d - r e s u lts were v e ry g r a t i f y i n g .
COMBINATION o f INTRAVENOUS w ith INHALATION ANAESTHESIA:
In d u c tio n o f a n a e s th e s ia wi th in tra v e n o u s p e n to th a l sodium and subsequent
maintenance w ith in h a la tio n n itr o u s oxide-oxygen proved v e ry s a t i s f a c t o r y
fo r p a r t i a l r e s e c tio n o f r i b i n two c a s e s , b o th a d u l t s ,
A smooth ra p id
in d u ctio n was o b ta in e d , and th e need f o r suboxygenation i n m a in ta in in g
a n ae sth esia w ith n itr o u s oxide-oxygen o b v ia te d .
In tra v e n o u s a n a e s th e s ia was n o t a method o f c h o ice f o r c h ild r e n .
For a d u lts w ith a d i s l i k e of gas a n a e s th e s ia , how ever, in tra v e n o u s p e n to th a l
sodium was a good te ch n iq u e f o r i n t e r c o s t a l d ra in a g e and f o r subsequent
p a r t i a l r e s e c tio n o f r i b , th e com bination o f in tra v e n o u s p e n to th a l and
in h a la tio n n itr o u s oxide-oxygen a v a lu a b le te ch n iq u e f o r prim ary p a r t i a l
r i b re s e c tio n .
The l a t t e r m ight a ls o b e used a s an a l t e r n a t i v e to
in h a la tio n n itr o u s oxide-oxygen - m inim al d i - v i n y l e th e r when cyclopropane
was no t a v a ila b le f o r r i b r e s e c tio n i n a l l a d u l t s .
I n th e s e c a s e s th e a g e n ts u sed f o r g e n e ra l a n a e s th e s ia were th o se
which have been shown to cause no damage to th e lu n g s , to be a s s o c ia te d
w ith ra p id re c o v e ry and to have th e minimum e f f e c t on m etab o lic p ro c e s s e s .
They provided q u ie t a n a e s th e s ia w ithout m a te r ia lly i n t e r f e r i n g w ith th e
cough r e f l e x .
P o s itiv e p re s s u re was, o f c o u rse , u n n e ce ssa ry .
I n th e o n ly f a t a l c a s e , a fem ale c h ild aged 4 y e a r s , d e ath o ccu rred
fo u rte e n days a f t e r i n t e r c o s t a l d ra in a g e f o r r i g h t s id e d empyaema.
P a ra c e n te s is p e r i c a r d i i f o r p y o -p ericard iu m had been perform ed two days
b efo re d e a th .
Aflftflfttbe g la aBfl
C om plications o f P e p tic U lc e r
Sffrriflftl
A cute g a s t r i c u lc e r s u s u a lly h e a l r a p id ly when a p p ro p ria te m ed ical
tre a tm e n t i s c a r r ie d o u t.
O c c a s io n a lly , h o w e v er,. they p e r f o r a te
n e c e s s ita tin g o p e ra tio n .
The tre a tm e n t o f ch ro n ic u l c e r s , g a s tr ic o r duodenal, i n th e f i r s t
in s ta n c e sh o u ld be m e d ic a l.
The in d ic a tio n s f o r s u r g ic a l in te r v e n tio n
may be summarised a s fo llo w s :
P e r f o r a t io n .
P e r i g a s t r i c a b sc e ss .
O rganic p y lo r is s te n o s is
o r h o u r- g la s s c o n s t r i c t i o n w hich impedes stomach em ptying.
S u s p ic io n o f carcinom a.
I n t r a c t a b l e g a s t r i c haemorrhage from
th e e ro s io n o f a s c l e r o t i c a r t e r y i n th e f l o o r o f an u l c e r .
R epeated haem orrhages.
tr e a tm e n t.
F requent r e la p s e s a f t e r e f f i c i e n t m edical
Large p e n e tr a tin g u l c e r , dem onstrable r a d io lo g ic a lly .
F o r th e u p p e r abdom inal o p e ra tio n s re q u ire d f o r th e s e c o m p lic atio n s
th e a n a e s th e s ia o r a n a lg e s ia anployed should a ffo rd th e b e s t p o s s ib le
o p e ra tin g c o n d itio n s and freedom from r e s p i r a t o r y se q u e la e .
The a g en ts
used should be a s n o n -to x ic and th e methods adopted a s s a f e a s p o s s ib le .
A ttem pts a t r a i s i n g th e a n a e s th e tic to le ra n c e o f th e p a tie n ts in advance
of any s u r g ic a l p ro c e d u res a r e most d e s ir a b le .
Com binations o f a n a e s th e tic s and a n a lg e s ic s a re most s a t i s f a c t o r y f o r
g a s tr ic s u rg e ry .
A s friiltiA u a c s th e tis t i s e s s e n t i a l .
The com bination o f s p in a l a n a lg e s ia w ith in h a la tio n a n a e s th e s ia ,
u sin g p e rc a in e .1 :1 3 3 0 , h y p o b aric s o lu tio n and n itr o u s oxide-oxygen w ith
minimal d i- v i n y l e th e r i s i d e a l .
S p in a l b lo c k up to T .3 o r T .4 p ro v id es
p e rfe c t o p e ra tin g c o n d itio n s - a b so lu te m uscular r e la x a ti o n , m inim al
abdominal r e s p i r a t o r y movement a n d c o n tra c te d i n t e s t i n e s - even i n th e most
muscular s u b je c ts .
I t a f f o r d s a ls o p r o te c tio n from " r e f le x " shock, a most
im portant c o n s id e ra tio n i n lo n g , d i f f i c u l t and shock-producing g astrecto m ies*
The p a t i e n t s a r e g iv en an adequate dose o f omnopon-hyoscine su b cu tan eo u sly
th r e e - q u a r te r s o f an h o u r b e fo re going to th e o p e ra tin g th e a t r e and a re
l e f t u n d is tu rb e d i n a q u ie t room.
A m o d ified F o w le r's p o s iti o n i s
d e s ir a b le d u rin g t h i s p e rio d i n p e r f o r a tio n c a s e s .
ap p reh en sio n i s thus a lla y e d .
P o s t-o p e ra tiv e
The g e n e ra l c o n d itio n o f p a t i e n t s w ith
p e rfo ra te d u lc e r s i s much im proved.
As a p ro p h y la c tic a g a in s t th e
c ir c u la t o r y d e p re ss io n a s s o c ia te d w ith h ig h -b lo c k s p in a l a n a lg e s ia , one
g ra in o f ep h ed rin e i3 a d m in is te re d in tra m u s c u la rly a t th e com pletion of
th e su barachnoid i n j e c t i o n o f p e re a in e s o lu tio n .
To av o id p sy ch ic s t r a i n
and th e " v a g o -tra c tio n -n a u s e a " r e f l e x (nausea r e s u l t i n g from t r a c t i o n on
th e stomach) d u rin g o p e ra tio n co n scio u sn ess i s a b o lish e d w ith n itr o u s
oxide-oxygen.
Very sm all q u a n t i t i e s o f v in e sth e n e a re added to perm it a
high p e rc e n ta g e o f oxygen w ith th e n itr o u s o x id e and to e n su re ste a d y
m aintenance o v e r a c o n sid e ra b le p e rio d , i f n e c e s s a ry .
The p a r t i a l
re b re a th in g employed guards a g a in s t profound r e s p ir a to r y d e p re ss io n and
m ain tain s blood p re s s u re .
When s p in a l a n a lg e s ia i s e o n tr a - in d ic a te d , a v e r tin b a s a l n a rc o s is
combined w ith e n d o tra c h e a l in h a la tio n n itr o u s oxide-oxygen, c lo se d c i r c u i t
tech n iq u e, d i - e t h y l e th e r a s an a d ju v an t and abdom inal f i e l d b lo ck w ith
o n e-h alf p e rc e n t novocaine s o lu tio n c a r r ie d o u t by th e surgeon when th e
p a tie n t i s under th e g e n e ra l a n a e s th e s ia i s most s u ita b le f o r le n g th y
o p e ra tio n s.
