,,h&book ,,( ,,an,,/hetics ,,by ,j4 ,,/u>t ,,ross1 ,m4,b41 ,,*4,b41 ,f4,r4,c4,s4,e4 ,,lectur] ,,9 ,,practical ,,an,,/hetics1 ,,univ]sity ,,( ,,ed9burgh2 ,,honor>y ,,an,,/heti/ ,,ed9burgh ,,d5tal ,,s*ool2 ,,an,,/heti/1 ,,deaconess ,,hospital2 ,,in/ructor ,,9 ,,an,,/hetics1 ,,ed94 ,,royal ,,infirm>y ,) an ,introduction ,,by ,,hy4 ,,alexis ,,?omson1 ,c4,m4,g41 ,m4,d41 ,f4,r4,c4,s4,e4 ,,pr(essor ,,( ,,surg]y1 ,,univ]sity ,,( ,,ed9burgh ,,& ,,*apt]s ,,^u ,local & ,sp9al ,an/hesia ,,by ,,wm4 ,,qu>ry ,,wood1 ,m4,d41 ,f4,r4,c4,s4,e4 ,,lately ,,tempor>y ,,assi/ant ,,surgeon1 ,,ed9burgh ,,royal ,,infirm>y ,,& ,,^u ,intratra*eal ,an/hesia ,,by ,h4 ,,torrance ,,?omson1 ,m4,d41 ,f4,r4,c4,s4,e4 ,,an,,/heti/ ,,to ,,! ,,lei? ,,hospital ,,ed9burgh ,e4 ,s4 ,,liv+/one1 #ag ,,teviot ,,place #aiai ,,cont5ts ,,*ap4 ,,page ,,introduction ,,by ,,pr(essor ,,alexis ,,?omson ix ,,preface xi ,i4 ,,physiological ,,action ,,( ,,an,,/hetic ,,drugs #a ,,ii4 ,,%ock ,,& ,,an,,/hesia #e ,,iii4 ,,asphyxia ,,or ,,anox,,mia #ae ,,iv4 ,,me?ods ,,( ,,an,,/hetis+ #bh ,v4 ,,! ,,cl9ical ,,obs]vation ,,( ,,! ,,pati5t #ca ,,vi4 ,,! ,,prep>ation ,,( ,,! ,,pati5t #db ,,vii4 ,,nitr\s ,,oxide #df ,,viii4 ,,nitr\s ,,oxide ,,& ,,oxyg5 #fj ,,ix4 ,,e!r #gd ,x4 ,,intratra*eal ,,e!r #if ,,xi4 ,,*lor(orm #aji ,,xii4 ,,e?yl ,,*loride #abb ,,xiii4 ,,mixtures ,,( ,,nitr\s ,,oxide ,,& ,,e?yl ,,*loride #abh ,,xiv4 ,,mixtures ,,( ,,*lor(orm ,,& ,,e!r #acd ,,xv4 ,,sequ5ces #acg ,,xvi4 ,,! ,,accid5ts ,,( ,,an,,/hesia #adj ,,xvii4 ,,! ,,sequel ,,( ,,an,,/hesia #aea ,,xviii4 ,,po/ure ,,( ,,! ,,pati5t #aeg ,,xix4 ,,! ,,*oice ,,( ,,! ,,an,,/hetic #afb ,,xx4 ,,local ,,an,,/hesia #aga ,,xxi4 ,,sp9al ,,an,,/hesia #aic ,,app5dix #bja ,,index #bji ,,li/ ,,( ,,illu/rations4 ,,fig4 ,,page4 #a4 ,%ock 7,grey & ,p>sons7 #f #b4 ,%ock 7aft] ,crile7 #h #c4 ,diagram to ,illu/rate ,anoci-,association 7aft] ,crile7 #aa #d4 ,app>atus = ,lane's ,sal9e ,infusion #ac #e4 ,diagram ( ! ,vici\s ,circle ( ,asphyxia #bj #f4 ,hewitt's ,m\? ,props #bb #g4 ,bellamy ,g>dn]'s ,m\? ,props #bc #h4 ,phillips' ,modification ( ,hewitt's ,artificial ,air-way #bc #i4 ,silk's ,nasal ,tubes #bc #aj4 ,tongue ,=ceps & ,glossotilt #bd #aa4 ,app>atus = ,op5+ ,cl5*$ ,jaws #be #ab4 ,frame = ,adapt+ ,v]tical ,cyl9d]s to ,foot ,use #dg #ac4 ,nitr\s ,oxide ,cyl9d]s 7upright & angle7 #dh #ad4 ,complete ,nitr\s ,oxide ,app>atus #di #ae4 ,b>? #c-way ,nitr\s ,oxide ,tap #ej #af4 ,hewitt's ,wide-bore ,nitr\s ,oxide ,valves #ej #ag4 ,a%'s ,modification ( ,pat]son's ,nasal ,gas #eh #ah4 ,hewitt's ,app>atus = ,nitr\s ,oxide & ,oxyg5 #fc #ai4 ,diagram to ,illu/rate ,action ( ,hewitt's & ,tet]'s ,gas-,oxyg5 ,me?ods #fg #bj4 ,details ( ,cl>k's ,expiratory ,valve #fh #ba4 ,! ,cl>ke ,gas-oxyg5 ,app>atus #fi #bb4 ,m>%all's ,sight-fe$ ,gas-oxyg5 ,app>atus #gj #bc4 ,clov]'s ,e!r ,inhal]1 ) ,nitr\s ,oxide ,atta*m5t #gg #bd4 ,clov]'s ,inhal]1 ,diagram ( a ,v]tical ,section #gh #be4 ,hewitt's ,wide-bore ,e!r ,inhal] #hj #bf4 ,ormsby's ,e!r ,inhal] #ha #bg4 ,bellamy ,g>dn]'s ,mask & ,e!r ,dropp] #hc #bh4 ,f\r ,photographs to ,illu/rate ! ,adm9i/ration ( ,op5 ,e!r #hd-e #bi4 ,%ipway's ,w>m$ ,e!r ,app>atus #ia #cj4 ,diagram ( ,intratra*eal ,app>atus #ih #ca4 ,electric ,bl[] = ,intratra*eal ,me?od #ii #cb4 ,kelly's ,intratra*eal ,app>atus #ajj #cc4 ,%ipway's ,intratra*eal ,app>atus #ajb #cd4 ,hill's ,direct ,l>yngoscope #ajd #ce4 ,diagram ( ,blood-pressure ,curves ,obta9able ) ,*lor(orm #aaj #cf4 ,v]non ,h>c\rt's ,p]c5tage ,*lor(orm ,inhal] #aae #cg4 ,*lor(orm ,mask #aaf #ch4 ,*lor(orm ,drop ,bottles #aag #ci4 ,junk]'s ,*lor(orm ,app>atus #aai #dj4 ,tube ( ,e?yl-,*loride #abb #da4 ,e?yl-,*loride ,inhal] #abd #db4 ,guy's ,gas & ,e?yl-,*loride ,inhal] #abh #dc4 ,details ( ,guy's ,inhal] #abi #dd4 ,diagram ( ,gas-,oxyg5 ,me?od ,introduc$ by ,dr ,guy & ! ,au?or #acj #de4 ,! ,guy ,ross ,gas-,oxyg5 ,in/rum5t #aca #df4 ,r5dle's ,cone #ace #dg4 ,clov] ,inhal] adapt$ = ! ,e?yl ,*loride-,e!r ,sequ5ce #aci #dh4 ,two ,photographs illu/rat+ ,sylve/]'s ,artificial ,respiration #adf-g #di4 ,sitt+-up ,po/ure = ,op]ations ^u ! ,head & ,neck #aei #ej4 ,o',malley's ,po/ure = ,intra-nasal ,surg]y #afj #ea4 ,all-metal ,syr+e = ,infiltration ,an/hesia #agf #eb4 ,infiltration ( ! ,bra*ial ,plexus #ahc #ec4 ,ne$le & ,syr+e = ,sp9al ,analgesia #aid #ed4 ,position ( ! ,pati5t = ,sp9al ,analgesia #aif ,,introduction4 ,! secur+ ( a safe an/hesia dur+ op]ations is m important ?an ev] be=e1 p>tly because ( ! m]e numb] ( op]ations1 & p>tly because ( ! great] ext5t to :i* o!r op]ative risks--hmorrhage1 %ock & infection--h be5 ov]come4 ,! risk f ! an/hetic is n[ s v small t ! jo9t aim ( ! surgeon & an/heti/ to aboli% x altoge!r is n f> f be+ accompli%$4 ,! au?or ( ?is volume has done a good deal to accompli% ?is end1 & x is a matt] ( congratulation t he has n[ publi%$ an acc\nt ( 8 me?ods1 s t a l>g] circle may b5efit f 8 tea*+ & 8 exp]i5ce4 ,! au?or v prop]ly goes fur!r & ma9ta9s t an/hesia mu/ n only be safe b mu/ also be good2 good an/hesia is absolutely vital to good surg]y4 ,only a g5]ation back _m surgeons pr(ess$ to see no diff]5ce z to :o gave ! an/hetic2 at ! pres5t day no "o will+ly emb>ks ^u a difficult op]ation )\t ! aid ( a skill$ an/heti/4 ,9 v>i\s p>ts ( ! book ! au?or has v rightly laid great emphasis ^u ! influ5ce :i* ! "w ( ! surgeon has ^u t ( ! an/heti/4 ,! latt] may le>n mu* f an occasional glance at ! field ( op]ation4 ,he %\ld n int]e/ himself 9 ! details ( op]ative proc$ure to ! di/raction ( 8 m9d f 8 own responsibilities2 b he c1 9 abdom9al surg]y1 see = himself :e!r ! muscles are prop]ly relax$1 & obs]ve ! /ate ( op]ation1 s t he c :5 necess>y deep5 ! an/hesia 9 good "t1 :ile n ma9ta9+ deep an/hesia :5 a light "o w\ld suffice4 ,f9ally1 he c *eck 8 o!r s\rces ( in=mation z to ! condition ( ! circulation by notic+ ! =ce ) :i* cut art]ies sp\t1 ! col\r ( ! blood & ! size ( uncut ve9s4 ,l o!r bran*es ( m$ic9e1 adequate /udy z well z practical exp]i5ce is requir$ 9 ord] to ma/] ! art ( adm9i/]+ an/hetics1 & t a reliable manual ( in/ruction is ess5tial1 goes )\t say+2 ,i feel on p]fectly safe gr\nd 9 recomm5d+ ?is book z su* bo? to ! /ud5t & ! practition]4 ,,alexis ,,?omson4 ,,preface4 ,?is little book is an attempt to pres5t to ! /ud5t & practition] a cond5s$ acc\nt ( mod]n an/hetic views & practice4 ,9 *oos+ a g5]al s*eme ,i h tri$ to lay emphasis ^u ! relation ( an/hesia to g5]al m$ical sci5ce r ?an ^u elaborate descriptions ( an/hetic app>atus & me?ods :i* a few ye>s h5ce may be sup]s$$4 ,i h !re=e devot$ ! fir/ f\r *apt]s to an acc\nt ( ! v>i\s =ces :i* modify ! physiology ( ! pati5t dur+ an op]ation "u a g5]al an/hetic1 9 s f> z we at pres5t und]/& !m4 ,i tru/ t !y w prove n only a s\nd basis = ! in=mation giv5 9 ! re/ ( ! book b also a help t[>ds =m+ a judgm5t ^u new me?ods & appliances z & :5 !y meet ! att5tion ( ! read]4 ,9 mak+ a selection ( drugs & appliances = description1 ,i h elim9at$ ^? :i* d n appe> to me to h any real sph]e ( usefulness4 ,! acc\nt ( nitr\s oxide & oxyg5 has be5 giv5 9 "s detail4 ,bo? ! pr(ession & ! lay public h arriv$1 ?r\gh ! exp]i5ces ( ! w>1 at a m j appreciation ( ! possibilities ( ?is comb9ation ?an 0 at all g5]al be=e ! ye> #aiad4 ,at ! pres5t day1 no "o :o proposes to engage 9 an/hetic "w c af=d to rema9 unpractis$ 9 its adm9i/ration4 ,i h an apology to make to my wom5 read]s4 ,?r\gh\t ! book1 :5 speak+ ( ! an/heti/1 ,i h presum$ ! male sex4 ,su* phrases z 88 or h]0 & 8he or %e0 are t$i\s & inelegant1 & _! omission mu/ n be tak5 z =getfulness on ! au?or's "p t wom5 frequ5tly make v good an/heti/s4 ,pr(essor ,alexis ,?omson has add$ to ! _m k9dnesses ,i h receiv$ at 8 h&s by writ+ ! ,introduction :i* imm$iately prec$es ?is ,preface1 & ,i wi% to express my s9c]e ?anks to him = su* a valuable addition to ! book4 ,f ,mr ,david ,wallace1 ,f4,r4,c4,s4,e41 ,i h receiv$ mu* valuable help & guidance 9 an/hetic matt]s4 ,x 0 l>gely due to 8 k9dly assi/ance & moral support t ,i 0 enc\rag$ to p]sev]e ) my e>ly attempts to use nitr\s oxide & oxyg5 9 major surg]y4 ,! h9ts :i* are giv5 9 connection ) ,g5ito-,ur9>y ,surg]y are also d]iv$ f him4 ,! *apt]s ^u ,local & ,sp9al ,an/hesia are entirely ! "w ( ,mr ,wood1 to :om ,i mu/ express my gratitude = ! admirable way 9 :i* he has done ! "w4 ,i mu/ also ?ank ,dr ,torrance ,?omson mo/ s9c]ely = 8 useful contribution 9 *apt] ,x1 :i* con/itutes a complete monograph ^u ,intratra*eal ,an/hesia4 ,to ,dr ,wm4 ,guy ,i am indebt$ = ! photographs :i* appe> 9 ! book1 & ,i mu/ express my s9c]e gratitude to him = ! tr\ble he has tak5 9 ! matt]4 ,mu* ?anks are also due to ! foll[+ firms :o h be5 k9d en\gh to l5d illu/rative blocks3--,messrs ,claudius ,a% ,co4 ,ltd41 ,g4 ,b>? ,co41 ,de ,trey ,co41 ,j4 ,g>dn] ,son1 ,all5 ,hanbury's ,ltd41 ,mey] ,phelps1 ,coxet] ,son1 ,d[n ,bros41 ,ltd41 ,krohne ,sesemann1 & ,mr ,j4 ,h4 ,montague4 ,la/ly1 ,i mu/ express my high appreciation ( ! c\rtesy :i* ! publi%]s h %[n to me1 & ( _! g5]osity 9 ! matt] ( illu/rations4 ,j4 ,,/u>t ,,ross4 ,octob] #aiai4 ,h&book ( ,an/hetics4 ,,*apt] ,i4 ,,physiological ,,action ,,( ,,an,,/hetic ,,drugs4 ,e an/hetic drug has c]ta9 ph>macological peculi>ities ( its own1 b all h mu* 9 common1 & x is to ^! common features we %all fir/ direct our att5tion4 ,rea*+ ! blood /ream by absorption f ! lung alveoli1 ! drug ent]s into loose comb9ation ) ! r$ blood corpuscles2 a small proportion only is c>ri$ 9 ! plasma4 ,)9 ! corpuscles x mu/ ( necessity displace a c]ta9 proportion ( ! oxyg5 normally c>ri$3 ?is factor is ( great importance only 9 ! case ( nitr\s oxide gas1 :i* readily displaces ! l>g] "p ( ! normal oxyg5 cont5t4 ,9 ! case ( o!r an/hetics1 ! same process occurs2 b to a less ext5t4 ,detail$ figures ( ! ext5t to :i* ! blood gases are alt]$ 9 v>i\s /ages ( *lor(orm an/hesia w be f\nd 9 ,app5dix ,,iii4 ,! actions ( individual drugs ^u ! circulatory1 respiratory1 & excretory sy/ems diff] s consid]ably t a small section has be5 devot$ to ?is subject 9 ea* ( ! *apt]s devot$ to nitr\s oxide1 e!r1 & *lor(orm respectively4 ,"o feature is1 h[ev]1 dep5d5t ^u ! /ate ( an/hesia r ?an ! action ( ! p>ticul> drug1 & t is a c]ta9 slight fall ( blood pressure4 ,?is ph5om5on is se5 ev5 9 natural sleep1 & is presumably due simply to lack ( normal /imuli su* z tactile1 visual1 & auditory impressions :i* 9 ! ord9>y circum/ances ( life1 help to ma9ta9 ! tone ( ! vasomotor sy/em4 ,t su* a fall is due to ! /ate ( an/hesia admits ( little d\bt1 b ! fact is n always easy to demon/rate s9ce ea* ( ! drugs !mselves h a m>k$ influ5ce ^u ! ,b4,p41 :i* masks ! pure effect ( ! an/hetic sleep4 ,action ^u ! ,n]v\s ,sy/em4 ,x is 9 ?is sy/em1 ( c\rse1 t we look = ! *>act]i/ic action ( an/hetics1 s9ce if we _h a *oice1 x is ! bra9 only :i* we %\ld desire to influ5ce by our drug4 ,x us$ to be said t an/hetics p>alyse ! bra9 f above d[nw>ds1 b t is only approximately true4 ,m correctly we may say t ! m highly develop$ p>ts ( ! bra9 are e>lie/ affect$1 & t ^? portions1 su* z ! vital m$ull>y c5tres1 :i* man %>es 9 common ) 8 humbl] zoological relatives1 ma9ta9 _! activity until ! la/4 ,moreov]1 x mu/ be rememb]$ t be=e any bra9 c5tre succumbs1 x passes ?r\gh a prelim9>y /age ( excitem5t1 v>y+ 9 int5sity ) v>y+ drugs & also ) diff]5t types ( pati5ts4 ,^? :o are accu/om$ to adm9i/] to _! n]v\s c5tres repeat$ l>ge doses ( su* n]ve poisons z alcohol & tobacco1 may %[ v evid5t signs ( ?is prelim9>y c]ebral irritation dur+ ! process ( induction ( an/hesia2 s d also ! unhappy possessors ( n]v\s sy/ems d]ang$ f o!r causes su* z epilepsy4 ,! fir/ c5tres to be attack$ are ^? ( ?\ght & p]ception4 ,! pati5t is incapable ( coh]5t reason+1 & loses t\* to "s ext5t ) impressions f ! outside _w4 ,muscul> s5se & co-ord9ation next become affect$4 ,al?\gh /ill able to move ! limbs or ! head1 movem5ts are incoh]5t1 & if at ?is /age ! pati5t 7 put ^u 8 feet1 he w\ld /agg] z he does 9 alcoholic intoxication4 ,by ?is "t s5sation1 bo? tactile & special1 beg9s to be affect$4 ,! pati5t is no long] cognisant ( pa91--if cut he w\ld at any rate n h a remembrance ( pa94 ,! special s5ses are at ?is /age also lo/1 "o ( ! la/ to g be+ ! auditory s5se1 a po9t :i* is sometimes =gott5 by ^? incl9$ to talk :ile an/hesia is be+ induc$4 ,muscle tone is ! next function to be lo/1 & at ?is /age all movem5ts on ! "p ( ! pati5t %\ld cease except ^? ( respiration4 ,! reflexes disappe> at v>y+ /ages3 ! sp9al reflexes1 e4g4 ! knee-j]ks1 disappe> fairly e>ly1 probably be=e muscle tone is entirely aboli%$1 b c]ta9 o!r reflexes p]si/ to a lat] /age4 ,^? :i* are ( mo/ int]e/ to ! an/heti/ are ! conjunctival1 corneal1 & pupill>y reflexes ( :i* he w f9d full details 9 ,*apt] ,v4 ,la/ly ! vital m$ull>y c5tres1 respiratory1 vasomotor1 & c>diac are ov]come1 & at ?is /age we h pass$ beyond ! /age ( a prop] an/hesia into t ( ov]-dosage4 ,9 pass+ x may be obs]v$ t ! level at :i* "o endeav\rs to "w is t indicat$ by ! loss ( muscle tone & ( "s ( ! reflexes & ! full activity ( ! m$ull>y c5tres1 & t an an/hetic is good or bad accord+ z x gives a wide or n>r[ m>g9 betwe5 ^! two ev5ts4 ,^u ! p]iph]al n]ves1 an/hetics h mu* less effect ?an on ! c5tral n]v\s sy/em4 ,f>adisation ( a motor n]ve w 9 ! deepe/ an/hesia /ill cause imm$iate contraction ( ! muscles suppli$ by x1 %[+ t ! conductivity ( ! n]ve is unaffect$4 ,( f> m importance1 h[ev]1 is ! fact t ! s5sory n]ves are n p>alys$4 ,t pa9 is n felt by ! pati5t is due simply to ! loss ( function ( ! c]ebral s5sory c5tres2 injury to ! n]ve /ill causes an impulse to be transmitt$ to ! bra94 ,s9ce no op]ative proc$ure c be c>ri$ out )\t m or less trauma 7injury7 to s5sory n]ves1 we may picture ! bra9 ( ! pati5t und]go+ a surgical op]ation :ile "u a g5]al an/hetic1 z be+ con/antly bomb>d$ by s5sory /imuli1 :i* ?\gh n consci\sly appreciat$ by ! sleep+ pati5t1 are yet capable ( produc+ reflex effects ( a def9ite "*1 ! importance ( :i* to ! "w ( ! surgeon & an/heti/ x is difficult to exagg]ate1 & ( :i* a cond5s$ acc\nt w be f\nd 9 ! succe$+ *apt]4 ,,*apt] ,,ii4 ,,%ock ,,& ,,an,,/hesia4 ,"u ?is %ort & conv5i5t title1 ! au?or proposes to discuss all ! *anges obs]vable 9 ! pati5t's condition1 ! causation ( :i* c be trac$ to ! proc$ure ( ! surgeon4 ,! use ( ! t]m %ock 0 at "o "t1 & by "s tea*]s /ill is1 re/rict$ to a def9ite cl9ical condition4 ,! pati5t 0 describ$ z ly+ pallid & almo/ pulseless1 ) dilat$ pupils1 cold sweat+ sk91 & gasp+1 irregul> respirations4 ,9 ! view m g5]ally tak5 to-day1 t is b ! extreme & f9al manife/ation ( a syndrome1 :i* any pati5t :o suff]s trauma 7:e!r inflict$ accid5tally or by ! surgeon7 exhibits 9 a great] or less degree1 & f :i* g5]al an/hesia protects a pati5t to a v limit$ ext5t only4 ,pr(essor ,crile1 to ^: "w we owe s mu* ( our k on ?is subject1 has said1 8,9 g5]al an/hesia1 "p ( ! bra9 only is asleep40 ,?\gh consci\sness is aboli%$1 _m p>ts ( ! bra9 are q capable ( respond+ to c5tripetal impulses pass$ to ! bra9 ?r\gh s5sory n]ves injur$ by ! knife4 ,a full acc\nt ( ! *anges demon/rat$ by ,crile 9 "s ( ! cells ( ! grey matt] ( ! bra9 z a result ( su* /imuli1 & ( ! int]pretation put ^u ^! by _! discov]]1 is n suitable = a text-book ( an/hesia4 ,x is suffici5t to say t su* *anges h be5 discov]$1 & t _! occurr5ce z a result ( trauma is n prev5t$ by inhalational an/hesia4 ,su* *anges1 ?\gh ( ! utmo/ int]e/ sci5tifically1 _c be demon/rat$ cl9ically1 & x is to alt]ations ( blood pressure & ( respiration t we mu/ look = cl9ical evid5ce ( ! effects ( %ock /imuli4 ,illu/ration3 ,,fig4 #a4--,%ock--,blood pressure ( a dog und]go+ lam9ectomy "u g5]al an/hesia 7,grey & ,p>sons47 7,reproduc$ by k9d p]mission ( ! ,au?ors47 ,) e incision by ! surgeon1 s5sory n]ve twigs are ( necessity injur$4 ,! fibres f\nd 9 s5sory n]ves are1 x w be rememb]$1 ei!r pressor1 or depressor--t is1 /imulation ( !m1 causes ei!r an increase or decrease ( ! blood pressure1 ! dep? & frequ5cy ( respiration be+ usually affect$ 9 ! same direction z ! ,b4,p4 ,t su* *anges d commonly occur is easily recognis$ by cl9ical obs]vation4 ,! v]ie/ beg9n] 9 an/hesia soon le>ns to expect a deep]1 quick] respiration & a /rong] pulse z soon z ! op]ation has begun4 ,^! *anges h be5 /udi$ exp]im5tally ^u animals & ^u ! human subject by ! use ( ! sphygmomanomet]3 ,fig4 #a1 drawn f ,grey ,p>son's ,arris & ,gale ,lectures ( #aiab1 %[s a trac+ f a dog und]go+ lam9ectomy "u g5]al an/hesia1 & gives a good idea ( ! e>ly evid5ces ( %ock4 99 99 99 99 99 ,we may cond5se ! results ( mu* "w on ?is subject "u ! foll[+ head+s3-- 7a7 ,mo/ /imuli f ! field ( op]ation cause a %>p rise ( blood pressure1 foll[$ by a %>p fall4 7b7 ,successive /imuli deliv]$ quickly "o aft] ano!r add _! effects toge!r1 ! total result be+ consid]ably great] ?an f "o sev]e trauma4 7c7 ,aft] a "t1 ! pressor effect ( /imuli beg9s to less53 ! animal or pati5t 8we>s out10 & f9ally no pressor result c be obta9$ by ! mo/ massive /imulation3 ! curve ( ,b4,p4 /eadily falls3 ! condition ( full surgical %ock is produc$4 7d7 ,! te>+ or pull+ ( tissues produces m p[]ful /imuli ?an ! use ( a %>p knife1 &1 !re=e1 br+s on ! full condition ( %ock m rapidly4 7e7 ,/imuli f "s tissues cause mu* m reflex effect ^u ! organism ?an f o!r less s5sitive /ructures4 ,?is is well exemplifi$ :5 an abdom9al section is 9 progress4 ,incision ( sk9 causes imm$iate response 9 deep5$ respiration & high] ,b4,p43 division ( ! fascia v little effect4 ,if ! muscle is divid$ by ! knife1 aga9 little reflex effect is noticeable1 b if x be /ret*$ & split by ! f+]s1 ! response is p[]ful4 ,! p>ietal p]itoneum1 h[ev] delicately h&l$1 is "o ( ! mo/ s5sitive /ructures 9 ! body1 &1 unless ! pati5t is fully "u at ! /age ei!r ( op5+ or clos+ ?is lay]1 actual brea?-hold+ or /ra9+ w occur4 ,on ! o!r h&1 incision or suture ( ! holl[ visc]a w cause practically no response h[ev] light ! an/hesia1 provid$ ^! /ructures1 & _! connections ) ! p>ietes1 are n pull$ ^u4 7f7 ,/imulation ( c]ta9 select$ areas1 ( :i* ! sp]matic cord is a well-kn[n b by no means ! only example1 results 9 an almo/ imm$iate fall ( blood pressure ) little or no prelim9>y rise4 ,9 ! op]at+ !atre1 we sometimes see fa9tness or syncope aris+ q sudd5ly dur+ op]ations 9 su* regions4 ,?is subject is expla9$ m fully 9 ,*apt] ,,xvi4 "u ! t]m 8,reflex ,syncope40 ,illu/ration3 ,,fig4 #b4--;,comb9$ blood pressure *>t %[+ ! av]age ( a numb] ( exp]im5ts4--,a--,"u nitr\s oxide & oxyg54 ,b--,"u e!r4 ,at ea* spot m>k$ x1 a trauma 7burn+ ( ! paw7 0 inflict$4 7,aft] ,,crile47 7g7 ,:ile no g5]al an/hetic protects absolutely f %ock /imuli1 "s an/hetics give m protection ?an o!rs4 ,nitr\s oxide is ! mo/ effective 9 ?is respect1 its p[]s be+ two & a half times great] ?an t ( e!r3 *lor(orm is ev5 less effective ?an e!r 7see ,fig4 #b74 7h7 ,! claim made by ! old] g5]ation ( surgeons t %ock c\ld be prev5t$ by ! use ( a deep an/hesia1 & t ! occurr5ce ( any 8,reflex syncope0 0 always a sign ( too light an an/hesia _c be made good4 ,at ! same "t1 x mu/ be admitt$ t too light an an/hesia does increase ! likelihood ( %ock4 ,prolong$ deep an/hesia1 on ! o!r h&1 produces by itself a condition indi/+ui%able f %ock1 ) ! s+le exception ( nitr\s oxide gas4 7i7 ,op]ative %ock is pr$ispos$ to by sev]al factors ( :i* ! foll[+ are ! mo/ important3-- #a4 ,hmorrhage be=e or dur+ op]ation4 #b4 ,sepsis4 #c4 ,fe>4 #d4 ,prolong$ />vation4 #e4 ,c]ta9 diseases1 especially hyp]?yroidism 7exop?almic gtre74 ,!ories ( ,%ock4 ,s f> z we h t\*$ 9 ! above ^u !ory1 x has be5 !ory :i* receives g5]al acceptance & :i* accords ) kn[n cl9ical facts4 ,:5 we come to discuss ! reason :y blood-pressure falls 9 %ock1 we are 9 m debatable c\ntry4 ,crile's orig9al view 0 t ! up/roke se5 9 su* *>ts z %[n 9 ,fig4 #a are caus$ by reflex vaso-con/riction1 & t ! f9al fall ( ,b4,p4 0 due to exhau/ion ( ! vaso-motor c5tre4 ,?is view he does n seem to h modifi$ z a result ( 8 lat] discov]y ( deg5]ative *anges 9 c]ta9 cells ( ! grey matt] ( ! bra94 ,o!r work]s1 ,j4 ,d4 ,malcolm 9 ?is c\ntry1 & ,y&ell ,h5d]son1 ( ,yale1 ,u4,s4,a41 ma9ta9 an op9ion diametrically opposite4 ,9 _! view1 9 fully develop$ %ock1 ! vessels are 9 vaso-con/riction1 & ! circulation is arre/$ f undue int]nal resi/ance to blood fl[4 ,a ?ird explanation ( l[]$ ,b4,p4 has be5 (f]$1 & :ile its significance is n und]/ood1 !re is fairly g5]al agreem5t z to its validity4 ,?is factor is a r$uction 9 ! total blood volume--an oligmia4 ,no "o has z yet demon/rat$ to :at region or organ ! miss+ blood volume has retreat$4 ,,y&ell ,,h5d]son',s ,,acapnic ,,!ory ,,( ,,%ock4 ,acapnia is a condition 9 :i* ! ,,co#b cont5t ( ! blood & tissues has be5 br\ght to too l[ a level4 ,^? :o climb m\nta9s suff] f x1 & s d ^? :o brea! rapidly & heavily = a prolong$ p]iod4 ,c>bon dioxide is necess>y = ! vig\r ( ! respiratory c5tre1 ( :i* x may be t]m$ ! natural regulator4 ,moreov]1 ! he>t & ! great ve9s :i* empty into x require a c]ta9 proportion ( ,,co#b 9 ! blood4 ,admitt$ly1 pati5ts inhal+ an/hetics d on occasion brea! too deeply4 ,sometimes !y d s volunt>ily be=e los+ consci\sness1 sometimes reflexly z a result ( su* a manuvre z /ret*+ ! sph9ct] ani4 ,d !y !reby br+ _! ,,co#b d[n to a level :i* does s]i\s h>m & :i* c be consid]$ a cause ( collapse "u an/hesia8 ,h5d]son says !y c & d3 mo/ o!r work]s d5y ! possibility4 ,illu/ration3 ,,fig #c4--;,diagram 7aft] ,,crile7 to illu/rate anoci-association4 ,9 8,a0 ! trauma is inflict$ on ! leg1 & ! bra9 be+ :olly unprotect$1 consid]able %ock is suff]$4 ,9 8,b0 ! bra9 is protect$ by inhalational an/hesia f ! effects ( fe>1 etc4 ,9 8,c0 ! s5sory n]ves f ! seat ( trauma are block$ by novoca9e1 & ! bra9 also protect$ by inhalational an/hesia4 ,!oretically no %ock is suff]$4 ,prev5tion & ,treatm5t ( ,%ock4 ,!re are _m !ories ( %ock b only "o anti-%ock te*nique :i* w be> exam9ation4 ,f\nd+ ^u 8 own !ory1 ,crile ab\t #aiac elaborat$ 8 ,,anoci-,,association me?od ( :i* ! foll[+ are ! lead+ features 7see ,fig4 #c73-- 7a7 ,prev5tion ( fe>4--,e memb] ( ?is team is taught ! all-important art ( s deal+ ) ! pati5t t no unnecess>y fe> is all[$ to rema9 9 8 m9d4 ,t art does n consi/ 9 endless repetition ( ! phrase1 8,d n be fright5$10 b r 9 ea* s be>+ himself or h]self be=e ! pati5t t he may gradually acquire ! conviction t he is surr\nd$ by c>eful1 k9dly1 & skilful p]sons :o are do+ = him :at !y d = hundr$s ( o!rs1 & do+ x ) an expectation ( 8 e>ly & complete recov]y s c]ta9 t !y d n ne$ to put x into words unless def9itely que/ion$4 ,su* an art is n acquir$ 9 a day1 & "s unhappy few are s con/itut$ t !y c nev] acquire x4 ,z a fur!r prev5tative ( fe>1 & also = o!r reasons expla9$ 9 ,*apt] vi41 ! pati5t receives a dose ( morphia 7? gra91 ) ? gra9 atrop9e1 hypod]mically7 ?ree qu>t]s ( an h\r be=e op]ation4 ,"s surgeons g fur!r1 & give a s$ative ! night be=e op]ation4 ,v]onal gr4 viii4 is ! fav\rite prescription ( ,pr(4 ,alexis ,?omson ( ,ed9burgh4 7b7 ,! s5sory n]ves are 8block$0 by infiltration ) novoca94 ,by ! sy/ematic use ( local 9 conjunction ) g5]al an/hesia1 ! h>mful /imuli f ! area ( op]ation are prev5t$ f rea*+ ! bra94 ,= ! details ( ?is measure1 ! read] is ref]r$ to ,*apt] xx4 7c7 ,! an/hetic ( *oice 9 ,crile's practice is nitr\s oxide & oxyg5 7see ,*apt] vii474 ,! :ole ( ?is te*nique has n be5 g5]ally adopt$ z a r\t9e1 b nev]!less ! tea*+s ( ,crile h greatly influ5c$ ! m9d & practice ( mo/ surgeons & an/heti/s4 ,traces ( t tea*+ are to be f\nd ev]y:]e 9 ! organisation built up dur+ ! ,great ,w> to save z _m z possible ( ! lives ( badly sma%$ m54 ,at no previ\s "t 9 ! hi/ory ( surg]y 0 ! problem ( %ock s press+1 & a brief resum ( ! me?ods adopt$ is "h set d[n1 z an example ( h[ %ock %\ld be dealt )4 ,illu/ration3 ,,fig4 #d4--,lane's app>atus = subcutane\s infusion ( sal9e solution4 ,treatm5t ( ,%ock among ! ,casualties ( ! ,w>4 ,! fir/ ess5tials dem&$ 7 ! mo/ c>eful organisation1 ! provision ( equipm5t f> 9 advance ( mo/ home civilian hospitals1 & ( surgical teams specially tra9$ to a high level ( excell5ce4 ,^u recov]y f ! field1 ! injur$ man receiv$ at ! ,,advanc$ ,,dress+ ,,/ation1 su* fir/ aid dress+ z 0 necess>y1 & a sub/antial dose ( morphia4 ,:5 ! latt] _h _h "t to take effect1 ! case 0 pass$ back to ! ,field ,ambulance 7:]e he receiv$ 8 fir/ dose ( antitetanic s]um71 & f !re to ! ,,casualty ,,cle>+ ,,/ation4 ,dur+ e /age ( ! j\rney1 he receiv$ z mu* w>m fluid n\ri%m5t z possible4 ,arriv$ at ! ,c4,c4,s41 ! sev]e case 0 pass$ fir/ into ! ,,resuscitation ,,w>d4 ,?is dep>tm5t1 "u ! *>ge ( a specially tra9$ ,m4,o41 conc5trat$ l>gely ^u two measures--! ?or\gh w>m+ ( ! pati5t1 & ! replac+ z f> z possible ( ! fluids lo/ to him by hmorrhage & %ock4 ,! w>m+ 9 _m ,c4,c4,s4's 0 effect$ by electric radiant heat ba?s4 ,! fluids 7 replac$ ei!r by way ( infus+ blood f ano!r pati5t1 or by ! use ( gum sal9e solution4 ,introduc$ into a ve91 ! action ( ?is solution p]si/s = a mu* long] p]iod ?an t ( ord9>y sal9e1 be+ less easily lo/ by osmosis ?r\gh ! capill>ies into ! tissues4 ,f ! resuscitation w>d1 ! pati5t pass$ to ! ,,op]at+ ,,!atre4 ,?\gh ! full te*nique ( anoci-association 0 n always possible1 ! maxims :i* ,crile _h s\ght to inculcate into ! practice ( surg]y influ5c$ ! "w ( surgeons & an/heti/s v pr(\ndly4 ,nitr\s oxide & oxyg5 0 us$ = all ! sev]ely %ock$ cases1 & infiltration ) local an/hetics :]e feasible & necess>y4 ,subcutane\s ,infusion ( ,sal9e4 ,= ^? :o d n feel b\nd to adopt ! ,crile te*nique ?is is a simple measure :i* does mu* to m9imise %ock 9 prolong$ abdom9al op]ations4 ,sal9e infusion into a ve9 is s rapidly excret$ t its influ5ce is v fugaci\s1 b if ! fluid be introduc$ "u ! sk9 dur+ ! p]iod ( op]ation x is sl[ly absorb$ z requir$ by ! blood4 ,sir ,arbu?not ,lane is a /rong advocate ( ?is measure4 ,fig4 #d %[s a suitable app>atus4 ,! ne$les are ?ru/ into ! loose areol> tissue "u ! brea/1 "o on ea* side1 & a p9t or m ( fluid is sl[ly run 9 f ! res]voir4 ,,*apt] ,,iii4 ,,asphyxia ,,or ,,anox,,mia4 ,"s degree ( asphyxia is a common complication ( inhalational an/hesia3 inde$ "s small degree ( x is almo/ unavoidable4 ,x is h>dly too mu* to say t ! diff]5ce betwe5 a good & a bad an/heti/ is t ! "o recognises & deals ) asphyxia 9 its e>ly /ages1 :ile ! o!r all[s x to assume s]i\s proportions be=e he becomes aw>e ( its exi/5ce4 ,! man :o only realises t asphyxia is pres5t :5 ! pati5t is deeply cyanos$ & has ceas$ to be able to draw any air at all into 8 *e/ may "k mu* ( ! physiology ( an/hetic drugs1 & be well up 9 complicat$ an/hetic app>atus1 b kn[s no?+ ( ! prop] practice ( an/hesia4 ,asphyxia arises dur+ an/hesia f sev]al causes4 ,9 ! fir/ place1 ! drug :i* ! pati5t is inhal+ & absorb+ into ! blood1 turns out f 8 r$ corpuscles a correspond+ quantity ( oxyg54 ,:ile ?is is only se5 9 its extreme =m 9 ! case ( nitr\s oxide gas1 x is a factor act+ ev5 9 ! case ( o!r an/hetics4 ,secondly1 dur+ deep an/hesia1 ! respiratory c5tre may be some:at depress$1 & ! =ce & frequ5cy ( ! respiratory act dim9i%$4 ,?irdly1 ! respiratory passages may be p>tially or :olly occlud$ f me*anical causes4 ,?is is f> ! mo/ important type ( asphyxia1 be+ ! mo/ common1 ! mo/ fatal1 & ! mo/ easily prev5t$4 ,common ,causes ( ,me*anical ,asphyxia4 7#a7 ,,cl5*+ ,,( ,,! ,,jaws arises n uncommonly dur+ an/hesia1 be+ specially frequ5t t[>ds ! end ( ! induction p]iod4 ,s9ce a v l>ge proportion ( individuals h nasal passages insuffici5t 9 bore to c>ry ! full volume ( respir$ air1 respiration mu/ be ob/ruct$ if ! jaws are cl5*$4 7#b7 ,,fall+ ,,back ,,( ,,! ,,l[] ,,jaw ,,& ,,base ,,( ,,! ,,tongue ,,ov] ,,! ,,epiglottis4--,?is is always liable to happ5 aft] ! muscles are deeply relax$4 7#c7 ,,muc\s ,,or ,,blood ,,or ,a ,,=eign ,,body ,,is ,,drawn ,,by ,,inspiration ,,into ,,! ,,air ,,passages4--,*anges ( position ( ! head may release muc\s :i* has be5 ga!r+ 9 "s p>ts ( ! m\? or ph>ynx4 ,= in/ance1 if ! head has be5 ly+ on ! side = "s "t1 a pool ( muc\s or saliva commonly ga!rs 9 ! mo/ dep5d5t *eek1 & unless ?is is mopp$ out be=e ! head is br\ght into ! mesial position1 ?is pool w be sudd5ly tipp$ backw>ds1 & v probably drawn into ! l>ynx4 ,aga91 9 op]ations ^u ! nasal or oral cavities1 blood is always liable to be inspir$1 & n a few tee? h f\nd _! way into ! air passages 9 ! practices ( d5tal surgeons :o d n take precautions aga9/ ?is accid5t4 7#d7 ,,spasm ,,( ,,! ,,adductors ,,( ,,! ,,vocal ,,cords is "o ( ! mo/ common & mo/ baffl+ incid5ts 9 an/hesia4 ,x ann\nces its pres5ce by ! comm5cem5t ( l>yngeal /ridor1 a high-pit*$ cr[+ noise1 :i* is z annoy+ = ! surgeon & an/heti/ to he> z x is detrim5tal to ! progress ( a smoo? an/hesia4 ,inspir$ muc\s or blood almo/ inv>iably sets x up1 & ! two conditions ( fluid 9 ! l>ynx & n>r[+ ( ! glottis f approximation ( ! cords1 add _! effects toge!r1 ) result+ ob/ruction ( a high degree4 ,l>yngeal /ridor1 h[ev]1 frequ5tly occurs ev5 :5 no fluid has be5 inspirat$4 ,x may be set up z a reflex f ! area ( op]ation4 ,dilatation ( ! sph9ct] ani1 & removal ( ! prepuce 9 circumcision1 are two common examples ( ?is4 ,x is also und\bt$ly sometimes caus$ by giv+ too /rong a vap\r dur+ ! latt] "p ( ! induction /age4 ,/ridor un=tunately sometimes occurs f no obvi\s cause at all1 or to speak m correctly1 f causes :i* are at pres5t n kn[n to u4 ,x is ! au?or's belief t "o ( ^! causes may prove to be morphia giv5 z a prelim9>y to inhalational an/hesia4 ,9 8 exp]i5ce1 /ridor has be5 m frequ5t ) morphia ?an )\t1 p>ticul>ly if *lor(orm be ! an/hetic *os54 ,beyond t he _c at pres5t g4 7#e7 ,,pressure ,,^u ,,! ,,air ,,passages ,,( ,,neopla/ic ,,or ,,inflammatory ,,swell+s ,,9 ,,! ,,neck4--,9 su* cases any ob/ruction :i* may exi/ be=e induction w probably become int5sifi$ dur+ ! process1 & a complete arre/ ( respiration is n uncommon4 ,l>ge gtres are ! mo/ common type ( neoplasm to give tr\ble1 & all acute inflammatory conditions 9 ! neck :i* ext5d t[>ds ! tra*ea are notori\s = _! t5d5cy to give cause = anxiety dur+ an/hesia4 ,! ,physiology ( ,asphyxia4 ,an animal1 subject$ to asphyxia1 ei!r me*anically or o!rwise1 %[s ! foll[+ signs3-- 7a7 ,increase ( ! =ce & frequ5cy ( ! respiratory movem5ts ( *e/ & abdom54 ,ev5 ?