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THE CHOICE OF AN ANESTHETIC.*
BY ALBERT I. BOUFFLEUR, M. D. Professor of Anatomy Northwestern University Woman's Medical School; Demonstrator of Operative Surgery Rush Medical College; Attending Surgeon Cook County Hospital, etc., Chicago.
The subject upon which I have been requested to prepare a paper is such a large one, if it be thoroughly considered, that it is quite impossible for me to properly present it in the few minutes which have been assigned to me. There has been a vast amount of experimentation and observation in the effort to solve this question, and the many contributions to the literature of the subject contain much valuable material which is deserving of more free quotation and individual reference than my time will permit of.
The general subject of anesthesia and anæsthetics is indeed a broad one, and the more one studies it the more he is impresesd with the great variance of opinion, not alone as to the choice and mode of administration, but as to practically every minute phase of their physiological effect and therapeutic action.
Whether we shall use a local or a general anæsthetic is a question which receives considerable attention, but deserves a great deal more than is given to it. The introduction of the use of cocaine was a great boon to the cause of local anesthesia, and notwithstanding the fact that a great variety of minor and major operations have been performed under its wonderful benumbing effect, its use, which promised to become so universal, was soon checked and has since been limited by the frequent occurrence of alarming symptoms and even death. The impetus given to the subject has, however, not been lost, for we find it still used extensively but more care* Read at a meeting of the Chicago Medical Society, April, 1897.
fully, and whatever favor cocaine has lost bids fair to be recouped by the Schleich method, which is a happy combination of the mechanical and therapeutic means of producing local anesthesia. As another essayist will present this subject in extenso, I will leave it with the statement that there is unquestionably a large and growing class of cases in which modern methods of producing local anesthesia are positively indicated in preference to our present methods of producing general anæsthesia.
The choice of an anesthetic for the production of general anesthesia is one of the most serious obligations of the surgeon, but, strange to say, it is perhaps given the least consideration of any part of the surgical procedure. In the majority of operations the entire danger is that from the anesthetic, and yet as students but few of us received any little thepractical, and, in fact, very oretical instruction in the choice of anææsthetics, their proper administration, etc. being the case, I hardly think it to be wondered at that many practitioners are undecided as to the choice of an anæsthetic in a
given case, and naturally drift into the routine of using the same anæsthetic in every case or of employing the one which happens. to be at hand. It is needless to say that such a practice is both unscientific and dangerous, and in my opinion it is one of the prime factors in producing the great mortality rate of anæsthesia.
The choice of an anæsthetic should depend upon the safety of the agent, the condition of the patient, the necessities of the operation and the attending circumstances. The first is in reality the prime factor, while the others are secondary, and in a measure are included under the first heading.
The war of opinions between the advocates of the various anesthetic substances has not
statement they should be given some credence.
been allowed to abate by the death of the former leaders, but instead of the few, there are now many who take positive positions for or against the various substances, and especially as to chloroform and ether, which are the only substances admitting of general
Statistically there can be no question but that, as ordinarily administered, ether is by far the safer anæsthetic, and yet there are some extensive and well authenticated reports which demonstrate beyond the possibility of a doubt that in properly selected cases and when properly administered chloroform is quite as safe as ether. The following ratios are those given by men who have given the subject of anæsthetic statistics some special study, and it will be readily appreciated that there is great variance in the conclusions reached. There is no attempt at completeness, but merely to present a general list which includes the conclusions of practically all the principal tabulators.
The compilations from which the above ratios have been abstracted comprise over 1,000,000 chloroformizations and over 500,000 etherizations, with an average mortality rate. of 1 to 3.355 for chloroform and 1 to 16,768 for ether. The figures of Baudens, McGuire and Lawrie are not trustworthy for general deductions, since the first two were administered in military practice under circumstances where accurate records could not be kept, while in the last instance they were made in a hot and dry climate; conditions most propitious for the safe administration of chloroform. Statistics compiled as has been the custom from all sources are very unreliable, since but a comparatively small proportion of the fatal cases and even a smaller proportion of the administrations are ever recorded, and added to these we have the effect of duplications, which is readily noted in the above figures.