The t o t a l e f f e c t s o f th e s e v a rio u s a g e n ts i n sim ultaneous
e x h ib itio n produce adequate depth w ith o u t i t bein g n e c e ssa ry to u se any
one o f th a n i n such q u a n tity o r c o n c e n tra tio n t h a t h a im fu l e f f e c t s may
re s u lt.
With t h i s te ch n iq u e th e e n d o tra c h e a l ro u te f o r th e a d m in is tra tio n
o f th e in h a la tio n a n a e s th e tic s i s a l l im p o rta n t.
airw ays th ro u g h o u t;
I t a s s u re s patency o f th e
p a r t i a l r e s p ir a to r y o b s tr u c tio n w ith lab o u red b re a th in g ,
so common i n l i g h t a n a e s th e s ia w ith n itr o u s o x id e -o x y g e n -d i-e th y l e th e r
when a pow erful u p p er abdom inal i3 s tim u la te d cannot o c c u r.
a n a e s th e s ia i s under d e f i n i t e c o n tr o l a t a l l tim e s.
The
The ad v an tag es o f
th e c lo se d c i r c u i t p r in c ip le a re economy o f u se o f a g e n ts , v e ry q u ie t
r e s p i r a t i o n w ith m inim al abdom inal movement, c o n se rv a tio n o f body h e a t and
m o is tu re , and p re v e n tio n of mucous s u rfa c e d e s s ic a ti o n .
I n p a tie n ts w ith
p e r f o r a tio n s which may r e q u ir e more th a n mere s u tu rin g t h i s method i s
extrem ely s a t i s f a c t o r y , omnopon-hyoscine h y p n o sis being s u b s titu te d
f o r a v e r t i n b a s a l n a r c o s is .
F o r bad r i s k s u b je c ts i n whom th e s h o r te s t p ro ced u res o n ly are
proposed - sim ple s u tu rin g o f a p e r f o r a tio n , ra p id g a stro -je ju n o sto m y in h a la tio n a n a e s th e s ia w ith cyclopropane-oxygen, c lo se d c i r c u i t , combined
w ith lo c a l a n a lg e s ia i s th e most v a lu a b le method.
I t g iv e s good s u r g ic a l
aceess and th u s e n a b le s th e surgeon to perform h is o p e ra tio n e f f i c i e n t l y
and e x p e d itio u s ly .
F ie ld block o f th e abdom inal w a ll by p ro v id in g a
lo c a l m uscular r e la x a ti o n a v o id s any need f o r "pushing" th e cyclopropane
a n a e sth e sia and so o b v ia te s t h e r i s k s o f r e s p i r a t o r y a r r e s t and to x ic e f f e c t s
on th e h e a r t m uscle.
In c re a s e d c a p i l l a r y o o zin g i s o f l i t t l e moment when
i t o ccu rs o n ly over a s h o r t p e rio d .
L ig h t p re m e d ica tio n w ith onmopon, o n e - th ir d o f a g r a in , and a tro p in e ,
one-hundredth o f a g r a in g iv e n hypoderm ically th r e e - q u a r te r s o f an hour
before o p e r a tio n , i s n e c e s s a ry .
The w e ll marked r e d u c tio n i n m o r ta lity from g a s tr i c o p e ra tio n s ,
revealed by a stu d y of th e s t a t i s t i c s f o r th e l a s t th re e y e a r s , i s
c o n siste n t w ith th e o p in io n form ed, from c l i n i c a l observation-, o f th e
value o f th e com binations of a n a e s th e tic s and a n a lg e s ic s d e sc rib e d .
A n a e s th e s ia and A n a lg e s ia f o r th e S u r g ic a l ComTaicationa
o f D ia b e te s M e ll ltm
A t S t . Jam es’ H o s p ita l, from November 1937 to F e b ru a ry 1939,
tw enty-one p a tie n ts s u f f e r in g from d ia b e te s m e ll itu s were o p e ra te d upon
f o r some c o m p lic a tio n o f th e d ia b e tic s t a t e .
The fo llo w in g i s a co nvenient c l a s s i f i c a t i o n o f th e c o m p lic atio n s
en co u n tered and th e o p e ra tio n s perform ed.
Number o f Cases
Gangrene o f le g
,.
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E x c is io n
5
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solution
of Howard Jo n es
4»
The Management o f th e D ia b e tic S u rg ic a l Cases -p resented.
Each p a tie n t was an in d iv id u a l problem .
A g e n e ra l o u tlin e o n ly , can
be g iv en o f th e p re lim in a ry p re p a ra tio n and p o s t-o p e ra tiv e tre a tm e n t a d o p ted .
I n th e c a se s o f gangrene and in f e c tio n s (c a rb u n cle and a b sc e ss) re c o rd e d ,
th e p a t i e n t s w ere known d ia b e t ic s whose d is e a s e had p re v io u s ly been
c o n tro lle d by d i e t and i n s u l i n .
The developm ent o f gangrene and th e
o ccu rren ce o f in f e c tio n d is tu rb e d th e balan ce - th e c l i n i c a l f e a tu r e s o f
t h i r s t and p o ly u ria and th e chem ical s ig n s o f hy p erg ly caem ia, g ly c o s u ria
and k e to n u ria shown by th e p a t i e n t s in d ic a te s c l e a r l y th a t th e d ia b e te s
was o u t o f c o n tr o l.
Time was a v a ila b le f o r th e p re -o p e ra tiv e
re -e s ta b lis h m e n t o f c o n tro l and f o r th e a d o p tio n o f a sim ple and e a s ily
a s s im ila b le d ie t o f ad eq u ate c a lo r ic v a lu e and w ith a c arb o h y d rate c o n ten t
of a t l e a s t 3D0 grammes.
I n s u l i n was g iv e n a t fre q u e n t i n t e r v a l s (ev ery
fo u r h o u rs) i n s u f f i c i e n t dosage to com pletely a b o lis h k e to n u ria and to
reduce hyperglycaem ia and g ly c o s u ria to a minimum.
As a p ro p h y la c tic
a g a in st o p e ra tio n and p o s t-o p e ra tiv e d e h y d ra tio n abundant f l u i d s were
a d m in iste re d .
A ll o p e ra tio n s were perform ed a t o r ab o u t midday.
in s u lin on th e morning o f o p e ra tio n were o m itte d .
B re a k fa s t and
G lucose, grammes 3) by
mouth, preceded by in s u l i n u n its 25 su b cu tan eo u sly g iv en tw enty m inutes
e a r l i e r , was a d m in iste re d th r e e hours b e fo re a n a e s th e s ia .
P o s t- o p e r a tiv e ly ,
during th e rem ainder o f th e day o f o p e ra tio n , th e p a ti e n ts were g iv en m ilk ,
6 ounces every two h o u rs - fo u r fe e d s .
Two drachms o f g lu co se were added
to th e second and f o u r th m ilk fe e d s , and i n s u li n was in je c te d tw en ty m inutes
before them .
The u r in e was te s t e d every two hours and, k e to n u ria being
ab sen t, th e dose o f in s u l i n preceding th e m ilk -g lu co se fe e d s determ ined
a s fo llo w s :
Red,______ Orange_______ Yellow______ Y ello w -g reen
20
15
ID
5
th e num erator r e p r e s e n tin g th e r e s u l t s o f th e B en e d ic t t e s t s and the
denom inator th e dosage o f i n s u l i n .
I t was p o s s ib le th e n ex t morning to r e tu r n to th e same d e t a i l s o f management
a s b e fo re o p e r a tio n .