\gh !re be a complete me*anical ob/ruction1 increas$ ef=ts to brea! w /ill be made = "s mom5ts1 al?\gh air no long] passes 9 & out ( ! *e/4 7b7 ,!re is a consid]able rise ( blood pressure ow+ to a high degree ( vaso-con/ruction4 7c7 ,! pupils dilate4 7d7 ,g5]alis$ convulsions4 7e7 ,! animal succumbs f9ally f c>diac failure4 ,no he>t muscle c cont9ue to function prop]ly if suppli$ by ! coron>y art]ies ) v5\s blood4 ,moreov]1 ! he>t pump has to act aga9/ ! greatly increas$ p]iph]al resi/ance induc$ by vaso-con/riction4 ,x mu/ !re=e be a matt] ( "t only :5 ! /ronge/ & heal?ie/ he>t w cease to contract "u ! abnormal conditions ( asphyxia4 ,!re are 9 asphyxia1 two alt]ations 9 ! blood-gasses1 i4e4 lack ( oxyg5 & increase ( ,,co#b4 ,! action ( ^! two conditions h be5 diff]5tiat$ by exp]im5tal "w 7,/>l+1 ,kayala1 ,j]usalem71 & "o c say def9itely t ! excess ( ,,co#b is ! cause ( ! increas$ activity ( ! respiratory ef=ts1 & t ! rema9+ ph5om5a are due to oxyg5 />vation4 ,?is po9t is ( "s importance 9 consid]+ an/hetic me?ods 9 :i* re-brea?+ 7brea?+ 9 & out ( a bag7 is practis$4 ,! use ( su* me?ods has (t5 be5 ?\ghtlessly condemn$ z 8poison+ ! pati5t ) 8 own ,,co#b40 ,)9 ! limits usually practis$1 a re-brea?+ me?od does n involve any su* risk1 provid$ oxyg5 />vation does n occur4 ,?is po9t is ref]r$ to aga9 9 ,*apt] iv4 ,cl9ical ,signs ( ,me*anical ,asphyxia 9 ! ,an/hetis$ ,subject4 ,! classical signs ( asphyxia above describ$ are h>dly to be expect$ 9 ! op]at+ !atre1 b ess5tially ! condition ( ! pati5t :o develops respiratory ob/ruction :ile "u an an/hetic is simil> to t produc$ exp]im5tally 9 animals 9 ! laboratory4 ,! *anges mo/ easily obs]v$ are z foll[s3-- 7#a7 ,alt]ation ( ! col\r4--,cyanosis %[s itself e>lie/ 9 ! lips1 & ! lobules ( ! e>s1--lat] ! :ole face becomes dusky4 7#b7 ,dilatation ( ! pupil1 :i* ceases to respond to ! /imulus ( light4 7#c7 ,! respiratory movem5ts increase 9 dep? & frequ5cy4--,! *e/ & abdom9al walls heave =cibly2 b 7#d7 ,! volume ( air pass+ 9 & out ( ! glottis is dim9i%$4--,9 complete ob/ruction1 ( c\rse1 none passes at all4 ,9 pass+ we may draw ! moral t p]si/5ce ( *e/ movem5ts is no pro( ( ! passage ( air 9 & out ( ! *e/3 t c only be prov$ by he>+ ! movem5t ( air ?r\gh glottis & m\? or nose1 or feel+ x on ! delicate sk9 ( ! back ( ! obs]v]'s h&4 7#e7 ,true convulsions are n se51 unless we may consid] ! jactitation ( deep ,n#b,o an/hesia z su* 7see ,*apt] ,,vii474 ,nev]!less1 !re are obvi\s & mo/ valuable signs ( asphyxia to be f\nd 9 ! muscul> sy/em (t5 q e>ly4 ,^! consi/ 9 ! incid5ce ( muscul> rigidity1 :i* is frequ5tly obs]v$ fir/ 9 ! muscles ( ! abdom9al wall4 ,a surgeon p]=m+ lap>atomy w notice at once ! occurr5ce ( ?is ph5om5on1 ?an :i* h>dly any?+ c complicate & delay 8 task m effectively4 ,! an/heti/ :o kn[s 8 "w w1 ^u he>+ f ! surgeon a compla9t z to ! rigidity ( ! abdom9al wall1 devote 8 att5tion fir/ to secur+ a p]fectly free air-way be=e decid+ t a deep] an/hesia is requir$4 ,illu/ration3 ,,fig4 #e4--,vici\s circle ( asphyxia4 ,prev5tion & ,treatm5t ( ,asphyxia4 ,once asphyxia1 especially me*anical asphyxia1 has begun1 x almo/ inv>iably t5ds to get worse4 ,! engorgem5t affects among o!r v5ules1 ^? :i* run "u ! muc\s membrane ( ! respiratory tract1 /ill fur!r ob/ruct+ ! passage ( air4 ,! muscul> rigidity1 moreov]1 soon manife/s itself 9 ! adductors ( ! vocal cords & ! muscles :i* close ! jaws3 ! pati5t has ?us ent]$ into a 8vici\s circle10 ,fig4 #e4 ,x is evid5t t ! prev5tion ( ! e>lie/ signs ( asphyxia is to ! an/heti/ a matt] ( vital int]e/4 ,! c>d9al po9ts to wat* are z foll[s3-- 7#a7 ,keep ! neck ( ! pati5t z f> z possible 9 a natural position1 i4e4 d n ei!r flex or ext5d ! head unduly ^u ! body unless ! nature ( ! op]ation dem&s su* an unusual position4 7#b7 ,ma9ta9 a free passage = air ei!r ?r\gh ! nose or ! m\?4 7#c7 ,keep ! l[] jaw 9 good position ?r\gh\t ! adm9i/ration4 7#d7 ,avoid turn+ ! face f ! lat]al to ! dorsal 7face up7 position unless ess5tial4 ,if x has to be done1 be c>eful fir/ to mop out any 8pool0 f ! dep5d5t *eek4 7#e7 ,deal z effectively z possible ) ! e>lie/ appe>ance ( l>yngeal /ridor4 ,let u see h[ 9 a normal case1 ^! rules c be appli$4 ,) ! pati5t ly+ 7or1 9 exceptional circum/ances1 sitt+7 9 a com=table position1 ! %\ld]s & head rais$ above ! re/ ( ! body & ! face look+ upw>ds 7or /raight =w>ds1 9 ! case ( ! sitt+ pati5t71 ! an/hetic is begun sl[ly1 & ! pati5t enc\rag$ to take 8 "t & to brea! naturally4 ,at ?is /age ! jaw ne$s no support1 ! muscles be+ nei!r relax$ by deep an/hesia1 nor spa/ic f asphyxia4 ,) ! adv5t ( muscul> relaxation1 ! head is turn$ to "o side1 t :i* is opposite to ! side on :i* ! surgeon w be work+1 be+ usually *os54 ,we mu/ n[ det]m9e :e!r ! pati5t c brea! be/ ?r\gh ! m\? or ! nose1 & make sure t ! *annel *os5 is z free z possible4 ,9 ! majority ( cases x w be f\nd t respiration is oral1 & t all t is necess>y is to support ! l[] jaw by a f+] hook$ into ! depression j bel[ ! symphysis m5tes4 ,! h&s ( ! an/heti/1 !re=e1 take up a position f :i* 9 n9e cases out ( t5 !y w nev] require to be mov$4 ,! h& ( ! side t[>d :i* ! pati5t's face is turn$ supports ! jaw & keeps ! face-piece or mask adapt$ to ! face4 ,! middle f+] is press$ into ! space bel[ ! symphysis m5tis1 & ex]cises traction =w>ds & a little upw>ds1 ?us prev5t+ ! jaw f slipp+ backw>ds2 ! index f+] lies along ! l[] "p ( ! mask1 ma9ta9+ adaptation betwe5 x & ! *92 ! ?umb be>s on ! mask high] up1 keep+ its upp] "p press$ aga9/ ! bridge ( ! pati5t's nose1 & also s]v+ z a po9t d'appui1 or fulcrum1 f :i* ! jaw traction by ! middle f+] c conv5i5tly be ex]cis$4 ,?is grip once le>nt is n fatigu+ to ! h&1 & is 9 ! au?or's op9ion "o ( ! ess5tial po9ts = ! beg9n] to ma/] 7see ,fig4 #bh;,c1 page #he74 ,! opposite h& holds ! drop bottle1 if ! me?od 9 use is an op5 "o1 ! wri/ re/+ ^u ! upp]mo/ side ( ! pati5t's head4 ,illu/ration3 ,,fig4 #f4--;,hewitt's d5tal props4 ,fig4 #bh;,c %[s ?is grip 9 op]ation1 :ile ,fig4 #bh;,d %[s ! alt]native frequ5tly adopt$4 ,?is alt]native has v>i\s disadvantages4 ,x cov]s up a l>g] "p ( ! pati5t's face ?an ! me?od recomm5d$1 & x t5ds to tilt ! mask sideways4 ,! little f+] is suppos$ to be hook+ =w>d ! jaw by press+ beh9d its angle1 b su* a me?od is v fatigu+ if 9 use = m ?an a few mom5ts4 ,9 a proportion ( cases1 x is f\nd t a free air-way _c be ma9ta9$ by ^! simple measures4 ,upp] or l[] tee? 7or bo?7 may be miss+ & traction ^u ! l[] jaw only closes ! m\? ! m firmly4 ,9 mo/ ( ^! cases1 ! difficulty c be met by ! use ( ! d5tal prop4 ,^! are made 9 v>i\s sizes & %apes1 ( :i* ! be/ kn[n are ,hewitt's & ,bellamy ,g>dn]'s 7see ,figs4 #f & #g74 ,! latt] are made ( alum9ium & are ( small size only4 ,!y are ! mo/ conv5i5t = cases ) tee? bo? 9 ! upp] & l[] jaw1 b :o suff] f a rec$+ l[] jaw n easily kept =w>d unless ! prop is us$ z a rock]1 z x 71 ^u :i* x c be slid =w>d4 ,hewitt's props are ( plat$ metal1 ) lead on ! cups1 to avoid injury to ! tee?4 ,!y are made 9 five sizes1 ( :i* ! middle & l>g] are v conv5i5t = cases 9 :i* "o or bo? r[s ( tee? are miss+4 ,illu/ration3 ,,fig4 #g4--;,bellamy ,g>dn]'s ,d5tal ,props4 ,illu/ration3 ,,fig4 #h4--,phillips' modification ( ,hewitt's artificial airway4 ,= cases entirely )\t tee?1 & 9 :i* a l>ge flabby tongue is prone to fall back ov] ! epiglottis1 ! m\? tube 7,fig4 #h7 is v conv5i5t4 ,! rubb] %ank lies along ! top ( ! tongue1 ! metal end lies betwe5 ! gums4 ,z orig9ally introduc$ by ,hewitt1 ! air-way 0 circul> 9 cross section1 b ! flatt5$ model figur$ is a di/9ct improvem5t4 ,x 0 introduc$ by ,dr ,phillips4 ,illu/ration3 ,,fig4 #i4--,silk's nasal tubes4 ,occasionally "o decides to facilitate nasal r ?an oral brea?+1 & if ! natural passages are inadequate1 rec\rse may be _h to ! passage ( a %ort piece ( dra9age tube ( ! calibre ( a numb] #aj ca!t]1 & ab\t #c in*es 9 l5g?4 ,) su* a tube 9 "o or bo? sides ( ! nose1 rea*+ f ant]ior to po/]ior n>es1 nasal respiration is usually possible ev5 9 mu* ob/ruct$ noses 7,silk74 7,fig4 #i47 ,illu/ration3 ,,fig4 #aj;,a4--,bellamy ,g>dn]'s tongue-clip4 ,illu/ration3 ,,fig4 #aj;,b4 ,r+ tongue =ceps4 ,illu/ration3 ,,fig4 #aj;,c4 ,glossotilt4 ,illu/ration3 ,,fig4 #aa;,a4--,boxwood w$ge = op5+ jaws4 ,illu/ration3 ,,fig4 #aa;,b4--,w$ge = op5+ jaws4 ,illu/ration3 ,,fig4 #aa;,c4--,m\? gag4 ,if prop] & timely use be made ( "o or o!r ( ^! simple devices1 ! use ( ! tongue =ceps is r>ely necess>y4 ,occasionally1 h[ev]1 x may be requir$1 & a suitable appliance %\ld always be at h& = an em]g5cy4 ,fig4 #aj %[s two types4 ,! little clip ( ,mr ,bellamy ,g>dn] is pref]able to ! r+ type1 ! passage ( ! spike ?r\gh ! tongue sub/ance produc+ less aft] pa91 ?an ! bruis+ foll[+ ! use ( ! o!r in/rum5t4 ,! ?ird draw+ 9 ,fig4 #aj is ( an in/rum5t n mu* kn[n outside ,ed9burgh2 x is call$ a glossotilt1 & is int5d$ to lev] =w>d ! base ( ! tongue1 z an alt]native to nipp+ ! tip ( ! organ ) =ceps1 & has1 9 ! op9ion ( "s1 v>i\s advantages4 ,be=e us+ ei!r m\? prop or tongue =ceps1 x is occasionally necess>y to use "s me*anical means to lev] op5 a tightly cl5*$ jaw4 ,! e>li] "o int]f]es 9 a case ( me*anical asphyxia1 ! less necessity w exi/ = ! use ( su* means4 ,fig4 #aa %[s two well-kn[n m\? gags1 & also a box-wood w$ge1 ! use ( :i* is less liable to injure tee? ?an a metal in/rum5t4 ,if a gag is us$1 ! blades :5 clos$ %\ld lie ! "o beh9d ! o!r1 n side by side4 ,?is ensures a m9imal ?ickness to be ins]t$ betwe5 ! tightly cl5*$ tee?4 ,treatm5t ( ,l>yngeal ,/ridor4 ,?is is ( necessity difficult s9ce ! causation ( ! condition is 9 _m cases obscure4 ,! error common to mo/ beg9n]s1 & to _m :o w\ld res5t su* a title be+ appli$ to !m1 is to reg>d ! appe>ance ( /ridor z an indication to deep5 ! an/hesia4 ,:e!r ! cause lie 9 local irritation ( ! l>yngeal muc\s membrane or 9 "s /imulus f ! area ( op]ation1 ! condition is presumably always ess5tially a reflex spasm ( ! adductors ( ! vocal cords1 b x is a reflex :i* may p]si/ ev5 9 an an/hesia s deep t ! vital m$ull>y c5tres are 9 p]il4 ,! prev5tive treatm5t consi/s *iefly 9 foll[+ ! o!r rules set =? above = ! prev5tion ( asphyxia ) su* fai?ful c>e1 t ! pati5t nev] ent]s into ! vici\s circle ( asphyxia ( :i* /ridor is s prom95t a feature4 ,pati5ce 9 ! induction /age--! avoidance ( =c+ ! an/hetic ^u ! pati5t--is a safegu>d n to be =gott54 ,once ! condition has aris51 x saves "t to )draw ! an/hetic altoge!r1 & to all[ ! pati5t to brea! no?+ b fre% air4 ,brisk friction ( ! lips ) a r\gh t[el (t5 does good1 presumably by sett+ up a 8cross reflex40 ,9 sev]e cases1 a mo/ valuable measure is ! inhalation ( pure oxyg51 a cyl9d] ( :i* %\ld always be at h& 9 ! op]at+ !atre4 ,ev5 an ob/ruct$ air-way w convey en\gh undilut$ oxyg5 to r$uce ! v5osity ( ! blood1 & s cut across ! 8vici\s circle40 ,s mu* = ! treatm5t ( ! e>ly /ages ( asphyxia1 ! m advanc$ /ages con/itute "o ( ! 8accid5ts ( an/hesia10 & are dealt ) 9 ,*apt] ,,xvi4 ,,*apt] ,,iv4 ,,me?ods ,,( ,,an,,/hetis+4 ,c]ta9 t]ms su* z 8op5 me?od10 8clos$ me?od10 etc41 are us$ 9 describ+ diff]5t sy/ems ( an/hetis+1 & x w save "t lat] if ^! are n[ def9$4 ,! ,,op5 ,,me?od is "o 9 :i* ! drug is dropp$ or p\r$ ^u a fabric /ret*$ on a mask :i* does n lie 9 close apposition to ! face4 ,if ! /ud5t w exp]im5t ) su* a mask z ,s*immelbus*'s1 he w f9d t by no ef=t c he make its :ole circumf]5ce t\* 8 face at ! same "t4 ,an/hetics vap\ris$ f su* masks mu/ ( necessity be inhal$ freely dilut$ ) fre% air4 ,^! masks are only suitable = use ) *lor(orm4 ,! ,,p]halation ,,me?od4--,?is t]m is n us$ (t51 b x is ! mo/ /rictly correct "n to give to ! process commonly call$ 8op5 e!r40 ,if ! /ud5t w exam9e ,bellamy ,g>dn]'s op5 e!r mask 7,fig4 #bg7 he w f9d t x is delib]ately %ap$ to lie ov] its entire circumf]5ce 9 close apposition to ! face ( ! av]age pati5t4 ,9 actual use x is well h[ev] to make sure ( ?is apposition by ! use ( a r+ ( gauze z %[n 9 ,fig4 #bh;,a4 ,^u ! mask is /ret*$ gauze ( a ?ickness j z great z w p]mit free respiration to take place ?r\gh its lay]s4 ,! :ole bulk ( ! respir$ air mu/ pass ?r\gh ! fabric1 none escap+ betwe5 ! face & mask4 ,! t]m 8,,semi-,,op50 is appli$ to v>i\s me?ods n[ r>ely se54 ,"o ( ! be/ kn[n ( ^! 0 ! an/hetic cone1 /ill us$ by a few = ,c4,e4 mixture 7see ,fig4 #de74 ,! t]m 8,,clos$ ,,me?od0 is appli$ to "o 9 :i* ! pati5t brea!s 9 & out ( a clos$ bag4 ,! ,clov] & ,ormsby inhal]s are 8clos$0 in/rum5ts4 ,) ?is me?od ! pati5t rapidly uses up ! oxyg5 ( ! conta9$ air1 & accumulates consid]able ,,co#b2 life c\ld n be su/a9$ = any long p]iod ( "t "u su* a sy/em4 ,oxyg5 mu/ be suppli$ f "t to "t by p]mitt+ say "o brea? 9 five to be tak5 f ! fre% air in/ead ( f t 9 ! bag4 ,alt]natively1 oxyg5 f a cyl9d] may be suppli$ by an accessory pipe into ! inhal]4 99 99 99 99 99 ,?is me?od is also ref]r$ to z ! ,,re-,,brea?+ ,,me?od4 99 99 99 99 99 ,! ,,valv$ ,,me?od is us$ only ) 8gas0 or 8gas-oxyg540 ,! facepiece fitt+ accurately1 ! pati5t draws all ! volume ( 8 inspiration f ! inhal]3 8 expirations he propels ?r\gh a valve1 into ! g5]al atmosph]e ( ! room4 ,if nitr\s oxide unmix$ ) oxyg5 is be+ giv51 ! pati5t suff]s f oxyg5 />vation ev5 m rapidly & completely ?an 9 ! re-brea?+ me?od4 ,dur+ ! induction p]iod ( gas an/hesia1 su* oxyg5 />vation is practis$ delib]ately1 & if n pu%$ too f> is h>mless4 ,x _c1 h[ev]1 be cont9u$ = m ?an a brief space ( "t4 ,! admixture ( oxyg5 to ! vap\r be+ brea!d entirely aboli%es ?is unfav\rable feature ( ! valv$ me?od4 ,!re is1 h[ev]1 ano!r consequ5ce ( ! use ( 8valves0 :i* is unaffect$ by ! addition ( oxyg54 ,ref]5ce has already be5 made to ,y&ell ,h5d]son's acapnic !ory1 & if "u any =m ( an/hesia ! pati5t c be r$uc$ to a condition ( ,,co#b />vation1 x w be :5 ! valv$ sy/em ( adm9i/ration is 9 op]ation = a prolong$ p]iod4 ,z a matt] ( exp]i5ce1 pati5ts brea?+ 8on ! valves0 d (t5 exhibit %all[ respirations & slight pallor :i* is rapidly & v /rik+ly rem$i$ by turn+ to ! rebrea?+ me?od4 ,"o c h>dly d\bt t ! improvem5t is due to a gradual re-accumulation ( c>bon di-oxide 9 ! blood & tissues4 ,two o!r t]ms ref]r+ n to ! type ( inhal] b to ! me?od ( supply+ ! drug1 are 9 use4 ,by ! 8,,drop0 ,,me?od1 we mean "o 9 :i* ! an/hetic is suppli$ 9 a /eady s]ies ( drops4 ,! fl[ may be quick or sl[1 b x always arrives on ! mask 9 isolat$ drops ( uni=m size4 ,su* a me?od dem&s m con/ant att5tion ?an ! next to be describ$1 b x is capable ( yield+ t ev5 uni=mity ( vap\r /r5g? s desirable 9 op5 me?ods4 ,,! ,,d\*e ,,me?od is un=tunately f> m commonly us$ by ^? ^: att5tion has nev] be5 drawn to ! significance ( ! diff]5ce betwe5 ! two4 ,supplies ( ! drug r5d]$1 say1 e tw5ty seconds _c possibly give an ev5 vap\r /r5g?4 8,,s+le ,,dose0 me?ods are ( use *iefly 9 d5tal surg]y4 ,! pati5t is *>g$ up ) ! an/hetic1 & ! op]ator has to beg9 8 "w z soon z ! mask is )drawn f ! face1 ceas+ z soon z ! pati5t %[s any signs ( recov]+ consci\sness ( pa94 ,s+le dose an/hetics are 9 a class by !mselves4 ,9 ord] to a*ieve success ) !m1 special exp]i5ce on ! "p ( ! adm9i/rator & mutual confid5ce betwe5 op]ator & an/heti/ are ess5tial4 ,! p]iod ( an/hesia available to ! op]ator :i* any p>ticul> 8s+le dose0 an/hetic may be expect$ to yield is obvi\sly a matt] ( ! fir/ importance1 & ! table giv5 9 ,*apt] ,,xix4 w be f\nd helpful 9 ?is connection4 ,,*apt] ,v4 ,,! ,,cl9ical ,,obs]vation ,,( ,,! ,,pati5t4 ,/ages ( ,an/hesia4 ,an/hesia has be5 divid$ into f\r cl9ical /ages correspond+ to ! degrees to :i* ! n]v\s sy/em has be5 affect$4 ,! b\nd>ies betwe5 ^! /ages are (t5 ill-def9$1 b ! t]m9ology has "s value z facilitat+ description4 ,,! ,,fir/ ,,/age la/s f ! comm5cem5t ( inhalation up to ! "t :5 volitional self-control is lo/ by ! pati5t4 ,,! ,,second ,,/age 9 ! old] text-books 0 said to be *>act]is$ by /ruggl+1 %\t+1 & brea?-hold+4 ,) a pati5t n addict$ to alcohol & ) ! an/hetic skilfully adm9i/]$1 ?is description is unduly lurid4 ,,! ,,?ird ,,/age is t ( full surgical an/hesia4 ,,! ,,f\r? ,,/age is t ( ov]-dosage4 ,! ,ocul> ,reflexes 9 ,an/hesia4 ,^! give su* valuable assi/ance to ! an/heti/ t x w be well to def9e & describe !m z a prelim9>y4 ,!y are ?ree 9 numb]4 ,,! ,,conjunctival ,,reflex is be/ elicit$ by draw+ ! upp] lid upw>ds f ! eyeball & reta9+ x 9 t position ) "o f+]1 :ile ) ano!r f+] ! ocul> conjunctiva is lightly t\*$ 9 ! area ( ! inn] can?us4 ,if ! an/hesia is v light1 bo? lids attempt to approximate & close ! palebral fissure4 ,! upp] lid may slip d[n f "u ! reta9+ f+] & come into its prop] place1 :ile ! l[] lid is elevat$4 ,at a deep] level ( an/hesia !re is n complete action ( ! orbicul>is b m]ely ( a c]ta9 "p ( x1 s t all t is obs]v$ is a twit* inw>ds ( ! l[] lid4 ,ev5 ?is =m ( ! reflex disappe>s be=e ! corneal reflex4 ,,! ,,corneal ,,reflex is elicit$ by pu%+ up ! upp] lid by "o f+] & ) ! pulp ( ! same f+] lightly bru%+ ! c5tre ( ! cornea z soon z x is expos$1 :5 we feel or see ! upp] lid come back into position ) a %>p def9ite twit*4 ,! exam9+ f+] mu/ be slipp$ sm>tly out ( ! way z soon z ! cornea has be5 t\*$4 ,ev5 9 deep an/hesia1 a trace ( ?is reflex c usually be elicit$ if ! little manipulation be prop]ly p]=m$4 ,! conjunctival & corneal reflexes are frequ5tly confus$ 9 ! m9d ( ! /ud5t4 ,! mo/ common mi/ake made is to p9 ! upp] lid firmly some:]e 9 ! region ( ! bony ro( ( ! orbit1 to dab ! eye f> too vigor\sly1 & to believe t no reflex is pres5t because no movem5t ( ! upp] lid takes place4 ,9 ! fir/ place1 ! upp] lid _c move if x is rigidly held aga9/ a bony plate3 9 ! second place1 x is :olly unnecess>y to inflict ^u ! cornea m ?an ! lighte/ ( t\*es4 ,bo? ^! reflexes are to be us$ ) great discretion1 undue frequ5cy & excessive vig\r ( t\* be+ alike capable ( sett+ up s]i\s inflammatory reaction4 ,,! ,,pupill>y ,,light ,,reflex is elicit$ by %utt+ (f light f bo? pupils = t5 to tw5ty seconds & !n sm>tly )draw+ ! protect+ f+]s & all[+ z /rong a light z possible to fall on to ! eye4 ,! response ( ! cili>y muscle %\ld always be pres5t2 its abs5ce is a c]ta9 indication ( some?+ wrong3 "s sluggi%ness may be p]missible "u e!r1 b ev5 t is sugge/ive ( tr\ble if *lor(orm is ! an/hetic4 ,! use ( a prelim9>y hypod]mic ( morphia t5ds to make ! pupil some:at small] ?an normal1 & to elicit ! light reflex x may be necess>y to cut (f illum9ation = a some:at long] p]iod ?an if no morphia _h be5 giv54 ,nev]!less ) a little c>e1 ! light reflex %\ld always be capable ( demon/ration ev5 9 ! morph9is$ subject4 ,! ,obs]vation ( a ,normal ,case4 ,9 ! case ( nitr\s oxide & ( e?yl *loride1 ! pati5t passes ?r\gh ! v>i\s /ages v rapidly1 & ! picture ( an/hesia z induc$ by ei!r ( ^! two is !re=e be/ describ$ sep>ately4 ,! foll[+ may be tak51 !re=e1 z an acc\nt ( :at is to be obs]v$ 9 ! pati5t inhal+ e!r or *lor(orm1 unless a specific ref]5ce is made to "o ( ! o!r an/hetics4 ,,fir/ ,,/age4--,! fir/ sign t "s effect is be+ produc$ 9 ! pati5t is usually ! appe>ance ( ! movem5ts ( swall[+2 ! hyoid & ?yroid c be felt or se5 to be mov+ 9 conjunction ) ! muscles ( deglutition4 ,dur+ ?is /age1 ! pati5t be+ /ill to "s ext5t "u volitional control1 !re %\ld be no o!r movem5t notic$4 ,! eyes are usually clos$ & ! col\r normal2 ! respiration may be hurri$ by excitem5t1 b judici\s h&l+ ( ! pati5t w d mu* to m9imise ?is4 ,,! ,,second ,,/age is really ent]$ :5 volitional control is lo/4 ,x may be *>act]is$ by /ruggl+ & %\t+ by ! pati5t1 ev5 if ! an/hetic is prop]ly adm9i/]$2 b ) a heal?y pati5t & a good an/heti/1 all t usually occurs 9 ! way ( movem5t by ! pati5t is "s rigidity ( ! limbs & a slight attempt1 p]haps1 to lift ! head f ! pill[ or a limb f ! c\*4 ,! brea?+ t5ds dur+ ! fir/ "p ( ?is /age to be light & is r>ely entirely regul>3 slight pauses occur1 usually aft] an inspiration1 less commonly aft] expiration4 ,s]i\s 8hold+ ( ! brea?0 7aft] an inspiration7 r>ely occurs save 9 ! type ( pati5t :o is also /ruggl+2 if x does occur to a degree :i* causes any blu5ess ( ! pati5t's face 7cyanosis71 x usually calls = ! removal ( ! an/hetic = a mom5t until normal brea?+ has be5 resum$4 ,! col\r ( ! face r>ely dep>ts mu* f normal dur+ ! second /age1 unless cyanosis f brea?-hold+ int]v5es4 ,! eyes are usually op5$1 z ! second /age progresses1 & ! eyeballs t5d to rotate sl[ly 9 e plane4 ,! pupils are usually l>ge1 b react %>ply to light4 ,bo? conjunctival & corneal reflexes are brisk4 ,,! ,,onset ,,( ,,! ,,?ird ,,/age is m>k$ by ! appe>ance ( muscul> relaxation4 ,any limb :i* ! pati5t may h be5 hold+ rigidly up s9ks d[n on to ! c\*1 & x w be f\nd t if an attempt be n[ made by ! an/heti/ 7z x %\ld be7 to turn ! head ( ! pati5t to "o side or ano!r1 ! muscles ( ! neck no long] resi/4 ,! respiration also alt]s 9 type1 los+ its t5d5cy to lightness & irregul>ity1 & becomes full1 deep1 & regul>4 ,9 op5 e!r an/hesia p>ticul>ly1 expiration commonly assumes a 8bl[+0 type v *>act]i/ic1 & :i* to ! tra9$ e> is ( itself an indication t full surgical an/hesia is pres5t or at any rate n f> di/ant4 ,! col\r v>ies some:at ) ! an/hetic 9 use4 ,) e!r x is usually some:at high] ?an normal1 & a trace ( blu5ess may be pres5t if ! me?od is ! 8clos$0 "o4 ,any?+ m ?an a trace1 h[ev]1 mu/ be reg>d$ z abnormal1 :atev] ! me?od or an/hetic may be4 ,) *lor(orm ! col\r is p]haps a little pal] ?an t normal to ! individual4 ,! eyelids are usually half op51 & ! eyeballs at re/ look+ =w>d & slightly d[nw>ds4 ,an extreme rotation d[nw>d may usually be tak5 z a sign ( v deep an/hesia4 ,! pupil is1 z already said1 always active to light1 b its actual size v>ies ) ! an/hetic us$4 ,) e!r1 p>ticul>ly 8clos$0 e!r1 x may be l>ge 7#d-e millimetres73 ) op5 e!r1 prec$$ by morphia1 ab\t #c-d millimetres3 a good *lor(orm an/hesia usually exhibits a pupil ( only #b-c millimetres1 & if morphia has also be5 giv51 x may be p9-po9t 9 size4 ,too mu* emphasis mu/ n be plac$1 h[ev]1 ^u ! m]e size ( ! pupil2 t may v>y )9 wide limits )\t necess>ily indicat+ s]i\s abnormality4 ,! ess5tial po9t is t ! light reflex %all be brisk4 ,a pupil ( #e millimetres react+ %>ply to light may be ( no special mom5t3 "o ( t size immobile to light w\ld cause real anxiety4 ,! conjunctival reflex usually disappe>s fairly e>ly 9 ! ?ird /age3 if briskly pres5t1 ! an/hesia is c]ta9ly a light "o1 & probably insuffici5t = an abdom9al section4 ,! corneal reflex if prop]ly tak5 9 ! way already describ$ c usually be elicit$ ?r\gh\t ! ?ird /age4 ,9 an an/hesia deep en\gh = abdom9al section x is1 ( c\rse1 n brisk1 b we may say g5]ally t its entire abs5ce is presumptive evid5ce ( a v deep an/hesia--probably undesirably deep4 ,x mu/ n be =gott5 t "s local causes su* z dry+ ( ! surface ( ! cornea may cause x to disappe>1 & 9 case ( d\bt x is sometimes wor? :ile to wa% out ! eye ) a little sal9e solution4 ,if aft] do+ s ! an/heti/ /ill f9ds ! reflex n pres5t he %\ld be on 8 gu>d4 ,provid$1 h[ev]1 t ! light reflex is /ill pres5t & col\r & respiration satisfactory1 he ne$ n consid] t ! pati5t is 9 any imm$iate dang]4 ,broadly speak+1 !n1 ! ?ird /age1 ! /age :i* is call$ = by ! requirem5ts ( major surg]y1 is *>act]is$ by 7#a7 full regul> respirations2 7#b7 col\r n mu* remov$ f normal2 7#c7 mod]ate siz$ pupil1 l>g] 9 ! case ( e!r ?an *lor(orm2 7#d7 conjunctival reflex fa9t or abs5t2 7#e7 corneal reflex j pres5t1 or1 9 a deep ?ird /age1 j abs5t2 7#f7 light reflex pres5t3 ^! may be reg>d$ z ! signs ( fully develop$ surgical an/hesia4 ,! absolute beg9n] may be s completely out ( 8 reckon+ z to mi/ake ! quietude ( ! lat] "p ( ! fir/ /age = ! appe>ance ( ! ?ird /age4 ,= ! prev5tion ( s gross an error z t1 ! read] ne$ only be ref]r$ to a pati5t /udy ( ! =ego+4 ,b ev5 a man ) consid]able exp]i5ce may frequ5tly be 9 d\bt exactly z to h[ f> ?r\gh ! ?ird /age 8 pati5t has pass$4 ,he may h atta9$ a level :i* w p]mit an incision to be made into ! sk9 )\t movem5t on ! "p ( ! pati5t1 b n "o :i* w\ld relax ! abdom9al muscles suffici5tly = ! p]itoneum to be op5$ )\t elicit+ consid]able resi/ance f ! abdom9al muscles4 ,9 su* mom5ts ( d\bt1 ! au?or is accu/om$ to reque/ ! surgeon to make 8 sk9 incision1 & obs]ve ! effect :i* ?is trauma has ^u ! dep?1 frequ5cy1 & regul>ity ( respiration4 ,?is furni%es a mo/ valuable guide to ! dep? ( an/hesia4 ,9 a ?ird /age ( v light degree1 ! respiratory rhy?m w be int]rupt$ & ! brea? held = a second 9 inspiration4 ,ap>t f any o!r sign1 t may be tak5 z an index t ! an/hesia is v light--too light to p]mit ( op5+ ! p]itoneal cavity4 ,9 a v deep an/hesia ! respiration is little affect$ by ! sk9 incision1 :ile at a mod]ate & m desirable level ! respiration is quick5$ & deep5$1 b unaffect$ 9 ! regul>ity ( its rhy?m4 ,,! ,,f\r? ,,/age ,,is ,,/age ,,( ,,ov]-,,dose4--,?is /age is1 ( c\rse1 nev] ent]$ volunt>ily4 ,its e>lie/ signs are loss ( all tone 9 ! muscles ( expression1 complete loss ( corneal reflex1 a widely dilat$ pupil ins5sitive to light1 & a type ( respiration :i* ?\gh def9itely weak5$ may %[ occasional deep gasps4 ,circulatory failure & cessation ( respiration f failure ( ! m$ull>y c5tre are ! clos+ ph5om5a ( ov]dose4 ,! ,circulation 9 ,an/hesia4 ,x w be p]haps notic$ t 9 ! =ego+1 no ref]5ce has be5 made to ! exam9ation ( ! pulse4 ,?is is n an ov]sight on ! "p ( ! au?or4 ,x is p]fectly true t "u any an/hetic n complicat$ by an asphysical elem5t1 ! blood pressure falls z ! drug takes effect1 & t 9 ! case ( *lor(orm ! fall is (t5 q consid]able4 ,su* a fall c be appreciat$ by ! skill$ f+]1 b only by conc5trat+ ^u t exam9ation a degree ( att5tion :i* necess>ily detracts f ! adm9i/rator's available en]gy = ! obs]vation ( o!r signs :i* are ( equal value1 & c be m rapidly & c]ta9ly appreciat$ & apprais$4 ,x is nev]!less ess5tial to assure oneself dur+ ! :ole progress ( an an/hesia t ! circulation is 9 a satisfactory condition4 ,two obvi\s guides to ?is are ! col\r ( ! pati5t's face & ! =ce ) :i* cut art]ies sp\t4 ,z reg>ds ! col\r 9 circulatory failure1 "o w\ld naturally expect a pallid face1 & ?is inde$ is ! rule4 ,x mu/ n be =gott51 h[ev]1 t cyanosis may sometimes be c>diac 9 orig94 ,cases d sometimes occur :5 a blui% t+e is se5 on ! lips1 e>s1 & no/rils1 ap>t f any obvi\s cause ( oxyg5 />vation4 ,9 ^! we may reasonably suspect t ! "r he>t is fail+1 & take measures accord+ly4 ,ano!r valuable index to ! /ate ( ! circulation is ! 8sk9 reflex10 t is1 ! spe$ ) :i* ! circulation returns to an area ( ! sk9 :i* has be5 p9*$4 ,! /ud5t %\ld tra9 8 eye by occasionally p9*+ ! lobule ( ! pati5t's e> & obs]v+ fir/ ! :ite area s produc$1 & lat] ! rate at :i*1 9 a normal case1 ! heal?y col\r returns4 ,abnormal ,ph5om5a 9 ,an/hesia4 ,x is n int5d$ to furni% "h any acc\nt ( matt]s m suitably treat$ "u ! 8,accid5ts ( ,an/hesia10 :i* are fully describ$ 9 ,*apt] xvi41 b m]ely to draw ! att5tion ( ! /ud5t to c]ta9 dep>tures f ! normal c\rse ( an/hesia :i* are enc\nt]$ ) v>y+ frequ5cy1 to ascribe !m z f> z possible to _! true causation1 & indicate me?ods ( prev5tion4 ,! abnormalities fall into two classes1 ^? connect$ ) ! n]v\s & muscul> sy/ems1 & ^? 9 :i* respiratory *anges are evid5t4 ,,motor ,,& ,,n]v\s ,,sy/em4 ,clonus or tremor sometimes appe>s 9 "o or m limbs1 ev5 ! trunk be+ affect$ 9 sev]e cases4 ,e!r is practically ! only an/hetic "u :i* ! tremor ev] appe>s1 & ! condition is (t5 spok5 ( z 8e!r tremor40 ,x r>ely appe>s 9 ! female subject1 be+ almo/ limit$ to p[]fully built "y m54 ,com+ on t[>ds ! end ( ! second /age1 x frequ5tly p]si/s 9 ! deepe/ ( ?ird /ages1 & 9 bad cases !re is usually no option b to *ange ov] to *lor(orm--always suppos+ t ! tremor w int]f]e ) ! "w ( ! surgeon4 ,if x w n1 ! condition calls = no active treatm5t1 s9ce x is 9 itself n dang]\s4 ,movem5ts recall+ to ! obs]v] ! condition ( a!tosis se5 9 ! limbs ( hemiplegics are occasionally se5 9 ! an/hetis$ pati5t4 ,! f+]s ( a h& may be sl[ly mov$1 or "o or o!r %\ld] may be %rugg$4 ,! exact cause ( ^! movem5ts is obscure4 ,!y occur 9 all types1 bo? sexes1 & at all ages2 !y are n necess>ily asphyxia ?