NITROUS OXIDE GAS

GAS

AND ETHER ANES

THESIA.

BY H. P. DERRY, M. D., MACON.

Since March, 1888, I have given chloroform and ether in this city and elsewhere, for various surgeons at more or less frequent intervals. Since June, 1902, the majority of my anesthesias have been induced with nitrous oxide gas and ether, and continued with ether or chloroform, as circumstances demanded.

Each

I have endeavored to keep a record of these cases both as to pulse, respiration and quantity of ether used.. In order to do this, I selected a bottle which would hold 100 grammes of ether, the contents of one small can. This I marked off into five parts, each part representing 20 grammes of ether, or about fluid ounces one. of these divisions I subdivided into four parts of five drammes each. With this bottle and an Esmarch stopper from a chloroform bottle with outpour slightly enlarged, I was prepared to make a record of quantity of ether used at any time during the anesthesia. I have expressed quantities in grammes, for the reason that. every one present knows that the contents of one small can of ether is 100 grammes.

Anesthesia was induced and continued with the Bennett inhaler in the majority of cases, but later on with one of my own construction, which does the work required of it equally as well, is less cumbersome, and allows the administration of oxygen gas, either with or

without ether any time during the anesthesia, and requires but one bag. I always use the Esmarch inhaler with chloroform, unless it be in special operations upon the mouth or face. In these cases, I use the Esmarch to induce anesthesia, and then resort to an apparatus improvised by myself, which allows the transmission of chloroform vapor through a tube and its delivery at the patient's mouth or nose. Its chief advantage is that the anesthetist is out of the surgeon's way; there is no interruption on account of imperfect anesthesia, and no time is lost.

The dangers of this instrument in inexperienced hands is evident, but by regulating the flow of air through the chloroform, and the distance at which the delivery tube is held from the patient's mouth, by effects obtained, I consider it about as safe as the various other methods used to obtain the same results.

With this instrument, oxygen gas may be given with the chloroform vapor, or the chloroform may be cut off, and the oxygen given through same tube without removing it from patient's mouth by the simple closing of a valve. Nitrous oxide gas, ether and chloroform each have their indications and contraindications. There is no safest anesthetic without a full knowledge of the patient's condition. His history, record under previous auesthesias, condition of kidneys, lungs, heart, bloodvessels, freedom of respiration, and habits should all be investigated before deciding on the safest anesthetic.

Nitrous oxide gas increases greatly arterial tension, and should not be given in vascular degeneration and especially in arteriosclerosis. Hare reports two cases of apoplexy as result of using this gas in patients with arteriosclerosis. In valvular diseases of heart if compensation be incomplete, and in a weak dilated heart by increasing arterial tension, it may cause fatal results.

In goitre simple, or exophthalmic, and in Angina Ludovici it is contraindicated. In obstructions to respiration from any cause it should be given with caution, bearing in mind that the gas is of itself an asphyxiating gas if continued alone for any considerable length of time. Nitrous oxide gas is not unpleasant to taste or smell, relieves to a considerable extent or entirely the disagreeable effects of the induction stage of ether anesthesia, according to the manner in which it is given. With ether as with gas the same conditions remain as to diseases which are influenced by arterial tension. Ether is not contraindicated in kidney disease to the extent once believed. A trace of albumin, or casts, unless other evidence of kidney degeneration exists, does not bar its use.

(August 17, A. M. A.) Hare does not think it strongly contraindicated in Bright's disease, if the anesthetist is impressed with the fact that the kidneys are affected, and necessary precautions are used.

Dr. John Munro, as quoted in J. A. M. A., January 16, 1904, concludes that we should expect renal irritation in over one-third of the surgical cases in a municipal hospital.

"A trace of albumin, with or without hyaline and granular casts unattended by any other evidence of renal damage, should not influence the prognosis in surgical disease or operation.

"In a number of septic cases the renal disturbance subsided as soon as drainage was established by operation. Albumin and casts alone he does not consider a contraindication to the administration of ether."

Ether is not the cause of pneumonia to the extent once believed. In an article appearing in the Therapeutic Gazette, date and year unknown, title "Post Operative Lung Complications," I find the following:

"Gottstein notes that of 114 laparotomies under cocaine anesthesia there were 27 cases of lung complications, or about 15 per cent.; while in 119 abdominal sections performed under a general anesthetic gave only 7 cases of lung complications, or 6 per cent.

"Mikulicz, also quoted by Anderson (Pacific Medical Journal, November, 1903) notes 7.5 per cent. of pneumonia and 3.4 mortality in 1,000 cases of major operations under general anesthesia; while there were 12.8 per cent. of pneumonia and 4.8 per cent. of mortality in 273 celiotomies under local anesthesia. Moreover, the statistics of the Presbyterian Hospital of New York show with equal conclusiveness that the risk of pneumonia following chloroform administration is two and one-half times greater than from ether. These facts, Anderson states. are borne out at St. Winifred's Hospital, San Francisco."

Geo. Spencer, of Philadelphia, in July American Medicine of 1903, says: "In the administration of ether to upward of 2,000 patients I have never had a case of pneumonia following the administration."

In my individual experience, I have had one case of pneumonia following administration of ether, but it was of septic origin and could not be blamed to the anesthetic.

The question of rigidity of the abdominal walls is one of importance to the anesthetist as well as the operator. A rigid condition of the abdominal muscles is not always due to the too sparing use of the anesthetic; it may be due to an overdose. A cyanosed patient is usually a rigid one. A surgeon who handles the contents of the abdominal cavity in a rough manner will usually require a more liberal use of an anesthetic in his cases than one who does not, and will see rigid abdominal muscles more frequently. "This may be due to

stretching of the parietal peritoneum." (K. G. Lennander in Central Piatt, Chi. Lipsic, February 23d.)

Blumfield, in Year Book of Med. and Surgery, says: "Abdominal rigidity is due to shape of trunk as it affects the upper portion of the recti muscles. To thickness of abdominal wall if due to muscular development. To abdominal sensibility to reflex effects. To manipulations within abdominal cavity." Thorough relaxation of the abdominal walls can not always be overcome without endangering the life of the patient, but as a rule if ether fail to relax, and the pulse admits of the change, I resort to chloroform, and with it I seldom fail to obtain relaxation.

With all forms of anesthesia respiration must be perfect to obtain perfect results. An irregular respiration is at all times troublesome to the anesthetist, and is especially dangerous in chloroform anesthesia, where if sufficient chloroform be dropped on the inhaler to insure a surgical degree of anesthesia during shallow respirations, and a few deep respirations be taken, poison. ing from chloroform may result.

I always dread an anesthesia where there be any obstruction whatsoever to respiration, be it from causes within or without. You cannot increase the embarrassment of an already labored respiration without adding an element of danger. Theoretically at least, in such cases an asphyxiating gas, such as nitrous oxide, should be avoided. So should ether, if given in too concentrated a form or in a closed inhaler. Chloroform in these cases would appear to be the safest anesthetic, and would be, if it were not for other existing conditions. One of the simplest operations, and most common, for this reason, and because of the frequent deaths reported during or immediately following it, is the operation for adenoids. Chaldecott, in Year Book Med, and