Abatement o f th e need f o r i n s u l i n , synchronous w ith
re c o v e ry , was dem onstrated by re p e a te d chem ical exam inations o f th e blood
and u r i n e .
Recovery com plete, f i n a l ad ju stm en ts o f d ie t and in s u l i n were made, and
th e p a t i e n t s observed f o r seven days b e fo re d isc h a rg e to th e o utdoor
d ia b e tic c l i n i c .
I n th e d ia b e tic p a tie n ts undergoing c a ta r a c t e x tr a c ti o n s , perform ed
under l o c a l a n a lg e s ia , p re -o p e ra tio n s t a b i l i s a t i o n o f d i e t and i n s u li n was
u n d ertaken and an adequate f lu i d in ta k e a s s u re d .
Midday was th e tim e o f
o p e ra tio n in th e s e c a s e s , and on th e morning o f o p e ra tio n , b re a k fa s t being
w ith h e ld , th e u s u a l dose o f in s u l i n p lu s 10 u n its more was g iv e n succeeded i n
tw enty m in u tes by g lu c o s e , grammes 2 f o r each u n i t o f in ia u lin , p er o s , th re e
hours b e fo re a n a lg e s ia .
A f te r o p e ra tio n a l t e r n a t e m ilk and mi l k-g lu c o s e feed s
a t tw o -h o u rly i n t e r v a l s and in s u l i n , dosage ( in th e absence o f k e to n u ria )
according to th e c o lo u r scheme, b e fo re th e two m ilk -g lu co se fe e d s , were given
during th e r e s t o f th e day o f o p e ra tio n .
The p a t ie n t s were a b le to resume
th e ir p re - o p e r a tiv e ly s t a b i l i s e d d i e t and in s u l i n th e n ex t m orning.
Routine u r in e exam inations Rnd blood sugar e stim a tio n s were continued
throughout th e p e rio d o f in door tre a tm e n t and su p e rv isio n m ain tain ed a t
the outdoor c l i n i c f o r d ia b e te s .
The d ia b e t ic s whose d is e a s e was com p licated by g a l l sto n e s were prepared
fo r ch olecystectom y by th e p ro v is io n o f a generous d ie t i n s o f t and sim ple
form , adequate i n s u l i n and abundant f l u i d s .
The o p e ra tio n having been
• f ix e d ’ f o r noon on a p a r t i c u l a r day, g lu c o se by mouth grammes 53, preceded
by i n s u l i n su b cu tan eo u sly u n i t s 25, was a d m in iste re d a t 9 a.m . on th e day
o f o p e r a tio n , th e u s u a l b r e a k f a s t and in s u l i n being o m itte d .
W ith th e e x c e p tio n o f one case th e p o s t-o p e ra tiv e management was
a s fo llo w s :
D uring th e rem ainder o f th e day o f o p e ra tio n a l t e r n a t e m ilk
and m ilk -g lu c o s e fe e d s and i n s u l i n b e fo re th e m ilk -g lu c o se fe e d s in
accordance w ith th e r e s u l t s o f th e B en ed ict t e s t s were g iv e n .
Next
m orning th e d ie t which would be g iv en to s i m il a r n o n -d ia b e tie p a t ie n t s was
begun.
U n til su ch tim e a s th e p a tie n ts were a b le to ta k e t h e i r
p re -o p e ra tio n le v e l o f carb o h y d rate by mouth any d e fic ie n c y below t h i s
t o t a l amount was made good a s g lu c o se .
I n s u lin was p re s c rib e d in
s u f f i c i e n t dosage to allow of th e u t i l i s a t i o n o f th e p o s t-o p e ra tiv e d ie t
and ad ju v an t g lu c o s e .
T h e re a fte r a g ra d u a l resum ption o f th e p a t i e n t s ’
custom ary d i a b e t i c d i e t s was made and th e in s u l i n re q u irem en ts m od ified
a c c o rd in g ly .
C o n tro l and t r a n s i t i o n were e f f e c te d th ro u g h o u t by r e g u la r
exam inations o f th e u rin e and e stim a tio n s o f th e b lo o d -su g a r.
P o s t-o p e ra tiv e vom iting and k e to s i s were encountered i n one g a l l
b ladder c a s e .
The a d m in is tra tio n o f an abundance o f f l u i d and o f an
adequate su p p ly o f c arb o h y d rate was a ss u re d by r e c t a l g lu c o s e - s a lin e ,
93 grammes o f g lu c o se i n 1 l i t r e o f norm al s a l i n e , and 40 u n i t s o f in s u l in
were g iven s u b c u ta n e o u sly .
W ith th e u rin e k e to n e -fre e n ex t morning , c o n tro l
s im ila r to th a t a lre a d y d e sc rib e d f o r th e o th e r cholecystectom y cases was
p r a c tic a b le .
Comnentary on th e M ethods o f A n a e sth e sia and A n a lg e sia employed.
LOCAL ANALGESIA
C a ta ra c t e x tr a c tio n s were perform ed u n d er l o c a l a n a lg e s ia , a
com bination o f s u rfa c e w ith n e rv e -b lo c k a n a lg e s ia c a r r ie d o u t w ith a l l
th e p re c a u tio n s o f modern a s e p s is .
The p a tie n ts had had omnopon
h y p o d erm ically , l / 6 t h to l / 3 r d o f a g r a in , th r e e - q u a r te r s o f an hour
b efo re coming to th e o p e ra tin g t h e a t r e .
The i n s t i l l a t i o n o f a few
drops o f p e rc a in e 1 p e rc e n t s o lu tio n in to the c o n ju n c tiv a l sac was
follow ed by th e r e tr o b u lb a r i n j e c t i o n o f 1 c . c . o f 1:1000 p e rc ain e
s o lu tio n around th e c i l i a r y g a n g lio n .
The r i s k o f i n f e c tio n was n e g lig ib le i n th e absence o f s e p s is i n th e
neighbourhood.
P e rc a in e was chosen i n p re fe re n c e to co cain e f o r th e
s u rfa c e a n a lg e s ia because o f i t s more prolonged a c tio n and freedom from
any concom itant to x ic o r p sy c h o lo g ic a l e f f e c t s .
T h is sim ple te c h n iq u e y ie ld e d e x c e lle n t r e s u l t s - a q u ie sc e n t p a t ie n t,
adequate a n a lg e s ia and m inim al p o s t-o p e ra tiv e in te r f e r e n c e w ith
m etabolism .
SPINAL ANALGESIA
Subarachnoid s p in a l b lo c k was employed i n two o f th e c a se s of
am putation o f le g and i n th e th r e e c a se s o f ch o lecy stecto m y .
In a ll
fiv e , E th e rin g to n W ilso n ’ s m o d ific a tio n o f th e Howard Jo n es te c h n iq u e ,
using 1:1930 h y p o b aric p e rc a in e s o lu tio n , was ad o p ted .
T h re e -q u a rte rs o f an hour b e fo re o p e ra tio n th e p re lim in a ry s e d a tiv e s
were given and th e p a t i e n t s had t h e i r eyes l i g h t l y bandaged and t h e i r e a rs
Plugged w ith c o tto n w ool.
The volumes o f p e rc ain e s o lu tio n in j e c te d , th e
P o s t-in je c tio n ’ s i t t i n g u p ’ p e rio d s allow ed , and th e le v e ls o f a n a lg e s ia
a tta in e d were th e fo llo w in g :
Volume o f P e rc a in e
S o lu tio n
A m putation o f le g
C holecystectom y
S ittin g -u p
P e rio d
L ev el o f
S p in a l B lock
8 c .c .
30 seconds
Up to T .1 2
10 c . c ,
50 seconds
Up to T ,4
E phedrine g ra in s 1 a d m in is te re d in tra m u s c u la rly a t th e c o n c lu sio n o f
th e su b arachnoid i n j e c t i o n proved i t s v a lu e as a p ro p h y la c tic a g a in s t
c ir c u la to r y d e p re s s io n .