\gh a trace ( asphyxia seems sometimes to conduce to !m4 ,!y p]si/ = "s "t aft] ! ?ird /age has be5 ent]$1 & ultimately disappe> )\t any obvi\s cause o!r ?an ! passage ( "t4 ,x is r>e = !m to cont9ue m ?an five or t5 m9utes aft] full an/hesia has be5 induc$4 ,_! practical importance lies purely 9 ?is1 t ! inexp]i5c$ an/heti/ obs]v+ "s muscul> movem5ts /ill p]si/+1 may take !m z an infallible sign t an/hesia is n complete1 & may delib]ately take 8 pati5t to a deep] level4 ,if 9 d\bt1 ! an/heti/ mu/1 ( c\rse1 consult all ! o!r recognis$ guides1 su* z ! eye reflexes1 b once he has se5 ^! movem5ts 9 a case1 & _h demon/rat$ to him _! sl[1 rhy?mical "*1 he is n likely to be misl$ on a future occasion4 ,muscul> rigidity has be5 m5tion$ already 9 ,*apt] iii4 ,:5 x p]si/s 9 a pati5t 9 :om o!r signs sugge/ t a full an/hesia has be5 produc$1 ! an/heti/ w usually f9d t att5tion to ! air-way1 & p]haps a :iff ( oxyg51 w rem$y ! tr\ble4 ,respiratory ,abnormalities4 ,%all[ brea?+ or ev5 slight tempor>y arre/s ( respiration arise frequ5tly4 ,dur+ ! induction /age !y may be due to3-- #a4 ,apna or acapnia foll[+ volunt>y excessive brea?+4 #b4 ,us+ morphia be=e *lor(orm4 ,at a lat] /age1 x may be due to3-- #a4 ,acapnia foll[+ excessive brea?+ excit$ reflexly f ! seat ( op]ation4 #b4 ,direct reflex inhibition ( ! respiratory c5tre4 ,an example ( ?is is se5 sometimes :5 ! bladd] is ov]-di/5d$ by lotion4 #c4 ,imp5d+ vomit+4 ,moi/ s\nds n uncommonly appe>4 ,! /ud5t's g5]al k ( m$ic9e w enable him to decide :e!r ! fluid is likely to be 9 ! ph>ynx1 l>ynx1 tra*ea1 or bron*i4 ,if 9 "o ( ! fir/ two nam$1 x w suffice to swab out ! ?roat & enc\rage ! pati5t to c\gh4 ,if1 h[ev]1 moi/ure is evid5tly pres5t 9 ! tra*ea or bron*i1 ! condition is "o call+ = consid]able c>e & judgm5t4 ,x arises m commonly ) e!r ?an ) *lor(orm4 ,mu* w dep5d ^u h[ mu* long] ! surgeon requires to f9i% 8 op]ation4 ,if only a few m9utes m are requir$1 no?+ is necess>y b to cut d[n ! am\nt ( e!r be+ giv5 to ! m9imum possible4 ,if1 h[ev]1 ! surgeon has /ill a good deal to d1 ! safe/ ?+ is to )draw ! e!r & sub/itute *lor(orm or a mixture4 ,be x cle>ly und]/ood1 h[ev]1 t su* a *ange ov] is n devoid ( risk4 ,if x is to be made1 x mu/ be done e>ly1 be=e ! pati5t is cyanos$ & almo/ dr[n$ 9 8 own secretion4 ,9 a neglect$ case :]e cyanosis has already appe>$1 !re w be no option b to int]rupt ! op]ation1 empty ! *e/ by enc\rag+ c\gh+1 & to aid ! process by compress+ ! pati5t's *e/ dur+ expiration4 ,!reaft] *lor(orm may be giv51 b ) ! greate/ c>e4 ,gasp+ & sigh+ are n common ph5om5a b :5 !y occur1 call = close notice f ! an/heti/4 ,exclud+1 ( c\rse1 su* occurr5ces 9 ! fir/ /age1 be=e volitional control has be5 lo/1 !y may be usually b n inv>iably ascrib$ to ov]dosage or to ! appe>ance ( def9ite surgical %ock4 ,:5ev] !y are notic$1 !re=e1 x behoves ! adm9i/rator to ov]haul ! pati5t ?or\ghly1 to consult ! eye reflexes1 ! sk9 reflex1 & ! pulse1 & n to re/ until he is assur$ t !re are no o!r signals ( dang] to be f\nd4 ,/]tor & /ridor4 ,! fir/ ( ^! is caus$ by flapp+ ( ! s(t palate4 ,x is a noise l[ 9 pit*1 resembl+ ord9>y snor+4 ,indicat+ z x does t ! palatal & !re=e probably o!r muscles1 are relax$1 x may if mod]ate 9 volume usually be tak5 z a fav\rable sign4 ,if x becomes v l\d1 h[ev]1 ! probability is t ! base ( ! tongue has fall5 back2 cyanosis w beg9 to appe>1 b w imm$iately be rem$i$ by pull+ =w>d ! jaw or 9 extreme cases1 us+ ! tongue =ceps4 ,/ridor is a high-pit*$ s\nd produc$ by approximation ( ! vocal cords4 ,x has already be5 dealt ) 9 ,*apt] iii4 ,false ,an/hesia4 ,?is t]m has be5 appli$ to a condition (t5 se5 9 *ildr51 & occasionally 9 adults4 ,x is almo/ limit$ to *lor(orm3 ! au?or has nev] se5 a g5u9e case :5 e!r has be5 9 use4 ,x appe>s v quickly aft] inhalation has begun3 ! muscles are relax$1 ! respirations quiet & regul>1 ! conjunctival reflex sluggi%4 ,a v m>k$ feature is ! excessive smallness ( ! pupil4 ,obvi\sly !n1 ! condition mu* resembles a true ?ird /age1 b if ! op]ation be begun1 ! mi/ake w v rapidly be made evid5t1 = ! pati5t w at once move & cry out4 ,9 ess5ce1 ! condition is simply "o ( ord9>y sleep4 ,x c be recognis$ by its appe>ance aft] a p]iod ( inhalation too brief = ! induction ( true an/hesia1 by ! v small pupils & ! lightness ( ! respiration4 ,x w be a wa/e ( "t to p]mit ! condition to cont9ue1 z ! lightness ( ! respiration delays ! tak+ 9 ( a dose ( ! an/hetic suffici5t to induce a prop] ?ird /age4 ,! rem$y is simple1--rub ! lips & face sm>tly ) a t[el or ! h&1 :5 respiration w at once deep5 & ! pupil dilate4 ,!reaft]1 ! induction %\ld proce$ normally4 ,,*apt] ,,vi4 ,,prep>ation ,,( ,,! ,,pati5t4 ,= all b %ort an/hesias conduct$ *iefly by nitr\s oxide1 ! inte/9al tract ( ! pati5t mu/ receive c>eful prep>ation4 ,9 do+ ?is1 "o mu/ avoid excessive />vation & purgation1 bo? ( :i* t5d to increase %ock4 ,we w suppose t ! op]ation is tim$ = #aj a4m4 on ,tuesday morn+4 ,on ,monday morn+ ! pati5t receives an ap]i5t :i* may be v>i$ a little to suit 8 ta/e & habits4 ,if he has no pref]5ce1 !re is no?+ bett] ?an an ounce ( ca/or oil4 ,dur+ ! re/ ( ,monday1 he has a light diet3 fi% & milk pudd+ 9 ! middle ( ! day1 a little s\p at night4 ,! ap]i5t %\ld op]ate be=e #i p4m4 ,:5 t is ov]1 ! pati5t retires to b$4 ,dur+ ! day he may be all[$ to move ab\t 8 room a little1 b %\ld n und]take any ex]tion4 ,if !re be excessive n]v\sness1 or a natural t5d5cy to insomnia1 sulphonal gr4 #ae or v]onal gr4 #h may be giv5 e>ly 9 ! ev5+1 to ensure a night's re/4 ,ab\t #f a4m4 on ,tuesday morn+1 a l>ge soap & wat] enema is giv51 & :5 ?is has op]at$1 a cup ( tea or a little s\p or ,bovril may be tak54 ,!reaft] no?+ %\ld be giv5 by m\?4 ,! e>ly =5oon is ! "t ( *oice = any op]ation1 b if an aft]noon "t be ( necessity *os51 ! pati5t %\ld n be />v$ ?r\gh\t ! =5oon4 ,a repetition ( ! e>ly morn+ meal may be all[$ ab\t #aa a4m4 ,9 cases su* z ga/ro-ent]o/omy1 :]e ! alim5t>y tract w be op5$1 ! prep>ation mu/ be a little m /r+5t4 ,x is usual to all[ no solids at all ! day be=e4 ,a sal9e enema may be giv5 an h\r or two be=e op]ation1 :5 ! soap & wat] has be5 evacuat$4 ,prelim9>y ,hypod]mic ,m$ication4 ,?is great improvem5t 9 an/hesia 0 practis$ _m ye>s ago by a few surgeons1 b x 0 only :5 op5 e!r assum$ its pres5t position ( pre-em95ce t x 0 widely adopt$4 ,! pres5t r\t9e is to give morphia gr4 1 atrop9e gr4 to adult pati5ts ?ree qu>t]s ( an h\r be=e op]ation4 ,x has ! foll[+ advantages3-- 7#a7 ,! n]v\s fe>s ( ! pati5t give place to a feel+ ( bi5-tre4 7#b7 ,! secretions ( saliva & ( muc\s f ! respiratory muc\s membranes are limit$4 7#c7 ,a little less inhalational an/hetic is requir$4 7#d7 ,! aft] vomit+ is less5$1 & probably ! liability to inflammatory respiratory complications also r$uc$4 ,! disadvantages c be met by prop] c>e & dosage4 ,!y are z foll[s3-- 7#a7 ,morphia plus *lor(orm depresses ! respiratory c5tre at an e>ly /age ( an/hesia4 ,respiration becomes infrequ5t & %all[1 & cyanosis appe>s be=e ! pati5t is really suffici5tly an/hetis$ = ! purposes ( ! surgeon4 7#b7 ,! l>g] ! dose ( morphia1 ! m tr\blesome is ?is premature failure ( respiration4 ,! moral is obvi\s3 give ! small doses above recomm5d$ & induc$ ) mixtures weak 9 *lor(orm1 or bett] /ill ) e!r only 7see page #hf74 ,"s ye>s ago1 be=e ^! facts 7 appreciat$1 !re 0 a fa%ion = giv+ v l>ge doses ( prelim9>y n>cotics4 ,! comb9ations mo/ fav\r$ 7 z foll[s3-- ,,scopolam9e-,,morph9e4 ,scopolam9e is a =m ( hyoscyam9e & is itself a p[]ful n>cotic4 ,two or sometimes ?ree doses ( ! mix$ drugs 7 giv5 at int]vals ( an h\r1 ! la/ half an h\r be=e op]ation4 ,scopolam9e gr4 1 morphia gr4 0 ! usual =mula3 "s surgeons add$ a dose ( atrop9e or /ry*n9e ) ! idea ( /imulat+ ! respiratory c5tre4 ,! pati5ts w5t to ! op]at+ or an/hetis+ room s dr[sy t !y 7 unaw>e ( _! surr\nd+s1 & aft]w>ds _h no recollection ( ! actual beg9n+ ( ! inhalation4 ,s humane a me?od naturally attract$ a good deal ( att5tion1 b ! s]i\s depression ( ! respiratory c5tre :i* seems inevitable 9 ! me?od has gradually caus$ x to disappe> f ! practice ( mo/ surgeons & an/heti/s4 ,at ! pres5t day1 x is only to be recomm5d$ 9 midwif]y practice2 to ! dr[sy semi-consci\s condition produc$1 ! "n ( ,twilight ,sleep has be5 giv54 ,,omnopon ,,& ,,omnopon-,,scopolam9e4 ,omnopon is compos$ ( a mixture ( sev]al ( ! alkaloids d]iv$ f opium2 ! mak]s claim t x produces less aft] malaise ?an morphia alone4 ,x may be giv5 be=e an/hesia 9 doses ( - gr41 ei!r alone or comb9e ) a small dose ( scopolam9e4 ,x gives q good results if n pu%$ to excess4 ,,h]o9 ,,hydro*loride ,?is comp>atively mod]n s$ative is us$ by "s surgeons 9 pref]5ce to morphia4 ,a dose ( gr4 is q suffici5t1 ?ree qu>t]s ( an h\r be=e op]ation4 ,atrop9e %\ld always be comb9$ ) x4 99 99 99 99 99 ,to "y *ildr51 morphia %\ld n be giv51 b atrop9e may be giv5 freely4 ,a *ild ( twelve mon?s tol]ates a dose ( gr4 q well3 "o ( six ye>s1 w take gr4 ,9 ages rang+ f #ab ye>s upw>ds1 greatly r$uc$ doses ( morphia may be giv54 ,no *ild "u #ae ye>s requires m ?an gr4 ( morphia at mo/4 ,,*apt] ,,vii4 ,,nitr\s ,,oxide4 ,special ,physiology4 ,^u ! n]v\s sy/em1 nitr\s oxide acts l o!r an/hetics1 b ! /ages ( an/hesia are pass$ ?r\gh s rapidly t a second /age c h>dly be di/+ui%$4 ,x is r>e = /ruggl+ or excitem5t to be manife/1 unless air or oxyg5 be admitt$ at ! same "t1 :5 ! effect :i* l$ ,humphrey ,davy m ?an a c5tury ago to apply to nitr\s oxide ! "n ( 8laugh+ gas0 is v evid5t inde$4 ,^u ! o!r sy/ems ( ! body1 nitr\s oxide has little if any effect 9 itself4 ,! ess5tial po9t to rememb] 9 connection ) nitr\s oxide adm9i/]$ unmix$ ) air or oxyg5 is t !re is an inevitable elem5t ( asphyxia4 ,! l>g] "p ( ! oxyg5 normally c>ri$ by ! r$ blood corpuscles is elim9at$ & replac$ by ,n#b,o3 oxyg5 />vation is !re=e ( necessity pres5t4 ,9 o!r words1 ! 8vici\s circle ( asphyxia0 7see ,fig4 #e7 is ent]$1 & muscul> spasm is b\nd ultimately to appe>4 ,moreov]1 ! blood pressure rises v mat]ially z a result ( ! lack ( oxyg54 ,t no h>m results to ! normal heal?y pati5t f ?is rise is due to ! fact t ! gas does n 9 itself poison ! he>t muscle1 :i* c !re=e /& up to ! extra /ra9 ( work+ aga9/ high] resi/ance1 s long z ! process is n c>ri$ to extremes4 ,a he>t muscle weak5$ by ! action ( *lor(orm w\ld give out at once if expos$ to su* a te/4 ,app>atus4 ,nitr\s oxide is suppli$ by ! mak]s z a fluid cond5s$ 9 iron bottles or cyl9d]s1 & only becomes gase\s ^u be+ releas$ f !m4 ,9 pass+ f ! fluid to ! gase\s /ate1 heat is ( c\rse lo/1 & x w be notic$ t ! end ( ! cyl9d] :i* is 9 use becomes rapidly cru/$ ov] ) fro/4 ,ice1 moreov]1 =ms 9 ! small *annel at ! head ( a cyl9d]1 & is apt f "t to "t to block x4 ,! cyl9d]s are ( v>i\s sizes & designat$ aft] ! numb]s ( gallons ( gas :i* !y w supply3 #be is ! smalle/ size1 #ej or #ajj are m usual2 any?+ up to #ejj is occasionally met ) 9 hospital practice4 ,moreov] ! cyl9d]s are ( two types1 call$ respectively v]tical 7= use 9 ! upright position71 & angle = use 9 ! horizontal position 7see ,fig4 #ac74 ,illu/ration3 ,,fig4 #ab4--;,frame = adapt+ v]tical cyl9d]s to foot use4 ,illu/ration3 ,,fig4 #ac;,a4 ,,fig4 #ac;,b4 ,two types ( ,n#b,o cyl9d]s4 ,a4 ,v]tical 7or ord9>y74 ,b4 ,angle4 ,! cyl9d]s are fix$ 9 frames ( v>i\s types ( :i* examples are se5 9 ,figs4 #ac & #ad4 ,^u ea* cyl9d]1 ( :atev] size or type1 w be f\nd a label /at+ its weight :5 full & empty1 ! diff]5ce repres5t+ ! weight ( ! cont5ts :5 ! bottle is full4 ,= in/ance1 9 ! case ( ! #ej-;gallon cyl9d] ! weight ( its full *>ge is #ae ounces4 ,weigh+ ! cyl9d] is ! only c]ta9 means :i* we h to e/imate h[ mu* ( ! *>ge rema9s4 ,! /ud5t w readily appreciate !re=e t once a cyl9d] has be5 us$ at all !re is always a risk ( ! supply ( gas f x runn+ out dur+ an adm9i/ration4 ,x is = ?is reason t cyl9d]s are habitually us$ 9 c\ples1 "o ( :i* is always suppos$ to be q full4 ,to ?is "o x is well to atta* a label m>k$ 8full10 & c>e mu/ be tak5 to replace at once a cyl9d] kn[n to be empty4 ,9 ?is way we always h ^u ! frame "o cyl9d] p>tly & ano!r entirely full4 ,illu/ration3 ,,fig4 #ad4--;,complete ,n#b,o app>atus1 %[+ tw9 cyl9d]s1 supply pipe1 #b-;gallon bag1 #c-way tap1 & face-piece4 ,by :atev] mak]s ! cyl9d] is suppli$ x w be f\nd t ! ?read ^u ! outlet pipe is ! same1 & ! metal nipple figur$ 9 ,fig4 #ad w fit x4 ,to ! di/al end ( ! nipple1 a rubb] tube is atta*$ :i* leads to a rubb] bag usually ( #b gallons capacity4 ,! rema9d] ( ! app>atus may be ( sev]al types4 ,fig4 #ae %[s ! ord9>y ,b>? ?ree-way tap ) facepiece2 ! indicator on ! tap has ?ree possible positions designat$ on ! dial z 8,air10 8,valves10 & 8,no ,valves40 ,if ! tap is po9t$ backw>ds t[>ds ! bag at ! position m>k$ 8air0 ! end ( ! bag is clos$ & ! pati5t is brea?+ air only4 ,) ! tap 9 ! middle position ( 8valves10 ! inspiration ( ! pati5t w draw gas f ! bag1 b ! expiration closes ! valve :i* is n[ 9 op]ation at ! orifice ( ! bag1 & w op5 ! expiratory valve :i* conducts ! expir$ air into ! g5]al atmosph]e4 ,9 ! ?ird position ( 8no valves0 ! pati5t brea!s bo? 9 & out ( ! bag4 ,illu/ration3 ,,fig4 #ae4--;,b>? #c-way ,n#b,o tap4 ,illu/ration3 ,,fig4 #af4--;,hewitt's wide-bore gas valves4 ,fig4 #af %[s ! ,hewitt type ( inhal]4 ,! calibre ( ! orifices ?r\gh :i* respiration takes place is great] ?an 9 ! ,b>? ?ree-way tap1 & to t ext5t ?is type ( valve is to be pref]r$4 ,al?\gh diff]5tly arrang$ exactly ! same possibilities are pres5t 9 x4 ,! facepiece is sometimes made ( celluloid ) an inflatable rubb] edg+4 ,! object ( ?is type ( facepiece is t ! col\r ( ! lips may be appreciat$ by ! an/heti/ dur+ ! adm9i/ration4 ,! pref]able plan is to make ! :ole facepiece ( rubb] ) an inflatable bord]4 ,su* a facepiece made by a good mak] w la/ _m ye>s1 & is mu* m /able & reliable ?an its celluloid competitor4 ,! ,c>e ( ! ,nitr\s ,oxide ,app>atus4 ,?is is a matt] ( consid]able mom5t1 p>ticul>ly to ^? :o d n use _! app>atus e day4 ,aft] use1 ! valves1 facepiece1 & bag %\ld be disconnect$ f ea* o!r1 all moi/ure wip$ away f ! bright p>ts1 & ! bag hung up ) its op5 end d[nw>ds1 & pref]ably 9 a w>m room4 ,if re-brea?+ has be5 ext5sively practic$ x is well to wa% ! bag out ) "s c>bolic lotion be=e hang+ x up4 ,! rubb] valves 9 ! valvepiece are liable to lose _! ela/icity1 p>ticul>ly if kept 9 a cold place aft] becom+ damp4 ,f "t to "t ! valve piece %\ld be tak5 to pieces1 ! valves c>efully dri$ 9 front ( a w>m fire & p[d]$ ov] ) a little talc4 ,adm9i/ration4 ,mo/ commonly nitr\s oxide is adm9i/]$ to a pati5t sitt+ 9 a *air4 ,c>e %\ld be tak5 t ! respiration ( ! pati5t %all n be ob/ruct$ by tight clo?+ r\nd ! ?roat or *e/1 & t ! head & neck are nei!r unduly flex$ nor ext5d$ ^u ! %\ld]s4 ,! pati5t %\ld n h any solid food = two h\rs be=e ! an/hetic4 ,at ! la/ mom5t he %\ld be in/ruct$ to empty 8 bladd]4 ,artificial d5tures if pres5t %\ld be remov$1 &1 if ! an/hetic is be+ giv5 = ! purpose ( ! extraction ( a too?1 x w be necess>y be=e apply+ ! facepiece to ins]t betwe5 ! tee? a d5tal prop4 7,see ,fig4 #f47 ,/&+ to ! left & slightly beh9d ! pati5t ! an/heti/'s fir/ /ep is to secure good apposition betwe5 facepiece & face4 ,?is is be/ done by work+ f above d[nw>ds3 t is to say1 secure fir/ a good fit at ! bridge ( ! nose1 & !n approximate ! rema9d] ( ! rim ( ! facepiece to ! *eeks & l[] jaw4 ,dur+ ?is /age ! indicator ( ! tap is kept at 8,air40 ,work+ ) ! left foot ! adm9i/rator n[ op5s ! head ( "o ( ! cyl9d]s ) ! foot key4 ,x is wise fir/ to h loos5$ ?is ) a h& key1 & leave x j 8on ! sw+10 o!rwise "o's boots are apt to suff]6 ,gas is all[$ to fl[ into ! bag until x is p>tially1 b by no means tightly di/5d$4 ,! pati5t is in/ruct$ to brea! naturally & easily1 & dur+ ! :ole process ! an/heti/ %\ld conv]se ) him 9 a quiet easy way4 ,! tap is n[ turn$ to 8valves0 & ! pati5t beg9s to inspire ! gas1 a supply ( :i* is all[$ to fl[ /eadily f cyl9d] into bag4 ,aft] a few brea?s ( ! gas1 :5 ! s5sibilities ( ! pati5t are a little dull$1 x is wise to all[ ! gas to fl[ a little m freely & to di/5d ! bag4 ,?is ex]cises ^u ! pati5t a slight positive pressure1 :i* has be5 prov$ bo? exp]im5tally & practically to increase ! rapidity ( ! absorption4#a ,! valves are left 9 op]ation = "s ?irty or =ty seconds1 aft] :i* "t ! supply ( gas %\ld be cut (f & ! tap be pu%$ ov] to ! position ( 8no valves0 = fur!r tw5ty seconds4 ,?is %\ld be ample to secure full gas an/hesia4 ,! ph5om5a se5 9 nitr\s oxide an/hesia are s diff]5t f ^? ( any o!r t a few words mu/ be said ab\t !m4 ,)9 a few seconds ( ! inhalation beg9n+1 ! col\r ( ! pati5t %[s evid5ce ( ! pres5ce ( ! gas 9 8 blood4 ,! normal complexion *anges fir/ to a dull p9k1 & v rapidly to ! def9ite blue ( cyanosis4 ,! eye symptoms are ( ! utmo/ value4 ,v e>ly ! pupil beg9s to dilate1 & ! eyeball t5ds dur+ ! fir/ tw5ty or ?irty seconds to rotate z if ! pati5t 7 look+ = "s object 9 8 field ( vision4 ,9 full an/hesia ! eyeball1 h[ev]1 comes to re/1 usually po9t$ d[nw>ds4 ,! pupil is widely dilat$1 ! conjunctival reflex is almo/ or ev5 entirely aboli%$1 b ! corneal reflex is /ill brisk4 ,! respiration t5ds to become /eadily deep] & m frequ5t1 & 9 ! lat] /ages /]tor at lea/1 if n /ridor usually develops4 ,! muscles "u ord9>y nitr\s oxide an/hesia are r>ely entirely relax$1 b ! limbs hang motionless1 & x is only if an attempt be made to move !m into "s abnormal position1 t "o appreciates ! p]si/5ce ( muscul> tone4 ,a ph5om5on peculi> to nitr\s oxide an/hesia is obs]v$ 9 its deepe/ /age4 ,designat$ z jactitation1 x consi/s 9 a tremor beg9n+ 9 ! limbs1 b spread+ f !m to ! trunk if its developm5t is all[$ to proce$4 ,x is a f9] movem5t ?an t describ$ "u 8e!r tremor0 7page #ch71 & :olly diff]5t 9 type f ! a!tosis ref]r$ to on page #ch4 ,jactitation is almo/ :olly an asphyxial ph5om5on1 & is !re=e def9itely an indication t ! process ( oxyg5 />vation has be5 c>ri$ z f> z is p]missible4 ,! signs ( fully develop$ nitr\s oxide an/hesia !n are3-- #a4 ,deep regul> snor+ respirations4 #b4 ,dilat$ pupils4 #c4 ,rotation ( ! eyeball d[nw>ds4 #d4 ,loss ( conjunctival b p]si/5ce ( corneal reflex4 #e4 ,a col\r ( ! sk9 def9itely blue1 b n blacki% blue4 #f4 ,! comm5cem5t ( jactitations4 ,! signs ( ov]dose are3-- #a4 ,an enorm\sly dilat$ pupil n re-act+ to light4 #b4 ,loss ( corneal reflex4 #c4 ,a blacki% blue col\r4 #d4 ,jactitations fully develop$4 #e4 ,fail+ respirations4 ,! f9al arre/ ( respiration 9 nitr\s oxide an/hesia is usually pa9fully sudd54 ,^u ! respiratory side ! only w>n+ is "o or two gasps1 & ev5 t is sometimes abs5t4 ,! p>alys$ pupil & ! jactitations are ! mo/ useful signs ( ov]dose4 ,! above1 !n1 may be tak5 z an acc\nt ( :at "o expects to see 9 a normal gas an/hesia dur+ ! induction /age4 ,= ! great majority ( cases1 nitr\s oxide is giv5 = ! purpose ( r5d]+ pa9less ! extraction ( a too?1 & x is1 9 ?is l>ge class ( case1 ! induction /age only :i* ne$ be consid]$4 ,x requires only "s fifty to sixty seconds to br+ ! pati5t to ! /age describ$ "u ! head+ 8fully develop$ an/hesia0 & :5 t has be5 atta9$1 ! mask may be remov$ & ! op]ation begun4 ,f ! mom5t ( removal ( ! mask1 h[ev]1 x mu/ be not$ t ! pati5t beg9s to brea! fre% air & to elim9ate ! ,n#b,o4 ,! p]iod ( an/hesia available to ! surgeon or d5ti/ dur+ :i* he mu/ p]=m ! op]ation1 is !re=e v small4 ,9 ?irty seconds ! pati5t has frequ5tly recov]$ suffici5tly to beg9 to feel pa91 & x is r>e to secure m ?an =ty-five or fifty seconds by ! use ( a s+le dose ( nitr\s oxide4 ,nitr\s ,oxide & ,air4 ,if ! nature ( ! op]ation does n necessitate ! removal ( ! mask f ! face1 x is possible to ma9ta9 nitr\s oxide an/hesia = "s consid]able "t4 ,! exact l5g? ( t "t v>ies a good deal ) two factors--! type ( pati5t & ! exp]i5ce ( ! adm9i/rator4 ,heavily built muscul> pati5ts are n easily dealt ) by prolong$ gas an/hesia 7unless ) admixture ( oxyg5 z expla9$ 9 *apt] viii47 ,( f> great] importance1 h[ev]1 is ! o!r factor4 ,! /ud5t c easily be taught to give a s+le dose ( gas = ! extraction ( a too?1 or ! mom5t>y incision ( an abscess4 ,he w1 h[ev]1 be wise to secure a good deal ( practice 9 t class ( "w be=e attempt+ to prolong gas an/hesia = m ?an a m9ute or two4 ,) reasonable skill & exp]i5ce & ! utmo/ c>e1 x is1 h[ev]1 p]fectly possible to prolong nitr\s oxide an/hesia = p]iods ( five1 t51 or ev5 fifte5 m9utes 9 ! av]age heal?y pati5t4 ,z soon z ! signs ( full an/hesia appe>1 ! valve tap is pu%$ back to 8air0 = ! space ( "o inspiration & "o expiration1 & !n at once pu%$ back to 8no valves40 ,by ?is manuvre1 "o inspiration ( air is p]mitt$ to ! pati5t1 ^: col\r at once %[s amelioration1 or at any rate no fur!r progression ( cyanosis4 ,! admission ( air is repeat$ e ?ird1 f\r?1 or at mo/ fif? respiration4 ,aft] ! fir/ m9ute or s ( ?is cycle ( ev5ts1 x is obvi\s t ! cont5ts ( ! bag w be compos$ ( a mixture ( nitr\s oxide1 air1 & ,,co#b 9 proportions q impossible to calculate4 ,x is !re=e be/ to pu% ! indicator to 8valves10 & all[ ! bag to be empti$ by ! suction ( ! pati5t's inspirations4 ,! cyl9d] head is !n op5$ by ! turn+ ( ! foot-key1 & ! bag fill$ aga9 ) gas4 ,! cycle ( 8air0 & 8no valves0 is !n begun aga9 = ano!r m9ute or s4 ,x mu/ be und]/ood t by ?is process1 x is n to be expect$ t an ideal an/hesia c be produc$4 ,"s movem5t ( ! pati5t w n improbably take place :5 s5sitive /ructures are cut or h&l$ by ! surgeon1 & at no "t w ! muscles be entirely relax$4 ,su* an an/hesia is !re=e only suitable = a limit$ class ( case1 b does admirably =1 say1 op5+ an abscess1 explor+ its int]ior1 & remov+ f x a seque/rum or an easily f\nd =eign body4 ,dur+ 8 s]vice 9 ,mac$onia ! au?or _h n at 8 disposal any ( ! appliances lat] to be describ$ "u ! head+ ( nitr\s oxide & oxyg51 & f\nd 8gas & air0 a mo/ useful =m ( an/hesia = ! requirem5ts ( milit>y surg]y z se5 9 a ,base ,hospital1 "u active s]vice conditions4 ,contra-indications to ! ,use ( ,pure ,nitr\s ,oxide ,gas4 ,9 ! heal?y subject1 !re is no saf] an/hetic ?an nitr\s oxide :5 adm9i/]$ prop]ly & limit$ to its prop] prov9ce4 ,f ! acc\nt giv5 ( ! physiological action ( ! gas x w1 h[ev]1 be obvi\s to ! /ud5t t 9 a limit$ class ( case its use is n p]missible4 ,su* cases fall into two categories4 ,fir/ly1 cases 9 :i* an asphyxial elem5t already exi/s w h _! condition greatly aggravat$ by ! sub/itution ( ,n#b,o = ! oxyg5 9 _! blood4--,already caught 9 ! vici\s circle ( asphyxia1 nitr\s oxide w\ld b pu% !m deep] into ! vortex4 ,examples ( su* cases are pati5ts suff]+ f tum\rs or inflammatory swell+s 9 ! neck :i* are press+ ^u ! air passages4 ,9 pass+1 "o may note t x might be ! desire ( ! surgeon to submit an individual case fall+ into ?is gr\p to ! op]ation ( tra*eotomy = ! imm$iate relief ( ! condition4 ,! %ort space ( "t requir$ = ?is little op]ation might well tempt ! unw>y to *oose nitr\s oxide z ! an/hetic1 & 9 po9t ( fact su* an error ( judgm5t has m ?an once be5 made ) fatal results4 ,secondly1 no pati5t suff]+ f any condition :i* w be aggravat$ by a sudd5 rise ( blood pressure1 %\ld be submitt$ to nitr\s oxide undilut$ by oxyg54--,examples ( su* conditions are cases ( dilat$ "r he>t ) weak5$ c>diac musculature4 ,su* he>ts c\ld n be expect$ to "w aga9/ a p]iph]al resi/ance sudd5ly rais$1 say1 f #abj mm4 ( ,hg1 to #ahj or ev5 #bjj mm4--figures well )9 ! possible 9 deep gas an/hesia4 ,simil>ly1 s great an increase ( pressure w\ld be dang]\s to a pati5t suff]+ f an aneurysm1 or f ext5sive art]io-scelorosis ) high blood pressure4 ,x w be not$ t ! above w>n+s are limit$ to ! use ( pure nitr\s oxide1 t is1 ,n#b,o unmix$ ) oxyg54 ,! ext5t to :i* ! dang]s ref]r$ to c be met by ! admixture ( oxyg5 9 ! mann] to be describ$ 9 ! next *apt] is l>gely a matt] ( ! skill & exp]i5ce ( ! adm9i/rator4 ,nasal ,me?ods4 ,! object ( us+ ?is r\te is to be able to cont9ue ! adm9i/ration ?r\gh\t ! p]iod 9 :i* ! d5ti/ is do+ 8 "w4 ,! ess5tials ( a suitable app>atus are3-- #a4 ,a malleable nosepiece :i* c be closely adapt$ to ! nose4 #b4 ,two supply pipes f bag to nosepiece4 #c4 ,"s means ( admitt+ air to ! /ream ( gas4 #d4 ,a two-gallon bag4 #e4 ,a supply ( gas4 #f4 ,a m\? cov] ) an expiratory valve only4 ,! pati5t is in/ruct$ to brea! 9 ?r\gh ! nose1 b to expire ?r\gh ! m\?4 ,! gas is suppli$ "u "s pressure & ! m\? cov] ensures t no air is inspir$ by t r\te4 ,"s pati5ts f9d x easi] to conduct bo? inspiration & expiration ?r\gh ! nose1 & = _! b5efit an expiratory valve is also provid$ 9 ! nosepiece4 ,aft] unconsci\sness has sup]v5$1 ne>ly all pati5ts beg9 to-&-fro nasal brea?+4 ,! m\? cov] may !n be remov$1 & if x be desir$ to economise gas1 ! expiratory valve 9 ! nosepiece may be ?r[n out ( action4 ,illu/ration3 ,,fig4 #ag4--;,a%'s ,modification ( ,pat]son's ,nasal ,gas ,,description3--,a--,nose-,cap ,atta*m5t ) ,/opcock = ,air & ,gas1 & ) ,inspiratory & ,expiratory ,valves & ,%utt]4 ,b--,nose-,cap4 ,c--,slid+ ,clip on ,india-rubb] ,tub+s4 ,d--,bifurcat$ ,m\nt4 ,e--,bag ,m\nt4 ,f--,gas ,bag ,compressor4 ,g--,gas ,bag4 ,h--,india-rubb] ,tub+4 ,,mc--,m\? ,cov]4 ,?is is fitt$ ) an expiratory valve1 & %\ld be us$ at ! same "t z ! ,nose-,cap4 ,by us+ ! two toge!r pati5ts are m quickly an/hetis$ ?an !y w\ld be if only ! ,nose-,cap 7 us$1 & ! ,nitr\s ,oxide is economis$4 ,air mu/ be admitt$ 9 limit$ quantity ?r\gh ! tap aft] ! fir/ ?irty seconds or s2 by a judici\s regulation ( ?is me*anism1 an/hesia may be prolong$ = five or t5 m9utes4 ,facility ) nasal gas comes only aft] "s consid]able practice4 ,fig4 #ag %[s ,a%'s ,no4 #c ,pat5t$ ,nasal ,inhal]1 :i* admits ( ,air or ,gas be+ adm9i/]$ ei!r by ! ,naso-,oral ,me?od1 or by to-&-fro nasal brea?+4 ,air only is admitt$ :5 ! ,%utt] ,a is op5 & turn$ to ! "r z f> z x w g4 ,nitr\s ,oxide is admitt$ :5 ! ,%utt] ,a is op5 & turn$ to ! left z f> z x w g1 & ! pati5t w brea! x 9-&-out ?r\gh ! nose4 ,= ! ,nasal ,oral ,me?od1 close ,%utt] ,a & turn x to ! left z f> z x w g4 ,?is w cause ! pati5t to inhale ?r\gh ! nose & exhale ?r\gh ! m\?4 ,nasal atta*m5ts are provid$ ) mo/ ( ! gas-oxyg5 app>atuses m5tion$ 9 ! next *apt]4 ,) !m good results c be obta9$ ) mu* great] ease4 ,= a m detail$ acc\nt ( nasal me?ods1 ! /ud5t is ref]r$ to works devot$ entirely to ,d5tal ,an/hesia4 ,,*apt] ,,viii4 ,,nitr\s ,,oxide ,,& ,,oxyg54 ,! acc\nt giv5 9 ! previ\s *apt] ( an/hesia by nitr\s oxide & air w h conv9c$ ! /ud5t t x is a some:at inelegant me?od ) a limit$ sph]e ( usefulness4 ,! reason is obvi\s4 ,9 atmosph]ic air1 oxyg5 exi/s only 9 ! proportion ( ab\t "o to f\r ( nitrog54 ,to su/a9 life x is !re=e necess>y to admit to ! an/hetic mixture an am\nt ( air :i* leaves too little room = ! an/hetic factor--nitr\s oxide4 ,if1 h[ev]1 pure oxyg5 be us$1 ! nitr\s oxide is dilut$ to a mu* less degree1 & f> bett] results are obta9$4 ,! exact scope = gas-oxyg5 an/hesia _c at pres5t be def9$ ) c]ta9ty4 ,! "w ( ,crile1 & ! exp]i5ce ( ! w> h done mu* to enl>ge x4 ,we may say t ! foll[+ are def9ite indications = its use3-- 7#a7 ,m9or op]ations la/+ #e-ae m9utes1 p>ticul>ly if p]=m$ on out-pati5ts4 7#b7 ,op]ations ( any v>iety ^u ! subjects ( sev]e %ock4 7#c7 ,op]ations ^u pati5ts suff]+ f acute sepsis4 7#d7 ,op]ations repeat$ ^u ! same subject at %ort int]vals4 ,z reg>ds 7#c7 & 7#d71 ! lack ( toxic prop]ties 9 nitr\s oxide gas1 & ! rapidity ) :i* x is elim9at$1 give x a trem5d\s advantage ov] e!r or *lor(orm4 ,to m5 ) %att]$ bones & ext5sive damage to s(t tissues1 badly infect$ ) sepsis1 :o requir$ repeat$ op5+ up ( pockets1 *ang+ ( gauze packs1 etc41 ! advantage ( gas-oxyg5 ov] e!r 0 evid5t1 & 0 easily appreciat$ by ! pati5ts !mselves dur+ ! late w>4 ,!re are1 h[ev]1 c]ta9 drawbacks to ! me?od :i* mu/ be appreciat$-- 7#a7 ,! necess>y plant is heavy1 bulky1 & co/ly2 x _c be easily transport$4 7#b7 ,! runn+ co/ is high z comp>$ ) e!r or *lor(orm4 7#c7 ,x has be5 said by "s t gas-oxyg5 c only be giv5 by an exp]t4 ,t is a /atem5t too extreme1 9 ! au?or's op9ion4 ,c]ta9ly1 ( all an/hetics x is ! mo/ difficult to give successfully4 ,adequate /udy & prop] tea*+ by an exp]t are requir$1 b giv5 ^! two helps1 any "o c soon le>n to adm9i/] gas-oxyg5 = m9or surg]y4 ,consid]ably m exp]i5ce is1 h[ev]1 necess>y be=e ! beg9n] %\ld give x = an abdom9al section4 ,app>atus4 ,a good gas-oxyg5 app>atus is necess>ily r complicat$4 ,! ma*9es 9 ! m>ket are num]\s1 & ( ! mo/ div]se ext]nal appe>ance4 ,c]ta9 broad pr9ciples1 h[ev]1 und]lie all ! ma*9es1 & x is to be hop$ t "s "o ( !m w be=e long become practically ! /&>d4 ,once t is effect$1 hospitals & nurs+ homes c\ld be expect$ to provide !m4 ,s long z e an/heti/ asks = a diff]5t ma*9e1 !y c]ta9ly nev] w d4 ,a good ma*9e mu/ provide means = ! foll[+3-- 7#a7 ,an ev5 fl[ ( bo? gases "u p]fect control4 7#b7 ,a p]c5tage ( ,oxyg5 9 ! mixture ris+ at ! w ( ! adm9i/rator f #b to #ae or #bj4b ,to meet ?is requirem5t x is n necess>y t any indicator %\ld be provid$ :i* %[s ) ma!matical precision :at p]c5tage ( oxyg5 is be+ giv54 ,! col\r ( ! pati5t tells u at once if too mu* or too little oxyg5 is be+ suppli$1 & all we ne$ 9 ! app>atus is "s me*anism :]eby we c tell approximately to :at ext5t we are increas+ or decreas+ ! p]c5tage4 7#c7 ,positive ,pressure4--,if ! pressure at :i* ! gases are suppli$ to ! pati5t c be rais$ a little above t ( ! ord9>y atmosph]e1 absorption is increas$ & a deep] an/hesia produc$4 ,9 ! au?or's view1 ?is is an ess5tial po9t 9 a good in/rum5t4 7#d7 ,re-brea?