But notwithstanding their unreliability, when they in general verify a fact or
Scotch and German statistics are the most reliable, and even these differ widely in their ratios; a difference which can be accounted for by the methods of administration. The Germans are given to pushing chloroform narcosis, which may account for their high mortality rate, while the Scotch are credited with giving chloroform very carefully and to selected cases only. The fact that three prominent Scotch surgeons have observed the administration of chloroform over 34,000 times with only three deaths would certainly seem to establish the fact that when properly administered in selected cases it is a safe anæsthetic. On the other hand, general statistics compiled from various sources show the decided superiority of ether. Does this not indicate that generally too little care is manifested in selecting the case, or in administering the drug, more than that the danger of the substances are relatively so different? An occasional death from chloroform can readily be accounted for by an idiosyncrasy on the part of the patient, just as well as with the use of ether. We find patients who are especially susceptible to the effects of morphine, cocaine, alcohol, and even quinine, and why should we not find some with an idiosyncrasy to chloroform or ether? The element of idiosyncrasy is an undeterminable one, and, therefore, the administration of any anæsthetic is always attended by some degree of danger. I do not wish to be understood as an advocate of the indiscriminate use of chloroform, because I am fully convinced that, as ordinarily administered, chloroform is several times more dangerous than ether. The annoying and even serious symptoms which sometimes develop during etherization cannot be compared to that awful condition of sudden primary syncope which stops our patient's heart in a single moment without any warning, and in the treatment of which our efforts are so commonly futile. One experience of this character has imbued me with the desire to impress upon every young physician, especially, as forcibly as words can, the gravity of his responsibility in using an anæsthetic. Fortunately the post-mortem in my Own case demonstrated that there was no pathological condition which might have been
recognized before deciding upon the agent to be used, and, therefore, as the anesthetic was being properly given by a skilled anesthetizer, we must conclude that it was a case of primary syncope due to an idiosyncrasy of the patient to the effects of chloroform.
While the consensus of opinion in America favors ether as the safer anæsthetic, there are a great many surgeons who maintain that in properly selected cases, and in the hands of a skilled anæsthetist, chloroform is as safe as ether, and as it is quite universally admitted that its administration is easier and its after effects less serious than those of ether, they have good reasons for its general employment. The condition of the patient should receive careful attention, since it is an important element in determining the relative safety of the various anæsthetics. Ether acts as a stimulant to the vascular system and as a positive irritant to the respiratory and renal mucous membranes. It should, therefore, be avoided in patients afflicted with marked degeneration of the blood vessels and in those suffering with pulmonary or renal disease, etc.
Under the head of attendant circumstances I desire to especially mention the presence of a competent anæsthetizer. I believe there is as much propriety and demand for a specialist in this line as in any other department of medicine or surgery. The surgeons of Great Britain alone seem to have fully grasped this phase of the subject. The mortality tables of any operation show that in the hands of some operators, experts, if you please, the rate may have been most satsfactory, while with others who chanced to be less skillful, or from unavoidable reasons, it was very bad. Because the results were unfavorable in the hands of one, is no reason why all should condemn any procedure. As an illustration: Because some of us may not possess the skill to successfully catheterize the ureters is no argument whatever that the operation of nephrotomy should invariably be performed to the exclusion of ureteral catheterism in determining the source of a pyuria. The professional anææsthetist should be encouraged in his specialty, and when we have the aid of his skilled services our mortality rates will improve.
When a large number of patients are to be anæsthetized, and especialy when we are un
able to make careful examination of the urine (e. g., when many people are injured and require immediate attention as the result of a railway wreck, riots or war at some remote point), chloroform is unquestionably the safer anææsthetic. The quickness of securing anæsthesia, the absence of the need of a cone, etc., and the rapidity of the recovery from its effects, and the rarity of annoying after-effects, are elements of undoubted superiority under such circumstances.
As no convincing arguments have been presented to successfully change the relative safety of ether and chloroform, we must conclude that ether is generally the safer anæsthetic, and especially so far as the immediate effects are concerned.
In collapse or extreme prostration, as cases of prolonged suppuration with hectic or anæmic states, collapse following hemorrhage, etc., as it stimulates the heart, and but little anæsthetic is required. (2-9.)
3. In heart disease the dangers of any anæsthetic are increased, but ether is to be preferred to chloroform. In uncomplicated mitral regurgitation some claim that ether can be given as in any ordinary case. (10.)
4. In persons who are free from pronounced pulmonary and renal disease.
5. In persons who have recently been chloroformized, as repeated or prolonged chloroformizations cause changes in the myocardium and thereby greatly increase the danger of its readministration. (11.)
6. In rectal surgery it is generally preferred, as the degree of narcosis must be very profound; but chloroform is preferred by some operators as it does not cause so much local venous engorgement and is considered equally safe.
While chloroform is ordinarily more dangerous than ether, it is comparatively safe when skillfully administered to persons not afflicted with organic or functional cardiac incompetency, or who have recently been chlo
roformized. It should be preferred in the following conditions:
1. In hot climates where ether is usually inapplicable and where the free circulation of dry and warm air increases the safety of chloroform.
2. Whenever a large number of persons are to be anææsthetized, and especially if we are unable to determine the condition of the kidneys.
3. In cases of nephritis.
4. In cases of aneurism and marked atheroma of blood vessels, where the struggling and vascular stimulation of ether might cause rupture, excepting when the circulation is disturbed by fatty degeneration or valvular disease of the heart. Senger reports a case of apoplexy occurring during ether anæsthesia. (17.)