I n th e p a t i e n t s undergoing am putatio n o f le g a b o l i t i o n of
c o n sc io u sn ess, c o n sid ered d e s ir a b le , was o b ta in e d w ith in h a la tio n
n itr o u s oxide-oxygen, m inim al q u a n titie s o f d i- v i n y l e th e r b ein g added
to av o id any need f o r suboxygenation.
O f th o s e o p e ra te d upon f o r g a l l
sto n e s , th e f i r s t and second s l e p t th roug h o u t th e o p e ra tio n .
The t h i r d
p a tie n t even though d is tu rb e d by n a u se a , consequent upon v i s c e r a l t r a c t i o n
during a d i f f i c u l t o p e ra tio n , re fu s e d in h a la tio n a n a e s th e s ia .
S p in a l
analgeB ia, s e le c te d f o r i t s s l i g h t e f f e c t on m e ta b o lic p ro c e ss e s , gave a
very good r e s u l t i n th e am putation c a s e s .
I n th e cholecystectom y cases
high s p in a l b lo c k p rovided th e b e s t p o s s ib le o p e ra tin g c o n d itio n s fla c c id abdom inal w a ll, q u ie t b re a th in g and c o n tra c te d i n t e s t i n e s .
W ith
no a b so lu te c o n tr a - in d ic a tio n s to i t s u se i n th e s e p a t i e n t s , i t was th e
method o f c h o ic e .
I n h a la tio n a n a e s th e s ia w ith n itr o u s oxide-oxygen supplem ented w ith
minimal d i- v i n y l e th e r would have o b v ia te d th e " v a g o -tra c tio n -n a u se a "
re fle x and d o u b tle s s ly have avoided th e p o s t-o p e ra tiv e vom iting and
k e to sis met w ith i n th e t h i r d cholecystectom y c a se ,
inhalation anaesthesia
I n h a la tio n cyclopropane-oxygen a n a e s th e s ia , c lo sed c i r c u i t tech n iq u e
* ith t o t a l r e b re a th in g arid carbon d io x id e a b so rp tio n was used f o r
^ p u ta tio n o f le g on th r e e o c c a s io n s .
I n th e f i r s t o f th e s e p a t i e n t s th e u se o f s p in a l a n a lg e s ia
was p re c lu d ed by s e p s is i n th e re g io n o f th e proposed lumbar p u n c tu re .
I n h a la tio n a n a e s th e s ia was n e c e s s a ry ;
cyclopropane-oxygen was p r e f e r r e d .
O ccu rrin g ov er a s h o r t p e rio d th e in c re a s e d c a p il l a r y b le e d in g a s s o c ia te d
w ith cyclopropane a d m in is tra tio n gave no cause w hatever f o r co n cern .
The e x c e lle n t end r e s u l t o b ta in e d i n t h i s case was re p e a te d i n th e o th e r
two d ia b e t ic s r e q u ir in g am putation.
INTRAVENOUS ANAESTHESIA
F or th e e x c is io n o f c a rb u n c le s and th e in c is io n and d ra in a g e o f
a b sc e sses in tra v e n o u s a n a e s th e s ia w ith p e n to th a l sodium , 5 p e rc en t aqueous
s o lu tio n , preceded by omnopon and a tro p in e a d m in iste re d h y p o d erm ically ,
gave a smooth in d u c tio n , adequate a n a e s th e s ia and a ra p id re c o v e ry .
The absence o f p o s t- a n a e s th e tic nausea and vom iting was p a r t i c u l a r l y
advantageous.
The e f f e c t s on c arb o h y d rate m etabolism and on th e r e a c tio n o f the
blood were alm ost n e g lig ib le .
The s in g le -d o s e method was a l l th a t was
re q u ire d .
The a n a e s th e tic and a n a lg e s ic a g en ts employed in th e s e r ie s o f
s u rg ic a l d ia b e tic c a se s p re se n te d were th o se known to have th e minimum
e ffe c t on th e h y d ro g en -io n c o n c e n tra tio n o f t h e blood and on th e blood
sugar.
•xeluded.
The u se o f ch lo ro fo rm , condemned by tru s tw o rth y a u t h o r i t i e s , was
D i- e th y l e th e r was av o id ed .
F o c i o f I n f e c t io n
I n h i s s e a rc h f o r prim ary f o c i d u rin g th e tre a tm e n t o f d is e a s e s ,
such a s rheum atism i n i t s v a rio u s form s, p e p tic u l c e r and f o c a l n e p h r i t i s ,
in which n o n -s p e c if ic i n f e c tio n p la y s a p a r t , th e p h y s ic ia n can o f te n fin d
ample e v id en c e , naked e y e, b a c te r io l o g ic a l and r a d io lo g ic a l, to c o n v ic t
th e t o n s i l s and a d e n o id s, th e a cc e sso ry n a s a l s in u s e s and th e t e e t h .
He d i r e c t s t h a t th e s e so u rc es o f in f e c tio n be e r a d ic a te d .
The methods
o f a n a e s th e s ia and a n a lg e s ia used a t S t . Jam es’ H o s p ita l f o r th e s u r g ic a l
p ro ced u res in v o lv e d w i l l be d e s c rib e d .
A dequate p re p a ra tio n and the
a d m in is tra tio n o f any n e c e ssa ry o r d e s ir a b le p re lim in a ry m e d ic a tio n i s
p r a c t i c a l i n p a t i e n t s under tre a tm e n t i n th e m edical w ards.
TONSILEECTOMT and ADENOIDECTOMY
When perform ed, g u i l l o t i n e e n u c le a tio n o f t o n s i l s and c u r e tta g e o f
ad en o id s i n c h ild re n i s c a r r ie d out under th e s in g le -d o s e e th y l c h lo rid e
o r e th y l e h lo r id e - d ie th y l e th e r m ethods.
D is s e c tio n to n s ille c to m y demands
q u ie t a n a e s th e s ia w ith re la x e d m uscles f o r an i n d e f i n i t e p e rio d .
An
a c tiv e cough r e f l e x i s e s s e n t i a l a t th e c o n c lu sio n o f th e o p e r a tio n .
The
tech n iq u e adopted i s a s fo llo w s :
One hour b e fo re o p e ra tio n a hypodermic i n j e c t i o n o f a tr o p in e , dose
acco rd in g to age, i s g iv en to g e th e r w ith paraldehyde p e r rectu m , 1 drachm
per s to n e o f body w eight a s a 10 p e rc e n t s o lu tio n i n normal s a l i n e , in
nervous c h ild r e n .
P arald eh y d e, however, i s c o n tra -in d ic a te d i n c a se s o f
n e p h ritis .
A n a e sth e sia i s induced w ith th e e th y l c h lo r id e - d i- e th y l e th e r
sequence and w ith th e p a tie n t in th e " th y ro id p o s itio n " i s m a in ta in ed by
th e i n s u f f l a t i o n o f d i- e th y l e th e r vapour th ro u g h th e m e tal p ip e on th e
tongue d e p re ss o r o f th e B oyle-D avis gag.
w ith a n a d ju s ta b le 'j a c k ’ .
have been removed.
The gag i s h eld i n p o s itio n
The adenoids a re c u r e tte d a f t e r th e t o n s i l s
I n a l l a d u lts th e t o n s i l s a re en u cle a ted by d is s e c tio n .
L ocal a n a lg e s ia h as n o t found fa v o u r.
The in c re a s e d r i s k o f d eep c e r v ic a l
in f e c tio n a f t e r o p e ra tio n i s a s e rio u s o b je c tio n to i t s u s e .