+4--,to supply ! :ole volume ( gases requir$ = inspiration dur+ a long op]ation is co/ly & q unnecess>y4 ,yet t is :at is be+ done if ! :ole adm9i/ration is conduct$ ^u ! 8valvul>0 pr9ciple4 ,moreov]1 a prolong$ inhalation ^u ! valves t5ds to remove a great deal ( ,,co#b f ! pati5t's blood & tissues 7see ,*ap4 ,,iv474 ,p]iods ( p>tial or complete re-brea?+ d mu* to deep5 respiration1 & r$uce ! co/ ( ! an/hetic4 7#e7 ,w>m+ ! ,gases4--,:ile n ess5tial1 ?is is c]ta9ly an advantage4 7#f7 ,addition ( ,e!r ,vap\r to ! mixture4--,gas-oxyg5 ev5 well giv5 is h>dly capable ( r$uc+ to quiesc5ce v robu/ p1 unless ! oxyg5 p]c5tage is kept to an undesirably l[ level4 ,! m]e/ trace ( e!r vap\r z an adjunct is a great assi/ance dur+ ! /ages ( ! op]ation :]e v s5sitive /ructures su* z ! p>ietal p]itoneum are be+ h&l$4 ,! m exp]i5c$ ! an/heti/1 ! less w he require su* assi/ance4 ,hewitt's ,app>atus4 ,?is1 ) ! exception ( "o design$ by ,dr ,guy & ! au?or1 & describ$ on page #acj1 is ! only ma*9e ) any pret5ce to portability by h&4 ,x does n satisfy all ! requirem5ts above ref]r$ to1 b ! fact t x 0 ! fir/ practicable means introduc$ 9 ?is c\ntry to give gas-oxyg5 entitles x to full description4 7,see ,fig4 #ah47 ,illu/ration3 ,,fig4 #ah4--;,hewitt's gas oxyg5 app>atus4 ,ess5tially x consi/s ( ! foll[+3-- 7#a7 ,a supply ( nitr\s oxide & oxyg5 9 sep>ate cyl9d]s4 ,hewitt's own /& held two ( nitr\s oxide & "o ( oxyg54#c 7#b7 ,rubb] pipes ( supply = ea* ( ! two gases4 ,= conv5i5ce1 x is sometimes arrang$ t "o ( ^! %all run inside ! o!r4 7#c7 ,two #b-;gallon bags4 ,nitr\s oxide is l$ into ! "o1 oxyg5 into ! o!r4 ,! m\? ( ea* bag is gu>d$ by an inspiratory valve4 7#d7 ,! mix+ *amb]4 ,^u ! surface ( ?is are m>k$ successively3 8,air10 8,n#b,o10 8,o#b1 #a #b #c #d #e #f #g #h #i #aj40 ,z ! indicator is pu%$ f 8air0 to 8,n#b,o10 ! pati5t beg9s to inhale nitr\s oxide only1 b z x travels into ! num]als #a1 #b1 etc41 a proportion ( oxyg5 is add$4 ,imm$iately bel[ ! mix+ *amb] is ! expiratory valve4 7#e7 ,la/ly1 !re is ! facepiece1 id5tical ) t us$ = pure nitr\s oxide4 ,x w\ld be fallaci\s to suppose t ! num]als #b1 etc41 on ! dial repres5t accurately ! p]c5tage ( oxyg5 yield$ by ! in/rum5t :5 ! indicator po9ts to "o ( ^! figures1 nor did ,hewitt ev] make su* a claim4 ,:at ! figures d repres5t is a numb] ( holes 9 ! wall ( ! mix+ *amb]1 opposite to ! ap]ture f ! oxyg5 bag1 :i* are uncov]$ "o by "o z ! indicator moves ov]4 ,! am\nt ( oxyg5 :i* ent]s into ! mix+ *amb] is regulat$ by ! numb] ( ^! holes uncov]$1 & also by ! t5sion ( ! oxyg5 bag4 ,if ! figure on ! dial is to be ev5 a r\gh index ( ! actual p]c5tage ( oxyg5 pres5t 9 ! mixture1 x is necess>y to keep ! t5sion reasonably con/ant1 i4e4 to regulate ! fl[ ( oxyg5 f ! cyl9d] by manipulation ( ! foot key4 ,9 a brief adm9i/ration =1 say1 a d5tal case1 ?is is n necess>y4 ,x is suffici5t to fill ! oxyg5 bag once1 & !n turn (f ! supply4 ,if1 h[ev]1 a long adm9i/ration is requir$1 a con/ant fl[ ( oxyg5 ( j ! requisite am\nt mu/ be secur$4 ,adm9i/ration4 ,put ! lev] at 8air10 & fill up ea* bag to an equal & mod]ate degree ( di/5tion4 ,adapt ! facepiece accurately to ! pati5t's face1 & !n pu% ! lev] to 8,n#b,o04 ,aft] a few inhalations1 move to #b ( oxyg52 regulate ! fl[ ( nitr\s oxide f ! cyl9d] s t ! ,n#b,o bag rema9s slightly di/5d$4 ,gradually move ! indicator along ! num]als until ! figure #f or #h is rea*$ at ! end ( ab\t a m9ute or a m9ute & a half4 ,wom5 & *ildr5 require m oxyg5 ?an m54 ,! =m] are easily cyanos$2 if ! latt] are f$ too g5]\sly ) oxyg51 !y are apt to become excit$4 ,take z y\r guide to ! am\nt ( oxyg5 requir$ ! col\r ( ! pati5t1 ! type ( respiration1 & ! size ( ! pupil4 ,! col\r aim$ at c only be le>nt by exp]i5ce1 b is be/ describ$ z a dull p9k4 ,! ,type ( ,respiration4--,too little oxyg5 leads to /]tor & ev5 /ridor2 too mu* oxyg51 to a light almo/ noiseless respiration1 :i* to ! exp]i5c$ e> is ! c]ta9 precursor ( a /age ( excitem5t4 ,su* a /age is cle> evid5ce ( too mu* oxyg5 hav+ be5 giv54 ,! pupil %\ld n be dilat$ to any?+ l ! degree se5 ) undilut$ nitr\s oxide4 ,a mod]ate di/5tion only is to be desir$4 ,full ,an/hesia %\ld be rea*$ 9 #ajj-abj seconds4 ,x is m>k$ by3-- 7#a7 ,dull p9k complexion2 7#b7 full respiratory movem5ts ) a /]tor n exce$+ t ( g5tle snor+2 7#c7 eyeballs rotat$ d[nw>ds2 7#d7 mod]ately dilat$ pupils2 7#e7 loss ( conjunctival reflex2 7#f7 corneal reflex pres5t b n v active4 ,if ! object be ! removal ( a too?1 ! mask may n[ be remov$1 & ! d5ti/ may rely ^u a p]iod ( an/hesia some:at long] ?an t furni%$ by pure nitr\s oxide4 ,he ought to secure approximately "o m9ute 9 :i* to d 8 "w4 ,an/hesia by ?is app>atus may h[ev] be prolong$ = an indef9ite "t if desir$4 ,9 ord] to ma9ta9 ! pati5t 9 ! condition describ$ above1 x w be necess>y gradually to increase ! supply ( oxyg54 ,= ?is purpose ,hewitt add$ to 8 mix+ *amb] a supplem5t>y oxyg5 supply giv+ #aj or #bj volumes ( oxyg54 ,z a matt] ( fact1 all ! necess>y supply c be got ?r\gh ! orig9al t5 holes if ! t5sion 9 ! oxyg5 bag be increas$4 ,! regulation ( all ?is requires1 ( c\rse1 consid]able practice & exp]i5ce4 ,! signs ^u :i* we rely = w>n+ t ! supply ( oxyg5 is insuffici5t to keep ! pati5t safe1 are *iefly ! col\r ( ! face1 :i* mu/ n pass f dull p9k to blue1 & ! size ( ! pupil4 ,illu/ration3 ,,fig4 #ai4--;,diagrams to illu/rate action ( 7,a7 ,hewitt 7,b7 ,tet] gas oxyg5 app>atus4 ,note t 9 ,a ! m\?s ( bo? bags are gu>d$ by valves ( inspiration1 :ile 9 ,b ! oxyg5 bag only possesses x4 ,defici5cies ( ,hewitt's ,app>atus4 ,^! are *iefly two3-- 7#a7 ,!re is no means ( produc+ positive pressure4 ,any attempt to di/5d ! nitr\s oxide bag beyond a c]ta9 po9t simply leads to escape ( ! gas ?r\gh ! mix+ *amb] & out ( ! expiratory valve ev5 dur+ inspiration4 ,to ?is defect especially mu/ we attribute ! fact t an an/hesia deep en\gh = abdom9al section is difficult to secure ) ! ,hewitt in/rum5t4 7#b7 ,!re is no means ( secur+ re-brea?+4 ,! :ole adm9i/ration mu/ ( necessity be conduct$ 8^u ! valves40 ,?is latt] fault is rem$i$ by ! modification introduc$ by ,burns1 :o took away ! inspiratory valve f ! m\? ( ! ,n#b,o bag1 & fitt$ a cap ov] ! expiratory valve :i* c\ld be rotat$ s z to ?r[ ! valve out ( action4 ,! au?or fir/ met ?is modification at a ,base ,hospital 9 ,france1 & f\nd x a great improvem5t ^u ! orig9al in/rum5t4 ,x is1 h[ev]1 only an imp]fect attempt to adopt ,tet]'s *ief pr9ciple4 ,! ,tet] & ,alli$ ,ma*9es4 ,! rapid spread ( nitr\s oxide & oxyg5 an/hesia 9 ! ,u4,s4,a4 br\ght =w>d a numb] ( ma*9es ( :i* ,tet]'s 0 ! =]unn]2 ! o!r well-kn[n ma*9e ( ! gr\p is ! ,cl>ke4 ,!y diff] 9 pr9ciple f ! ,hewitt app>atus 9 t !y p]mit re-brea?+ & ! use ( positive pressure4 ,diagrammatically1 ! two are contra/$ 9 ,fig4 #ai4 ,illu/ration3 ,,fig4 #bj4--;,details ( ! ,cl>ke ,expiratory ,valve4 ,9 ! position ( ! lev] m>k$ 8op50 ! valve lifts easily & widely1 & ! brea?+ w be purely valvul>3 9 ! position m>k$ 8half op510 ! valve lift is dim9i%$1 & ! brea?+ is p>tly valvul>1 p>tly to-&-fro4 ,9 ! position 8clos$0 re-brea?+ only is possible4 ,! key to ,tet]'s advance is 8 removal ( ! inspiratory valve f ! m\? ( ! nitr\s oxide bag1 & 8 sub/itution = ,hewitt's rubb] expiratory valve1 ( a rigid valve1 ! lift ( :i* c be dim9i%$ or entirely aboli%$1 at w 7see ,fig4 #bj74 ,by damm+1 z x 71 ! fl[ f ! expiratory valve1 ! adm9i/rator c oblige ! pati5t to practise a c]ta9 am\nt ( re-brea?+1 &1 if he keeps up a free fl[ ( ! gases1 he c develop a pressure 9 ! nitr\s oxide bag def9itely exce$+ t ( ! atmosph]e4 ,tet] also introduc$ into 8 app>atus a means to w>m ! gases1 & to add a little e!r vap\r to ! mixture :5 requir$4 ,illu/ration3 ,,fig4 #ba4--,! ,cl>k gas oxyg5 ma*9e4 ,! ,cl>ke ma*9e is simil> 9 pr9ciple to ! ,tet]1 b makes a /rong po9t ( ! intimate mixture ( ! two gases produc$ 9 ! mix+ *amb] :i* occupies ! c5tre ( ! app>atus 7,fig4 #ba74 ,9 bo? ^! ma*9es1 x w be obs]v$1 ! two bags = ,n#b,o & ,o#b respectively are atta*$ to ! /&1 & ! mix$ gases are l$ to ! pati5t by a pipe ( wide bore4 ,:5 re-brea?+ occurs1 x mu/ !re=e be up & d[n ?is pipe1 b ! wid? ( ! bore seems to obviate any disadvantage :i* !oretically might be expect$ f ?is =m ( respiration4 ,illu/ration3 ,,fig4 #bb4--,m>%all's sight-fe$ gas-oxyg5 app>atus4 ,( ! two glass bottles ! "o to ! left is ! sight-fe$1 t to ! "r ! e!r *amb]4 ,9 ! exp]i5ce ( ! au?or & ( _m o!r an/heti/s1 v good results c be obta9$ f ei!r ( ^! ma*9es4 ,sight ,fe$ ,ma*9e4 ,9 ! au?or's op9ion1 ma*9es bas$ ^u ?is pr9ciple are likely to take a prom95t place 9 ! future ( gas-oxyg54 ,fig4 #bb expla9s ! simple me*anism4 ,ea* gas is l$ ?r\gh a tube dipp+ into wat] conta9$ 9 ! sight fe$ mix+ *amb]4 ,! ends ( ! pipes are op51 & on ! sides ( ea* pipe also are a numb] ( holes4 ,if ! pressure at :i* ei!r gas is deliv]$ is small1 bubbles w be se5 asc5d+ t[>ds ! surface ( ! wat] f ! upp] holes only4 ,! great] ! pressure1 ! fur!r d[n ! pipe does ! gas c>ry be=e all ( x escapes ?r\gh a hole1 & "o c !re=e get an accurate e/imate ( ! pressure f ! numb] ( holes ?r\gh :i* ! bubbles are se5 escap+4 ,^u ! surface ( ! wat]1 ! two gases meet & ent] into mixture & are convey$ away by ! ?ird pipe :i*1 ( c\rse1 does n dip into ! wat]4 ,once ! eye ( ! an/heti/ is tra9$ to its use1 ?is is a v simple means ( gaug+ ! relative proportions ( oxyg5 & nitr\s oxide :i* are be+ deliv]$1 & manipulation ( ! cyl9d] heads comb9$ ) visual inspection ( ! sight fe$ enable "o to /rike ! "r proportions v easily4 ,! nitr\s oxide is usually kept at a con/ant pressure suffici5t to ensure bubbles1 n only f all ! side holes1 b also a few f ! op5 end ( ! tube4 ,! oxyg5 pressure is begun at ! po9t :]e !re is a little bubbl+ f ! top hole only1 & is gradually increas$ until !re is a full supply f two holes1 occasionally a little ev5 f a ?ird4 ,messrs ,coxet] h rec5tly br\ght out two sight fe$ ma*9es design$ by ,mr ,leon>d ,boyle & ,dr ,ge(frey ,m>%all1 ( :i* ! latt] is %[n 9 ,fig4 #bb4 ,?is app>atus may be put up 9 ei!r portable =m or a l>g] type = use 9 hospitals4 ,an e!r *amb] is provid$ = use :5 necess>y 9 ei!r type4 ,z orig9ally introduc$1 ! rema9d] ( ! app>atus consi/$ simply ( an ord9>y two gallon bag1 ,b>? #c-way tap1 & rubb] facepiece4 ,) su* an appliance1 x is n possible to secure 8positive pressure1 a po9t :i* ! au?or br\ght to ! notice ( ! mak]s4 ,messrs ,coxet] are will+ to supply a facepiece & expiratory valve :i* obviate ?is defect1 be+ suppli$ ) a mica expiratory valve ! lift ( :i* c be controll$4 ,!re %\ld be no inspiratory valve4 ,adm9i/ration ( ,gas-oxyg5 = ! purposes ( ,major ,surg]y4 ,! pati5t is prep>$ ) ! same scrupul\s c>e z if e!r or *lor(orm is to be adm9i/]$4 ,half an h\r be=e op]ation1 morphia gr4 & atrop9e gr4 are giv5 hypod]mically4 ,! an/heti/ be=e beg9n+ adm9i/ration1 mu/ look ov] ! app>atus mo/ c>efully & satisfy himself t e "p ( x is 9 p]fect ord]1 & t a suffici5t supply ( bo? gases is at h&4 ,! inhalation is begun by ! use ( nitr\s oxide alone1 giv5 8on ! valves10 & at no great pressure4 ,aft] a few brea?s1 oxyg5 is add$ v gu>d$ly1 ! proportion be+ /eadily rais$ dur+ ! fir/ two m9utes3 aft] t po9t1 a fur!r increase w n be necess>y until sev]al m m9utes h elaps$4 ,! pressure at :i* ! mixture is be+ giv5 is also /eadily increas$ & %\ld rea* ! maximum p]missible )9 a few m9utes4 ,a useful plan is to all[ ! fl[ ( gases to rema9 con/ant1 b to close ! expiratory valve at frequ5t int]vals = ab\t =ty to sixty seconds at a "t4 ,dur+ ?is p]iod ( complete re-brea?+ ! t5sion 9 ! supply+ bag w ( c\rse rise1 fall+ aga9 slightly :5 ! expiratory valve is all[$ once m to come into action4 ,z soon z ! t5sion falls appreciably1 ! valve is aga9 clos$ d[n4 ,x is wise1 p>ticul>ly 9 "o's e>ly days1 to give a trace ( e!r vap\r dur+ ! latt] "p ( ! induction /age1 & to ma9ta9 x until ! op]ation is well "u way4 ,once ! an/heti/ is satisfi$ t ! n>cosis is prov+ deep en\gh = ! purposes ( ! op]ation1 ! e!r may be %ut (f & w probably n be requir$ aga94 ,rememb] t dep? ( an/hesia c be secur$ 9 ?ree ways--7#a7 cutt+ d[n ! oxyg5 p]c5tage2 7#b7 increas+ ! t5sion ( ! mix$ gases2 7#c7 add+ a little e!r4 ,( ^!1 ,no4 #a is mo/ undesirable1 & if c>ri$ to ! lea/ excess ov] a p]iod ( m ?an a m9ute or two may lead to an accid5t4 ,no4 #c is ! means = ! beg9n] to rely ^u1 until he le>ns ! judici\s & skilful use ( ,no #b4 ,! an/heti/ :o is le>n+ ! me?od ( an/hes+ mu/ resolve t no?+ %all tempt him to ov]/ep ! /age ( dull p9k col\r1 & mod]ate pupils4 ,if ) gas-oxyg5 alone1 he _c get a satisfactory an/hesia )\t resort+ to oxyg5 />vation1 let him n be a%am$ to turn on 8 e!r4 ,abdom9al relaxation suffici5tly complete to p]mit ! surgeon to explore ! abdom9al cavity ) ease1 is n readily secur$ by gas-oxyg5 9 a pati5t ( robu/ type4 ,=tunately1 x is ! weakly or ! sev]ely %ock$ :o really ne$ ?is =m ( an/hesia1 & 9 !m abdom9al relaxation is fairly easily obta9$4 ,pr(essor ,crile1 z has already be5 expla9$1 does n rely ^u ! inhalational an/hetic alone4 ,he infiltrates ea* lay] ( ! p>ietes ) novoca91 ?us produc+ a local an/hesia4 ,if ?is me?od be fai?fully c>ri$ out by ! surgeon1 a mo/ complete relaxation ( ! muscles c be secur$4 ,,*apt] ,,ix4 ,,e!r4 ,! drug commonly kn[n z e!r & o!rwise describ$ z e?ylic e!r or sulphuric e!r1 has a *emical =mula 7,c#b;,h#e7b,o4 ,x is a transp>5t col\rless fluid ) a specific gravity ( #gbj to #gbc4 ,a br& mu* us$ 9 ! ,/ates has an ,s4,g4 ( #gac only1 a po9t :i* is greatly emphasis$ by its support]s1 :o claim t x volatises quick] & !re=e is m p[]ful 9 action4 ,! au?or has 9 actual practise n f\nd mu* diff]5ce betwe5 ?is br& & any good ,briti% "o4 ,e!r is highly inflammable & volatilises readily at ord9>y room temp]atures4 ,its boil+ po9t is #if to #ih ,fahr4 ,:e!r evaporat+ f a fabric su* z gauze1 or f bulk 9 a j>1 e!r cools v rapidly1 & ! fall 9 temp]ature soon r$uces ! ease ( its volatisation4 ,?is po9t is ( "s practical importance 9 an/hetics1 & "s ye>s ago ! au?or made a numb] ( obs]vations1 hi!rto unpubli%$1 ) a view ( asc]ta9+ "s def9ite facts 9 ?is connection4 ,8 results w be f\nd 9 ,app5dix ,i4 ,e!r vap\r is heavy--two & a half times heavi] ?an air4 ,x !re=e t5ds 9 a room to fl[ t[>ds ! floor1 & to rema9 = "s "t unmix$ ) ! g5]al atmosph]e4 ,s9ce x is highly explosive1 ?is con/itutes a def9ite dang] if any nak$ light or op5 fire is pres5t4 ,ev]yone :o h&les e!r %\ld be> 9 m9d ^! physical peculi>ities ( its vap\r4 ,e!r is affect$ by prolong$ exposure to bright sunlight1 & also by prolong$ bubbl+ ?r\gh x ( air1 nitr\s oxide1 or oxyg54 ,e!r :i* has be5 subject$ to any ( ^! measures %\ld be inspect$ be=e be+ put back into res]ve1 & if any br[n discoloration is notic$1 x %\ld ei!r be s5t to ! hospital laboratory = r$i/illation1 or pres5t$ to ! !atre si/] = use z a clean+ ag5t4 ,su* contributions are always gratefully receiv$4 ,mo/ ( ! ord9>y impurities ( e!r are acid 9 reaction1 :ile e!r itself is absolutely neutral4 ,any specim5 :i* turns litmus pap] r$ %\ld be s5t to ! laboratory = exam9ation4 ,s\rces ( ,supply4 ,e?ylic alcohol may be prep>$ ei!r f e?yl alcohol or f me?ylat$ spirits4 ,9 ! =m] case x c>ries1 h[ev]1 ! co/ ( ! duty impos$ ^u potable _s1 & s9ce p]fectly good an/hetic e!r c be prep>$ f ! latt] s\rce1 x is wa/e ( money to use ! m exp5sive article4 ,physiology4 ,e!r acts ^u ! n]v\s sy/em l o!r an/hetics3 z comp>$ ) *lor(orm1 h[ev]1 ! /age ( excitation ( ea* c5tre be=e its p>alysis is apt to be m>k$4 ,!re is1 !re=e1 9 "s subjects1 a great] t5d5cy to /ruggle2 heal?y subjects prop]ly h&l$ d n %[ mu* evid5ce ( irritation ( ! c]ebrum4 ,all1 h[ev]1 %[ "s evid5ce ( /imulation ( ! respiratory c5tre1 :i* is n prolong$4 ,prolong$ deep & rapid respiration "u e!r is due to o!r causes ?an ! action ( ! drug itself4 ,x is ( c\rse se5 9 8clos$ e!r10 b ! active ag5t is excess ( ,,co#b1 n e!r4 ,! work+ m>g9 ( safety 9 e!r1 i4e4 ! /age betwe5 loss ( sp9al reflexes & ! poison+ ( respiratory c5tre is mu* wid] ?an 9 *lor(orm4 ,"s exp]im5ts ( ,wall] made _m ye>s ago %[$ t ^u n]ve tissue1 e!r acts mu* less p[]fully ?an *lor(orm3 9 ! proportion1 he f\nd1 ( "o to sev5 or eight4 ,^! laboratory results h receiv$ entire confirmation by lat] work]s :o h e/imat$ ! actual vap\r /r5g? requir$ ( ei!r drug to produce or ma9ta9 an/hesia4 ,r\ghly1 to induce an/hesia1 we require #b p] c5t4 *lor(orm1 or #af to #ah p] c5t4 ( e!r 7see ,app5dix ,,ii474 ,! ,circulation4 ,! fir/ effect ( e!r is a tempor>y /imulation ( ! he>t1 :i* beats m rapidly & m /rongly1 ?us rais+ ! blood pressure4 ,?is effect is n v prolong$2 l all o!r drug /imulation1 x is foll[$ by depression4 ,9 ! heal?y subject prop]ly an/hetis$1 su* depression is v mod]ate 9 degree1 & 9 a normal adm9i/ration x is probable t ! he>t1 aft] ! fir/ few m9utes1 is act+ v mu* at its normal spe$ & =ce4 ,e!r is1 h[ev]1 a m>k$ vaso-dilator1 & ! net result ^u blood pressure is a slight fall aft] ! fir/ few m9utes4 ,if ! me?od 9 use is 8clos$10 ! pressure rema9s slightly rais$ = "s consid]able "t1 usually ?r\gh\t ! adm9i/ration4 ,! slight anoxaemia induces a vaso-con/riction2 & ! ,,co#b excess1 9 ! view ( ,h5d]son 7see page #aj71 ma9ta9s a good return ( v5\s blood to ! he>t & a satisfactory c>diac output4 ,= a note ( c]ta9 blood *anges result+ f e!r & o!r an/hetics 7see ,app5dix ,,iii474 ,respiratory ,sy/em4 ,9 addition to ! effect ^u ! m$ull>y c5tre already ref]r$ to1 e!r effects ! respiratory tract m pr(\ndly ?an o!r an/hetics4 ,! muc\s membranes are irritat$1 & 9 "s cases !re is a great outp\r+ ( muc\s4 ,?\gh usually limit$ to ! upp] "p ( ! tract 7nose1 ph>ynx1 & tra*ea71 ! irritation sometimes ext5ds deeply into ! *e/1 affect+ ev5 ! small bron*ioles4 ,^! unpleasant effects ( e!r are 9 ! great majority ( cases1 q transi5t3 aft] ! fir/ t5 m9utes no addition to ! secretions is notic$4 ,9 a m9ority1 h[ev]1 ! effect p]si/s1 ! :ole *e/ is fill$ ) moi/ s\nds1 & p]si/5ce ) ! drug is impossible4 ,! kidneys are always slightly irritat$ by e!r1 & if !y are or rec5tly h be5 subject to inflammatory disease1 a v acute exac]bation is apt to foll[ ! use ( ! drug4 ,9 ! heal?y kidney ?is is n to be fe>$1 nor does x seem to be an appreciable dang] :]e "o kidney is s\nd1 ev5 if ! o!r is ! seat ( gross organic disease necessitat+ its dra9age or removal4 ,illu/ration3 ,,fig4 #bc4--;,clov]'s e!r inhal]1 ) nitr\s oxide atta*m5t4 ,me?ods ( ,adm9i/ration4 ,_m me?ods h be5 tri$1 b ^? :i* at pres5t hold ! field are-- 7#a7 ,clos$ ,e!r4 7#b7 ,op5 ,e!r1 m prop]ly call$ ! ,p]halation ,me?od4 7#c7 ,! 8,vap\r0 ,me?od4 7#d7 ,! ,rectal ,me?od 7,gwa?mey's oil-e!r74 7#e7 ,! ,intratra*eal ,me?od1 describ$ sep>ately 9 ,*apt] ,x4 ,illu/ration3 ,,fig4 #bd4--;,diagram ( a v]tical section ?r\gh ! middle ( ,clov]'s ,inhal]4 ,a4 %[s ! e!r dome2 ,b4 ,c5tral tube remov$ f app>atus 7#a7 ,clos$ ,e!r4 ,! two inhal]s orig9ally br\ght out = ?is 7 ,clov]'s 9 ,london1 & ,ormsby's 9 ,dubl94 ,at a lat] date ,hewitt's 8wide bore0 modification ( ! ,clov] 0 introduc$4 7a7 ,! ,clov] in/rum5t 7see ,fig4 #bc7d consi/s ( a face-piece1 a dome-%ap$ e!r *amb]1 & a "o-gallon bag1 usually atta*$ to ! top ( ! e!r *amb] by a ,t-%ap$ tube4 ,! details ( ! me?od by :i* ! am\nt ( e!r inhal$ by ! pati5t is graduat$ are be/ appreciat$ by unscrew+ ! mill$ head at ! top ( ! dome1 & )draw+ ! tube :i* runs ?r\gh x 7see ,fig4 #bd74 ,9 ! tube w be f\nd two slots1 "o ab\t half an in* above ! o!r1 & ea* ext5d+ = half ! circumf]5ce ( ! tube4 ,betwe5 ^! two slots ! tube is divid$ by a diaphragm4 ,9 any case1 !re=e1 air pass+ up or d[n ! tube mu/ pass 9 & out ( ^! slots4 ,n[ turn to ! tubul> space left 9 ! dome piece1 & exam9e visually & ) ! f+] its int]ior4 ,on ! "o side ( its middle w be f\nd two slots lead+ into ! circul> e!r *amb] :i* occupies a l>ge "p ( ! dome4 ,on ! o!r side w be f\nd a small cavity1 z deep f above d[nw>ds z ! two slots comb9$1 b n communicat+ ) ! e!r *amb]4 ,x is obvi\s t ) ! tube inside1 if ?is cavity is opposite ! slots 9 ! tube1 air w pass up ! tube out ( "o slot & back into ! o!r1 )\t com+ into contact ) ! e!r at all4 ,if on ! o!r h& ! slots 9 ! tube are opposite ! slots 9 ! e!r *amb]1 ! air passes ov] ! surface ( ! conta9$ e!r1 & volatises "s ( x4 ,int]m$iate positions ( ! tube give a condition :]e "p only ( ! air passes ov] ! e!r4 ,! indicator atta*$ to ! tube1 comb9$ ) ! figur+ 8,o1 "o1 two1 ?ree1 full10 to be f\nd on ! outside ( ! base ( ! dome1 %[s at any mom5t :at proportion ( ! air is pass+ into ! e!r *amb]4 ,to use ! in/rum5t1 fill ! metal measure provid$ ) e!r1 )draw ! /opp] f ! e!r *amb]1 & p\r 9 ! ounce & a half ( e!r :i* ! measure conta9s4 ,replace ! /opp]1 & bl[ ?r\gh ! tube to expel any e!r vap\r :i* may h appe>$ 9 x4 ,leave ! rubb] bag at fir/ unatta*$3 ! pati5t w feel m com=table if dur+ ! fir/ m9ute ! top ( ! tube is op54 ,) ! indicator at #j adapt ! face-piece to ! face & all[ ! pati5t to brea! up & d[n ! tube4 ,by rotat+ ! dome1 e!r is !n gradually turn$ on1 until ! figure two is rea*$ 9 ! fir/ m9ute4 ,! indicator is !n slipp$ back ne>ly to z]o = a second1 & ! rubb] bag slipp$ on dur+ an expiration3 x mu/ be mod]ately inflat$ to supply ! requisite volume ( air = respiration4 ,illu/ration3 ,,fig4 #be4--;,hewitt's wide-bore e!r inhal]4 ,! rotation ( ! dome is aga9 begun & ! indicator is made to travel away f ! z]o1 until at ! end ( ab\t five m9utes1 x rea*es 8full40 ,aft] ! fir/ few m9utes1 x w be necess>y to give an occasional brea? ( fre% air1 o!rwise an undesirable degree ( cyanosis w result1 b x mu/ be done ) great discretion1 or /ruggl+ w ensue4 ,at ! end ( ab\t five m9utes1 an/hesia %\ld be fully e/abli%$4 ,a little extra e!r is !n p\r$ into ! *amb]1 ! indicator pu%$ back to ab\t 8two0 & ! adm9i/ration cont9u$4 ,"o brea? ( fre% air is giv5 9 e ?ree or f\r4 ,spells may be giv5 ) ! bag (f altoge!r1 b dur+ su* p]iods ! indicator w require to be advanc$ a little1 & refills ( e!r provid$ m frequ5tly ?an w\ld be necess>y if ! bag 7 on4 ,hewitt's-wide-bore4 ,! pr9ciple ( ?is is id5tical ) t ( ! ,clov]1 b ! *annels be+ wid]1 !re is less me*anical int]f]5ce ) ! +ress & egress ( air4 ,! actual con/ruction diff]s also1 9 t to turn on ! e!r1 in/ead ( rotat+ ! dome1 "o moves ! indicator 7see ,fig4 #be74 ,! in/rum5t c]ta9ly gives results a little bett] ?an ^? obta9able by ! ,clov]1 b x is heavi]1 & r m bulky4 ,ormsby's ,inhal] 7,see ,fig4 #bf74 ,?is consi/s ( a facepiece1 a cage made ( wire or ?9 /eel slips & conta9+ a sponge2 & la/ly1 a "o gallon bag :i* fits ov] ! cage4 ,9 ! face-piece is an air v5t1 :i* c be ei!r entirely clos$1 p>tially or entirely op5$4 ,illu/ration3 ,,fig4 #bf4--,ormsby's ,inhal]4 ,! cage = ! sponge does n %[ 9 ! figure1 x projects upw>ds f ! bag-m\nt1 & is !re=e enclos$ 9 ! bag4 ,to use ! in/rum5t1 take out ! sponge & w>m x ei!r by wr++ x out ( hot wat]1 or bett] by leav+ x a few m9utes on ! top ( a hot /]ilis]4 ,pu% x back into ! cage1 op5 ! air v5t fully1 & hold+ ! inhal] upside d[n1 p\r on to ! sponge a measure full 7ab\t half an ounce7 ( e!r4 ,tell ! pati5t to inhale deeply1 & !n cat* ! result+ expiration 9 ! bag by quickly adapt+ ! facepiece to ! face at ! appropriate second4 ,aft] a few seconds1 beg9 to close ! air v5t1 :5 x w be f\nd t ! bag beg9s to wax & wane ) ea* expiration & inspiration respectively4 ,aft] ! fir/ ?ree m9utes1 ! inhal] mu/ be remov$1 m e!r p\r$ 91 ! air v5t op5$ aga9 p>tially1 & ! inhal] aga9 appli$ to ! face4 ,aft] full an/hesia is induc$1 ! air v5t may con/antly be left p>tially op54 ,n4,b4--,x mu/ be obs]v$ t ! air v5t is n valv$3 x is m]ely an op5+ ?r\gh :i* "p ( ! respir$ air may pass 9 & out )\t go+ ne> ! e!r sponge4 ,9 actual practice1 ! induction /age ( clos$ e!r is almo/ inv>iably assi/$ by us+ ei!r nitr\s oxide1 or a small dose ( e?yl *loride z a prelim9>y3 ^! me?ods are describ$ 9 ,*apt] ,,xv4 ,! "q n[ arises1 :at scope is to be assign$ 9 mod]n an/hesia1 to clos$-e!r me?ods4 ,=m]ly a l>ge proportion ( an/hesias1 long or %ort1 7 conduct$ by ! clos$ me?od1 & :ile ! great] numb] ( an/heti/s no long] utilise !m to ! same ext5t z =m]ly1 !y may /ill be reg>d$ z ( ! utmo/ value 9 a limit$ class ( cases4 ,!y are spe$y 9 action1 p[]ful en\gh to ov]come ! mo/ refractory pati5t1 & ) reasonable skill v safe4 ,on ! o!r h&1 ! an/hesia obta9$ is n ( ! mo/ desirable type4 ,!re is a great deal ( salivation & muc\s secretion f ! respiratory muc\s membranes2 ! respiratory movem5ts are deep] ?an 9 op5 me?ods1 f ! excess ( ,,co#b pres5t 9 ! blood1 & ?is leads to a good deal ( heav+ ( ! abdom9al wall1 :i* may be mo/ tr\blesome to ! surgeon if he is op5+ or clos+ t cavity4 ,moreov]1 aft] _! use m heada*e1 malaise1 & vomit+ occur ?an aft] op5-e!r1 & p]haps a little m t5d5cy to bron*itis or pneumonia4 ,= ^! reasons1 _m an/heti/s & surgeons n[ object to _! use 9 abdom9al surg]y1 ?