5. In cases of obstruction in the respiratory tract or of acute or pronounced pulmonary disease, as bronchitis, pneumonia, phthisis or any condition productive of dyspnoea.
6. In cases requiring the use of the thermocautery about the head, or in operating near an open fire.
7. In children generally.
8. In weak and sickly persons who, as a rule, take chloroform with less danger than the strong and robust, because they struggle less and thus the strain on the heart is less. 9. In persons who have taken food within four hours.
IO. In obstetrics, but not for post-partum operations. (1.)
II. In brain surgery, with morphine. Ether causes too much vascular excitement in the brain. The morphine prolongs the anæsthesia with but little chloroform. (2.)
Mr. Dean, members of the faculty and gentlemen of the graduating class:-To me this occasion bears much which is the essenced sacredness of duty. During the years we have been together our relation has been that of teacher and pupil. You, gentlemen of the class, are now about to go upon the active stage of life and become a part of historied present and future. The importance of the role you assume must abide in you alone; the proper interpretation of your own character by your
*Delivered to the graduating class of the Beaumont Hospital Medical College, April 15, 1897.
selves will and must form any and ali success you may achieve.
The saddest of all things in life to me is the fact that there are but few men who know themselves; nay, thou needst not go to the Antipodes, nor search unknown realms to demonstrate this doleful truth, but everywhere, all around, you will find that such is the fact. Aye, still more must I say, that the portentious enigma of this life looms into veritythat men, yea, worthy men, have lived a life utterly ignorant of their own inherent worth and capacity. They have studied the iilimitable, the starry maze of the skies, the play of atoms, the ponderous domes of materiality, the vibrant cilia of the microbe, the imponderable forces of nature-but not that which to them is greater than all of these, the real virtue, worth and acting power of their own souls. True, indeed, with the freedom of man's mind. and will comes the fateful freedom of mistake; hence I say to you-study thyselves more than all else in the world and with the perfection of interpretation must your success and happiness come. Aye, 'tis true as existence-as you know and appreciate yourselves, so will the world appreciate you; for amidst the winding corridors, the barred portals and the babbling buzz of an asylum will you oft find the man who studied a very world, but not his ownself.
The virtue of your existence must depend upon your usefulness to yourselves and the world around you. Your usefulness depends upon your industry-to halt and ignore labor is but to lapse into a living death, yea, the mummification of worthy function. Permit me to quote from Addison a strong and classical warning. He says: "In the school of Pythagoras it was a point of discipline, that if among the akoustikoi or probationers there were any who grew weary of studying to be useful and returned to an idle life, they were to regard them as dead; and, upon their departing to perform their obsequies, and raise them tombs with inscriptions, to warn others of the like mortality, and quicken them to refine their souls above that wretched state."
Not to labor is but to defy God and nature. Adapt yourself and your occupation to the kindly trend of nature, and she becomes an angel of help. She hath the sweetened charity and the benevolent function of a saint. Love
her and aid her whenever you can, as in her help comes the consummation of purpose, Oppose her and she will cast you aside as the wind does the dried leaf in the autumn wood.
Now, then, gentlemen, in these parting hours let us hold communion in the broader, and, we will hope, in most virtued thought. To me it hath ever seemed that the greatest of all great studies in this world, as it always has been and must always be, is the study of the mind. And, yet, forsooth, I have often thought that mind has been more idly studied and less understood than anything else in this world. Intellect in man is that mental faculty which remembers, reasons and wills, through this intellect comes man's capacity to know. It is the brain which begets this intellect, which thus enables us to know. I am also sure that it is the brain which makes us know, feel and will, and we know that man, brain and blood are the necessary factors which create and make mind or soul. I also believe that the germ cell of not only man, but of all life, is immortal; for we would find, could we but trace it, that the first germ cell which was brought to earth contained within it the formative and perpetuating energy which has made this world thrive in the marvelous growth of life, that this germ cell received not its perpetuating power and formative energy from this world, but that in its birth it was derived from within its very self; that to this very day it inheres within as it did from the very instant of its birth. Yea, with reverence, with thankfulness, with full and willing souls, we believe that this inherent force is exemplified in man through the heredity which is daily, yearly, yea, its millions of years accumulated a monstrous force-the ponderous wonder of man's intellectuality. Aye, we truly feel that we have no means of proof, but we have an abiding and constantly increasing stubbornness of faith, that it was the God-given force. imparted to the first germ cell, which, as the rolling millions of years teem and overflow in the present, came from this God endowed cell. We cannot fathom its limits, but we can partly comprehend its myriads of wonders. Hence, we believe that man to-day represents the perfection of existence, the ponderosity of a constantly accumulating, wonderously endowed, formative and perpetuating force, given to us