E n d o trach eal
n itr o u s o x id e -o x y g e n -d i-e th y l e th e r in h a la tio n a n a e s th e s ia , tr a n s n a s a l
in tu b a tio n w ith a w id e-b o re M agi11 tr a c h e a l tube and a pharyngeal pack
of gauze i s p r e f e r r e d to th e endopharyngeal i n s u f f l a t i o n m ethod.
An
adequate dose o f omnopon and a tro p in e i s g iv en th r e e - q u a r te r s o f an hour
p re v io u s ly .
The tr a c h e a l tube i s ranoved when, alm ost im m ediately th e
o p e ra tio n i s o v e r, th e cough r e f le x h as re tu rn e d .
OPERATIONS on th e ACCESSORY NASAL SINUSES
I n tr a n a s a l d ra in a g e o f th e acc e sso ry s in u s e s i n a d u lts i s perform ed
u n d e r l o c a l a n a lg e s ia .
The fo llo w in g i s a b r i e f d e s c r ip tio n o f th e
te c h n iq u e u se d :
T h re e -q u a rte rs o f an hour b e fo re o p e ra tio n th e p a ti e n t i s g iv en an
adequate dose o f omnopon-hyoscine.
lo c a l a n a lg e s ia i s u n d e rta k e n ;
H a lf an h o u r b e fo re o p e ra tio n th e
th e whole procedure a com bination o f
s u rfa c e w ith n erve b lo ck a n a lg e s ia ta k e s about te n m in u te s.
The n o s t r i l s
a re f i r s t p u r if ie d w ith 2 p e rc e n t m ereurochrom e, and th e mucous s u rfa c e s
o f th e n a s a l fo s s a e a re th e n p a in te d over w ith p e rc a in e , 2 p e rc e n t s o lu tio n ,
w ith a d r e n a lin .
Care i s n e c e ssa iy to p re v e n t any o f th e s o lu tio n from
t r i c k l i n g down in to th e pharynx.
The ro o f o f th e nose i n th e re g io n o f
th e c r ib r if o r m p l a t e i s a v o id ed .
S lu d e r’s method o f n erv e b lo ck in g is
employed a t th e c o n clu sio n o f th e s u rfa c e a p p lic a tio n .
two s h o rt s i l v e r w ire probes a r e u s e d .
Two long and
They a re tip p e d w ith wool which
i s th e n soaked i n th e p e rc a in e -a d re n a lin s o lu tio n .
The two s h o r t ones
are passed up a s f a r forw ards and a s h ig h up a s p o s s ib le to l i e a t th e
ro o f o f th e nose n e a r th e p o in t of e n tra n c e of th e n a s a l n erv e and kept
in p o s itio n f o r two m in u te s.
The long ones a re s lip p e d backwards and
o b liq u e ly upwards u n t i l they a re f e l t to impinge on th e a n t e r i o r w a ll o f
the sphenoid s in u s ;
a n a lg e s ia from block o f th e s p h e n o -p a la tin e g an g lio n
and i t s b ranches r e s u l t s w ith in two m in u te s.
The p a tie n t i s ready f o r o p e ra tio n a f t e r a la p s e o f tw enty m in u te s,
■Providing c a re i s ta k e n to avoid traum a, th e r e i s no r i s k o f in tro d u c in g
In fe c tio n in to th e deeper t i s s u e s from th e s u rfa c e w ith t h i s te c h n iq u e .
I n a d u lts when g e n eral a n a e s th e s ia i s re q u e ste d and f o r a l l c h ild re n
en do tracheal in h a la tio n a n a e s th e s ia w ith n itr o u s o x id e -o x y g e n -d i-e th y l e th e r
i s used.
A M a g ill tu b e i s in tro d u c e d through th e mouth under d i r e c t
lary n g o sco p y .
The e n tra n c e o f blo o d i n t o th e la ry n x and tr a c h e a i s
p rev en ted d u rin g o p e ra tio n by packing th e pharynx w ith gauze soaked in
l i q u i d p a r a f f in and a f t e r o p e ra tio n by a b r is k cough r e f l e x .
By th e
p re lim in a ry a d m in is tra tio n o f a hypodermic in j e c t i o n o f p i t u i t r i n (which
drug h a s been shown to d e crea se th e c o a g u la tio n tim e o f th e b lo o d ), by th e
p re lim in a ry a p p lic a tio n by p a in tin g o r sp ra y in g o f p e rc a in e a d re n a lin
s o lu tio n to th e n a s a l mucosa and by th e a d o p tio n o f th e e n d o tra ch e a l
method which e n su re s a p e r f e c t ly f r e e airw ay th ro u g h o u t, e x c e s siv e
haem orrhage, th e form er bugbear o f in h a la tio n a n a e s th e s ia f o r i n t r a - t r a c h e a l
s u rg e ry , i s o b v ia te d .
E x te n siv e o p e ra tio n s on th e n a s a l s in u s e s a re c a r r ie d o u t u n d e r
in h a la tio n a n a e s th e s ia , e n d o tra c h e a l a d m in is tr a tio n .
DENTAL EXTRACTIONS
F o r c h ild r e n , in h a la tio n a n a e s th e s ia w ith d i - v i n y l e th e r i s th e
method o f choice*
U sing Goldman’s c lo se d in h a l e r , 3 c .c * "V inesthene"
(th e p r o p r ie ta r y p re p a ra tio n ) from an ampoule i s th e average amount f o r
a s in g le -d o s e te c h n iq u e .
e ig h t e x tr a c ti o n s .
T h is p ro v id e s ad eq u ate a n a e s th e s ia f o r s i x o r
The o u ts ta n d in g advan tag es o f t h i s method a re s a f e ty ,
r a p id it y o f in d u c tio n and re c o v e ry , absence o f nausea and vo m itin g and
of to x ic e f f e c t s on th e b o d ily organs and fu n c tio n s a f t e r a d m in is tr a tio n .
A d e n ta l prop o r a M ason's gag i s in s e r te d i n th e mouth b e fo re th e
in d u c tio n o f a n a e s th e s ia .
A gauze pack p la ce d behind th e tongue when
in d u c tio n i s com plete i s a w ise p re c a u tio n a g a in s t th e in h a la tio n o f
f o re ig n b o d ie s .
D en tal e x tr a c tio n s i n a d u lts a re perform ed under n a s a l n itr o u s
oxide-oxygen.
An i n t e r m i t t e n t flow a p p a ra tu s i s i d e a l .
a d m in is tra tio n a prop i s i n s e r t e d .
B efo re every
A fte r a n a e s th e s ia i s e s ta b lis h e d a p ro p e rly
designed and s u ita b ly p la ce d m outh-pack p re v e n ts th e a s p ir a ti o n o f d e b r is ,
the i n s p ir a tio n o f a i r and th e escape of 'g a s ’ .
A d u lts who d i s l i k e n itr o u s
oxide a re g iv en in tra v e n o u s a n a e s th e s ia w ith p e n to th a l sodium, 5 p ercen t
aqueous s o lu tio n .
Preceded by omnopon, l / 3 r d o f a g r a in , and a tr o p in e ,
1/lQOth o f a g r a in , doses up to ID c . c .
S ecure q u ie t a n a e s th e s ia w ith
muscular r e la x a ti o n f o r p e rio d s up to f i f t e e n m in u te s.
i s n o t m a te r ia lly in t e r f e r e d w ith .
The cough r e f le x
Recovery i s l e s s ra p id th a n a f t e r
n itro u s oxide-oxygen b u t t h i s i s no g r e a t d isad v an tag e in in d o o r p a t i e n t s .
The p re c a u tio n s n e c e ssa ry a r e a
recumbent p o s itio n o f th e p a t i e n t , th e
in s e r tio n o f a prop o r gag b e fo re th e in tra v e n o u s i n j e c t i o n and th e u se of
A mouth-pack d u rin g o p e r a tio n .
When prolonged a n a e s th e s ia i s a n tic ip a te d
ii
endotracheal n itr o u s o x id e -o x y g e n -d i-e th y l e th e r i s employed.