\gh "s /ill adh]e to !m = ! induction /age1 pass+ to ! op5 me?od :5 ! pati5t is once well "u4 7#b7 ,op5 ,e!r4 ,z already expla9$ ! /rictly accurate t]m = ?is is ,p]halational ,e!r1 b s cumb]some a t]m9ology /&s small *ance ( g5]al acceptance4 ,app>atus4 ,! ess5tial po9ts 9 a prop] outfit h already be5 expla9$ 7see page #bh7 & are all well met by ! mask & e!r dropp] introduc$ by ,mr ,bellamy ,g>dn] 7see ,fig4 #bg74 ,! mask is cov]$ ) f twelve to sixte5 lay]s ( gauze1 & lies on ! gauze r+1 %[n 9 ! ,fig4 #bh;,a1 :i* completes ! fit betwe5 face & facepiece4 ,! dropp] fits into ! ord9>y six ounce disp5s>y bottle3 ! long arm dips into ! e!r1 ! %ort "o all[s air to ent] ! bottle to replace ! e!r us$4 ,a dropp] c also be improvis$ by us+ a cork ) slots cut at ea* side & ) a gauze or wool wick ins]t$ along "o ( ^!4 ,! au?or f9ds ^! unc]ta9 9 _! action1 h[ev]3 ) ,g>dn]'s dropp]1 a /eady fl[ ( drops ( e!r sl[ or fa/ z requir$1 c always be obta9$ once ! /ud5t has acquir$ ! knack ( us+ ! appliance4 ,illu/ration3 ,,fig4 #bg4--;,bellamy ,g>dn]'s 7,a7 op5 e!r mask2 7,b7 e!r dropp]4 ,illu/ration3 ,,fig4 #bh4 ,a4--,op5 e!r4 ,ready to beg94 ,b4--,op5 e!r4 ,cond5s+ t[el 9 position4 ,illu/ration3 ,,fig4 #bh4 ,c4--,op5 e!r4 ,correct me?od ( hold+ m\? & jaw4 ,d4--,op5 e!r4 ,alt]native me?od ( hold+ mask4 ,! t[el & gauze h be5 remov$ s z to %[ ! tilt+ ( ! mask :i* ?is me?od is liable to cause4 ,to ,mr ,bellamy ,g>dn]'s outfit1 ! au?or adds a fold$ t[el1 p9n$ at "o corn]1 s z to =m a %ort cone4 ,! base ( ?is cone embraces ! mask & face2 ?r\gh its upp] app]ture ! an/hetic is dropp$ on to ! mask4 ,! cone c be rotat$ into ! position mo/ conv5i5t = ?is purpose 9 any giv5 position ( ! pati5t's head 7,fig4 #bh74 ,problems ( ! ,induction ,p]iod4 ,op5-e!r is n a p[]ful an/hetic1 j n p[]ful en\gh = "o to be sure t "o c induce full an/hesia ) x alone1 9 a p[]ful subject4 ,! reason = ?is is %[n 9 ,app5dix ,,ii1 & may be "h cond5s$ by expla9+ t "s #ah p] c5t4 to #bj p] c5t4 ( e!r vap\r is requir$ to induce an/hesia1 :ile x is n easy to get m ?an #ad p] c5t4 (f an op5 mask4 ,h[ is ?is situation to be met8 ,ref]5ce has already be5 made to "o solution ( ! problem4 ,a clos$ e!r me?od may be us$ = induction1 & ?is practice is widely us$4 ,! au?or does n (t5 adopt ?is c\rse1 fe>+ t ! undesirable features ( clos$ e!r may p]si/ ev5 aft] ! *ange to an op5 me?od has be5 made4 ,ano!r possibility ev5 m widely fav\r$ is to use *lor(orm z ! induc+ ag5t1 & only to turn to e!r :5 full an/hesia is obta9$4 ,to ?is plan ! au?or is /rongly oppos$4 ,x exposes ! pati5t to ! risks ( ! induction /age ( *lor(orm :i* are mu* great] ?an ^? ( ! lat] /ages4 ,moreov]1 to develop ! full advantages ( op5-e!r1 a prelim9>y hypod]mic ( morphia is ess5tial1 & ! drawbacks ( *lor(orm plus morphia are else:]e m5tion$ 7page #dc74 ,! use ( a mixture ( *lor(orm two p>ts1 e!r ?ree p>ts1 pres5ts ! same disadvantage1 b 9 a degree s mu* small] t 9 p[]ful or alcoholic pati5ts1 ! au?or believes ?is to be ! me?od ( *oice 7see ,*apt] xiv474 ,dr ,silk has rec5tly sugge/$ ano!r plan4 ,he has s\ght to make op5-e!r easy = ! non-exp]t ) a view ( enc\rag+ ! wid] use ( s valuable a me?od4 ,= ?is purpose he advocates ! admixture ( "o "p ( *lor(orm 9 ?irty-two ( e!r 7a dram ( *lor(orm 9 f\r ounces ( e!r74 ,?is is to be giv5 9 exactly ! same way z p]halational e!r1 & w1 ,silk says1 give a type ( an/hesia1 & a degree ( safety1 id5tical ) ^? ( pure e!r4 ,! au?or's exp]i5ce ) ,silk's mixture is too limit$ to enable him to (f] any op9ion ^u its m]its4 ,la/ly1 !re rema9s ! plan ( us+ e!r z ! ma9 induc+ ag5t1 b assi/+ its action by ! int]mitt5t & mo/ gu>d$ addition ( small quantities ( ,c#b;,e#c mixture4 ,?is is ! au?or's 8/ock0 me?od2 b 9 tea*+ x to /ud5ts1 too mu* emphasis _c be laid ^u ! small quantities ( *lor(orm mixture requir$ or p]missible4 ,z a consequ5ce ( ! p]halational me?od "h advocat$1 e drop ( *lor(orm :i* appe>s on ! mask w :5 volatilis$1 give a v mu* high] p]c5tage ( ,,*cl#c vap\r 9 ! inspir$ air1 ?an ! same quantity exhibit$ on ! ord9>y op5 *lor(orm mask4 ,once ! /ud5t has grasp$ ?is ess5tial fact1 ord9>y c>e & intellig5ce w enable him to gu>d aga9/ a dang] :i* is only exi/5t if unappreciat$4 ,! ,adm9i/ration4 ,= _m ( ! h9ts giv5 9 ?is section ! au?or is indebt$ to ,dr ,w4 ,j4 ,f]guson ( ,new ,york1 & ,dr ,hornabrook ( ,melb\rne4 ,success 9 induc+ ) op5-e!r is atta9$ only by att5tion to a numb] ( small details4 ,! /ud5t :o ?9ks t "s ( ^! are too trifl+ = 8 notice is usually ! man :o in=ms y t induction by op5-e!r is impossible1 ! fact really be+ t he has n tak5 ! tr\ble to le>n1 or has nev] _h prop] tuition4 ,! foll[+ are ! po9ts dem&+ att5tion3-- #a4 ,always give a dose ( morph-atrop9e or o!r n>cotic1 half to ?ree-qu>t]s ( an h\r be=eh&4 #b4 ,see t ! pati5t is com=table on ! table4 ,prop up 8 head & %\ld]s a little ) pill[s4 ,9 p[]ful subjects ,hornabrook tilts ! :ole table d[n at ! foot-end1 = a few degrees4 #c4 ,adh]e /rictly to p]halation & to ! drop me?od4 ,y w nev] induce ) op5-e!r if ! :ole volume ( ! respir$ air does n pass ?r\gh ! gauze4 #d4 ,*at to ! pati5t z long z consci\sness c possibly p]si/4 ,tell him he is do+ v well4 ,don't %\t complicat$ in/ructions at him z to h[ to brea!3 x annoys & muddles him4 #e4 ,:5 ! gauze r+ & ! mask are 9 position1 all[ "o or two drops ( e!r to fall on ! mask1 !n pause3 9 a few seconds ! mild e!r vap\r s =m$ w soo! ! upp] respiratory tract1 & prep>e x = ! /rong] vap\rs yet to come4 ,?is does n wa/e "t--x saves x4 #f4 ,:5 ! adm9i/ration is aga9 begun1 att5d closely to ! rate ( dropp+4 ,at fir/ n m ?an "o drop 9 ?ree or f\r seconds is want$4 ,! full rate ( dropp+ _c be atta9$ = at lea/ n9ety seconds4 #g4 ,give no mixture = ! fir/ n9ety seconds2 !reaft] "s five to t5 drops e half m9ute or e tw5ty seconds accord+ to type ( pati5t4 ,h ! mixture bottle h&y s t no "t is wa/$ 9 *ang+ bottles4 ,/op ! addition ( mixture z soon z full an/hesia is atta9$4 #h4 ,slip ! fold$ t[el ov] ! mask & tuck its base well r\nd ! *9 & face4 ,d ?is only aft] ! fir/ two m9utes h elaps$4 #i4 ,z soon z ! neck muscles are relax$1 turn ! pati5t's head ov] to "o side1 & let ! h&s assume ! position describ$ 9 ,*apt] iii4 & illu/rat$ 9 ,fig4 #bh;,c4 #aj4 ,! /ud5t is w>n$ to disc\rage ! too e>ly att5tions ( ! nurse or h\se-surgeon4 ,^! (ficials are naturally anxi\s to 8get ! pati5t ready = ! ,*ief0 & are apt to />t 8clean+ up0 be=e ! pati5t has lo/ all consci\sness4 ,a man :o is do+ 8 level be/ to g to sleep1 d]ives nei!r pleasure nor pr(it f a :olly unexpect$ dab ( ice-cold me?ylat$ _s ^u 8 umbilicus4 ,by ! use ( ! me?od "h advocat$1 induction is s+ul>ly easy & successful 9 good subjects4 ,! /ruggl+ /age is ei!r n repres5t$ at all1 or appe>s only 9 ! =m ( ! lift+ ( a limb & a slight occasional pause or cat* 9 respiration4 ,full an/hesia is (t5 ann\nc$ audibly1 by ! comm5cem5t ( a g5tle 8bl[+40 ,once x is he>d1 ! an/heti/ may re/ assur$ t a workable level ( an/hesia is ei!r pres5t or n f> (f4 ,am\nts ( ,e!r requir$4 ,if ! above in/ructions are foll[$1 ! am\nt ( e!r requir$ is n excessive4 ,an/hesia is atta9$ aft] ! use ( ab\t #a to #b ounces ( e!r & "o or two drams ( mixture4 ,! next =ty to fifty m9utes dem& ab\t ano!r f\r or five ounces ( e!r2 no mixture at all4 ,"s practice1 is requir$ be=e ^! small figures are atta9$4 ,! m practice1 ! less e!r is requir$4 ,,iii4--,,vap\r ,,an,,/hesia4 ,9 a s5se1 all =ms ( e!r an/hesia are vap\r me?ods1 b 9 all ! =ms s f> describ$1 ! pati5t has to vap\rise ! drug = himself3 9 a true vap\r an/hesia ?is is done = him1 & ! mixture ( air & e!r vap\r propell$ t[>ds him4 ,"o ( ! ke5e/ advocates ( ?is me?od is ,dr ,gwa?mey1 ( ,new ,york4 ,he lays great /ress also ^u ! necessity ( w>m+ ! vap\r1 claim+ t ?is measure w prev5t ! loss ( heat to ! pati5t incid5tal to ! w>m+ up 9 ! air passages ( ! cold vap\r usually suppli$ by o!r me?ods2 b ! results ( ! laboratory exp]im5ts ^u :i* ,gwa?mey f\nd$ 8 case are inapplicable to ! human subject1 9 t !y 7 p]=m$ ^u dogs & cats1 :i* lose heat l>gely f ! m\? & air /ream4 ,man is n a hairy animal1 & transacts mo/ ( 8 !rmolysis ?r\gh ! m$ium ( 8 sk94 ,none ! less1 w>m+ ! vap\r ( e!r has value s9ce ! process removes "s ( ! irritant effects s m>k$ 9 ! case ( cold e!r vap\r4 ,app>atus = ! ,vap\r ,me?od4 ,9 #aiac1 ,k>l ,connell describ$ su* an app>atus1 :i* 0 !n 9 use at ! ,roosevelt ,hospital1 ,new ,york4 ,! e!r 0 vap\ris$ by dropp+ x into a w>m *amb]4 ,air 0 pump$ into ! *amb]1 & c>ri$ ! e!r vap\r 9 kn[n p]c5tage1 & at kn[n pressure z %[n by gauges4 ,su* me*anism is ideal1 b w\ld c]ta9ly be r co/ly4 ,its great value 0 t x in=m$ u ) c]ta9ty :at proportions ( e!r 9 ! atmosph]e 7 necess>y to induce & ma9ta9 an/hesia 7see ,app5dix ,,ii474 ,a simple me*anism 0 br\ght out %ortly aft]w>ds by ,dr ,%ipway1 ( ,guy's1 & is kn[n z ,%ipway's w>m$ ,e!r4 ,x consi/s ess5tially ( ! foll[+ p>ts 7see ,fig4 #bi73-- 7#a7 ,a small h& bell[s 7,b74 7#b7 ,an e!r bottle1 ) tube = deliv]y ( air /ream dipp+ deeply into ! fluid3 ! exit tube ( c\rse does n dip 94 ,! bottle /&s 9 a metal pan 9 :i* wat] at ab\t #ge ,fahr4 is to be plac$ 7,e74 7#c7 ,a !rmos flask 7,w7 9 :i* is a metal tube 7,u74 ,! e!ris$ air passes along ?is tube1 & picks up heat f its walls4 ,! !rmos is fill$ ) wat] at ab\t #ahj ,fahr4 ,illu/ration3 ,,fig4 #bi4--,%ipway's w>m$ e!r vap\r app>atus4 7#d7 ,a mask ^u :i* a t[el or gauze is to be /ret*$3 ! rubb] tube br++ ! air & e!r is br\ght ?r\gh ! cov]+ mat]ial & deliv]s ! an/hetic vap\r 9 ! region ( ! m\?4 7#e7 ,additional to ! above1 !re may be add$ a small *lor(orm bottle 7,c74 ,9 specim5s ( ! in/rum5t conta9+ ?is conv5i5ce1 !re has1 ( c\rse1 to be a regulat+ tap 7,t7 at ! head ( ! e!r bottle1 :i* w div]t m or less ( ! air /ream t[>ds ! *lor(orm4 ,?is little ma*9e1 some:at resembl+ a cruet /& 9 its appe>ance 0 widely us$ 9 ,france4 ,ow+ to ! k9dness ( ! ,ed9burgh ,r$ ,cross ,committee1 "o 0 provid$ = ! ,base ,hospital ) :i* ! au?or proce$$ to ,salonika1 :]e he us$ x ext5sively4 ,! impression ( x =m$ by himself & o!rs 0 t x 0 peculi>ly easy to ma9ta9 ) x a /eady level ( an/hesia4 ,x _h1 h[ev]1 no claim to bani% po/-an/hetic bron*itis & pneumonia1 ( :i* 9 spite ( mu* anxi\s c>e & ?\ght1 a fair numb] ( cases 7 se5 dur+ ! w9t] "t 7see page #aea74 ,9 us+ ! ma*9e1 x is necess>y to rememb] t f ! physical po9t ( view1 "o is provid+ f ! ma*9e a small "p only ( ! total volume ( air requir$ by ! pati5t4 ,! bell[s are q small3 "o squeeze ( ! h& w n supply m ?an ab\t ! equival5t 9 volume ( "o or two fluid ounces4 ,! l>g] "p ( ! volume requir$ by ! pati5t has to be obta9$ f ! g5]al atmosph]e1 s t ! p]c5tage ( e!r :i* may be z high z #be 9 ! exit tube1 w be greatly l[]$ by ! "t x rea*es ! pati5t's respiratory tract4 99 99 99 99 99 ,! actual /r5g? ( e!r brea!d by ! pati5t w dep5d ^u3-- #a4 ,! =ce & frequ5cy ) :i* ! pump is compress$4 7,n4,b4 ,x is ( c\rse useless to pump dur+ expiration74 #b4 ,! dep? ( e!r 9 ! bottle4 #c4 ,! temp]ature ( ! wat] ba? 9 :i* ! e!r bottle /&s4 ,! w>m wat] %\ld only be put 9 at ! la/ mom5t be=e />t+1 o!rwise v /rong e!r vap\r w collect on ! surface ( ! e!r1 & ! fir/ puff ( ! bulb w expel a highly irritant vap\r t[>ds ! pati5t4 ,) specim5s ( ?is ma*9e :i* h ! addition ( ! *lor(orm bottle1 x is p]fectly possible to conduct ev5 ! induction /age ( an/hesia2 a m]e trace ( *lor(orm vap\r w be suffici5t4 ,x is unnecess>y to give detail$ in/ructions = ! use ( ! ma*9e4 ,a prelim9>y consid]ation ( ! above physical facts1 toge!r ) a little cauti\s practice1 w enable ! /ud5t rapidly to acquire facility ) ! me?od4 ,,iv4--,,rectal ,,e!risation4 ,= su* op]ations z ! removal ( jaw or tongue !re are obvi\s advantages 9 be+ able to introduce e!r vap\r to ! blood p] rectum1 s9ce ! m\? & air passages are !reby left free = ! att5tion ( ! surgeon4 ,_m ye>s ago ?is 0 attempt$ by vap\ris+ e!r & propell+ ! vap\r ?r\gh a tube high up into ! rectum4 ,?is me?od 0 ab&on$1 z x l$ to a good deal ( inflammatory tr\ble aft]w>ds4 ,rec5tly1 ,dr ,gwa?mey sugge/$ a new me?od ( utilis+ ! rectal r\te :i* has l>gely ov]come ?is objection4 ,gwa?mey's ,oil ,e!r ,me?od4 ,?is consi/s 9 pass+ into ! rectum a mixture ( olive oil & e!r4 ,! b[el is fir/ c>efully wa%$ out1 & an h\r be=e op]ation1 ! pati5t receives a hypod]mic ( morphia1 gr4 2 atrop9e1 gr4 4 ,a suppository ( *loretone gr4 v is also pass$ into ! rectum to act z a local s$ative4 ,half-an-h\r lat]1 ! pati5t is put into ! left lat]al position1 a s(t ca!t] atta*$ to a funnel is pass$ "s six in*es up ! rectum1 & ! mixture ( oil & e!r p\r$ into ! funnel4 ,x is wise to take at lea/ five m9utes to introduce ! :ole dose4 ,! foll[+ table %[s ! dosage requir$3-- ---------------------------------------- --------------------------- ,/r5g? ( ,age ( ,pati5t4 ,e!r 9 ,quantity ( ,mixture requir$4 ,mixture4 ---------------------------------------- --------------------------- ,"u #f ye>s #ej ,"o ounce to ea* #bj p\nds body weight 7no prelim9>y morphia7 #f to #ab ye>s #ee to #fe ,d4 d4 #ab to #ae ye>s ,d4 ,"o ounce to ea* #bj p\nds body weight 7b use gr4 morphia7 #af ye>s & #ge ,"o ounce to ea* #bj p\nds body upw>ds weight ) gr4 morphia z a prelim9>y ---------------------------------------- --------------------------- ,9 practice !n1 = ! ord9>y adult1 "o uses eight ounces ( ! mixture1 six ounces ( :i* are pure e!r4 ,! oil & e!r require to be %ak5 toge!r1 b rema9 bl5d$ long en\gh = introduction4 ,9 five or t5 m9utes1 ! pati5t beg9s to feel a r pleas+ numbness & t+l+ 9 ! l[]1 & lat] ! upp] extremities1 & drops quietly to sleep 9 ab\t tw5ty m9utes4 ,9 a l>ge proportion ( cases1 x is necess>y to deep5 ! an/hesia by ! use ( ! op5 mask = a few m9utes1 b once a deep an/hesia has be5 ?us obta9$1 ! absorption f ! rectum w balance ! loss 9 expiration & ma9ta9 a good an/hesia = ?ree qu>t]s ( an h\r at lea/4 ,on return to b$ ( ! pati5t1 ! nurse passes two tubes plac$ side by side1 z high into ! rectum z %e c2 ! end ( a ,higg9son syr+e is ins]t$ into "o ( !m1 & a consid]able quantity ( soap & wat] is pump$ g5tly into ! b[el1 escap+ d[n ! second tube4 ,! wa%+ mu/ be cont9u$ until all smell ( e!r is remov$4 ,f9ally ! soapy wat] itself is wa%$ away by a little sal9e4 ,unless !re be "s pre-exi/+ local inflammatory disease ( ! rectum 79 :i* case ! me?od %\ld n be us$71 !re are no unpleasant sequel aft] oil e!r4 ,! *ief objection to ! me?od is ! am\nt ( lab\r ?r[n on ! nurs+ /aff1 :i* is s consid]able z to b> x f adoption z a r\t9e4 ,?is %\ld n1 h[ev]1 be all[$ to prev5t its use 9 ! limit$ numb] ( cases 9 :i* x is /rongly indicat$4 ,^! are3-- 7#a7 ,panic-/ruck cases :o _c face ! ordeal ( ord9>y me?ods4 7#b7 ,nose1 ?roat1 & tongue op]ations :]e intratra*eal e!r is n available4 ,,*apt] ,x ,,intratra*eal ,,insufflation ,,( ,,e!r ,intratra*eal insufflation consi/s 9 driv+ a curr5t ( air "u pressure1 ?r\gh a tube introduc$ by way ( ! m\? & l>ynx1 deeply into ! tra*ea4 ,! curr5t ( air :i* is cont9u\s1 returns betwe5 ! tube & ! wall ( ! tra*ea1 & escapes ?r\gh ! m\? & nose4 ,c]ta9 ,physical ,consid]ations4 ,! "w ( ,meltz] & ,au] has demon/rat$ t ?is insufflation ( air into ! tra*ea "u adequate pressure v5tilates ! pulmon>y alveoli1 & enables ! normal diffusion ( gases to be c>ri$ out = _m h\rs1 indep5d5tly ( all respiratory movem5ts4 ,if ! air 9 its passage "u pressure is made to pass ?r\gh a *amb] conta9+ e!r1 we are enabl$ to introduce into ! pulmon>y alveoli1 e!r vap\r ( v>y+ /r5g?1 &1 by ?is means1 to ma9ta9 surgical an/hesia4 99 99 99 99 99 ,,! ,,actual ,,process ,,( ,,ext]nal ,,respiration consi/s 9 ! absorption ( oxyg5 f ! alveoli into ! blood ( ! lung capill>ies1 & ! elim9ation ( c>bon dioxide f ! lung capill>ies into ! alveoli4 ,! oxyg5 has to be br\ght f ! outside to ! alveoli1 & ! c>bon dioxide has to be conduct$ f ! alveoli to ! outside4 ,betwe5 ! outside & ! alveoli is ! long air%aft1 consi/+ ( m\? & nose1 ph>ynx1 l>ynx1 tra*ea1 bron*i & bron*ioles4 ,9 natural respiration ! conduction ( oxyg5 inw>ds1 & ( c>bon dioxide outw>ds1 is c>ri$ ?r\gh by a complicat$ pump+ me*anism4 ,9 ord9>y inhalation an/hesia1 ?is me*anism is entru/$ ) ! task ( introduc+ e!r vap\r into ! alveoli4 ,9 intratra*eal insufflation ! "w ( ?is natural pump+ app>atus is tak5 ov] by an artificial me*anism4 ,9 consid]+ ! ju/ification = ?is1 ! foll[+ po9ts are to be not$3-- 7#a7 ,! pati5t is unconsci\s--n naturally s z 9 sleep--b unnaturally z ! result ( drugs2 !re is !re=e a probability t ! elaborate natural me*anism may n "w smoo?ly--especially is !re a dang] t ! free airway may be int]f]$ )4 ,intratra*eal insufflation obviates ?is dang]4 7#b7 ,by means ( ! artificial me*anism1 air is br\ght ) "s =ce to ! m\? ( ! bron*i1 & ?us a m rapid & m p[]ful diffusion ( gases takes place4 7#c7 ,! me*anism ensures ! ma9t5ance ( a curr5t ( air bl[+ =cefully f ! tra*ea & l>ynx ?r\gh ! ph>ynx1 m\? & nose4 ,?is re-curr5t cont9u\s air-/ream effectively prev5ts ! entrance ( blood or any infecti\s mat]ial into ! bron*i & air cells1 & ?us ! dang] ( septic lung tr\bles is obviat$4 7#d7 ,9 c]ta9 intra?oracic op]ations ! normal respiratory me*anism is delib]ately int]f]$ )4 ,intratra*eal insufflation by ! con/ant ma9t5ance ( suffici5t positive pressure1 prev5ts or regulates ! collapse ( ! lung :i* occurs :5 ! ?orax is op5$1 & ?us obviates ! necessity = ! some:at elaborate positive & negative pressure cab9ets & masks :i* _h be5 devis$ = intra?oracic op]ations4 7#e7 ,incid5tally x may be not$ t intratra*eal insufflation ( air provides u ) an excell5t means = p]=m+ artificial respiration4 ,_m in/ances h n[ be5 record$ ( its utility 9 ?is respect4 ,dr ,elsb]g records ! case ( a pati5t :o _h tak5 morphia ) suicidal int5t1 on :om artificial respiration by ?is me?od 0 kept up = #ab h\rs1 )\t any respiratory movem5ts tak+ place1 recov]y ultimately ensu+4 ,! ,app>atus4 ,?is consi/s ( 7see ,fig4 #cj73-- #a4 ,in/rum5t = produc+ air curr5t 7,a74 #b4 ,e!r *amb] & v>i\s regulat+ taps 7,b74 #c4 ,device = w>m+ vap\r 7,c74 #d4 ,safety valve 7,d74 #e4 ,manomet] 7,e74 #f4 ,intratra*eal ca!t]1 ) rubb] tub+ l9k+ up ! v>i\s p>ts ( ! app>atus 7,h74 ,illu/ration3 ,,fig4 #cj4 ,diagram ( intratra*eal app>atus4 #a4 ,,! ,,air ,,curr5t is obta9$ ei!r by means ( an ord9>y glass-bl[]'s foot bell[s1 or an electric motor may actuate a rotatory bl[] :i* produces a curr5t ( air4 ,! bl[] may be made to rotate at a spe$ v>y+ f #ej to #ajjj revolutions p] m9ute 7see ,fig4 #ca74 ,! foot bell[s is simple & inexp5sive1 & !re is no reason :y x %\ld n be effici5t4 ,! electrically rotat$ bl[] is m effici5t1 ensures a smoo!r air curr5t1 & saves mu* lab\r4 #b4 ,,! ,,e!r ,,*amb]4--,e!r vap\r may be produc$ by ei!r ( two me?ods4 ,fig4 #cb %[s ,kelly's in/rum5t :]e air is bl[n ov] ! surface ( a consid]able quantity ( liquid e!r4 ,dr ,meltz]#e ma9ta9s t ! effectiv5ess ( ! e!rization is proportional to ! diamet] ( ! e!r bottle4 ,9 ?is connection x may be well to recall c]ta9 po9ts p]t95t to ! subject ( e!rization4 ,a satisfactory e!rization dep5ds on ! e/abli%m5t 9 ! blood & tissues ( an e!r t5sion ( def9ite /r5g?4 ,boo?by#f /ates t ?is t5sion %\ld correspond to ab\t #ae p] c5t4 ( e!r vap\r 9 ! alveol> cells4 8,if :5 ?is t5sion has be5 e/abli%$1 less ?an #ae p] c5t4 e!r vap\r is adm9i/]$1 outw>d diffusion occurs f ! tissues & blood to ! air & ! an/hesia becomes light]40 ,illu/ration3 ,,fig4 #ca4--;,electric bl[] to supply curr5t ( air = intratra*eal an/hesia4 ,illu/ration3 ,,fig4 #cb4 ,kelly's intratra*eal app>atus4 ,9 an app>atus su* z we are describ+ ! /r5g? ( ! e!r vap\r dep5ds on & is influ5c$ by a v>iety ( factors1 among :i* ! foll[+ may be specially not$3-- 7a7 ,! diamet] ( ! e!r *amb]4--,! l>g] ! diamet] ! /rong] w be ! e!r vap\r4 ,! *amb] is g5]ally kept two-?irds full3 ! less ! empty space 9 ! *amb] ! /rong] w be ! vap\r4 7b7 ,! rapidity ( ! air-curr5t4--,! l>g] ! am\nt ( air pass+ ov] ! e!r ! m rapid w be ! vap\ration1 ) ! result t ! temp]ature ( ! liquid e!r w rapidly fall & ! /r5g? ( ! e!r vap\r 9 ! air w be correspond+ly l[]$4 7c7 ,! temp]ature ( ! liquid e!r4--,! high] ! temp]ature ( ! liquid e!r ! /rong] w be ! p]c5tage ( e!r vap\r 9 ! air4 ,if ! e!r *amb] is plac$ 9 a ba? ( wat] :i* is ma9ta9$ /eadily at an adequate temp]ature & if ! rate ( ! air fl[ rema9s con/ant1 a con/ant /r5g? ( e!r vap\r w be giv5 (f4 ,x is well 9 ?is connection to rememb] t ! boil+ po9t ( e!r is l[ & t a v high p]c5tage ( e!r vap\r is readily obta9$ if ! temp]ature 9 ! wat] ba? is all[$ to rise beyond #hj;,f4 ,= fur!r in=mation reg>d+ e!r p]c5tages see ,app5dix ,i & ,,ii4 ,su* an in/rum5t z ,kelly's requires at its head a regulat+ tap1 movem5t ( :i* is capable ( div]t+ "p ( ! air /ream direct to ! pati5t )\t com+ 9 contact ) ! surface ( ! e!r4 ,9 ?is way ! maximum /r5g? ( vap\r may be dilut$ z & :5 requir$4 ,9 ,fig4 #cc is %[n ,%ipway's in/rum5t4 ,"h ! drug is dripp$ into a *amb]1 ! floor ( :i* is kept w>m4 ,! e!r volatilises at once & ! vap\r is c>ri$ away by ! air /ream pass+ ?r\gh ! *amb]4 ,! /r5g? ( e!r vap\r 9 ?is in/rum5t is regulat$ solely by ! rate ( drip :i* is 9 complete control ( ! adm9i/rator4 ,:i*ev] me?od ( mak+ e!r vap\r is utilis$ ! in/rum5t %\ld be capable ( produc+ a maximum at lea/ ( #ae p] c5t4 to #ah p] c5t41 & means mu/ be provid$ to r$uce ?is p]c5tage at w4 #c4 ,,device ,,= ,,w>m+ ,,vap\r4--,x is d\btful if ! w>m+ ( inspir$ or insufflat$ vap\r has any appreciable influ5ce on ! body temp]ature1 b !re is a fairly g5]al cons5sus ( op9ion t if ! e!r vap\r is w>m$ !re is less likelihood ( irritation ( ! respiratory muc\s membrane4 ,x is to be not$1 moreov]1 t 9 intratra*eal insufflation ! natural app>atus = w>m+ ! inspir$ air is put out ( action4 ,?is w>m+ c be effect$ by ! simple device ( c>ry+ ! tube ?r\gh a *amb] ( hot wat] aft] x em]ges f ! e!r *amb]4 #d4 ,,safety ,,valve4--,dr ,meltz] insi/s v /rongly on ! necessity ( hav+ a safety valve capable ( controll+ ! maximum pressure "u :i* ! air may ent] into ! intratra*eal tube4 ,by a simple device1 any excess ( desir$ pressure w cause ! air to bubble ?r\gh m]cury & ?us nev] rea* ! lungs4 ,9 ?is way any possibility ( accid5t f undue intrapulmon>y pressure is obviat$4 ,illu/ration3 ,,fig4 #cc4--,%ipway's intratra*eal app>atus4 #e4 ,,m]cury ,,manomet] to indicate ! pressure 9 ! tube 9 m4m4 ( m]cury4 ,x has be5 exp]im5tally e/abli%$#g 8t ! pressure 9 ! tra*ea & 9 ! bron*i is only a small fraction ( ! pressure 9 ! manomet] outside ( ! body1 & t ! intratra*eal pressure gr[s consid]ably less ) ! decrease ( ! diamet] ( ! intratra*eal tube40 #f4 ,,intratra*eal ,,ca!t]4--,x is ess5tial to h an in/rum5t ( adequate rigidity :i* c be satisfactorily /]iliz$4 ,! ord9>y c\d ca!t]s1 or ! silk web :ite enamell$ cyl9drical ca!t]s1 are suitable4 ,! size %\ld be select$ f a range ( #ah to #be ,fr5*4 ,x is pref]able to err r on ! side ( a small ?an a l>ge tube4 ,an ord9>y adult w require a tube ( ab\t size #bb to #bd1 a ple?oric alcoholic1 on ! o!r h&1 might ne$ a #be4 ,a tube ( too l>ge a calibre int]f]es ) ! free return ( air & spontane\s respiration soon becomes too sl[4 ,expiration is prolong$1 active1 & lab\r$1 & aft] a few m9utes1 respiratory movem5ts may cease entirely4 ,! only way to meet su* a situation is to )draw ! tube & ins]t a small] "o4 ,,te*nique ,,( ,,adm9i/ration4--,x is advisable 9 adults to adm9i/] ab\t ?ree qu>t]s ( an h\r be=e ! op]ation1 a hypod]mic injection ( morphia 7gr4 7 & atrop9e 7gr4 71 or ( scopolam9e 7gr4 7 & morphia 7gr4 74 ,! latt] comb9ation is m efficaci\s 9 alcoholic subjects4 ,9 *ildr51 atrop9e alone %\ld be giv54 ,x is to be rememb]$ t intratra*eal insufflation ( e!r is a me?od ( ma9ta9+ n ( induc+ an/hesia4 ,induction is c>ri$ out 9 ! ord9>y way4 ,:5 ?is has be5 done1 ! ca!t] is pass$4 ,! introduction ( ! ca!t] does pres5t "s difficulty1 b ?is is l>gely ov]come z skill & confid5ce are acquir$ ) practice4 ,x may be c>ri$ out indirectly1 or a view ( ! glottis may be obta9$ by ! aid ( su* an endoscope z ,hill's1 & ! ca!t] ins]t$ betwe5 ! cords4 ,! latt] me?od is probably ! m satisfactory1 b x is well to acquire ! skill to pass ! ca!t] indirectly z 9 a c]ta9 small proportion ( cases !re are ob/acles to ! use ( ! endoscope4 ,to facilitate ca!rization ! ph>ynx & epiglottic region may be coca9iz$ ) a #e p] c5t4 solution be=e induction4 ,hill's endoscope 7,fig4 #cd7 is di/ally illum9at$ by a small electric lamp1 :i* is connect$ ) a small pocket batt]y4 ,a useful modification ( ?is has be5 devis$ by ,mr ,dott4 ,9 x1 ! ca!t] is pass$ along a sep>ate comp>tm5t1 s t ! view ( ! glottis is undi/urb$4 ,! po9t ( ! ca!t] comes into view at ! di/al extremity ( ! endoscope & c be guid$ betwe5 ! cords into ! tra*ea4 ,illu/ration3 ,,fig4 #cd4--;,hill's ,direct ,l>yngoscope4 ,x is ess5tial be=e attempt+ intubation1 t !re %\ld be ?or\gh relaxation4 ,! l[] jaw %\ld be s slack t a gag is n requir$4 ,! head is !n plac$ 9 ! occipito-%\ld] position1 or is all[$ to hang ov] ! end ( ! table4 ,! tongue is controll$ by =ceps1 & ! endoscope pass$ sl[ly along its dorsum until ! epiglottis comes into view4 ,! po9t ( ! endoscope is !n pass$ suffici5tly f> bel[ ! tip ( ! epiglottis to ensure t x w n slip2 too deep ins]tion mu/ be avoid$4 ,! endoscope be+ held 9 ! left h&1 ! hyoid bone is lift$ up by a tilt+ movem5t ( ! h&4 ,! glottis is ?us br\ght into view4 ,! ca!t] /iff5$ by means ( a probe is !n pass$ ?r\gh ! glottis into ! tra*ea & ! endoscope )drawn4 ,! bifurcation ( ! tra*ea 9 ! adult is at a di/ance ( ab\t #bf cm4 f ! incisor tee?4 ,! ca!t] %\ld be m>k$ accord+ly1 & ins]t$ to a po9t j %ort ( ?is4 ,! probe is !n )drawn1 & connection made ) ! air curr5t4 ,x occasionally happ5s t unexpect$ difficulty is met ) on attempt+ to pass ! ca!t] by direct vision4 ,! l>ynx may be s fix$ t ! glottis does n readily come into view2 or 9 ! case ( an intraoral neoplasm ! view may be ob/ruct$ by ! pres5ce ( blood4 ,9 su* cases ! ca!t] c be introduc$ by ! indirect me?od4 ,! middle f+] ( ! left h& is pass$ along ! dorsum ( ! tongue until ! epiglottis is felt4 ,! index f+] is !n us$ to guide ! po9t ( ! ca!t] to ! glottis ?r\gh :i* x is !n pass$4 ,no undue =ce mu/ be us$4 ,a /ilette %\ld be ins]t$ into ! ca!t] :i* %\ld be m\ld$ almo/ to a "r angle at its t]m9al ?ird4 ,if ! /ilette is )drawn :5 ! po9t ( ! ca!t] is ov] ! m\? ( ! glottis1 ! in/rum5t w1 z a rule1 slip easily into ! tra*ea4 ,occasionally ! tube passes into ! sophagus4 ,) c>e & adequate relaxation su* a mi/ake %\ld n occur1 b ! possibility ( x %\ld be kept 9 m9d4 ,if ! op]ator w ab/a9 f attempt+ to pass ! ca!t] until su* "t z he has a satisfactory view ( ! glottis1 mi/akes ( ?is k9d w seldom occur4 ,! ess5tials are a good illum9ation & an adequate relaxation4 ,mild glottic spasm may sup]v5e on ! passage ( ! ca!t] b ?is rapidly passes (f4 ,at fir/ ! degree ( conc5tration ( ! vap\r %\ld be l[ or irritation w result1 evid5c$ by spasm & c\gh+4 ,! /r5g? ( ! vap\r is gradually increas$ until ! necess>y conc5tration is atta9$4 ,! pressure %\ld v>y accord+ to ! requirem5ts ( ! case & %\ld range betwe5 #aj mm4 to #be mm4 ,hg4 ,! safety valve mu/ be set s z to make any pressure above ?is impossible4 ,9 ! majority ( cases ! c\rse ( an/hesia is smoo? & unev5tful2 ! col\r rema9s a rosy p9k1 ! pulse is good1 & ! respirations quiet & regul>4 ,x is undesirable t ! respiratory movem5ts %\ld be aboli%$ altoge!r2 _! pres5ce indicates t nei!r ! c5tral nor ! p]iph]al respiratory me*anism is be+ ov]dos$ ) e!r4 ,!oretically1 ! con/ant plus-pressure 9 ! lungs might be ?\ght to int]f]e ) ! circulation 9 ! l>ge ve9s1 & 9 ! pulmon>y vessels !mselves4 ,x is !re=e well to r$uce ! pressure 9 ! ca!t] to z]o e m9ute by op5+ ! tap provid$ = ! purpose = a second or two4 ,at ! conclusion ( ! op]ation1 be=e )draw+ ! ca!t] x is well to flu% out ! lungs ) air s z to remove any e!r vap\r t is pres5t4 ,9 a c]ta9 numb] ( cases1 notably 9 big alcoholic subjects1 difficulty may be exp]i5c$ 9 secur+ a suffici5tly deep an/hesia ) good relaxation4 ,x is seldom1 h[ev]1 t pati5ce & ! c>eful introduction ( a /rong] vap\r w n suffice to ov]come ?is4 ,9 alcoholic subjects1 z previ\sly sugge/$1 prelim9>y m$ication ) scopolam9e & morphia w help4 ,x really becomes a "q1 if "o may put x s1 ( coax+ ! unconsci\s pati5t to tol]ate an e!r vap\r ( adequate /r5g?4 ,advantages & ,special ,indications4 ,! g5]al op9ion ( an/heti/s appe>s /rongly to fav\r ! view t ! abs5ce ( /ra9 & ! p]fect ration 9 intratra*eal e!r insufflation t5d to less5 ! %ock ( op]ation4 ,! po/-op]ative hi/ory ( pati5ts also sugge/s t !re is a less5$ liability to pulmon>y complications z comp>$ ) cases 9 :i* e!r has be5 adm9i/]$ by o!r me?ods4 ,dr ,elsb]g#h ( ,new ,york 9 ?is connection writes3 8,! abs5ce ( any pulmon>y complications has l$ u to use ?is me?od ( an/hesia 9 all pati5ts 9 :om pulmon>y complications 7 to be fe>$ aft] an an/hesia or op]ation4 ,?us on all a/hmatics1 9 pati5ts ) *ronic bron*itis & emphysema1 9 pati5ts :o require ga/ric resection & ! l1 we no long]1 dur+ two ye>s1 h se5 ! mu* dread$ po/-op]ative pneumonia :]ev] intratra*eal an/hesia 0 us$40 ,9 addition1 !re is ample evid5ce#i t ! introduction ( a ca!t] into ! tra*ea & its pres5ce !re9 does n t5d1 z might h be5 expect$1 to set up any irritation at ! "t or pr$ispose to subsequ5t tr\ble4 ,ap>t f ^! g5]al consid]ations1 :i* sugge/ ! advantage ( a some:at ext5d$ use ( intratra*eal e!r insufflation1 ! me?od has obvi\s advantages 9 all op]ations ab\t ! m\?1 su* z ^? = excision ( ! upp] jaw1 ^? und]tak5 = ! removal ( nasoph>yngeal gr[?s & v>i\s pla/ic op]ations involv+ ! nasal & buccal cavities4 ,9 su* cases ! dang] ( aspiration ( blood1 mucus1 etc41 is obviat$ & ! an/heti/ is well out ( ! surgeon's way1 :ile at ! same "t an ev5 int]rupt$ deliv]y ( e!r vap\r is effect$4 ,9 op]ations = removal ( gl&s 9 ! neck ! surgeon has ! field to himself1 & is n hamp]$ nor is 8 asepsis endang]$ by ! proximity ( ! an/heti/'s mask4 ,9 su* op]ations z lam9ectomy & nephrectomy ! po/ural difficulties ) :i* ! an/heti/ has to cont5d1 & :i* also t5d to int]f]e ) free respiration1 are elim9at$4 ,! great advantage ( ! me?od 9 intra?oracic op]ations has already be5 ref]r$ to4 ,! introduction ( intratra*eal insufflation ( e!r 0 r5d]$ possible by ! pione] "w ( ,drs ,elsb]g1 ,meltz]1 & ,au]4 ,! writ] w\ld l to ackn[l$ge 8 indebt$ness to _! writ+s1 ( :i* he has made free use4 ,,*apt] ,,xi4 ,,*lor(orm4 ,physical ,*>act]i/ics4 ,*lor(orm is *emically tri*lor-me?ane1 ,,*cl#c4 ,x is a col\rless1 transp>5t fluid1 ) a specific gravity ( #adia at #ag;,c4 ,its vap\r is ev5 heavi] ?an t ( e!r1 approximately f\r times heavi] ?an air4 ,x is n inflammable1 b ! action ( an op5 fire or nak$ flame t5ds to break x up into hydro*loric acid & phosg5e1 bo? ( :i* are highly irritant gases to all :o brea! !m4 ,! pati5t suff]s1 b s9ce all ! o!r occupants ( ! !atre are also affect$1 w>n+ is giv5 be=e s]i\s h>m has be5 inflict$4 ,*emically pure *lor(orm is a some:at un/able product1 b ! addition inv>iably made to x by ! produc]s1 ( a trace ( alcohol1 prev5ts any s]i\s risk ( decomposition 9 bulk4 ,x %\ld be neutral 9 reaction & h an agreeable non-irritat+ od\r3 dep>ture f ! normal 9 ei!r respect indicates ! possibility ( ! pres5ce ( acids or aldehydes1 & ! necessity = ref]r+ a specim5 to ! laboratory4 ,l e!r1 *lor(orm may be obta9$ f pure e?yl alcohol or f me?ylat$ spirits1 & ! rem>ks made 9 ! *apt] ^u e!r apply to ! case ( *lor(orm also4 ,a ?ird s\rce ( supply is acetone1 f :i* p]fectly good *lor(orm c be produc$4 ,physiology4 ,*lor(orm is an irritant to ! sk9 & muc\s membranes4 ,a drop left on ! sk9 & cov]$ ov] ) imp]meable mat]ial w produce a deep & pa9ful bli/]4 ,a drop fall+ into ! eye1 if n in/antly wa%$ away1 produces a v p[]ful inflammatory reaction1 & _m eyes h be5 totally lo/ f c>elessness 9 ?is respect4 ,su* incid5ts are ( c\rse actionable1 & heavy damages may be giv54 ,illu/ration3 ,,fig4 #ce4--;,diagrammatic repres5tation ( v>i\s blood pressure curves obta9able ) *lor(orm4 ,l9e ,,aba repres5ts curve desir$ 9 normal *lor(orm adm9i/ration4 ,l9e ,,abcb repres5ts gradual ov]dosage4 ,l9e ,,abcc repres5ts recov]y by inv]sion4 ,,dd repres5ts syncope f vagal inhibition3 9 its c\rse1 "o attempt ( ! he>t to 8escape0 is %[n4 ,! special peculi>ities ( ! action ( *lor(orm ^u ! n]v\s sy/em h already be5 emphasis$ 9 ! acc\nt giv5 ( ! physiology ( e!r 7see page #ge74 ,its action ^u ! circulatory & respiratory sy/ems has be5 ! subject ( _m rese>*es1 & ( mu* embitt]$ controv]sy4 ,! lit]ature is !re=e v ext5sive1 & ! acc\nt ( x mu/ be sev]ely cond5s$4 ,! foll[+ may be tak5 z a brief resum ( pres5t day op9ion 7see ,fig4 #ce73-- 7#a7 ,9 e case ( *lor(orm adm9i/ration1 !re is a fall ( blood pressure4 7#b7 ,if ! drug be pres5t$ 9 weak conc5tration 7less ?an #b p] c5t4 vap\r /r5g?71 ! fall is gradual & ev5 7l9e ,,ab74 7#c7 ,if ! same /r5g? 7say #b p] c5t47 ( vap\r z produc$ ! above effect be prolong$ unduly1 ! respiration w cease at a "t :5 blood pressure is /ill well above z]o 7l9e ,,abcb74 7#d7 ,! fall ( pressure is due to dim9i%$ =ce ( c>diac action1 & at a lat] /age also to vaso-motor p>esis4 7#e7 ,! cessation ( respiration is due p>tly to fall ( blood pressure 9 ! vessels supply+ ! m$ull>y c5tre2 p>tly to gradual poison+ ( ! c5tre itself by ! drug4 ,t ! fall ( ,b4,p4 9 ! c]ebral vessels is 9 itself "o explanation ( ! cessation ( respiration1 0 prov$ _m ye>s ago by ,leon>d ,hill 9 8 inv]sion exp]im5ts4 ,j at ! /age :5 respiration _h ceas$1 ! an/hetic 0 )drawn1 & ! animal inv]t$ into ! head-d[n position4 ,! ,b4,p4 9 ! c>otid at once began to rise1 & natural respiration 0 resum$ 7l9e ,a,,bcc74 ,! above conclusions ref] to *lor(orm giv5 9 mod]ate vap\r /r5g?2 o!r effects are produc$ if high] p]c5tages are adm9i/]$3-- 7#f7 ,) high conc5tration ( *lor(orm vap\r1 ! fall ( blood pressure is rapid1 & is apt to become sudd5ly precipit\s 7l9e ,,dd74 7#g7 ,! cause ( ^! sudd5 falls is inhibition ( ! he>t by ov]-activity ( ! vagus3 cutt+ ! vagi always t]m9ates ! effect unless delay$ s long t ! animal is dead3 9 an animal fully "u atrop9e1 ^! vagal actions _c be produc$4 7#h7 ,if ! he>t is inhibit$ by vagal action1 ! respiration ceases at once1 usually aft] "o deep inspiratory sigh4 7#i7 ,an inhibit$ he>t may 8escape0 f vagal action be=e ! animal is dead3 frequ5tly1 h[ev]1 ! inhibition p]si/s & ! animal dies4 7#aj7 ,/ruggl+ & brea?-hold+ 9 ! e>ly /ages ( induction cause sudd5 falls ( blood pressure4 ,_m obs]v]s believe t ^! falls also are due to vagal activity1 o!rs hotly d5y ?is4 ,all are unit$ 9 believ+ t to press *lor(orm ^u a pati5t :o is /ruggl+ & hold+ ! brea?1 is fraught ) grave risk ( caus+ sudd5 syncope4 7#aa7 ,! abnormal irritability ( ! vagus above ref]r$ to is a feature ma9ly ( ! induction /age1 disappe>+ once full an/hesia is develop$4 7#ab7 ,x is an und\bt$ cl9ical fact t !re is a risk ( sudd5 arre/ ( he>t's action if ! op]ation is begun be=e ! /age ( full an/hesia is rea*$4 ,a reasonable explanation ( su* accid5ts is furni%$ by suppos+ a reflex inhibition act+ ?r\gh ! vagal c5tre already r5d]$ hyp]-s5sitive by p>tial *lor(ormisation4 ,views ( ,goodman ,levy4 ,?is work] has demon/rat$ 9 animals t ! he>t is sometimes ?r[n by *lor(orm into ! condition ( fibrillation--a delirium ( ! c>diac muscle1 f :i* recov]y is r>e4 ,x occurs 9 ! e>ly /age1 be=e full an/hesia has be5 rea*$1 & is pr$ispos$ to by ! infliction ( trauma4 ,! practical outcome ( ?is is t ! induction /age ( *lor(orm %\ld n be unduly prolong$1 & t ! op]ation %\ld n be begun until ! ?ird /age is fully develop$4 ,s f> z ! au?or und]/&s ! views ( ,dr ,levy1 8 explanation ( *lor(orm syncope ne$ n be tak5 z introduc+ any new pr9ciple into ! adm9i/ration ( ! drug4 ,ev5 ^? :o lay mo/ emphasis ^u ! dang] ( us+ vap\rs ( too high a p]c5tage /r5g? w\ld admit ! =ce ( ,levy's cont5tions4 ,z usual1 safety lies 9 /e]+ betwe5 two extremes4 ,dur+ 8 "w on ?is subject1 ,levy fur!r demon/rat$ t ! introduction into ! circulation ( adr5al9 dur+ incomplete *lor(orm an/hesia 0 v liable to induce fatal c>diac fibrillation4 ,he ?us furni%$ ! explanation ( a numb] ( dea?s :i* _h occurr$ 9 ! practice ( nose & ?roat speciali/s4 ,s9ce ! publication ( ,levy's "w1 ! rule has be5 absolute t if adr5al9 is to be us$ 9 a case requir+ *lor(orm an/hesia1 ! adr5al9 mu/ prec$e1 n foll[ ! an/hetic4 ,adm9i/ration4 ,bas+ ^u ^! views z to ! action ( *lor(orm1 & ^u ! lessons ( practical exp]i5ce1 we may =mulate def9ite rules = giv+ ! drug4 ,g5]al ,pr9ciples = giv+ ,*lor(orm4 7#a7 ,give *lor(orm ev5ly1 n spasmodically4 7#b7 ,increase ! vap\r /r5g? ( *lor(orm gradually f z]o until #b p] c5t4 or at mo/ #b p] c5t4 is rea*$ at ! end ( two or ?ree m9utes2 ma9ta9 t /r5g? until full an/hesia is obta9$2 !reaft]1 drop d[n to #a-ae p] c5t4 ,?is w result 9 a ,b4,p4 curve correspond+ to ! l9e ,,aba 9 ! diagram 7,fig4 #ce74 7#c7 ,be guid$ *iefly by ! pati5t's respiration4 ,*lor(orm kills by /opp+ ! he>t1 b 9 ! imm5se prepond]ance ( cases1 evid5ce ( failure ( respiration appe>s 9 ample "t to give w>n+ ( approa*+ circulatory failure4 ,! eye reflexes give confirmatory evid5ce ( ! dep? ( an/hesia1 b ! sup]latively important ?+ is to ma9ta9 a free airway1 & be sure ! pati5t is us+ x4 7#d7 ,if s]i\s /ruggl+ & brea?-hold+ occur1 )draw ! an/hetic until ! pati5t 8resumes normal40 ,me?ods ( ,adm9i/ration4 ,! logical application ( su* g5]al pr9ciples w\ld be to use an in/rum5t :i* gives a def9ite & kn[n p]c5tage ( *lor(orm1 v>iable at ! wi% ( ! adm9i/rator4 ,_m su* ma*9es h be5 br\ght =w>d1 & :ile none ( !m h obta9$ g5]al acceptance1 a description ( ! be/ kn[n in/rum5t w be giv51 z ! read] may z a h\se-surgeon meet ) x1 & ) a surgeon :o wi%es x to be us$4 ,v]non ,h>c\rt's ,inhal]4 ,9 pr9ciple1 ?is is a 8draw-ov]0 in/rum5t2 ! pati5t's own inspirations are ! motive p[]4 ,pass+ ov] ! surface ( ! fluid drug1 ! inspir$ air picks up f x a kn[n p]c5tage ( vap\r4 ,! o!r sy/em available = ! con/ruction ( p]c5tage *lor(orm in/rum5ts is ! 8pl5um02 9 ?is ! vap\r is propell$ to ! pati5t by a pump4 ,illu/ration3 ,,fig4 #cf4--,v]non ,h>c\rt's ,p]c5tage ,*lor(orm ,inhal]4 ,9 appe>ance1 ! inhal] resembles ! lett] ,t1 ) a rubb] face-piece atta*$ to ! l[] end ( ! v]tical limb 7see ,fig4 #cf74 ,! ,t portion itself is made ( metal tub+ ( a def9ite size 9 cross section4 ,"o end ( ! horizontal limb admits pure air1 ! o!r1 air :i* has pass$ ov] *lor(orm & pick$ up f x a c]ta9 proportion ( vap\r4 ,! proportion ( ! total inspir$ volume ( air :i* passes ?r\gh ea* ( ! ends is regulat$ by a lev] se5 at ! junction ( horizontal & v]tical limbs1 & ! exact p]c5tage ( *lor(orm be+ inhal$ is indicat$ by a s]ies ( num]als m>k$ on ! dial ov] :i* ! lev] moves4 ,^! figures are correct provid$3-- 7#a7 ,! *lor(orm receptacle is n %ak5 7?is w\ld greatly increase ! p]c5tage74 7#b7 ,! temp]ature ( ! *lor(orm is n all[$ to fall bel[ #ac c5tigrade4 ,to ensure t ?is _c take place )\t ! k ( ! adm9i/rator1 two col\r$ beads are ?r[n into ! *lor(orm4 ,at ! desir$ temp]ature ( ! *lor(orm 7#ac-ae;,c7 ! blue bead s9ks to ! bottom1 ! r$ "o ne>ly to ! bottom4 ,bel[ #ac;,c1 ! r$ bead also t\*es bottom1 & :5 ?is is obs]v$1 ! *lor(orm vial is w>m$ up 9 ! palm ( ! h&4 ,at ! po9t #ae;,c1 bo? beads float1 & ! w>m+ mu/ !n /op1 or an undesirable addition to ! vap\r /r5g? yield$ w occur4 ,! face-piece is made ( rubb]1 & mu/ be closely adapt$ to ! face2 9 its side is se5 ! expiratory valve4 ,inspiratory valves are pres5t at ea* end ( ! horizontal limb4 ,! great advantage ( ?is in/rum5t1 to ! au?or's m9d1 is = tea*+ or demon/ration purposes4 ,if ! /ud5t sees ! lev] gradually be+ mov$ ov] f #b to #b p] c5t41 !n slipp$ back to ab\t #ae p] c5t4 aft] full an/hesia has be5 obta9$1 he beg9s to appreciate :at x is he is aim+ at :5 giv+ *lor(orm by ! ord9>y op5 me?od4 ,illu/ration3 ,,fig4 #cg4--,s*immelbu%*'s mask4 ,op5 ,me?od4 ,! appliances requisite are3-- 7#a7 ,a mask4 ,s*immelbu%*'s is ! be/ kn[n 7,fig4 #cg73 z else:]e expla9$1 x does n accurately fit ! face4 7#b7 ,mat]ial to /ret* on ! mask4 ,! be/ is two lay]s ( domette or "o ( flannelette3 surgical gauze is s light t heavy drops ( *lor(orm are apt to 8sp>k0 ?r\gh x & burn ! sk9 ( ! face3 l9t rapidly becomes sodd52 ! drug drips away f its edge in/ead ( vap\ris+ prop]ly4 7#c7 ,a good drop bottle1 ( :i* _m v>ieties are m>kett$ 7,fig4 #ch73 x is ess5tial t x %\ld be capable ( produc+ def9ite drops3 ! old me?od ( int]mitt5t 8d\*+0 ( *lor(orm is to be condemn$ z violat+ ! fir/ g5]al pr9ciple = giv+ ! drug4 ,illu/ration3 ,,fig4 #ch4--;,*lor(orm drop bottles4 ,x is n possible by ! op5 me?od to be ma!matically accurate ) p]c5tages1 b ! necess>y appliances are simple1 easily transport$1 & practically always at h&4 ,if ! /ud5t le>ns to use x1 & :ile do+ s to ?9k 9 p]c5tages1 he w a*ieve z good results z or bett] ?an he w ) p]c5tage in/rum5ts4 ,:ile he may n h 9 front ( 8 eyes a dial :i* %[s ! p]c5tage graphically1 obs]vation ( ! pati5t w in=m him :e!r ! p]c5tage be+ giv5 %\ld be ma9ta9$1 rais$1 or l[]$4 ,! only rema9+ po9t = him to realise1 !n1 is h[ 9 practice su* regulations ( p]c5tage /r5g? c be a*iev$ by ! op5 me?od4 ,! /r5g? ( ! vap\r w dep5d ^u ?ree factors3-- 7#a7 ,nature ( ! mat]ial us$ on ! mask4 7#b7 ,clos5ess ) :i* ! mask is adapt$ to ! face4 7#c7 ,am\nt ( *lor(orm exhibit$ on ! mask4 ,to ensure uni=mity ( result1 two ( ^! factors %\ld be kept con/ant1 & ! necess>y increase or decrease ( vap\r /r5g? a*iev$ by v>y+ ! ?ird4 ,always use ! same type & ?ickness ( mat]ial on ! mask1 & all[ ! mask to lie lightly on ! face4 ,if ! am\nt ( *lor(orm is !n regulat$ by a /rictly 8drop0 me?od1 results ( great uni=mity may be obta9$ by ! op5 me?od4 ,! ,junk] ,inhal]4 ,?is in/rum5t 0 orig9ally introduc$ z an attempt to a*ieve a p]c5tage me?od4 ,air is pump$ ?r\gh a c]ta9 dep? ( *lor(orm conta9$ 9 a bottle1 & ! vap\r br\ght to ! pati5t 9 ! face-piece %[n 9 ,fig4 #ci4 ,! calculations by :i* x 0 s\ght to e/abli% ?is z a reliable dosimetric or p]c5tage me?od are ( no great value4 ,f t /&po9t ! in/rum5t has n a*iev$ success4 ,x deliv]s to ! pati5t a small quantity ( high p]c5tage vap\r :i* is dilut$ by a mu* l>g] quantity ( air inspir$ by ! pati5t f ! g5]al atmosph]e1 & ! f9al p]c5tage inhal$ by ! pati5t is !re=e no m accurately kn[n to ! adm9i/rator ?an 9 ! op5 me?od4 ,! in/rum5t is1 h[ev]1 ( consid]able value = tongue & jaw cases1 :]e an/hesia has to be ma9ta9$ = "s consid]able "t aft] ! mask ) :i* an/hesia has be5 induc$ has _h to be remov$1 to give access to ! surgeon4 ,illu/ration3 ,,fig4 #ci4--;,junk]'s ,*lor(orm ,inhal] %[+ h& bell[s1 bottle & mask4 ,alt]natively to ! latt]1 ! nasal tube %[n above1 may be us$4 ,! ,figure #ci %[s ! in/rum5t z usually m>ket$4 ,x consi/s (3-- 7#a7 ,a h&-bell[s4 7#b7 ,*lor(orm bottle4 ,a m>k cut on ?is %[s ! level to :i* x is to be fill$3 if m ?an ! prop] quantity be p\r$ 91 droplets ( fluid *lor(orm are apt to be bl[n along ! exit tube1 ) dang]\s results4 ,= conv5i5ce & neatness1 x is usual to make ! exit surr\nd ! inlet tube4 ,! ent]+ air bubbles ?r\gh ! *lor(orm1 & a /ream ( air & *lor(orm vap\r passes out f ! exit tube4#aj ,x is unnecess>y to give a detail$ acc\nt ( ! use ( ! in/rum5t1 b ! /ud5t mu/ rememb] ! foll[+ po9ts3-- 7#a7 ,! am\nt ( *lor(orm vap\ris$ w dep5d on ! vig\r ( ! pump+1 ! dep? ( fluid1 & ! temp]ature ( ! *lor(orm4 ,9 ord] to a*ieve uni=m results1 x is !re=e necess>y to keep up a /eady b n excessive pump+1 to w>m up ! bottle occasionally by hold+ x 9 ! palm ( a dis5gag$ h&1 & to wat* t ! level ( ! *lor(orm does n fall too l[4 7#b7 ,! pump+ %\ld be tim$ to syn*ronise ) inspiration3 a puff ( vap\r deliv]$ dur+ an expiration w be wa/$4 ,advantages & ,disadvantages ( ,*lor(orm4 ,! light portable appliances :i* are alone necess>y = *lor(orm an/hesia1 ! comp>ative *eapness ( ! me?od1 & ! app>5t ease ) :i* its adm9i/ration may be conduct$1 are all great temptations to its use4 ,^? :o feel ! temptation /rong ^u !m are advis$ to rememb] ! foll[+ quotation f ! writ+s ( ,pr(essor ,leon>d ,hill3-- 8,*lor(orm is a drug us$ by ! "y an/heti/ ) ! utmo/ h>dihood1 & until he has _h ! mis=tune 9 8 practice to meet ) a dea? caus$ by x1 he d]ides ! dang] ( ! drug1 & ass]ts t its safety m]ely dep5ds on ! c>e & skill ( ! adm9i/rator4 ,aft] los+ 8 pati5t1 he falls to descant+ on ! unavoidable dang]s ( ! drug1 dang]s :i* he is n[ ! fir/ to ma9ta9 _c be met by any degree ( skill 9 adm9i/ration40 ,! mo/ di/ress+ & probably ! mo/ common *lor(orm fatalities are exemplifi$ 9 adm9i/ration giv5 = ! mo/ trifl+ conditions1 su* z op5+ abscesses or extract+ tee?4 ,9 g5]al1 we use *lor(orm if = any reason e!r is n applicable4 ,= examples ( cases ( ?is description1 ! read] is ref]r$ to ! *apt] ^u ! *oice ( an/hetics4 ,,*apt] ,,xii4 ,,e?yl ,,*loride4 ,*emically ?is drug has ! =mula ,c#b;,h#e;,cl4 ,x is a col\rless fluid s volatile t x boils at ord9>y room temp]ature4 ,its vap\r is highly explosive1 & ! fluid itself v inflammable4 ,! drug is suppli$ by ! mak]s 9 small tubes ) a metal end :i* c be op5$ by press+ a little lev] 7see ,fig4 #dj71 v>y+ 9 type ) ! br&s made by v>i\s mak]s4 ,two br&s are sold by ea* firm2 "o is *emically pure1 int5d$ = use z a g5]al an/hetic2 ! o!r is n s pure1 & is only sold = local an/hesia4 ,su* a product is n suitable = inhalation4 ,illu/ration3 ,,fig4 #dj4--,tube ( ,e?yl ,*loride4 ,physiology4 ,! special po9ts 9 ! physiology ( e?yl *loride may be briefly summ>is$ z foll[s3-- #a4 ,aft] a trifl+ prelim9>y rise1 ! effect ( ! drug is to l[] ! blood pressure appreciably4 ,9 ! human adult subject1 ?is fall becomes appreciable :5 m ?an #c c4c4 h be5 giv52 if ! dose exce$ #e c4c4 a fall ( #cj to #dj mm4 ( ,hg4 is probable1--occurr+ z x does )9 a p]iod ( p]haps tw5ty or ?irty seconds1 su* a fall _c be reg>d$ z safe4 #b4 ,! cause ( ?is fall is dim9i%$ c>diac output f weak5+ ( he>t muscle4 ,! vagus ?\gh n p>alys$1 does n appe> to be unduly irritable1 z x does ) *lor(orm4 #c4 ,! respiratory c5tre is at fir/ p]ceptibly /imulat$1 & respiration is !re=e deep] & quick] ?an normal4 ,! /imulant effect rapidly passes away & gives place to a /age ( depression4 ,9 ! majority ( cases1 dea? appe>s to take place f p>alysis ( ! respiratory c5tre1 ! he>t /ill %[+ a little p[] ( contraction aft] respiration has ceas$4 ,!re is !re=e a fair prospect ( recov]y if artificial respiration be resort$ to promptly4 ,me?ods ( ,adm9i/ration4 ,,op5 ,,me?od4 ,! extreme volatility ( ! drug has disc\rag$ mo/ an/heti/s f giv+ x ^u an op5 mask4 ,hornabrook1 ( ,melb\rne1 advocates ?is sy/em1 h[ev]4 ,8 mask fits ! face accurately1 & 8 :ole me?od is /rictly p]halational4 ,he uses "s #d-f c4c4 ( ! drug = a *ild1 #f-h c4c4 = an adult1 & a*ieves 8 an/hesia 9 a m9ute to a m9ute & a half4 ,he also advocates op5 e?yl *loride z a prelim9>y to op5 e!r4 ,= "s twelve mon?s1 ! au?or adopt$ ! me?od4 ,at ! end ( t "t he came to ! conclusion t :ile x greatly facilitat$ ! induction /age ( op5 e!r1 x appe>$ to increase ! aft] sickness4 ,he !re=e ab&on$ x1 ?\gh r reluctantly4 ,,clos$ ,,me?od4 ,?is is ! usual means employ$4 ,a v>iety ( inhal]s h be5 produc$ on ! m>ket1 "o ( :i* is %[n 9 ,fig4 #da4 ,ess5tially all consi/ (3-- 7a7 ,a face-piece :i* mu/ fit ! face ) reasonable accuracy4 7b7 ,a "o-gallon rubb] bag atta*$ to ! mask by a ,t-piece4 7c7 ,a glass vial1 ) num]als f #a to #e m>k$ on ! outside to facilitate ! measurem5t ( ! drug 9 c4c4 ,into ?is ! drug is squirt$ f ! mak]s' tube4 ,! vial is atta*$ to ! ,t-piece 7or alt]natively ! bottom ( ! bag7 by a rubb] tube4 ,illu/ration3 ,,fig4 #da4--;,e?yl ,*loride ,inhal]4 ,adm9i/ration4 ,to use su* an inhal]1 ! glass vial is fir/ deta*$ f ! rubb] tube1 & ! *os5 dose ( drug squirt$ into x4 ,a *ild ( five or six w require #c c4c41 an adult up to #e c4c42 ?is dose %\ld nev] be exce$$4 ,! vial is !n rapidly reconnect$ ) ! inhal]4 ,! face-piece is adapt$ to ! face1 c>e be+ fir/ tak5 to place betwe5 ! tee? a m\? prop or a gag4 ,?is enables "o to get imm$iate access to ! m\? :5 ! inhal] is remov$4 ,! pati5t is !n told to brea! deeply once or twice4 ,dur+ ! inspiration ! mask is lift$ slightly1 & ! ensu+ expiration is !n caught 9 ! bag by press+ d[n ! mask on to ! face4 ,to volatilise ! drug !re are two alt]native me?ods4 ,9 ! "o1 "p or ! :ole ( ! dose is tipp$ into ! rubb] bag by elevat+ ! vial4 ,a f> bett] is ! 8,vap\r0 me?od1 almo/ univ]sally us$ 9 ,ed9burgh ow+ to ! advocacy ( ,dr ,logan ,turn]4 ,a tumbl] is fill$ ) hot wat]1 & ! bottom ( ! glass vial is all[$ fir/ to t\*1 & aft] a few seconds to be imm]s$ 9 x4 ,"s ?irty to =ty seconds suffice to vap\rise ! :ole ( ! dose4 ,e?yl *loride giv5 by itself %\ld always be adm9i/]$ to a pati5t 9 ! recumb5t position4 ,a dose suffici5t to produce an/hesia )\t ! aid ( nitr\s oxide or e!r w n be safe 9 ! erect po/ure4 ,! case is q diff]5t :]e a small dose only is giv51 to assi/ ! action ( nitr\s oxide1 or facilitate ! induction /age ( e!r4 ,signs ( ,an/hesia4 ,e?yl *loride is v rapid 9 its action1 "s sixty seconds avail+ to produce q a deep an/hesia4 ,respiration is at fir/ deep5$ & quick5$3 z full an/hesia is atta9$ x rema9s r deep] ?an normal1 & is accompani$ usually by light snor+4 ,! col\r %\ld rema9 p]fectly good3 ! pupils %[ m>k$ dilatation1 ! corneal reflex is aboli%$1 & good muscul> relaxation is atta9$4 ,) no an/hetic is x s ess5tial z ) ?is1 to become acqua9t$ ) ! type ( respiration normally to be expect$1 & to wat* = any dep>ture !refrom ) cat-l vigilance4 ,! o!r dang] signal is ! pupil4 ,x %\ld be dilat$1 b a rim ( iris %\ld /ill be p]ceptible4 ,once an/hesia is e/abli%$1 ! inhal] %\ld be remov$1 & ! surgeon may beg9 8 "w4 ,he w h = its completion "s #hj-ij seconds aga9/ ! #dj-ej available aft] nitr\s oxide4 ,) e?yl *loride !re is a some:at prolong$ 8analgesic0 /age4 ,! pati5t is p>tly consci\s & may ev5 be phonat+1 b seems unconsci\s ( ! infliction ( pa9 unless v sev]e measures are be+ us$4 ,! ,scope ( ,e?yl ,*loride4 ,:5 fir/ introduc$1 x 0 expect$ by en?usia/s t ! lightness & portability ( ! drug itself & ( ! necess>y inhal]1 w\ld enable e?yl *loride to ou/ nitr\s oxide f its recognis$ place 9 surg]y & d5ti/ry4 ,^! high expectations h = sev]al reasons n be5 fulfill$4 ,9 ! fir/ place1 ?is drug is ess5tially a 8s+le dose0 an/hetic4 ,mo/ au?orities view coldly all attempts to prolong an/hesia by repeat$ or cont9u$ adm9i/ration4 ,secondly1 e?yl *loride has a mortality rate v mu* great] ?an nitr\s oxide if doses suffici5t 9 !mselves to produce an/hesia are habitually us$ 7vide supra74 ,! introduction ( ! 8vap\r0 me?od has done mu* to mitigate ! risks1 b ev5 !n1 ?is an/hetic _c approa* ! high level ( safety rightly cr$it$ to ,n#b,o4 ,moreov]1 x leads to aft] vomit+ mu* m commonly ?an its rival4 ,9 _m s*ools ^! consid]ations h be5 held s p[]ful t e?yl *loride has be5 entirely ab&on$4 ,x is1 h[ev]1 a v valuable drug = ! foll[+ purposes3-- 7#a7 ,! removal ( tonsils & ad5oids4 ,= ?is op]ation1 ! spe$ ) :i* ! pati5t 7usually a *ild7 loses consci\sness1 ! pleasant type ( an/hesia & abs5ce ( all s]i\s asphyxial ph5om5a1 & ! rapid re-appe>ance ( ! c\gh reflex :5 once ! inhal] is remov$1 are all /rong recomm5dations4 7#b7 ,z an adjuvant to gas1 or gas oxyg5 7see ,*apt] ,,xiii474 7#c7 ,z a help to ! spe$y & com=table induction ( 8clos$ e!r0 7see ,*apt] ,,xv474 ,,*apt] ,,xiii4 ,,mixtures ,,( ,,nitr\s ,,oxide ,,& ,,e?yl ,,*loride4 ,dr ,guy1 ,dean ( ! ,ed9burgh ,d5tal ,s*ool1 introduc$ "s ye>s ago a me?od ( giv+ e?yl *loride 9 mixture ) nitr\s oxide4 ,guy's objective 0 to utilise ! _m excell5t features ( ! drug )\t incurr+ ! risks :i* are app>5tly inh]5t 9 x :5 a dose suffici5t 9 itself to induce full n>cosis is us$4 ,giv5 9 mixture ) gas1 a mu* small] dose suffices4 ,illu/ration3 ,,fig4 #db4--;,guy's inhal] = ,n#b,o & ,e?yl ,*loride4 ,8 orig9al app>atus is %[n 9 ,fig4 #db1 ! details are %[n 9 ,fig4 #dc4 ,! horizontal limb ( a #c-way gas tap is prolong$ half an in*4 ,9 ea* side ( ! prolongation is a hole4 ,! bag m\nt has 9 its side also "o hole1 :i* is connect$ by a univ]sal ball & socket jo9t1 ) ! rubb] tube to :i* ! e?yl *loride vial is atta*$4 ,an indicator on ! outside ( ! bag m\nt & a m>k ^u ! outside ( ! horizontal limb ( ! #c-way tap1 s]ve by _! apposition or ! rev]se to %[ :e!r ! e?yl *loride vial is 9 direct cont9uity ) ! int]ior ( ! inhal]4 ,= purposes ( description1 ,dr ,guy calls ^! two positions1 89 regi/]0 & 8out ( regi/]40 ,to use ! in/rum5t1 ! e?yl *loride vial is remov$1 & ! side pipe atta*$ to a cyl9d] ( nitr\s oxide4 ,! indicator ( ! #c-way tap is put at 8air0 & ! bag m\nt 89 regi/]40 ,! bag is !n fill$ ) gas by op5+ ! head ( ! cyl9d]4 ,! bag m\nt is n[ put 8out ( regi/]10 & ! side tube disconnect$ ) ! cyl9d]4 ,! bag1 be+ clos$1 rema9s full ( gas4 ,illu/ration3 ,,fig4 #dc4--;,guy's ,in/rum5t = ,gas & ,e?yl ,*loride4 ,details ( valve piece & bag m\nt1 %[+ side tube = atta*m5t ( ,e?yl ,*loride vial4 ,a suitable dose ( e?yl *loride is n[ squirt$ into ! vial4 ,to an adult1 ,dr ,guy gives #c c4c43 on no acc\nt is ?is dose exce$$3 *ildr5 take #a-b c4c4--ev5 adults (t5 get less ?an #c c4c4 ,! vial is n[ atta*$ to ! side tube aga91 & ! inhal] is ready = use4 ,aft] application ( ! mask to ! face1 ! #c-way tap is at once pu%$ ov] to 8no valve0 & ! pati5t rebrea!s ! gas 9 & out ( ! bag = "s six or eight respirations4 ,! bag m\nt is n[ turn$ r\nd 8into regi/]10 & ! e?yl *loride tipp$ into ! bag4 ,9 a fur!r tw5ty-five seconds ! mask may be remov$ & ! op]ation begun4 ,! available p]iod ( an/hesia is eighty to n9ety seconds1 c\nt+ f ! in/ant ( ! removal ( ! inhal]4 ,?is me?od 0 9 use = "s ye>s at ! ,d5tal ,hospital ( ,ed9burgh2 no in/ance ( dang] to life 0 ev] se54 ,) s small a dose ( e?yl *loride1 ! erect position necess>y = ! purposes ( d5ti/ry is p]fectly safe4 ,illu/ration3 ,,fig4 #dd4--;,diagram ( ! me?od introduc$ by ,dr ,guy & ! au?or = giv+ ,nitr\s ,oxide & ,oxyg51 ) or )\t ,e?yl ,*loride4 ,?is inhal]1 ( c\rse1 w s]ve admirably = giv+ e?yl *loride )\t gas1 & ! au?or habitually uses x = giv+ ! drug by ! 8vap\r0 me?od4 ,9 #aiaa1 ,dr ,guy & ! pres5t au?or modifi$ ! me?od s z to p]mit ! use ( oxyg5 ) ! nitr\s oxide4 ,! inhal] :i* !y !n introduc$ s]ves also = nitr\s oxide & oxyg51 unaid$ by e?yl *loride1 & ! au?or has by its means giv5 gas-oxyg5 to a consid]able numb] ( major surgical cases4 ,he n[1 h[ev]1 limits its use to %ort an/hesias1 & uses a sight-fe$ or a ,cl>ke app>atus = long cases4 ,illu/ration3 ,,fig4 #de4--,! ,guy-,ross ,inhal] = ,nitr\s ,oxide & ,oxyg51 ) or )\t ,e?yl ,*loride4 ,9 ,fig4 #dd w be f\nd a diagram %[+ ! me?od by :i* ! oxyg5 is introduc$4 ,! #a-;gallon oxyg5 bag is ei!r atta*$ directly to a cyl9d]1 or susp5d$ on an upright z %[n 9 ,fig4 #de4 ,9 ei!r case1 ! bag is1 be=e ! adm9i/ration1 mod]ately fill$ ) oxyg53 "o bagful w suffice = a %ort an/hesia1 & ! supply ( ! oxyg5 f ! cyl9d] is !re=e turn$ (f at once4 ,= long cases1 ( c\rse1 a small trickle ( oxyg5 into ! bag is requir$ to replace ! gas us$4 ,9 ! outlet pipe f ! oxyg5 bag is plac$ a ball syr+e ( #b ounces capacity4 ,a valve 9 ! pipe obliges ! fl[ ( oxyg5 to take place 9 "o direction only :5 ! bulb is squeez$1 viz4 f oxyg5 bag to inhal]4 ,! rema9d] ( ! app>atus is id5tical ) ,guy's orig9al inhal]1 except t ! bag is ( #b-;gallon capacity1 & is p]=at$ at its base by a ,y-tube1 "o limb ( ! =k br++ 9 ! nitr\s oxide1 ! o!r ! oxyg54 ,me?od ( ,use4 ,a few brea?s ( pure nitr\s oxide gas are usually all[$ 8on ! valve40 ,rebrea?+ is !n in/itut$1 & ! addition ( oxyg5 begun4 ,! am\nt requir$ to ea* type ( pati5t c only be le>nt ) exp]i5ce1 b ! av]age is "o full compression ( ! bulb e t5 seconds4 ,if an/hesia is n complete at ! end ( "o m9ute1 put ! indicator to 8valves0 aga91 & all[ ! pati5t ne>ly to empty ! bag4 ,!n pu% back ! indicator to 8no valves10 & refill ! bag ) nitr\s oxide by op5+ ! cyl9d] ) ! foot key4 ,"s f\r to six compressions ( ! bulb are made :ile ! nitr\s oxide is runn+ 94 ,! "t w n[ h come to add ! dose ( e?yl *loride if x be judg$ necess>y at all4 ,?is w h be5 plac$ 9 ! vial be=e ! adm9i/ration is begun4 ,aft] empty+ ! e?yl *loride into ! bag ( ! inhal]1 an/hesia %\ld be complete 9 tw5ty-five seconds4 ,! same small doses ( e?yl *loride are us$ z is ! case ) ,guy's orig9al me?od4 ,aft] a little practice "u sup]vision1 /ud5ts at ! ,d5tal ,hospital le>n to use ?is me?od safely & well4 ,no example ( risk to life has aris5 aft] eight ye>s' daily exp]i5ce4#aa ,,*apt] ,,xiv4 ,,mixture ,,( ,,*lor(orm ,,& ,,e!r4 ,! m]e addition ( e!r does n remove all ! undesirable features ( *lor(orm an/hesia4 ,a he>t poison$ by excess ( ,c,h,cl#c does n respond to e!r /imulation4 ,nev]!less1 ,,ce mixtures ( v>y+ proportions h great value4 ,! less le?al drug takes on "p ( ! "w ( ! m dang]\s "o2 x also keeps ! respiratory c5tre active4 ,view+ mixtures z dilute *lor(orm1 x is also obvi\s t !re w be ) !m a great] m>g9 ( error 9 dosage1 ?an ) ! pure drug4 ,"s *emical *ange takes place :5 ! two drugs are mix$1 = heat is evolv$2 ( ! nature ( ?is *ange we are ignorant4 ,! fir/ mixture introduc$ 0 kn[n z ,,ace1 & consi/$ ( "o "p absolute alcohol1 two p>ts *lor(orm1 & ?ree p>ts e!r4 ,alcohol evaporates v sl[ly & if x be introduc$ at all x %\ld be 9 mu* small] proportion4 ,s*f]'s mixture is "o "p alcohol to n9e p>ts *lor(orm4 ,nei!r ( ^! mixtures is n[ mu* us$4 ,! mo/ useful comb9ation is two p>ts *lor(orm & ?ree p>ts e!r1 & is kn[n z ,c#b;,e#c4 ,9 special cases1 "o "p ( *lor(orm to two p>ts e!r may be bett]4 ,me?ods4 ,cones ( v>y+ type 7 at fir/ ext5sively us$ = mixtures4 ,! be/ kn[n is ,r5dle's 7,fig4 #df74 ,x is made ( celluloid1 & is p]=at$ at ! top by a s]ies ( small holes ?r\gh :i* ! an/hetic is introduc$4 ,a sponge is pack$ into ! upp] "p ( ! cone1 & a flannelette cov] completes ! appliance4 ,! objection to ! use ( ?is & k9dr$ cones is t s9ce *lor(orm evaporates m sl[ly ?an e!r1 ! m dang]\s drug is apt to collect 9 ! sponge1 completely alt]+ ! /r5g? ( ! vap\r aft] a "t4 ,?is fault is rem$i$ to a l>ge ext5t by ! op5 drop me?od n[ us$4 ,illu/ration3 ,,fig4 #df4--,r5dle's ,cone4 ,! ,op5 7,drop7 ,me?od4 ,= ?is ! mask & e!r dropp] ( ,bellamy ,g>dn] are admirably suit$ 7,fig4 #bg74 ,a mat]ial less close ?an ! gauze advocat$ = op5-e!r is requir$4 ,"o lay] ( flannelette does v well1 or ! *eap cotton t[els :i* us$ to be kn[n 9 ,ed9burgh z 8p5ny t[els0 9 ! pre-w> p]iod4 ,! mask %\ld fit ! face ) reasonable accuracy3 !re is no reason :y a gauze r+ %\ld n be us$ to ensure ?is if ! adm9i/rator is c>eful to adh]e /rictly to a 8drop0 me?od4 ,! bottle into :i* ! dropp] is ins]t$ %\ld be ( diff]5t col\r to ^? 9 :i* pure e!r is habitually c>ri$4 ,?is is a great] safegu>d aga9/ a dang]\s =getfulness ?an a m]e label4 ,z already said1 ! an/hetic mu/ be giv5 by a /rict 8drop0 me?od4 8,d\*+0 at frequ5t int]vals gives results f> inf]ior4 ,,! ,,type ,,( ,,an,,/hesia is a compromise betwe5 t ( *lor(orm & op5-e!r4 ,respirations & col\r are bett] ?an ) pure *lor(orm1 n s good z ) op5-e!r4 ,! size ( ! pupil is also int]m$iate4 ,,scope4--,z else:]e expla9$ !re are _m pati5ts to :om op5-e!r _c well be giv52 ! greate/ numb] ( ^! c take a mixture p]fectly & ,c4,e4 %\ld c]ta9ly be *os5 9 pref]5ce to pure *lor(orm :5 possible4 ,= refractory cases1 x s]ves admirably z ! induc+ ag5t be=e ! use ( op5-e!r4 ,,*apt] ,,xv4 ,,sequ5ces4 ,by a sequ5ce we mean a me?od 9 :i* an/hesia is p>tially or :olly induc$ by "o an/hetic or "o me?od1 & ma9ta9$ by ano!r4 ,! me?ods m5tion$ 9 ,*apt] ,,xiii4 z devis$ by ,dr ,guy = d5tal purposes are examples :i* h already be5 suffici5tly describ$4 ,c4,e4 ,mixture--,e!r ,sequ5ce4 ,( ! me?od ( induc+ an/hesia by ,c4,e41 & turn+ lat] to op5-e!r1 we h also already spok54 ,"o ?+ rema9s to be said 9 ?is connection4 ,le>n to judge ! appe>ance ( ! type ( pati5t :o w require ?is alt]native to op5-e!r induction1 & use ! sequ5ce to su* pati5ts f ! beg9n+4 ,don't />t (f ) op5-e!r1 & f9d out 9 a few m9utes t ! pati5t is too ob/rep]\s4 ,a *ange f mixture to e!r is h>mless1 ! rev]se process ne$s mu* c>e4 ,! sequ5ce ( ,c4,e4 to clos$ e!r 0 advocat$ by ,hewitt z a means ( deal+ ) v alcoholic m51 & = ?is purpose has great m]its4 ,! mixture is giv5 until ! /age ( /ruggl+ is j ab\t to comm5ce1 a po9t :i* exp]i5ce enables "o to fix ) consid]able accuracy4 ,! rema9d] ( ! induction is conduct$ by a clos$-e!r inhal]1 ei!r ! ,hewitt wide-bore or pref]ably ! ,ormsby4 ,! e!r indicator :i* /&s at ab\t "o :5 ! inhal] is fir/ appli$1 may be advanc$ v rapidly full e!r /r5g? be+ atta9$ )9 a m9ute or two4 ,z soon z rebrea?+ is begun ) ei!r ( ^! in/rum5ts1 x is v /rik+ to wat* ! rapid & app>5tly safe subsid5ce into an/hesia ( ! mo/ tr\blesome pati5t4 ,! /ruggl+ is cut %ort & greatly m9imis$ 9 viol5ce1 & a /age :i* "u ,c,h,cl#c might h pres5t$ "s consid]able risk ( second>y syncope1 is ?us elim9at$4 ,nitr\s ,oxide & ,e!r ,sequ5ces4 ,?is is a me?od greatly sup]ior to ! induction by clos$-e!r describ$ on p4 #gi4 ,in/ead ( ! #a-;gallon bag ( ! ,clov] or ,hewitt in/rum5t1 ! valve piece & #b-;gallon bag ( a gas app>atus are atta*$ to ! head ( ! e!r inhal] 7,fig4 #bc1 on page #gg74 ,once ! gas bag is inflat$ f ! cyl9d]1 ! supply ( gas may be cut (f4 ,a few brea?s ( gas 8^u ! valves0 are giv51 until ! bag is half empty2 ! valve tap is !n pu%$ ov] to 8no valves0 & rebrea?