The M ag ill
tube i s in tro d u c e d th ro u g h th e n o se.
L o cal a n a lg e s ia i s in a d v is a b le i n c h ild r e n .
I n a d u lts f o r
m u ltip le e x tr a c tio n s th e o n ly sa fe method i n th e p re sen c e o f fra n k
s e p s is , n e rv e -b lo c k analg esia,d em an d s an e x a c t an ato m ical knowledge,
c o n sid e ra b le p r a c tic e and s u f f i c i e n t tim e f o r th e s u c c e s s fu l blo ck in g
o f th e re q u ire d n e rv e s i n th e v a rio u s fo s s a e and fo ram in a.
Tfts B rg fttiB P g t sft. -Q firtflJ-a Jy.P9/? p £
A d m in is tra tio n o f some o f th e Newer
Jar. -tfrs.
The a d m in is tr a tio n of a v e r t i n per re c tu m f o r th e c o n tr o l o f th e
r e f l e x spasms o f te ta n u s h a s been d e sc rib e d on s e v e r a l o c c a s io n s .
At S t , James* H o s p ita l, d u rin g th e p e rio d from Ja n u a ry 1 s t to December 3 1 s t,
1938, th r e e c a s e s o f te ta n u s i n c h ild re n were t r e a t e d w ith a n t i t o x i n and
a v e r ti n w ith s u c c e s s .
The dose o f a v e r t i n re q u ire d was th e f u l l b a s a l
n a r c o tic dose o f 0 ,1 gramne a v e r tin p e r kilogramme of bodyw eight;
dose was i n e f f i c i e n t ,
a s m a lle r
Thi3 was re p e a te d a s o f te n a s n e c e s s a ry , t h r i c e d u rin g
th e tw e n ty -fo u r h o u rs i f need b e , t o avoid re c u rre n c e o f th e spasm s.
There was l e s s tendency f o r a 3 p e rc e n t s o lu tio n i n d i s t i l l e d w a ter to be
re tu rn e d th a n th e 8^ p e rc e n t s o lu tio n u s u a lly recommended.
The f i r s t r e c t a l i n j e c t i o n was a d m in iste re d under ch lo ro fo rm a n a e s th e s ia
in a l l th r e e c a s e s .
A ll th e enemata were g iv en w ith th e p a tie n ts ly in g on
t h e i r l e f t s id e s to a id r e t e n t i o n .
com pletion o f th e i n j e c t i o n s .
T h is p o s itio n was m a in tain ed a f t e r
There was th e n l i t t l e r i s k o f r e s p i r a t o r y
o b s tr u c tio n from f a l l i n g back o f th e tongue a s th e n a rc o s is deepened and
th e jaw r e la x e d .
As an a d d itio n a l p re c a u tio n th e n u rsin g s t a f f was a p p rise d
of th is p o s s ib ility .
To th e s e c h ild r e n , g iv e n abundant f l u i d s and l i b e r a l s u p p lie s o f g lu c o se ,
a v e r tin appeared to have an ex trem ely low t o x i c i t y .
I n one g i r l tw e n ty -fiv e
co n secu tiv e a d m in is tra tio n s produced no obvious i l l - e f f e c t s .
R epeated
exam inations of th e u rin e f o r th e p resen ce o f albumen, su g ar and k eto n es
proved n e g a tiv e .
W ith f r e s h p ro p e rly p rep ared s o lu tio n s a d m in iste re d a t body tem p eratu re
no lo c a l i r r i t a n t e f f e c t s were o b serv ed .
AVERTIN DOSAGE
Case I
A»McG,
Pay o f D isease
from A dm ission
Female
No. o f
Doses
Aged 12 y e a rs
Grammes A v e rtin
p er dose
Weight 32 kilogram mes
T o ta l A v e rtin in
24 h r s . I n Grms.
P ercen tag e
S o lu tio n in
D i s t i l l e d W ater
2
3
1s t dose
2nd
"
3 rd
"
2 .6
2 ,6
3 .2
8 .4
3
3
1 s t dose
2nd
"
3rd
"
3 .2
2.1*
3 .2
8 .5
4
3
1s t dose
2nd
"
3rd
"
2 .1 *
3 ,2
3 .2
8 .5
5
3
1 s t dose
2nd
»
3 rd
"
3 .2
2 .1 *
2 .1 *
7 .4
$s
6
2
3 .2
6 .4
3
7
2
3 .2
6 .4
3
8
2
3 .2
6 .4
3
9
1
3 .2
3 .2
3
10
1
3 .2
3 .2
3
I a 9 d a y s:
D oses 2 0 .
A v e rtin 5 8 .4 grammes
’‘O n e -th ird o f t o t a l i n j e c t i o n r e tu r n e d .
CASE I I
M.W.
Female
Day o f D ise a se
from A dm ission
No. o f
Doses
Aged 13 y e a rs
Graemes A v e rtin
p e r dose
W ei^ it 38 kilogramm es
T o ta l A v e rtin in
24 h o u rs . I n Grins
P ercen tag e
S o lu tio n in
Distilled viator
3 .8
3 .8
3 .8
1 1 .4
3 .8
7.6
3 .8
7 .6
3 .8
7.6
1 s t Dose 2*5
2 nd
3 .8
3rd
" 3 .8
3 .8
7.6
1 1 .4
3 .8
7 .6
3 .8
3 .8
12
In 1 2 d a y s:
^
Doses 25
A v e rtin 9 3 .7 grammes
p ero en t s o lu tio n o f a v e r tin d isp en sed i n m istak e f o r 3 p e rc en t s o lu tio n .
O n e -th ird o f t o t a l i n j e c t i o n re tu rn e d *
CASE I I I
J .C .
Day o f D isease
from A dm ission
H ale
Agea 10 y e a rs
No, o f
Doses
Grammea A v e rtin
per dose
W eight
29 kilogram aea
T o ta l A v e rtin i n
24 h o u rs . I n Grms.
P ercen tag e
S o lu tio n i n
D i s t i l l e d W ater
2
2
2 .9
5 .8
3
3
2
2 .9
5 .8
3
4
3
2 .9
8 .7
3
5
2
2 .9
5 .8
3
6
3
2 .9
8 .7
3
7
2
2 .9
5 .8
3
8
2
2 .9
5 .8
3
9
2
2.9
5 .8
3
10
2
2 .9
5 .8
3
11
1
2 .9
2 .9
3
I n 10 d a y s:
D oses 2 1 .
A v e rtln 60,9 grammes
A v e rtin n a rc o s is undoubtedly c o n trib u te d i n no smal l m easure to
th e s u c c e s s fu l tre a tm e n t o f th e s e sev e re c a se s o f te ta n u s .
I t enabled
a n tit o x in a d m in is tr a tio n , d re s s in g o f wounds, n a s a l fe e d in g and g e n e ra l
n u rs in g to be c a r r ie d out w ith o u t th e p r e c i p i t a t i o n o f r e f l e x spasm s.
H ere a re re c o rd e d two c a s e s o f co n v u lsio n s under in h a la tio n
a n a e s th e s ia w ith n itr o u s oxide - oxygen - d i - e th y l e th e r c o n tro lle d
by th e in tra v e n o u s i n j e c t i o n o f e v ip an sodium i n 10 p e rc e n t aqueous
s o lu tio n .
The co n v u lsio n s were n o t th e anoxaanic spasms o f g as a n a e s th e s ia
b u t th e e p ile p tif o r m s e iz u r e s which have been d e sc rib e d many tim e s tinder
th e misnomer o f " e th e r c o n v u lsio n s" .
They o c c u rre d i n p a t i e n t s w ith no h i s t o r y , fa m ily o r p e rs o n a l, o f
c o n v u lsio n s.
CASE I
J .N ,
M ale,
Aged 19 y e a r s .