+ begun4 ,e!r may be turn$ on a few seconds lat]1 & ! /r5g? ( ! vap\r may be increas$ m rapidly4 ,?ree-qu>t] /r5g? ( e!r may be atta9$ z a rule 9 n9ety seconds4 ,!re is v little likelihood ( /ruggl+ 9 ?is me?od4 ,e?yl ,*loride & ,e!r4 ,?is is a valuable me?od = %ort op]ations1 be+ easily portable1 spe$y & safe 9 action1 & fairly agreeable to ! pati5t4 ,"s an/heti/s use ?is induction me?od z a prelude to op5-e!r4 ,! ,clov] 7or ,hewitt wide-bore7 in/rum5t is int]pos$ betwe5 ! face-piece & ! ,t4 ( ! e?yl *loride inhal]1 z %[n 9 ,fig4 #dg4 ,a small dose ( e?yl *loride only is requisite2 = an adult1 #c c4c4 is en\gh4 ,?is is vap\ris$ ov] hot wat] 9 ! usual way2 a v light an/hesia is induc$ 9 "s sixty seconds1 & ! e!r c !n be turn$ on at a mu* quick] rate ?an if ! induction be conduct$ by t drug alone4 ,scope4 ,! gas-e!r & e?yl *loride-e!r sequ5ces are mo/ useful me?ods4 ,!y are quick1 safe1 & p[]ful4 ,illu/ration3 ,,fig4 #dg4--;,clov]'s ,inhal] adapt$ = ! ,e?yl ,*loride-,e!r sequ5ce4 ,ei!r may be us$ z 8s+le dose0 an/hetic1 ! e!r be+ pu%$ quickly up to 8full0 & ! inhal] !n )drawn4 ,if1 h[ev]1 no access to ! m\? is requir$ by ! surgeon1 e!r an/hesia may1 by occasional brea?s ( fre% air be prolong$ = z long z desir$4 ,,*apt] ,,xvi4 ,,! ,,accid5ts ,,( ,,an,,/hesia4 ,! m9or difficulties ( an/hesia h already be5 dealt )1 & if ! in/ructions already giv51 p>ticul>ly 9 ,*apt] ,,iii41 are fai?fully c>ri$ out1 incid5ts ( real dang] w r>ely occur4 ,! s\nde/ k & ! mo/ consci5ti\s c>e w1 h[ev]1 nev] entirely rid an/hesia ( an elem5t ( dang] to life4 ,! conditions n[ to be consid]$ are3-- 7,a7 ,vomit+4 7,b7 ,failure ( respiration4 7,c7 ,failure ( circulation4 7,a7 ,vomit+4 ,?is always exposes an unconsci\s pati5t to ! dang] ( inhal+ solid or fluid mat]ial into ! l>ynx1 ) result+ asphyxia4 ,if ! pati5t be tid$ ?r\gh t imm$iate difficulty1 he is liable to develop an inhalational pneumonia subsequ5tly4 ,a heal?y pati5t prop]ly prep>$ %\ld n vomit dur+ ! induction /age1 nor dur+ ! progress ( ! op]ation4 ,if he does1 x means t ! induction has be5 too sl[1 or t ! adm9i/ration has be5 int]mitt5t1 & ! pati5t has be5 p]mitt$ to come to too light a level ( an/hesia dur+ ! op]ation4 ,dur+ em]g5cy op]ations :]e ! pati5t's /oma* may be full ( food1 ! case is diff]5t4 ,su* pati5ts commonly vomit e>ly 9 ! induction /age1 & no skill c av]t ! incid5t4 ,a pati5t suff]+ f inte/9al ob/ruction1 or f g5]alis$ p]itonitis has 8 /oma* & inte/9es full ( highly infective fluid4 ,rev]se p]i/altic may set 9 m]ely z ! result ( ! inhalation1 or lat] f h&l+ ! cont5ts ( ! abdom51 & ! fecul5t fluid gu%es up ! sophagus ) little or no w>n+4 ,s9ce vomit+ 9 ^! cases may occur ev5 9 deep an/hesia1 :5 ! c\gh reflex :i* is ! normal s5try to ! entrance ( ! l>ynx1 is aboli%$1 ! dang]s ( insufflation are v real inde$4 ,p]sonally1 ! au?or pref]s to wa% out ! /oma* be=e beg9n+ to induce an/hesia 9 ^! cases1 b "s surgeons believe t ! %ock ( ?is proc$ure outweighs ! advantages4 ,,symptoms ,,& ,,treatm5t ,,( ,,vomit+4 ,9 ord9>y cases1 vomit+ is usually h]ald$ by a def9ite tra9 ( symptoms4 ,respiration becomes %all[1 ! col\r a little pale & ! pulse r small4 ,! pupil dilates1 b rema9s active to light1 indicat+ t ! alt]ation ( respiration & circulation is n due to ov]dose4 ,at ! fir/ appe>ance ( su* symptoms1 a brisk rub ( ! lips & !reaft] an increase ( ! vap\r /r5g? ( ! an/hetic w (t5 av]t ! imp5d+ vomit+ by deep5+ ! an/hesia1 b if ! possibility ( ?is complication has occurr$ to ! an/heti/ too late = its prev5tion1 ! head mu/ be turn$ well to "o side1 & ! o!r %\ld] slightly elevat$ by a pill[1 s t vomit$ mat]ial w fall out ( ! m\? at once4 ,:5 ! actual act ( vomit+ is ov]1 no "t mu/ be lo/ 9 mopp+ out ! m\? & press+ on ) ! production ( a deep] an/hesia4 7,b7 ,respiratory ,dang]s4 ,^! divide !mselves into two gr\ps3-- 7#a7 ,,me*anical4--,! respiratory movem5ts cont9ue1 b ! +ress & egress ( air is block$4 ,! symptoms & prev5tative treatm5t h be5 ref]r$ to at "s l5g? 9 ,*apt] ,,iii41 & no fur!r acc\nt ( ^! is !re=e necess>y4 ,! treatm5t ( a complete blockage ( ! air passages :i* resi/ ! measure !re describ$1 alone rema9 to be m5tion$4 ,( ^!1 ! only two effective are artificial respiration & tra*eotomy 7or l>yngotomy if pref]r$ by ! surgeon74 ,=cible artificial respiration by ! ,sylve/] me?od1 ) ! m\? gagg$ op5 & ! tongue held =w>d by ! tongue =ceps1 is frequ5tly successful 9 gett+ ov] ev5 a complete block1 b ! la/ resort ( op5+ ! air passage by ! knife mu/ n be delay$ until too late4 ,9 decid+ su* a po9t1 consid]able judgm5t is ( c\rse call$ =4 7#b7 ,,non-,,me*anical4--,respiratory arre/4 ,?is is usually se5 9 conjunction ) a s]i\s failure ( ! circulation caus$ by ov]-dosage4 ,exceptionally1 "s act ( ! surgeon sets up a reflex inhibition ( ! respiratory c5tre2 ! circulation is at ! same "t depress$1 b to a v>y+ degree4 ,! c>d9al symptom is arre/ ( all respiratory ef=t4 ,! treatm5t is be/ dealt ) "u ! head+ ( circulatory failure4 7,c7 ,circulatory ,failure1 or ,syncope4 ,by ! t]m syncope1 we mean a m or less sudd5 failure ( ! c>diac pump1 z oppos$ to ! =m ( circulatory failure se5 9 surgical %ock1 :]e ! condition is *iefly1 ?\gh n :olly1 "o ( vaso-motor p>alysis 7see ,*apt] ,,ii474 ,syncope occurs "u v>y+ conditions :i* may = descriptive purposes be divid$ into f\r classes4 ,x is n1 h[ev]1 always possible to decide ) c]ta9ty into :i* class an individual case %\ld be plac$4 ,! symptoms common to all classes ( syncope are3-- 7#a7 ,pallor1 & loss ( all tone 9 ! muscles1 noticeably ^? ( expression4 ,! pulse is weak or imp]ceptible4 7#b7 ,cessation ( respiration4 7#c7 ,dilatation ( ! pupil1 :i* ceases to react to light4 ,! f\r classes above m5tion$ are z foll[s3-- ,a4 ,,prim>y ,,syncope4 ,?is is peculi> to *lor(orm4 ,) no o!r an/hetic is x se51 at any rate 9 ! heal?y subject4 ,x arises dur+ ! induction p]iod1 & is n necess>ily prec$$ by any respiratory difficulty4 ,!re is "o big inspiratory gasp1 sudd5 & extreme pallor1 & ! pupil goes out to ! rim 9 a few seconds4 ,! only reasonable explanation ( su* an incid5t is ! occurr5ce ( vagal inhibition 7see page #aab74 ,its prev5tion !re=e is a matt] ( ! avoidance ( a high p]c5tage ( *lor(orm4 ,b4 ,,second>y ,,syncope4 ,?is t]m is appli$ to a collapse aris+ z a second>y result ( emb>rass$ respiration4 ,?\gh n peculi> to *lor(orm1 x is f> m common ) t drug ?an ) any o!r 7e?yl *loride except$74 ,! mo/ common "t = ! accid5t is t[>ds ! end ( ! induction p]iod4 ,! pati5t has probably be5 /ruggl+1 has cl5*$ ! jaws1 & develop$ 8me*anical0 asphyxia4 ,viol5t inspiratory ef=ts are /ill be+ made1 & consid]able cyanosis develops4 ,ei!r at ! v mom5t :5 ! respiratory difficulty is ov]come1 or :ile x /ill p]si/s1 ! col\r sudd5ly alt]s f blue to :ite1 & ! o!r symptoms ( syncope rapidly appe>4 ,! exact p]iod requir$ to trans=m a blue /ruggl+ pati5t ) heav+ *e/1 into "o ) pallid face1 & motionless *e/ & limbs1 v>ies greatly1 = reasons furni%$ bel[4 ,! mo/ reasonable explanation (f]$ ( su* an accid5t is t giv5 by ,leon>d ,hill4 ,! attempts to inspire ?r\gh an air way me*anically block$ cause an imm5se /ra9 ^u ! he>t muscle4 ,! fl[ ( blood 9 ! lung capill>y is h9d]$1 & ! "r side ( ! he>t becomes ov] di/5d$ ) blood4 ,its musculature is fur!r damag$ by ! fact t ! blood 9 ! coron>y vessels is defici5t 9 oxyg51 & t a consid]able dose ( an/hetic has already be5 absorb$4 ,!re is ! fur!r fact1 n m5tion$ by ,hill1 t dur+ ! :ole p]iod ( asphyxia ! p]iph]al resi/ance is ris+ f vaso-con/riction4 ,"u circum/ances su* z ^!1 x is obvi\s t any he>t mu/ ultimately succumb1 no matt] :at an/hetic is 9 use4 ,x is also obvi\s t ) *lor(orm & e?yl *loride1 :i* are !mselves he>t poisons1 second>y syncope w happ5 mu* m readily ?an ) e!r or nitr\s oxide1 :i* are n2 & t a he>t ) diseas$ musculature w fail quick] ?an a heal?y organ4 ,second>y syncope is almo/ c]ta9ly ! commone/ fatal accid5t ( an/hesia4 ,! reason :y ?is fact is n m widely recognis$ arises f ! natural in/9ct ( any "o :o has suff]$ ! mis]y & ignom9y ( caus+ a dea? "u an an/hetic1 to attribute x to "s cause beyond human control4 ,! ess5tial cause ( second>y syncope is failure to ma9ta9 a free air way1 :i* _c be /yl$ unavoidable4 ,two consolations may1 h[ev]1 hone/ly be (f]$ to ! p]son :o has act$ z an/heti/ 9 a case ( second>y syncope4 ,fir/ly1 x is1 9 c]ta9 types ( cases1 v difficult inde$ to ma9ta9 a free air way2 & secondly1 a he>t ) muscle deg5]at$ f fatty or o!r *anges1 may give out aft] v little respiratory emb>rassm5t4 ,,syncope ,,f ,,ov]dose4 ,?is is a m gradual affair ?an ! two =ego+2 & has be5 suffici5tly dealt ) 9 ! *apt] devot$ to ! ,/ages ( ,an/hesia 7see p4 #cf74 ,c4 ,,reflex ,,syncope4 ,exceptionally1 a pati5t n ov]dos$ ) an/hetic1 & n suff]+ f any me*anical ob/ruction to respiration1 has a sudd5 attack ( syncope dur+ ! progress ( ! op]ation4 ,we "h exclude pati5ts :o are suff]+ f surgical %ock2 ! condition arises too rapidly = su* an explanation to be accept$4 ,mu* speculation has be5 exp5d$ ^u ^! cases4 ,"o view is t "s proc$ure ( ! surgeon has set up a reflex inhibition ( ! he>t ?r\gh ! vagus2 ano!r1 t ! reflex has tak5 ! =m ( sudd5 vasomotor p>esis4 ,levy w\ld ascribe ! condition to c>diac fibrillation4 ,x may well be t all cases _c be met by "o explanation4 ,! old] surgeons /\tly ma9ta9$ t reflex syncope c\ld n arise if ! pati5t 7 prop]ly "u1 & t x 0 9 ! practice ( ^? an/heti/s :o 7 afraid ( pu%+ ! an/hetic suffici5tly1 t su* accid5ts occurr$4 ,! au?or's own belief is t a v light *lor(orm an/hesia does pre-dispose to ?is accid5t1 b t x may occur also at a deep1 ! v deepe/ possible level4 ,) an an/hetic o!r ?an *lor(orm1 x is extremely r>e--p]haps unkn[n4 ,treatm5t ( ,syncope4 ,?is mu/ be spe$y to be ( any avail4 ,! foll[+ are ! po9ts ^u :i* to conc5trate3-- 7#a7 ,)draw ! an/hetic4 7#b7 ,make sure t ! air way is free4 7#c7 ,beg9 artificial respiration by ,sylve/]'s me?od1 ! movem5t ( expiration be+ fir/ p]=m$ 7see ,fig4 #dh74 7#d7 ,l[]+ ( ! head & %\ld]s is usually to be recomm5d$4 ,x is be/ done by tilt+ ! :ole table z if = ! ,tr5del5b]g position4 ,! l[]+ ( ! head attracts m blood to ! c>otid art]y & raises ! blood pressure ( ! ma9 vessel & its c]ebral bran*es 7see ,fig4 #ce74 ,x mu/1 h[ev]1 be rememb]$ t x w also t5d to empty ! blood 9 ! ve9s ( ! l[] extremities & abdom5 into ! "r side ( ! he>t1 & cases 9 :i* m>k$ cyanosis has prec$$ pallor1 are probably suff]+ already f engorgem5t & dilatation ( ! "r he>t4 ,! tilt+ ( ! table %\ld 9 su* cases be v mod]ate 9 degree1 & %\ld n be p]si/$ 9 if x seems to d no good4 ,9 no case1 inde$1 %\ld ! tilt+ be extreme4 ,an angle ( m ?an #ae or #bj degrees is z likely to d h>m z good4 ,illu/ration3 ,,fig4 #dh;,a4--,artificial respiration by ,sylve/]'s me?od4 ,expiration4 7#e7 ,hot clo?s may be plac$ ov] ! precordial region1 c>e be+ tak5 n to burn ! sk94 7#f7 ,! only drugs likely to be ( any avail are atrop9e & /ry*n9e1 ! =m] be+ us$ ) ! idea ( p>alys+ ! t]m9ations ( ! vagus 9 ! he>t muscle1 ! latt] z a c>diac tonic & a /imulant to ! respiratory c5tre4 ,"s au?orities h recomm5d$ ! injection ( atrop9e by a long ne$le pass$ into ! he>t muscle1 b mo/ are cont5t to give ei!r or bo? drugs hypod]mically4 ,really to p>alyse ! vagus1 a v l>ge dose ( atrop9e is requir$--ab\t gr4 ,/ry*n9e %\ld be giv5 9 a dose ( - gr4 ,illu/ration3 ,,fig4 #dh;,b4--,artificial respiration by ,sylve/]'s me?od4 ,inspiration4 7#g7 ,9 cases :]e ! "r he>t has c]ta9ly be5 ov]-di/5d$1 ! exp$i5t ( v5esection has be5 tri$4 ,"s six ounces may be )drawn f ! ext]nal jugul> or "o ( ! ve9s ( ! arm4 7#h7 ,z a la/ resort1 ! he>t may be massag$4 ,! only practicable r\te is to op5 ! abdom5 7if n already done7 pass "o h& "u ! left side ( ! vault ( ! diaphragm1 plac+ ! o!r h& ov] ! precordial region4 ,betwe5 ! two h&s1 ! he>t c fir/ be ?or\ghly compress$ to empty its presumably flaccid & ov]-di/5d$ cavities1 & !n lightly massag$4 ,sev]al cases ( recov]y f ?is measure are on record4 ,/atus ,lymphaticus4 ,be=e leav+ ! subject ( accid5ts x may be well to allude to ?is condition1 :i* is also kn[n z /atus ?ymicus1 & z lymphatism4 ,x is met ) mo/ly 9 ! "y1 ! commone/ ages probably be+ five to fifte5 ye>s4 ,c]ta9 pa?ological conditions h be5 f\nd 9 fatal cases1 ( :i* ! mo/ important are an enl>gem5t ( ! ?ymus gl&1 ( v>i\s lymph gl&s1 & ( ! tonsils1 includ+ ! naso-ph>yngeal tonsil 7ad5oids74 ,! he>t muscle is frequ5tly deg5]at$4 ,( ! cause ( ^! abnormalities we are z yet 9 d\bt4 ,!re is "s reason to believe t ! condition t5ds to disappe> ) advanc+ ye>s1 if ! subject survive4 ,! mo/ out/&+ cl9ical fact 9 connection ) ! disease is its t5d5cy to cause sudd5 dea? on v little provocation4 ,a fright1 a sudd5 ex]tion1 & above all an an/hetic may cause sudd5 & fatal syncope4 ,,diagnosis4 ,suspicion t ! disease is pres5t may be ar\s$ 9 sev]al ways4 ,! pres5ce ( enl>g$ tonsils & ad5oids1 comb9$ ) g5]al enl>gem5t ( lymph gl&s f no obvi\s cause1 & a t5d5cy to fa9t1 make a v sugge/ive picture4 8,night-cr[+0 7a sudd5 attack ( l>yngeal spasm1 occurr+ at night1 & (t5 repeat$ at int]vals7 also raises grave d\bt4 ,! diagnosis c only be e/abli%$ ) c]ta9ty by an ,x-ray photograph1 :5 ! great enl>gem5t ( ! ?ymus may be se5 9 ! upp] "p ( ! *e/4 ,,an,,/hetics ,,9 ,,/atus ,,lymphaticus4 ,too frequ5tly ! condition has nev] be5 suspect$1 & a fatality occurs f sudd5 syncope1 usually dur+ ! induction p]iod1 b occasionally dur+ ! progress ( ! op]ation4 ,x w\ld1 h[ev]1 be fallaci\s to suppose t an an/hetic is necess>ily fatal ev5 to an und\bt$ case4 ,if ! drug 7pref]ably e!r7 be giv5 ) great c>e1 & ! op]ation done c>efully at a level ( an/hesia nei!r too light nor too deep1 !re is e reason to believe t ! dang] c be1 & (t5 is1 successfully av]t$4 ,at ! same "t1 x mu/ be und]/ood t 9 a kn[n case1 op]ation %\ld always be avoid$ or def]r$ if possible4 ,,*apt] ,,xvii4 ,,! ,,sequel ,,( ,,an,,/hesia4 ,respiratory ,sy/em4 ,aft] op]ations p]=m$ "u any =m ( an/hesia1 ev5 sp9al1 !re is always a possibility ( pneumonia or bron*itis4 ,! an/hetic itself is n always to blame4 ,! pati5t has suff]$ trauma & is conf9$ to b$1 & may develop a hypo/atic pneumonia j z a p]son :o has suff]$ f a fractur$ ?igh s commonly does1 ev5 ?\gh he has _h no an/hetic at all4 ,x is probable t organisms1 capable "u c]ta9 circum/ances ( caus+ inflammatory disease ( ! respiratory tract1 are pres5t 9 a l>ge proportion ( app>5tly heal?y p4 ,pneumococci & /reptococci ( v>y+ /ra9s may be gr[n f nasal or ph>yngeal secretions ( pati5ts :o suff] f cat>rh ( ^! regions1 & may reappe> ^u slight provocation ev5 :5 prolong$ treatm5t _h app>5tly bani%$ !m p]man5tly4 ,all t is requir$ to />t an acute infection ( lungs or bron*i1 is "s factor t depresses vitality & l[]s body resi/ance to ! organism4 ,& if 9 addition use has be5 made ( an inhalational an/hetic su* z e!r1 :i* may cause an imm$iate & fairly acute conge/ion ( ! respiratory muc\s membranes1 x is n to be wond]$ at t s]i\s sequel foll[ 9 a c]ta9 proportion ( cases4 ,laboratory results g to %[ t e!r l[]s ! opsonic index ( ! blood to pneumococci & /reptococci1 b )\t plac+ undue emphasis ^u a m]e isolat$ ph5om5on su* z t1 x is pla9 t ! :ole conditions ( ! pati5t aft] op]ation are fav\rable to ! occurr5ce ( pneumonia or bron*itis1 & t ( all an/hetics e!r is ! mo/ likely to be ! det]m9+ factor4 ,exp]i5ce ga9$ dur+ ! w> has ?r[n a c]ta9 am\nt ( light ^u ?is subject4 ,po/-an/hetic bron*itis & pneumonia 0 v preval5t among ! w\nd$1 f> m s ?an among civilian pati5ts4 ,x is1 ! au?or believes1 reasonable to attribute ?is fact to sev]al causes4 ,9 ! fir/ place1 ! soldi]'s life1 alt]nat+ betwe5 /uffy billets & wet tr5*es1 pr$ispos$ him to naso-ph>yngeal cat>rh ( a fairly high degree ( infectivity4 ,en?usia/ic press repres5tatives might /ate t y c\ld n take cold s long z y\r feet & legs 7 always buri$ 9 half froz5 mud1 b exp]i5ce h>dly bore out _! gold5 promises4 ,aga91 ! soldi] did n improve 8 cat>rh by invet]ate cig>ette smok+4 ,la/ly1 milit>y hospitals 7 l>ge in/itutions1 "s "u canvas1 "s 9 huts1 "s 9 build+s con/ruct$ = o!r purposes1 & rapidly alt]$ to ! urg5t ne$s ( ! army4 ,( :atev] type1 ne>ly all _h "o feature 9 common--_m ( ! surgical w>ds 7 a long 7& draughty7 way f ! op]at+ !atre4 ,= ! prev5tion ( po/-an/hetic pneumonia1 ! au?or (f]s ! foll[+ t5tative sugge/ions3-- 7#a7 ,see t ! sk9 is kept cov]$ up z mu* z possible dur+ ! op]ation & t ! pati5t is n expos$ to draughts dur+ or aft] x4 ,rooms c1 & %\ld be1 well v5tilat$ )\t cold draughts4 7#b7 ,if a pati5t has an acute or sub-acute naso-ph>yngeal cat>rh1 treat x z fully z possible be=e op]ation by sprays & g>gles4 7#c7 ,d n use e!r to pati5ts :o suff] or rec5tly h suff]$ f su* conditions4 7#d7 ,give a hypod]mic ( morphia & atrop9e be=e op]ation z a r\t9e4 7#e7 ,9 s f> z possible1 let ! pati5t's %\ld]s & head be rais$ by pill[s dur+ ! e>ly h\rs ( convalesc5ce4 7#f7 ,la/ly1 rememb] t :ile no c>e w absolutely bani% ^! dang]\s sequel f our practice1 ! great] c>e & skill %[n by ! an/heti/1 ! less bron*itis & pneumonia w appe> among 8 pati5ts4 ,z reg>ds e!r1 ! au?or believes t x is ! /r5g? ( vap\r us$1 m ?an ! duration ( ! an/hesia1 :i* c\nts4 ,x is = t1 among o!r reasons1 t he has = ! induction p]iod1 no hesitation 9 recomm5d+ a me?od :]eby a small "p ( ! requisite e!r /r5g? is replac$ by *lor(orm4 ,vomit+4 ,aft] an an/hesia la/+ m ?an a few m9utes1 x may almo/ be reg>d$ z normal = ! pati5t to vomit once or twice4 ,usually ?is occurs a few m9utes aft] ! adm9i/ration has ceas$4 ,9 ! case ( nitr\s oxide & oxyg51 ev5 ?is slight di/urbance may n occur4 ,! am\nt ( vomit+ :i* aft] ?is /age may be reg>d$ z normal is difficult to det]m9e4 ,! au?or took notes ( "s #cjj cases on ?is po9t4 ,! details ( 8 results are n suitable = a text book1 b1 broadly speak+1 x w\ld appe> t aft] an op]ation ( ord9>y duration & sev]ity1 ! vomit+ returns on ! av]age "s five or six times1 & usually ceases on ! ev5+ ( ! op]ation day4 ,a limit$ numb] cont9ue to vomit at int]vals until ! e>ly h\rs ( ! foll[+ morn+4 ,) nitr\s oxide & oxyg5 ! vomit+ is f> less ?an ! above1 ?\gh ev5 ) ?is an/hetic q sev]e emesis may occur4 ,) clos$-e!r1 ! tr\ble is v viol5t = a %ort "t1 l>ge quantities ( muc\s be+ eject$3 x is probable t aft] ! fir/ two h\rs1 x is no m m>k$ ?an aft] op5 me?ods4 ,! use ( morphia & atrop9e be=e op]ation mo/ c]ta9ly r$uces ! viol5ce & duration ( ?is sequela4 ,prolong$ m ?an tw5ty-f\r h\rs1 ! condition mu/ be reg>d$ z def9itely abnormal4 ,,prev5tion ,,& ,,treatm5t4 ,! adoption ( op5-e!r prec$$ by morphia & atrop9e & due skill & ?\ght on ! "p ( ! an/heti/1 comb9$ ) prop] prep>ation ( ! pati5t1 are ! only means ( prev5tion at our comm&4 ,! rais$ position ( ! head & %\ld]s dur+ ! recov]y /age und\bt$ly t5ds to r$uce ! nuisance4 ,x is a vex$ "q :e!r to give or to )hold fluids aft] op]ation--& ?is matt] is ( c\rse 9 ! h&s ( ! surgeon1 n ! an/heti/4 ,9 c]ta9 cases1 ! au?or believes t x is wor? :ile try+ ! effect ( a cup ( fre% tea ) v little sug> or milk4 ,ev5 if reject$ 9 a few mom5ts1 ! a/r+5t effect ( ! infusion seems to soo! ! ga/ric muc\s membrane1 & give relief4 ,po/-op]ative ,acidosis4 7,synonym--,delay$ ,*lor(orm ,poison+74 ,9 a limit$ numb] ( cases1 po/-op]ative emesis assumes a grave type1 & def9itely ?reat5s life4 ,su* cases began to be /udi$ 9 ! e>ly "p ( ?is c5tury1 & ?\gh our k ( ! condition is /ill incomplete1 ! /ud5t %\ld be acqua9t$ ) ! pres5t views held ^u ! subject4 ,cl9ically1 ! e>lie/ symptom to raise suspicion1 is ! reappe>ance ( vomit+ at a "t :5 "o w\ld expect su* tr\ble to h abat$1 usually tw5ty-f\r or ?irty-six h\rs aft] op]ation4 ,)9 a few h\rs1 ! nature ( ! vomit *anges f ! usual bili\s /oma* cont5ts1 & %[s obvi\s evid5ce ( ! pres5ce ( alt]$ blood4 ,! pulse & temp]ature beg9 to rise1 ! c\nt5ance assumes an anxi\s look4 ,a trace ( jaundice is usually pres5t4 ,! n]v\s sy/em becomes affect$ z %[n fir/ 9 re/lessness1 & lat]1 delirium4 ,e degree ( ?is condition is possible1 b a v l>ge proportion ( recognisable cases pass into coma1 & dea? sup]v5es )9 a few days1 sometimes less4 ,inve/igation into su* cases has %[n t ! ess5tial und]ly+ condition is an acidosis closely alli$ to t se5 9 diabetic coma4 ,! brea? has ! peculi> sweeti% aroma ( acetone1 & acetone1 diacetic acid1 & ,b4 oxybutyric acid successively appe> 9 ! ur9e4 ,po/-mortem1 ! mo/ /rik+ *ange f\nd is a pr(\nd fatty deg5]ation ( ! liv]1 ! cells ( :i* are dis9tegrat$ z 9 acute yell[ atrophy4 ,x is obvi\s f ! =ego+ t !re is pres5t a v rem>kable abnormality ( metabolism4 ,mr ,r5dle ,%ort1 9 8 admirable book1 ,! ,new ,physiology 9 ,surgical & ,g5]al ,practice1 gives ! foll[+ explanation ( ! condition3-- 8,! physiological process ( deal+ ) fat is to resolve x into c>bon di-oxide & wat]4 ,if we make a p\nd ( fat into tall[ c&les & burn x1 we %all obta9 c>bon di-oxide & wat]1 & a c]ta9 am\nt ( heat w be evolv$4 ,if ! p\nd ( fat is eat5 & absorb$ by a man or an animal1 x w be burnt to ! same end products1 & ! same am\nt ( heat w be giv5 out4 ,b 9 c]ta9 circum/ances1 an abnormal mode ( break+ d[n is foll[$1 & !re are produc$1 fir/ ,b4 oxybutyric acid1 !n diacetic acid1 & f9ally acetone4 ,if ?is takes place on a l>ge scale1 ! conv]sion into acetone fails to keep pace ) ! production ( acids4 ,!re=e fir/ acetone appe>s 9 ! ur9e1 !n diacetic acid1 & f9ally oxybutyric acid2 ! la/ may rise rapidly to an enorm\s figure3 #cj1 #ej1 or ev5 #ahj grams may be pass$ daily40 ,lat] 9 ! same *apt]1 ,%ort prop\nds ! "q z to :at are ! special circum/ances 9 :i* ! break+ d[n ( fat deviates f its normal c\rse1 & foll[s ?is dang]\s r\te4 ,! answ] is1 he says1 q def9ite & decisive4 ,:5 ! tissues are unable to obta9 sug> f ! blood1 fat is brok5 d[n via ^! dang]\s acids to acetone1 in/ead ( to c>bon di-oxide & wat]4 ,su* an inability on ! "p ( ! tissues to obta9 sug> arises "u sev]al conditions3-- 7a7 ,9 diabetes1 :]e sug> ?\gh freely pres5t 9 ! blood _c1 = "s reason /ill n cle>ly kn[n1 be assimilat$ by ! tissues4 7b7 ,9 poison+ by salicylates4 7c7 ,9 />vation1 = obvi\s reasons4 ,! supply ( sug> f ! liv] has be5 us$ up1 & ! pati5t1 liv+ on 8 own fats1 breaks !m up abnormally4 7d7 ,9 po/-an/hetic poison+1 = reasons :i* are at pres5t n cle>ly asc]ta9$4 ,^u ! !oretical side x is !re=e n possible to say m ?an t an/hetics sometimes initiate ?is abnormal metabolic process4 ,to ! "q z to :y & h[ !y d s1 we c z yet give no answ]4 ,^u ! practical side1 we c1 h[ev]1 speak mu* m def9itely4 ,acidosis foll[s ! use ( e!r v r>ely inde$3 aft] nitr\s oxide x is unkn[n4 ,*lor(orm has be5 ! drug us$ 9 almo/ e record$ case1 :ile e?yl *loride has be5 responsible 9 a few isolat$ in/ances4 ,"y *ildr5 are mu* m prone to suff] ?an adults1 ?\gh ! au?or _h a fatal case 9 a lady well ov] =ty ye>s ( age3 he has also se5 a case v ne>ly fatal 9 a soldi] ag$ tw5ty4 ,?is man 01 a week aft] recov]y f acidosis1 an/hetis$ = half-an-h\r ) nitr\s oxide & oxyg51 )\t exhibit+ any signs ( a return ( 8 dang]\s condition4 ,an/hesia repeat$ 9 ! same subject aft] a %ort int]val is m prone to />t ! process ?an a fir/ inhalation4 ,la/ly1 acute sepsis1 p>ticul>ly 9 ! "y1 is notori\s = its liability to be foll[$ by acidosis4 ,,prev5tion ,,& ,,treatm5t4 ,! obvi\s moral ( ! =ego+ is t *lor(orm %\ld n be adm9i/]$ to pati5ts suff]+ f acute sepsis1 p>ticul>ly if !y be v "y4 ,inde$1 s common is a mild degree ( acidosis among *ildr51 "s surgeons consid] !re is a def9ite risk 9 giv+ *lor(orm to !m at all unless special precautions are tak54 ,*ief among ^! are regul> dosage = a day or two be=e op]ation1 ) consid]able doses ( bic>bonate ( soda & sug>1 :i* is a r\t9e measure 9 "s *ildr5's hospitals4 ,z reg>ds curative treatm5t1 mu* c be done if ! gravity ( ! condition is recognis$ e>ly4 ,! /oma* is fir/ wa%$ out ) alkalis1 & a sub/antial dose 7"o dram7 ( bic>bonate ( soda left 9 x4 ,! same dose is repeat$ h\rly by ! m\?1 if reta9$1 or p] rectum4 ,a useful addition to ! alkal9e treatm5t is dextrose1 also 9 teaspoonful doses4 ,9 grave cases1 ^! drugs %\ld be giv5 intrav5\sly 9 sal9e solution4 ,^! measures comb9$ ) w>m?1 & ample fluids by m\? or rectum1 w (t5 save life1 b to be ( any value !y mu/ be begun e>ly4 ,fulm9at+ cases occur :i* succumb rapidly 9 spite ( treatm5t4 ,,*apt] ,,xviii4 ,,po/ure ,,( ,,! ,,pati5t4 ,! position 9 :i* ! pati5t is ly+ is ( z mu* importance to ! an/heti/ z to ! surgeon4 ,x is = ! surgeon to say :at he wants & = ! an/heti/ to realise h[ 8 own "w w be !reby affect$4 ,dorsal ,decubities4 ,?is is ! ord9>y position & calls = no ext5d$ comm5t4 ,! pill[s mu/ be s arrang$ t at no spot is ! body acutely flex$ or ext5d$4 ,abdom51 ?orax1 neck1 & head mu/ all be r\ghly 9 a /raight l9e4 ,deep-*e/$ subjects require a high] pill[ ?an ^? ) %all[ *e/s1 o!rwise ! neck is b5t back & respiration ob/ruct$4 ,! arms %\ld ei!r be fold$ & reta9$ by a b&age or o!r device ov] ! *e/1 or ext5d$ s t ! h&s c be slipp$ "u ! buttocks & reta9$ !re by ! body weight4 ,an arm :i* is all[$ to hang ov] ! side ( ! table is likely to %[ next day & = _m mon?s aft]w>ds1 ! condition ( drop-wri/ f musculo-spiral p>alysis4 ,face-d[n ,position4 ,?is is an awkw>d position = ! an/heti/2 !re be+ a g5]al t5d5cy to respiratory emb>rassm5t4 ,put a pill[ "u ! upp] "p ( ! ?orax1 leav+ ! l[] "p & ! abdom5 z free z possible4 ,let ! head project f ! pill[1 s t ! face c be got at )\t undue rotation ( ! neck4 ,! intratra*eal me?od is a great help4 ,lat]al ,position4 ,?is may be call$ = ei!r ) or )\t ! addition ( a s&-bag or inflatable air-pill[ to pu% ! lo9 upw>ds4 ,9 ei!r case1 !re is a t5d5cy = ! upp] %\ld] to fall =w>ds1 ! position !n assimilat+ itself to ! face-d[n position4 ,?is is be/ met by a support fix$ to ! table1 ^u :i* ! upp] arm may be re/$4 ,fail+ su* a conv5i5ce1 a s&-bag may be pu%$ 9 to keep up ! %\ld]1 or ! assi/ance ( a nurse may be requir$4 ,! ,tr5del5burg ,position4 ,slight tilt+ ( ! head end ( ! table d[nw>ds is (t5 useful 9 assi/+ ! return ( b[el into ! abdom53 9 ?is position1 ! pati5t usually takes ! an/hetic v well4 ,x mu/ n be assum$ until ! ?ird /age ( an/hesia is rea*$4 ,= _m gyncological op]ations1 h[ev]1 ! full ,tr5del5burg position is requir$4 ,heal?y subjects usually d q well 9 x1 b /\t p]sons n uncommonly %[ a good deal ( cyanosis4 ,at ! close ( ! op]ation x is ess5tial to re/ore ! table to ! horizontal sl[ly3 ! physics ( ! circulation are pr(\ndly modifi$1 & if any s]i\s degree ( %ock is pres5t1 rapid return to normal may initiate a collapse4 ,9 ! full position1 ! weight ( ! body %\ld be tak5 by metal supports atta*$ to ! table aga9/ :i* ! %\ld]s may re/4 ,to hang ! entire weight ( ! body ^u ! legs may cause a good deal ( aft]-suff]+ to ! pati5t4 ,! ,sitt+-up ,position4 7,see ,fig4 #di47 ,! object ( ?is position is to dim9i% v5\s engorgem5t & ble$+ 9 op]ations requir+ delicate dissection 9 ! region ( ! neck4 ,pr(4 ,alexis ,?omson introduc$ ! position into ,ed9burgh surg]y3 ! au?or 0 at fir/ r n]v\s ( x1 b has f\nd t ) prop] precautions ! pati5ts d uncommonly well4 ,beyond all d\bt1 ! position is a great help to ! "w ( ! surgeon4 ,n e surgical table is capable ( giv+ ! full position )\t ! use ( _m pill[s & s&bags4 ,! head-piece ( ! table is tilt$ up at an angle ( ab\t #ge or ev5 #hj1 & ! pati5t pull$ up s t ! flexion ( ! body occurs 9 ! lumb>1 n ! dorsal sp9e4 ,a small s&-pill[ is plac$ beh9d ! neck s z to produce slight ext5sion4 ,ano!r heavi] "o is plac$ "u ! ?ighs to prev5t ! body slipp+ d[n4 ,a slight tilt d[nw>ds t[>ds ! head end may be giv5 to ! table z a :ole ) ! same object4 ,illu/ration3 ,,fig4 #di4--,sitt+-up po/ure = op]ations on ! neck4 ,"o %\ld n 9 ?is position attempt to induce a deep *lor(orm an/hesia4 ,weak ,c4,e4 mixture at mo/1 b bett] simply op5-e!r is ! me?od ( *oice4 ,! induction is begun ) ! %\ld]s rais$ to a modifi$ degree1 & ! full position assum$ 9 a light ?ird /age an/hesia4 ,intratra*eal e!r comb9$ ) ?is position is an ideal an/hesia = ! removal ( goitre or ext5sive dissections 9 ! neck = enl>g$ gl&s4 ,o',malley's ,position = ,nasal ,surg]y4 7,see ,fig4 #ej74 ,! au?or became acqua9t$ ) ?is useful position :ile act+ z ,an/heti/ at ! ,royal ,h]b]t ,hospital1 ,woolwi*1 :]e ! ,nose & ,?roat ,dep>tm5t 0 "u ! *>ge ( ,major ,o',malley1 ,f4,r4,c4,s4 ,major ,o',malley 0 k9d en\gh 9 a rec5t lett] writt5 by reque/ to refre% ! au?or's memory ( ! details4 ,illu/ration3 ,,fig4 #ej4--,o',malley's po/ure = intra-nasal surg]y4 ,) ! pati5t ly+ z %ewn 9 ! photograph1 e "p ( ! int]ior ( ! nose c be easily inspect$ by ! surgeon2 ! elevation ( ! head & %\ld]s prev5ts undue ble$+1 & su* hmorrhage z does occur goes d[n ! gullet1 :]e x does no p>ticul> h>m1 in/ead ( into ! l>ynx4 ,! degree ( flexion ( ! head ^u ! neck is n s extreme z to int]f]e ) respiration4 ,! details ( ,o',malley's proc$ure are z foll[s3-- ,! int]ior ( ! nasal cavities are pack$ ) gauze soak$ 9 adr5al9 & novoca9 a qu>t] ( an h\r be=e op]ation1 & ! pati5t receives a v small dose ( morphia & atrop9e imm$iately be=e an/hesis is induc$2 giv5 9 ?is way x does n complicate ! induction ) *lor(orm to ! same ext5t z if giv5 e>li]4 ,! pati5t lies ) ! top ( ! head level ) ! top ( ! table1 & ! head & %\ld]s 7includ+ ! upp] two-?irds ( ! %\ld] blades7 support$ on ! usual dep? ( pill[4 ,induction is by *lor(orm or mixture2 a v light ?ird /age only is aim$ at4 ,:5 x is atta9$ ! m\? is op5$ by a gag1 & ,phillip's ,oral ,airway ins]t$ 7see ,fig4 #h74 ,/rict oral respiration is ess5tial to success4 ,if air is pass+ 9 & out ( ! nose1 blood is splutt]$ all ov] ! surgeon1 s]i\sly int]f]+ ) ! h>mony ( ! proce$+s4 ,junk]'s *lor(orm bottle is ready1 & ! end ( ! supply pipe is pass$ into "o ( ! side holes 9 ! air way4 ,! head ( ! table is n[ elevat$ to an angle ( #de1 & a small s& pill[ slipp$ beh9d ! occiput4 ,! gauze is remov$ f ! nose1 & ! op]ation c be p]=m$ ) great com=t4 ,! circulation ( ! pati5t ne$s c>eful wat*+ = ! fir/ m9ute or two aft] ! table head has be5 elevat$1 b !reaft] !re is usually no special cause = anxiety4 ,! area ( op]ation is locally an/hetis$ by ! action ( ! novoca9 & a light *lor(orm sleep only is requir$4 ,,*apt] ,,xix4 ,,*oice ,,( ,,an,,/hetic4 ,9 consid]+ ?is matt]1 "s repetition ( po9ts to :i* ref]5ce has already be5 made1 is inevitable4 ,inde$1 ?is *apt] may be reg>d$ z a revision ( ! :ole subject4 ,be=e decid+ ^u drug & me?od suitable = ! individual case1 we mu/ consid] ! age & sex1 ! physical type & temp]am5t1 ! possible pres5ce ( "s def9ite pa?ological condition1 & ! nature & duration ( ! op]ation4 ,9 relation to ?is la/ po9t1 we mu/ rememb] t an an/hesia mu/ be adequate to ! purpose ( ! surgeon1 b t x is improp] to incur m risk to life ?an is necess>y4 ,= in/ance1 an abdom9al section case mu/ be fully relax$1 & if 9 an individual case1 *lor(orm is ! only drug :i* w give t effect1 !re ne$ be no hesitation 9 us+ x4 ,on ! o!r h&1 _m o!r me?ods ) a f> small] mortality rate are available if all t is requir$ is ! extraction ( a too? or ! incision ( an abscess1 & 9 t gr\p ( cases1 unfamili>ity ) su* an/hetics z nitr\s oxide or 8e?yl *loride & e!r0 w n be held z a suffici5t def5ce if *lor(orm has be5 giv5 ) a fatal effect4 ,normal ,subjects4 ,let u take fir/ ! case ( ! heal?y adult ab\t to und]go a major op]ation4 ,= ?is1 we unhesitat+ly *oose :at we may t]m ! 