A dm itted:
6 ,1 0 ,3 8 ,
C om plaint:
Abdominal p a in , nausea
E le c tric ia n ,
and v o m itin g .
Yomited tw ice
b e fo re a d m issio n .
D u ra tio n :
24 h o u rs .
H is to ry :
No fa m ily h i s t o i y
of e p ile p s y .
No p e rso n a l h is to r y o f c o n v u lsio n s.
No p re v io u s a n a e s th e s ia .
P h y s ic a l E xam ination:
On ad m issio n G eneral c o n d itio n :
W ell n o u rish e d , w e ll developed, i n t e l l i g e n t
young man.
T em perature 1 0 1 ,4 °F ,
P u lse r a t e - 112 p e r m in u te .
R e s p ira to ry r a t e - 24 p e r m in u te .
A lim en tary system :
Tongue f u r r e d .
Blood p re s s u re 118/TO.
R ig id ity and te n d e rn e s s on
p re s s u re i n r i g h t i l i a c f o s s a .
U rin a ry system :
U rin e :
S p e c ific g r a v ity ID2 2 .
S li g h t a lb u m in u ria .
No su g ar o r k e to n es p r e s e n t.
C irc u la to ry system :
H e a rt
R e s p ir a to r y system :
No ap p aren t d is e a s e .
Nervous and locom otory system s:
D iagnosis:
A cid r e a c tio n .
H e a rt sounds n o rm al.
No murmurs.
No ap p aren t d is e a s e .
A cute a p p e n d ic itis .
A n aesth etic r i s k :
"B ",
O peration:
6 ,1 0 .3 8 .
Appendicectom y.
R e tro c o lic gangrenous appendix.
A n aesth esia:
P rem e d ic atio n - hypodermic i n j e c t i o n , morphine g r , l / 6 t h and
a tro p in e g r . 1/lD O th, g iv en ■£ hour b e fo re o p e ra tio n .
A gent and te c h n iq u e - in h a la tio n n itr o u s o x id e - oxygen d i-e th y l e th e r.
A d m in is tra tio n by means o f fa c e -p ie c e and r e t e n t i o n h a rn e s s .
Hot w a ter ja c k e t round th e e th e r b o t t l e of
th e n itr o u s oxide-oxygen a p p a r a tu s .
H irsc h a irw a y .
Sm all q u a n tity o f carb o n d io x id e added
to a n a e s th e tic m ix tu re d u rin g in d u c tio n .
Convulsions:
O n se t:
Time:
30 m inutes a f t e r commencement o f a n a e s th e s ia ,
d u rin g d e liv e ry of ap p en d ix .
Mode:
M uscular tw itc h in g ab o u t th e f a c e .
P ro g re s s :
R apid sp read o f spasms to o th e r m usoles u n t i l
whole body in v o lv e d i n pow erful spasmodic movements.
Je rk y r e s p i r a t i o n w ith la x y n g e a l s t r i d o r and in c re a s in g
c y a n o s is .
A d d itio n a l o b s e r v a tio n s :
P u p ils and eye r e f le x e s th o s e o f 1 s t p la n e ,
3 rd s ta g e ( s u r g ic a l) a n a e s th e s ia .
S k in d ry and h o t .
T h e a tre te m p e ra tu re 79°P .
H um idity re a d in g , " h i^ x " .
CASE n
A .B.
M ale.
Aged 5 y e a r s .
Schoolboy.
Admi t t e d :
2 3 .1 1 .3 8 .
C om plaint:
Abdominal p a in , nausea end v o m itin g .
D u ra tio n :
60 h o u rs .
H is to iy :
No fa m ily h is to r y o f e p ile p s y .
C hild h as n ev er s u ffe re d from c o n v u lsio n s.
No p re v io u s a n a e s th e s ia .
P h y s ic a l E xam ination:
On ad m issio n :
G en eral c o n d itio n :
W ell n o u rish e d bo y .
Tem perature 1D 2.3°F,
111 and to x ic - lo o k in g .
P u lse r a t e - 126 p e r m in u te .
R e s p ira to ry r a t e - 30 p e r m in u te .
A lim en tary system :
G e n e ra lis e d abdom inal r i g i d i t y and te n d e rn e s s
on p r e s s u r e .
U rin a ry system :
U rin e :
s p e c if ic g r a v ity 3D18,
T raee o f album en.
No su g ar o r k e to n es p r e s e n t.
H eart sounds norm al.
C irc u la to ry
R e s p ira to ry system :
"C ",
2 3 .1 1 .3 8 ,
Append!cectomy w ith d ra in a g e .
and p e r f o r a te d .
A n aesth esia:
No a p p a re n t d is e a s e .
A cute a p p e n d ic itis w ith g e n e ra l p e r i t o n i t i s .
A n aesth etic r i s k :
O peration:
No murmurs.
Poor a i r e n try - b o th b a se s .
Nervous and locom otory system s:
D iag n o sis:
A cid re a c tio n *
P rem e d ic atio n :
Appendix gangrenous
G e n era l p e r i t o n i t i s .
Hypodermic i n j e c t i o n , a tro p in e g r . l / l 5 0 t h ,
g iv e n - f hour b e fo re o p e ra tio n .
Agent and te c h n iq u e :
d i-e th y l e th e r.
I n h a la tio n n itr o u s oxide-oxygen-
A d m in is tra tio n by means o f f a c e - p ie c e and r e t e n t i o n h a rn e ss.
H irs e h a irw ay .
H ot w a te r ja c k e t round e tb e r b o t t l e o f n itr o u s oxide-oxygen
a p p a ra tu s ,
No carbon d io x id e used p r i o r to th e o n s e t o f c o n v u lsio n s.
C o n v u lsio n s:
O n se t:
Tima:
25 m inutes a f t e r conmencement o f a n a e s th e s ia .
D uring d e liv e r y o f appendix.
Mode:
T w itching o f f a c i a l m u scles.
P ro g re s s :
Whole body soon in v o lv e d i n rhythm ic spasm s.
J e rk y in e f f e c t u a l b re a th in g w ith r a p id ly in c re a s in g
c y a n o s is .
A d d itio n a l O b se rv a tio n s:
S ig n s o f a n a e s th e s ia a t o n s e t o f co n v u lsio n s th o se o f
1 s t p lan e s u r g ic a l a n a e s th e s ia .
S k in d ry and b u rn in g .
No p e r s p ir a tio n whatever*
T h e a tre te m p e ra tu re 80°F ,
H um idity re a d in g - " h ig h ” .
TREATMENT
I n b o th c a se s tr e a tm e n t, i n th e f i r s t in s ta n c e , was u n d ertak en
by th e House P h y s ic ia n a d m in is te rin g th e a n a e s th e tic .
E th e r a d m in is tra tio n
had been d is c o n tin u e d , th e fa c e -p ie c e removed, th e p aten cy o f t h e airw ays
v e r i f i e d and th e p a t i e n t ’s head r a is e d h ig h b e fo re my a r r i v a l i n th e
o p e ra tin g t h e a t r e .
A 10 p e rc e n t carbon d io x id e 90 p e rc e n t oxygen m ix tu re
was bein g i n s u f f l a t e d endopharyngeally th ro u g h th e m e tal pipe o f th e
H irs c h a r t i f i c i a l airw ay i n an a tte m p t to combat th e cy an o sis which had
developed w ith th e o n se t o f th e g e n e r a lis e d e p ile p tifo rm movements.
The
suTgeon was a tte m p tin g to com plete th e o p e ra tio n , w ith a l l p o s s ib le speed,
i n a co n vulsing p a t i e n t .
The f u r t h e r tre a tm e n t was a s fo llo w s
Case I
A t my re q u e s t th e s u r g ic a l m a n ip u la tio n s were te m p o ra rily suspended.
Calcium "Sandoz", 10 c . c . , 10 p e rc e n t was
arm w ith o u t improvement,
s o lu tio n was
g iv en in to a v e in in th e l e f t
E vipan sodium , 3 , 5 c . c , , i n 3D p e rc e n t aqueous
th e n a d m in iste re d in tra v e n o u s ly a t t h e r a t e o f 1 c . c . in
f i f t e e n seco n d s.
The co n v u lsio n s prom ptly c e a se d .
The p a tie n t was now
i n th e profound 3 rd p lan e o f 3 rd s ta g e ( s u r g ic a l) a n a e s th e s ia .
H is head
was low ered, th e carbon dioxide-oxygen i n s u f f l a t i o n sto p p ed , th e pharyngeal
airw ay removed, a w ide-bore M ag ill e n d o tra c h e a l tube passed th ro u g h th e
mouth under d i r e c t v i s i o n and in h a la tio n n itr o u s oxide-oxygen ( I S p e rc en t
oxygen) s t a r t e d .
The o p e ra tio n was resumed and f in i s h e d , ch lo ro fo rm
being added to th e n itr o u s oxide-oxygen i n q u a n t i t i e s s u f f i c i e n t to
m a in ta in a n a e s th e s ia i n th e normal 2nd p la n e .
The co n v u lsio n s d id n o t r e c u r .
The s e iz u re s c o n tr o lle d , th e p a t i e n t ’s te m p e ratu re was ta k e n p e r rectum
and h i s p u lse r a t e co u n ted .
The re a d in g s w ere:
105°F. and 142 p e r m in u te .
The th e a t r e fa n was s t a r t e d and k ep t go in g th ro u g h o u t th e rem ain d er o f th e
o p e r a tio n .
He was re tu rn e d to th e ward w ith a r e c t a l te m p e ra tu re o f
3D 2.4°F. and a p u lse r a t e o f 130 p e r m in u te , s p e c if ic in s tr u c ti o n s having
been g iv en to th e n u rs in g s t a f f to keep him c o o l.
te m p e ra tu re was 3D1.6°F, and h is p u ls e r a t e 1 24.
An hour l a t e r h is
W iihin a n o th e r hour h i s
te m p e ra tu re had f a l l e n to 1 0 1 °F ., and h is p u lse r a t e to 116.
N ext m orning, w ith a te m p e ra tu re o f 1 0 0 .2 °F . and a p u ls e r a te o f 130,
he looked a s w e ll a s any p a tie n t m ight a f t e r th e rem oval o f a gangrenous
appendix th e n ig h t b e fo re .
Case I I
The o p e ra tio n was abandoned f o r a s h o rt tim e .
An in tra v e n o u s i n j e c t i o n
o f 5 c . c . calciu m "Sandoz" was g iv e n w ith no e f f e c t w h atev er.
Evipan
sodium s o lu tio n , 1 .5 c . c . , o f 10 p e rc e n t, was g iv e n in tra v e n o u s ly and
im m ediately a r r e s t e d th e c o n v u lsio n s.
The s ig n s o f a n a e s th e s ia a t th e c o n clu sio n
o f th e ev ip an a d m in is tr a tio n were th o se o f th e deep 3 rd p la n e w ith th e
neuro-m uscular mechanism m arkedly d e p re sse d .
I n h a la tio n n itr o u s oxide
oxygen (18 p e rc e n t oxygen) through an e n d o tra c h e a l tu b e , in tro d u ce d
t r a n s o r a lly u n d er d i r e c t la ry n g o sco p y , w ith th e a d d itio n o f m inim al q u a n titie s
o f ch lo ro fo rm , m a in ta in ed a n a e s th e s ia i n th e d e s ir e d 2nd p la n e .
W ith th e
e x c e lle n t o p e ra tin g c o n d itio n s th u s p rovid ed i t was p o s s ib le to com plete
th e appendicectom y i n th e s h o r te s t p o s s ib le tim e .
There was no re c u rre n c e
o f th e c o n v u lsio n s,
R eadings o f th e r e c t a l te m p e ra tu re and o f th e p u ls e r a t e can be
c o n v en ie n tly summarised thus
R e c ta l Tem perature
D egrees F a h re n h e it
Convulsions c o n tr o lle d .
B efore le a v in g t h e a t r e .
1 hour a f t e r r e t u r n to w ard.
2 ho u rs a f t e r
"
"
12 h o u rs a f t e r "
”
106
103
102.3
101.7
101
P u lse R ate
B eats p e r M inute
150
140
136
125
120
The t h e a t r e fa n had been s e t going a s soon a s th e co n v u lsio n s had been
c o n tr o lle d and th e p a tie n t k ep t c o o l on h i s r e t u r n to th e w ard.
Both p a t i e n t s w ere u ltim a te ly d is c h a rg e d from h o s p i t a l w ith t h e i r
wounds 'h e a le d and s o u n d '.
A f te r a s u ita b le s ta y i n a co n v ale sce n t
home, th e young a d u lt was a b le to resume h i s work, th e schoolboy to go
back to sc h o o l.
Two f u r t h e r o b s e rv a tio n s a re w orthy o f n o te :
The f i r s t and second u r in e passed a f t e r o p e ra tio n was a c id in
r e a c tio n i n b o th in s ta n c e s .
The e th e r rem ain in g i n th e b o t t l e o f th e n itr o u s oxide-oxygen a p p a ra tu s
a f t e r th e a n a e s th e s ia e com p licated by co n v u lsio n s was d e lib e r a t e l y used
th e n e x t day f o r appendiceetom y i n n o n -p y re x ia l a d u lts to whom a tr o p in e ,
1/1QQth o f a g r a in by hypodermic i n j e c t i o n , had been g iv en p r e - o p e r a tiv e ly .
W ith almos t i d e n t i c a l atm ospheric c o n d itio n s i n th e o p e ra tin g t h e a t r e ,
w ith th e w ater ja c k e t o f th e e th e r b o t t l e f i l l e d w ith ho t w a te r, w ith a
l i t t l e carbon d io x id e added to th e a n a e s th e tic m ix tu re d u rin g in d u c tio n ,
and w ith b r i e f p e rio d s o f cy an o sis p e rm itte d d u rin g a d m in is tr a tio n , th e se
o p e ra tio n s were c a r r ie d o u t under 2nd p lan e s u r g ic a l a n a e s th e s ia w ith no
o ccu rrence o f tw itc h in g .
The enigma o f " E th e r C onvulsions" rem ains u n so lv e d .
The v a rio u s
c o n f lic tin g h y p o th eses - id io s y n c ra s y , c o n v u lsan t f a c t o r i n d i - e th y l e th e r ,
a tro p in e p o iso n in g , e x c e s s iv e ly deep o r p ro longed a n a e s th e s ia , in com plete
a n a e s th e s ia , a n o x ia , h y p ero x y g en atio n , r a p id in c re a s e i n blood carbon
d io x id e , a c a p n ia , c o n g e stio n o f th e R o lan d ic a re a o f th e c e r e b r a l c o rte x ,
d im in u tio n i n th e p h y s io lo g ic a lly a c tiv e f r a c t i o n o f th e serum -calcium ,
s e p ti c toxaem ia, h y p erth erm ia - are w e ll known.
The abundant l i t e r a t u r e
needs no f u r t h e r review o r a n a ly s is .
I n th e c a se s I have d e s c rib e d , e p ile p tif o r m s e iz u r e s began i n 1 s t p la n e ,
3 rd s ta g e a n a e s th e s ia w ith in h a la tio n n itr o u s o x id e - oxygen - d i - e t h y l e th e r
and w ere a b o lis h e d by im m ediately deepening th e a n a e s th e s ia w ith the
a d m in is tr a tio n , in tr a v e n o u s ly , o f ev ip an sodium .
p y re x ia l and toxaem ic.
B oth p a ti e n ts were
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