8/ock0 me?od--op5-e!r prec$$ by morphia & atrop9e4 ,if ! op]ation be brief1 we h a *oice ( me?ods4 ,= ! extraction ( tee?1 :]e access to ! m\? is ess5tial1 ! foll[+ table w help3-- ---------------------------------------- ------------------------------------ ,duration ( ,available ,,an,,/hetic ,,drug ,,& ,an/hesia1 :5 ,,rem>ks4 ,,me?od4 giv5 z 8,s+le ,dose40 ---------------------------------------- ------------------------------------ ,nitr\s oxide #cj to #dj seconds ,nitr\s oxide & #dj to #ej seconds oxyg5 ,e?yl *loride #gj to #ij seconds ,only to be recomm5d$ 9 special cases 7see page #abg74 ,gas & e?yl *loride #gj to #ij seconds ,gas-oxyg5 & e?yl #gj to #ij seconds *loride ,gas & e!r ,any?+ up to #b to #e ,may cause aft] vomit+4 m9utes accord+ to duration ( inhalation ,e?yl *loride & e!r,any?+ up to #b to #e ,may cause aft] vomit+4 m9utes accord+ to ,m portable4 duration ( inhalation ,nasal gas #e to #aj m9utes 7n a ,requires consid]able 8s+le dose0 an/hetic7 practice to give well4 ,nasal gas & oxyg5 ,no limit ,easi] to give ?an above b app>atus r importable4 ---------------------------------------- ------------------------------------ ,9 cases :]e access to ! m\? is n requir$1 & :]e x is !re=e unnecess>y to 8*>ge up0 ! pati5t ) an/hetic1 we h also a *oice :i* may be express$ tabul>ly3-- ---------------------------------------- ------------------------------------- ,,an,,/hetic4 ,,rem>ks4 ---------------------------------------- ------------------------------------- ,nitr\s oxide ,app>atus simple3 %ort adm9i/ration c be ma/]$ easily4 ,a little m practice requir$ = cases prolong$ by admitt+ air4 ,muscles n relax$1 & pati5t may move :5 cut4 ,nitr\s oxide & ,app>atus m complicat$1 b %ort adm9i/rations oxyg5 pres5t no great difficulty to ! beg9n]4 ,muscles n completely relax$ unless a little e!r add$4 ,gas & e!r ,quick & safe an/hetic4 ,deep an/hesia may be obta9$ if e!r is 8pu%$40 ,e?yl *loride & e!r,! same4 ,m portable ?an above4 ---------------------------------------- ------------------------------------- ,9 ?is gr\p ( %ort op]ations1 special ref]5ce mu/ be made to ! r$uction ( dislocations4 ,"h two important features require notice4 ,! :ole object ( ! proce$+ is to relax muscles1 & !re=e nitr\s oxide or gas-oxyg5 are unsuitable4 ,secondly1 ! t5d5cy to reflex syncope j at ! mom5t ( r$uction is v great4 ,= ?is reason1 *lor(orm has "h a pa9fully high mortality rate2 clos$-e!r1 prec$$ by gas or e?yl *loride1 is und\bt$ly ! me?od ( *oice4 ,! ,extremes ( ,age4 ,*ildr5 up to ! age ( t5 ye>s take e!r badly1 salivation & bron*ial secretion be+ sometimes v tr\blesome4 ,atrop9e mitigates ?is nuisance to a limit$ degree only4 ,*lor(orm is ! be/ drug up to five or six ye>s2 f five to t51 mixture2 aft] t1 op5 e!r4 ,9 *ildr5 ( any age1 suff]+ f acute sepsis1 ! imm$iate annoyances & possible respiratory sequel ( e!r mu/ be fac$ 7see page #aef71 ow+ to ! probability ( acidosis4 ,z reg>ds %ort an/hetics 9 *ildr51 nitr\s oxide1 if giv5 at all1 %\ld be freely dilut$ ) oxyg51 o!rwise mo/ undesirable cyanosis w occur4 ,to *ildr5 "u ?ree or f\r1 ev5 gas-oxyg5 is ( d\btful safety4 ,%ort an/hesias 9 su* cases may be induc$ by op5 e?yl *loride1 ) a few drops ( e!r add$4 ,old p are1 unless v feeble1 be/ an/hetis$ by a mixture ( *lor(orm & e!r4 ,:atev] an/hetic be *os51 ! utmo/ c>e mu/ be tak5 to avoid cyanosis4 ,a cyl9d] ( oxyg5 %\ld be at h& f :i* to enri* ! atmosph]e brea!d1 by trickl+ ! gas into ! m\? ?r\gh a rubb] tube1 & is a great safegu>d 9 deal+ ) ! old4 ,sex4 ,on ! av]age1 wom5 take an/hetics mu* bett] ?an m51 be+ f> less liable to jaw cl5*+ & o!r =ms ( me*anical asphyxia1 & %[+ less excitem5t dur+ ! induction /age4 ,9 ! female subject induction by op5-e!r requires v little assi/ance f ,c4,e4 mixture4 ,physical ,type & ,temp]am5t1 & ,habits ( ,life4 ,heavily built muscul> m5 are tr\blesome subjects4 ,induction requires a r /rong vap\r ( e!r3 if ! op5 me?od is us$1 !re may be to ! beg9n] mu* temptation to make use dur+ ! induction /age ( ,c4,e4 mixture to an ext5t n contemplat$ 9 ! description giv5 ( t me?od 9 *apt] ,,ix43 x is !re=e wise to induce ei!r ) clos$-e!r or ) ,c4,e4 mixture z describ$ 9 *apt] ,,xv41 & to *ange to ! p]halation me?od only :5 full an/hesia is atta9$4 ,z reg>ds alcoholics & excessive smok]s1 ^! are well dealt ) by ! ,c4,e4 op5-e!r sequ5ce4 ,rec\rse may be made to ! ,ormsby inhal] z already expla9$ on page #acg4 ,! read] is w>n$ n to be deceiv$ by ! /\t1 rosy face ( ! typical alcoholic4 ,he (t5 looks a great deal /rong] ?an he really is4 ,_m su* are really feeble subjects3 al?\gh !y %\t & /ruggle no great addition to ! usual vap\r /r5g? ( an/hetic is safe or requir$3 :at is requir$1 is a little extra "t4 ,once fully "u1 ! robu/ appe>ance ( ! pati5t disappe>s1 & ! fact t "o is deal+ ) a r brok5 con/itution & a poor circulation is obvi\s4 ,ref]5ce has already be5 made to ! fact t p]sons ) defective n]v\s sy/ems1 neurotics1 & especially epileptics1 %[ p]si/5ce ( "s muscul> movem5ts = "s "t1 & !re=e require v c>eful wat*+4 ,special ,op]ations & ,pa?ological ,conditions 9 ! ,pati5t4 ,^! are ( ! utmo/ importance1 b to consid] ea* fully f ! an/hetic po9t ( view1 w\ld lead u into great detail4 ,! an/heti/ mu/ acqua9t himself ) any abnormality pres5t1 & consid] x c>efully 9 ! light ( ! g5]al pr9ciples already expla9$4 ,! foll[+ v brief h9ts = select$ cases & op]ations may1 h[ev]1 be f\nd useful4 ,,upp] ,,air ,,passages4 ,artificial tee?4 ,mu/ be remov$ be=e induc+4 ,tongue & jaw cases4--,intratra*eal e!r ! be/--fail+ t1 rectal oil e!r1 or ,junk]'s inhal]4 ,nasal op]ations4--,if adr5al9 is to be us$1 x mu/ prec$e1 n foll[1 *lor(orm--_m fatalities h occurr$ f inject+ or ev5 pack+ ) adr5al9 9 light *lor(orm n>cosis4 ,"s surgeons object to e!r because ( ! ble$+1 b ?is c be l>gely rem$i$ by rais+ ! head & %\ld]s1 & by pack+ ) adr5al94 ,_m surgeons pref] local to g5]al an/hesia4 ,nasal insuffici5cy4--,don't all[ a pati5t to cont9ue to make ineffectual attempts to brea! ?r\gh a n>r[ nose4 ,e/abli% m\? brea?+1 or use ,silk's tubes 7see ,fig4 #i74 ,tonsils & ad5oids4--,give e?yl *loride by ! vap\r me?od4 ,tum\rs & inflammatory swell+s ob/ruct+ respiration4-- ,don't use clos$ me?ods4 ,h tra*eotomy in/rum5ts at h&1 & a cyl9d] ( oxyg54 ,gitres1 especially exoph?almic gitre4--,don't use *lor(orm3 x has caus$ _m fatalities2 morph-atrop9e1 foll[$ by op5-e!r is ! safe/4 ,9 bad cases1 use rectal oil e!r if intratra*eal is n available4 ,! 8sitt+ up po/ure0 is a great help 7see page #afh74 ,use anoci-association if surgeon is will+4 ,,*e/4 ,bron*itis & pneumonia 7see rem>ks 9 *apt] ,,xvii74 ,emphysema & rigid *e/ wall4--,pati5ts take an/hetics badly2 !y cyanose quickly1 ! abdom9al wall _c be made ei!r lax or quiet1 s9ce ! pati5t's natural me?od ( respiration is abdom9al r ?an ?oracic4 ,la/ly1 !re is frequ5tly a dilat$ he>t ) deg5]ate c>diac muscle1 giv+ an abnormal t5d5cy to second>y syncope4 ,give a trickle ( oxyg5 ?r\gh a tube f a cyl9d]3 don't be tempt$ to ov]dose ) an/hetic 9 ! va9 hope ( secur+ ideal relaxation ( ! abdom9al wall4 ,empyma4--,be c>eful3 a good _m accid5ts h happ5$4 ,use *lor(orm ) add$ oxyg53 aim at an an/hesia j deep en\gh to prev5t /ra9+ :i* might rupture ! empyma into ! lung & dr[n him 9 8 own pus4 ,)draw ! an/hetic z soon z ! abscess is op5$4 ,ph?isis4--,don't use clos$-e!r3 x may />t hmorrhage--op5-e!r r>ely does any h>m unless ! condition is v acute4 ,,circulatory ,,sy/em4 ,high t5sion1 art]io-scl]osis1 & aneurysm4--,avoid pure nitr\s oxide3 9 sev]e cases1 ,c4,e4 mixture & oxyg5 is ! safe/4 ,he>t4--,well comp5sat$ cases ( valvul> disease take *lor(orm or op5-e!r well1 provid$ a free air-way is ma9ta9$4 ,clos$ me?ods %\ld be avoid$4 ,cases ( myoc>dial disease ) dilat$ cavities pres5t special dang]s4 ,op5-e!r ) add$ oxyg5 meets ! case bett] ?an any o!r an/hetic4 ,p]ic>ditis1 bo? acute & *ronic1 has be5 f\nd z ! det]m9+ factor 9 _m an/hetic fatalities4 ,,acute ,,infecti\s ,,disease4 ,febrile pati5ts absorb an/hetics v rapidly & !re=e g "u v quickly4 ,acute septic cases mu/ n h *lor(orm or e?yl *loride 7see page #aee73 nitr\s oxide & oxyg5 is ideal1 e!r ! next be/4 ,pati5ts :o h suff]$ f acute infecti\s disease1 especially diph!ria & influ5za1 may pres5t "s weakness ( he>t muscle = _m mon?s aft] ! attack4 ,,exhau/$ ,,& ,,%ock$ ,,cases4 ,give nitr\s oxide & oxyg5 if possible--fail+ t1 e!r4 ,clos$-e!r sometimes does v well = ! induction /age4 ,,diabetes4 ,*lor(orm is :olly inadmissible4 ,,g5ito-,,ur9>y ,,sy/em4 ,kidneys4--,avoid e!r 9 acute or sub-acute nephritis3 give x1 h[ev]1 = nephrectomy :5 ! o!r kidney is s\nd4 ,bladd]4--,di/5d+ ! bladd] ) lotion (t5 causes reflex inhibition ( respiration3 if t happ5s1 /op ! an/hetic1 give artificial respiration1 & ask ! surgeon to get on ) op5+ ! bladd]4 ,morphia usually arre/s tempor>ily ! secretion ( ur9e3 x %\ld !re=e n be giv5 if *romocy/oscopy or ca!t]isation ( ! uret]s is contemplat$4 ,pro/atectomy cases are (t5 r brok5 subjects3 give a fairly deep an/hesia until ! %ell+ out ( ! pro/ate is begun3 !n be c>eful--! pati5t is brea?+ deeply z a rule1 & c readily get an ov]dose4 ,he w inevitably suff] a fair am\nt ( %ock3 be ready to l[] ! table at ! head end if any s]i\s collapse occurs4 ,don't be %y ( />t+ a little artificial respiration ev5 ?\gh ! natural function is n entirely aboli%$4 ,circumcision usually causes a good deal ( l>yngeal spasm1 especially 9 *ildr54 ,don't try to aboli% ?is by deep5+ ! an/hesia4 ,y won't succe$ unless y ne>ly kill ! pati5t4 ,rub ! lips1 & if v sev]e ask ! surgeon to /op a m9ute until ! cr[+ becomes less4 ,ca/ration4--,always give e!r1 or gas-oxyg54 ,ca/ration & r$uction ( dislocation are ! two commone/ causes ( reflex syncope "u *lor(orm4 ,,m5/ruation1 ,,pregnancy1 ,,& ,,lab\r4 ,x is usual to avoid an/hetics dur+ ! m5/rual p]iod if possible1 ! n]v\s sy/em be+ unlikely to be at its be/ at t "t4 ,pregnant pati5ts take no h>m f an an/hetic prop]ly giv51 b undue cyanosis mu/ be avoid$ or abortion may occur4 ,! pa9s ( lab\r may be alleviat$ by *lor(orm giv5 to an e>ly second /age only1 or by 8twilight sleep0 7see page #dd74 ,= ! major op]ations ( ob/etrics1 h[ev]1 e!r has its usual advantages1 provid$ no bron*itis be pres5t4 ,! %ock ( su* op]ations z a difficult v]sion is consid]able1 & q suffici5t to call = e!r r ?an *lor(orm4 ,indication = ,local & ,sp9al ,an/hesia4--,! =ego+ has be5 writt5 9 ref]5ce to inhalational an/hesia solely4 ,mr ,wood has indicat$ 9 *apt]s ,,xx4 & ,,xxi4 ! class ( case 9 :i* ! me?ods he describes are to be pref]r$4 ,,*apt] ,,xx4 ,,local ,,an,,/hesia4 ,by ! t]m local an/hesia1 or m correctly local analgesia1 is meant ! loss ( s5sibility to pa9ful /imuli )\t loss ( g5]al consci\sness4 ,x may be induc$ 9 a consid]able numb] ( ways1 b = practical purposes !re are only f\r me?ods ( value3--7#a7 by infiltration ( ! tissues to be op]at$ ^u by a solution ( ! drug1 7#b7 by inject+ ! solution into or ar\nd ! n]ve trunks supply+ ! "p1 7#c7 by pa9t+ ! solution on a muc\s surface1 & 7#d7 by ! application ( int5se cold4 ,! la/ me?od has only a limit$ application4 ,! me?od ( inject+ ! an/hetic into ! blood vessels ( ! "p is /ill 9 ! exp]im5tal /age & is n to be recomm5d$ = g5]al use4 ,x is advisable fir/ to consid] ! behavi\r ( ! pr9cipal drugs :i* are employ$4 ,coca9e4 ,?is 0 ! fir/ drug to be widely us$ = ! production ( local an/hesia4 ,x is an alkaloid occurr+ 9 ! leaves ( ,ery?roxylon ,coca4 ,x is only slightly soluble 9 wat]--ab\t #a 9 #acjj1 b ! hydro*loride ( coca9e is freely soluble1 & x is ?is salt t is commonly us$ = aque\s solutions4 ,! solutions d n keep well1 & %\ld be made up %ortly be=e be+ us$4 ,! drug is decompos$ by boil+4 ,,action4--,:5 a solution ( coca9e is inject$ into ! tissues1 ! s5sory n]ve end+s become an/hetic ov] ! area into :i* ! drug p5etrates1 direct p>alysis ( ! n]ve t]m9als be+ produc$4 ,:5 x is inject$ into or ar\nd a n]ve trunk x blocks ! transmission ( n]ve impulses4 ,:5 x is appli$ locally to a muc\s membrane1 x produces1 besides a loss ( s5sation1 a feel+ ( con/riction & a di/9ct pallor & contraction ( ! vessels1 :i* po9t to a local action on ! vessel walls4 ,! drug is v frequ5tly appli$ to ! eye4 ,!re x produces n only local an/hesia1 b also contraction ( ! conjunctival vessels1 & ?is is foll[$ by dilatation ( ! pupil & (t5 by p>tial loss ( ! p[] ( accommodation4 ,,coca9e ,,poison+4--,c]ta9 pati5ts %[ an idiosyncrasy to ! action ( coca9e1 & ! greate/ c>e mu/ be ex]cis$ 9 its use4 ,absorption ( small quantities usually causes m5tal excitem5t4 ,! pati5t becomes re/less & g>rul\s1 & a feel+ ( happ9ess may be produc$1 b 9 o!r cases ! pati5t becomes anxi\s & confus$4 ,9 "s pati5ts a small dose is foll[$ by a calm languor\s /ate1 resembl+ t produc$ by morphia1 b ) less t5d5cy to sleep4 ,! pulse is accel]at$1 ! respiration is quick & deep1 & ! pupils are dilat$4 ,:5 poison\s doses h be5 adm9i/]$1 ! he>t becomes extremely accel]at$1 p[]ful tonic or clonic convulsions sup]v5e1 ! brea?+ becomes rapid & %all[1 & may be f9ally arre/$ dur+ a convulsion4 ,9 "s cases a diff]5t set ( symptoms are obs]v$1 fa9t+ & collapse occur1 & convulsive seizures are almo/ entirely abs5t4 ,! he>t is sl[ & & weak1 ! respirations are sl[ & %all[1 ! sk9 is cyanotic & cold1 & dea? takes place f gradual arre/ ( respiration4 ,,treatm5t4--,! treatm5t consi/s 9 endeav\r+ to enc\rage ! action ( ! he>t by e possible means4 ,! pati5t is plac$ flat on 8 back1 if he is n already 9 ?is position1 hypod]mic injections ( e!r & /ry*n9e are adm9i/]$1 & hot c(fee giv5 by ! m\?2 w>m? is ( great importance4 ,artificial respiration is comm5c$ if respiration beg9s to fail4 ,!re is no specific antidote to coca9e4 ,,dosage4--,! maximum dose ( coca9e t c be giv5 ) safety is ( a gra94 ,! am\nt ( solution t may be employ$ dep5ds ^u ! /r5g?4 ,to make a #a p] c5t solution1 #a gr4 ( coca9e hydro*loride is dissolv$ 9 #aaj m9ims ( di/ill$ wat] or half /r5g? normal sal9e2 f ^! proportions ! am\nt ( coca9e 9 a giv5 solution c be calculat$4 ,x w be se5 t ! am\nt ( coca9e solution1 ev5 ) /r5g?s z weak z or p] c5t1 t c be us$ ) safety is small & insuffici5t to an/hetise an area ( any great ext5t4 ,ow+ to its toxicity coca9e has l>gely fall5 out ( use = ! production ( infiltration or regional an/hesia1 ?\gh x is /ill widely us$ 9 oph?almic surg]y & 9 ! surg]y ( ! e>1 nose & ?roat4 ,novoca9e4 ,?is drug is imm5sely sup]ior to coca9e = ord9>y surgical purposes4 ,x is ! hydro*loride ( a syn!tic base1 its *emical =mula be+ ,c#ac;,h#bj,n#b,o#b1 ,h,cl4 ,x is soluble 9 wat] #a 9 #a1 & c be heat$ to #abj;,c )\t decomposition4 ,its solutions possess slight antiseptic prop]ties1 & are capable ( repeat$ boil+ )\t affect+ _! /r5g?4 ,!y may be kept = sev]al mon?s )\t suff]+ any *ange 9 _! action1 a quality n possess$ by any o!r an/hetic ag5t4 ,! toxicity ( novoca9e is "o-fif? or "o-sev5? ( t ( coca9e4 ,:5 us$ 9 conjunction ) adr5al91 its an/hetic activity is equal to t ( coca9e4 ,:5 inject$ into ! tissues x produces no irritant effects l c]ta9 o!r local an/hetics1 notably /ova9e4 ,= ! production ( local an/hesia x is us$ 9 p] c5t4 solution ) ! addition ( ?ree or f\r m9ims ( #a 9 #ajjj solution ( adr5al9 *loride to ea* ounce4 ,sev]al ounces ( ?is prep>ation may be us$ ) ! greate/ safety4 ,all5 makes ! foll[+ /atem5t reg>d+ ?is drug3--8,aft] a r ext5d$ exp]i5ce1 includ+ a l>ge numb] ( cases embrac+ ! entire field ( surg]y1 9 :i* ?is ag5t has be5 almo/ exclusively us$1 we h fail$ to note a s+le case 9 :i* !re has be5 any unpleasant local or con/itutional action4 ,we1 !re=e1 feel ?or\ghly ju/ifi$ 9 unqualifi$ly recomm5d+ x z ! safe/1 mo/ reliable1 & satisfactory ( any local an/hetic ag5t yet introduc$40 ,tropacoca9e4 ,?is drug 0 fir/ isolat$ f ! leaves ( ! coca plant ( ,java1 b is n[ prep>$ syn!tically4 ,its =mula is ,c#ae;,h#ai,,no#b4 ,its action is exactly ! same z t ( coca9e1 except t x is "o-half z toxic & ! duration ( an/hesia is %ort]4 ,! hydro*loride is freely soluble 9 wat]1 & c be boil$ )\t fe> ( decomposition4 ,x is ! ag5t :i* is mo/ suitable = sp9al an/hesia1 z few] unpleasant effects h foll[$ its use ?an t ( any o!r drug4 ,/ova9e4 ,/ova9e is ! hydro*loride ( a syn!tic comp\nd ( ! b5zoyl gr\p4 ,x occurs z a :ite cry/all9e p[d]1 soluble 9 wat]1 #a 9 #ad4 ,its solutions )/& boil+1 b are decompos$ :5 heat$ to #abj;,c4 ,its action is ! same z t ( coca9e1 except t x is slightly less toxic & less p[]ful4 ,x has a di/9ct irritant effect locally4 ,:5 inject$ 9 dilute solution1 x produces a slight burn+ pa9 be=e an/hesia appe>s1 & v (t5 a di/9ct inflammatory reaction p]si/s = "s "t aft] ! op]ation4 ,x is !re=e unsuit$ = local an/hesia4 ,x has be5 widely us$ = ! production ( sp9al an/hesia1 especially by ! ,fr5* s*ool1 b s9ce its injuri\s effects on n]ve tissues h become m app>5t1 x has be5 less us$ ?an =m]ly4 ,euca9e4 ,euca9e 0 introduc$ z a sub/itute = coca9e1 &1 be=e ! introduction ( novoca9e1 0 ext5sively us$4 ,x has a simil> action to coca9e1 & al?\gh x is less toxic1 x is by no means free f dang] unless x is us$ 9 v dilute solutions4 ,x is a vaso-dilator1 & mu/ !re=e be us$ 9 comb9ation ) adr5al94 ,x c be boil$ )\t und]go+ decomposition1 & is practically non-irritant4 ,x has be5 l>gely sup]s$$ by novoca9e4 ,qu99e & ,urea ,hydro*loride4 ,! use ( ?is drug = purposes ( local an/hesia is /ill 9 ! exp]im5tal /age4 ,x is made by add+ urea to a solution ( qu99e 9 hydro*loric acid4 ,! cry/als are soluble 9 _! own weight ( wat]4 ,= ! production ( local an/hesia x is us$ 9 /r5g?s ( #be to #a p] c5t4 ,x is free f toxic effects1 & its solutions c be /]ilis$ by boil+4 ,! /rik+ feature ab\t ?is drug is ! extraord9>y duration ( ! an/hesia1 ?is be+ f "o to six days4 ,x has !re=e be5 us$ by ,crile & o!r ,am]ican surgeons to prev5t pa9 dur+ ! fir/ few days aft] op]ation4 ,! great drawback to its use1 h[ev]1 is t x causes a p]si/5t indurat$ condition ( ! tissues :i* int]f]es ) prim>y union1 & :i* is sometimes foll[$ by actual sl\gh+4 ,9 addition1 x is n[ e/abli%$ t its use has be5 foll[$ by tetanus 9 sev]al cases1 & x is recomm5d$ t a dose ( antitetanic s]um %\ld be giv5 imm$iately be=e or aft] ! injection ( qu99e4 ,al?\gh ! action ( ?is drug is ( great int]e/1 x _c be recomm5d$ at pres5t = ord9>y purposes4 ,adr5al94 ,adr5al9 is obta9$ z an extract f ! supr>5al gl&s ( animals4 ,x is a greyi% :ite p[d]1 slightly soluble 9 wat]1 & readily s 9 weak acids4 ,! usual prep>ation is a #a 9 #ajjj solution ( adr5al9 *loride 9 normal sal9e4 ,x conta9s #e p] c5t4 ( *lor(orm z a pres]vative4 ,! drawback to ! animal extract is t ! solution does n keep well1 decomposition be+ indicat$ by a br[ni% col\r4 ,( late a syn!tic prep>ation has be5 introduc$1 :i* appe>s to h ! same action1 & :i* c be /]ilis$ by boil+4 ,! action ( ! drug is to cause m>k$ vaso-con/riction by direct action on ! vessel walls4 ,x has no analgesic action1 & is us$ z an addition to solutions ( an/hetic drugs4 ,! advantages ( its use are t ! action ( ! an/hetic is conc5trat$ & prolong$1 ow+ to ! delay 9 absorption1 & t ! field ( op]ation is r5d]$ practically bloodless4 ,9 l>ge doses x may produce toxic symptoms 9 ! =m ( palpitations & brea?lessness1 or ev5 actual syncope1 s t c>e is necess>y 9 its use4 ,= purposes ( local an/hesia1 x is add$ to ! solution ( ! an/hetic drug 9 ! /r5g? ( #c drops to ! ounce1 & l>ge injections ( ?is dilute solution may be made )\t risk4 ,at lea/ tw5ty drops may be safely giv54 ,induction ( ,local ,an/hesia ,local an/hesia may be induc$ by ! use ( an/hetic drugs 9 ?ree ways--7#a7 infiltration an/hesia1 7#b7 regional an/hesia1 & 7#c7 by application to a muc\s surface or to ! surface ( ! eye4 ,,infiltration ,,an,,/hesia4--,9 ?is me?od an/hesia is induc$ by injection ( ! drug directly into ! tissues to be op]at$ ^u4 ,?is me?od acts by p>alys+ ! s5sory n]ve-end+s4 ,al?\gh ! t]m an/hesia is con/antly us$1 x is1 /rictly speak+1 an op]ative analgesia t is aim$ at2 x is a p>alysis ( ! pa9-conduct+ fibres1 & n ( ^? :i* conduct purely tactile s5sations1 ! pati5t be+ (t5 able to feel ! contact ( ! f+]s & in/rum5ts dur+ ! op]ation4 ,true an/hesia c be secur$1 b x is necess>y to use consid]ably /rong] solutions ?an ^? t are requir$ = ! production ( analgesia4 ,,solution ,,( ,,! ,,drug4--,novoca9e is f> sup]ior to any o!r drug = infiltration an/hesia4 ,! /r5g? = mo/ purposes is p] c5t41 ?\gh "s op]ators f9d p] c5t4 q satisfactory4 ,9 specially s5sitive p>ts1 su* z ! nose1 ?roat1 or m\?1 #a or ev5 #b p] c5t4 solutions may be pref]able4 ,suffici5t sodium *loride %\ld be add$ to prev5t osmosis ( ! solution into ! tissue cells4 ,! mo/ satisfactory prep>ation is3-- ,novoca9e #jbe1 #je1 #a or #b 7 to #b p]c5t47 ,normal salt solution 7half #ajjj 7#de p] c5t4 ,na,cl7 /r5g?7 ,illu/ration3 ,fig4 #ea4 ,all-,metal ,syr+e = ,infiltration ,an/hesia4 ,adr5al9 is add$ to ! solution 9 ! proportion ( #c drops ( #a 9 #ajjj adr5al9 *loride to ! ounce1 & z mu* z #f ounces ( ?is prep>ation may be safely giv54 ,! novoca9e solution c be boil$ be=e use1 b ! adr5al9 mu/ n be add$ until aft] boil+4 ,= private practice x is sometimes conv5i5t to procure ! novoca9e 9 tabloid =m ( def9ite /r5g? comb9$ ) sodium *loride4 ,^! tabloids are add$ to ! necess>y am\nt ( wat]1 & ! :ole boil$4 ,! adr5al9 c !n be add$4 ,,*oice ,,( ,,syr+e4--,! be/ =m ( syr+e = infiltration an/hesia is ! all-metal syr+e illu/rat$ 9 ,fig4 #ea4 ,x ought to h a capacity ( at lea/ #aj c4c4 ,! advantage ( ! all-metal syr+e ov] glass syr+es is t x c be safely /]ilis$ by boil+1 & does n get brok54 ,betwe5 ! syr+e & ! ne$le is a metal segm5t :i* is curv$ s t ! ne$le is set at an obtuse angle to ! syr+e4 ,?is r5d]s ! infiltration ( ! tissues at ! prop] dep? mu* easi]4 ,! ne$les employ$ are ! ord9>y hypod]mic ne$les :i* are sold 9 small tubes4 ,! sizes :i* %\ld be select$ are #a in*1 & #c or #c in*es4 ,! ne$le fits into a hole 9 a small metal m\nt1 :i* screws on to ! int]m$iate metal portion4 ,?is section also is atta*$ to ! syr+e by a screw1 & ^! screw atta*m5ts h ! advantage ( r5d]+ leakage impossible4 ,fail+ ! syr+e describ$1 a #aj c4c4 ,record syr+e w be f\nd to be q effici5t1 if suitable ne$les c be obta9$4 ,! syr+e1 ne$les1 & glass measure = ! solution %\ld be boil$ 9 pla9 wat] or normal sal9e1 z soda int]f]es ) ! action ( ! drug4 ,,te*nique ,,( ,,injection4--,! ne$le is introduc$ into ! subcutane\s tissue1 & pu%$ on sl[ly to its full l5g?1 ! fluid be+ inject$ z ! ne$le advances4 ,! ne$le is !n p>tly )drawn1 & pu%$ 9 9 a diff]5t direction s z to infiltrate a fre% area4 ,?is proc$ure is repeat$1 & z wide an area z possible infiltrat$ f ! "o puncture4 ,! ne$le c !n be completely )drawn & introduc$ at a fre% po9t :i* has already be5 r5d]$ analgesic4 ,! deep] tissues c ne>ly always be infiltrat$ f ! surface1 b if l>ge blood-vessels trav]se ! region to be infiltrat$1 x may be necess>y to def] ! deep] injection until ^! h be5 expos$4 ,x is wise to infiltrate wide ( ! int5d$ l9e ( ! incision1 s9ce x is n possible to anticipate ) c]ta9ty ! ext5t ( an op]ation until x has be5 comm5c$4 ,! secret ( successful an/hesia is to employ pl5ty ( ! solution1 & make ! injection ?or\gh4 ,! sk9 ov] ! area becomes blan*$ )9 a few m9utes ( ! injection ow+ to ! action ( ! adr5al94 ,an/hesia is n usually complete until t5 m9utes h elaps$1 & ! op]ation %\ld n be comm5c$ until x has be5 made c]ta9 by suitable te/s t ! an/hesia is complete4 ,! duration ( ! an/hesia is usually at lea/ an h\r & a half4 ,x w be se5 t ! injection 9 ! mann] describ$ above is entirely subcutane\s1 ! pa9-conduct+ n]ves f ! sk9 be+ caught up by ! drug z !y trav]se ! sup]ficial fascia 9 ! area infiltrat$4 ,?is me?od usually gives complete satisfaction1 b "s surgeons advise t ! infiltration %\ld be comm5c$ ) an intra-d]mal injection s z to r$uce ! pa9 ( ! ne$le punctures to a m9imum4 ,a f9e ne$le is employ$1 ! prick ( :i* is practically pa9less4 ,if ! sk9 at ! select$ po9t is p9*$ up betwe5 ! f+] & ?umb1 & held firmly1 ?is less5s its s5sibility4 ,! ne$le is advanc$ b5ea? ! epid]mis ) a quick b light ?ru/4 ,! injection into ! sub/ance ( ! sk9 causes a di/9ct :eal1 :i* /&s out f its surr\nd+s l an urtic>ial :eal4 ,f ?is />t+-po9t a long ne$le c be introduc$ into ! deep] tissues )\t pa94 ,! intra-d]mal injection may be c>ri$ along ! :ole l5g? ( ! area to be infiltrat$1 ea* fre% puncture be+ made 9 ! m>g9 ( ! :eal-l area already an/hetis$4 ,,precautions4--,! mo/ c>eful asepsis is ess5tial ?r\gh\t4 ,infiltration ) novoca9e causes no int]f]5ce ) ! heal+ ( ! w\nd1 & al?\gh cases ( sl\gh+ ( ! tissues h be5 report$ aft] its use1 ^! are almo/ c]ta9ly due to infection ( ! w\nd4 ,c>e mu/ be ex]cis$ also to avoid inject+ ! drug into a ve94 ,:5 ?is accid5t takes place1 ! drug is c>ri$ at once into ! g5]al circulation1 & may rea* ! high] n]ve c5tres 9 su* quantity z to produce s]i\s toxic results4 ,! use ( adr5al9 calls = special c>e & ?or\ghness 9 secur+ all ble$+-po9ts1 z1 aft] ! effect ( ! adr5al9 passes (f1 ev5 a slight ooze may increase & give rise to a hmatoma :i* may jeop>dise ! heal+ ( ! w\nd4 ,regional ,an/hesia4 ,9 ?is me?od ( produc+ an/hesia1 ! s5sory n]ve pa?s are block$ by inject+ ! an/hetic drug into1 or ar\nd1 a n]ve trunk4 ,by ?is proc$ure complete an/hesia is produc$ 9 ! area ( di/ribution ( ! n]ve1 & ! effect corresponds to a tempor>y physiological section ( ! n]ve trunk4 ,a tempor>y motor p>alysis is also produc$ 9 a mix$ n]ve4 ,,te*nique4--,! solution ( ! drug mu/ be /rong] ?an t employ$ = infiltration an/hesia4 ,a #b p] c5t4 solution ( novoca9e 9 half-/r5g? normal sal9e ) ! addition ( adr5al9 is employ$4 ,! injection may be p>aneural or intraneural4 ,a p>aneural injection is made by pass+ a ne$le ?r\gh ! tissues to ! kn[n position ( a n]ve trunk & inject+ ! an/hetic ar\nd x4 ,! solution gradually diffuses into ! n]ve tissue1 & an/hesia ( ! n]ve is produc$4 ,?is me?od is op5 to ! objection t unless ! an/hetic is accurately plac$1 no an/hesia w result1 & t 9 ! case ( c]ta9 n]ves !re is consid]able risk ( mak+ ! injection into a ve94 ,! latt] risk c be avoid$ by us+ a glassb>rell$ syr+e & apply+ a little suction be=e ! injection is made2 if a ve9 has be5 pi]c$1 blood w ent] ! syr+e4 ,! intraneural me?od is m accurate b requires ! exp5diture ( consid]able additional "t & tr\ble1 & is only employ$ :]e o!r me?ods ( an/hesia are n feasible4 ,! tissue ov] ! n]ve hav+ be5 infiltrat$1 ! n]ve is expos$ by op5 dissection4 ,x mu/ n be p9*$ by =ceps or o!r in/rum5ts1 z su* manipulations cause sev]e pa9 ref]r$ to its p]iph]al di/ribution4 ,! injection %\ld be made ) ! n]ve ly+ 9 its b$ by ins]t+ a f9e ne$le 9 ! long axis ( ! n]ve1 fir/ into ! %ea?1 :i* is infiltrat$1 & !n into ! n]ve itself4 ,! infiltration ( ! n]ve is cont9u$ until x pres5ts a fusi=m swell+ & ?is may require f #e to #ae m9ims ( ! solution4 ,complete an/hesia ( its entire di/ribution usually results 9 f five to t5 m9utes4 ,a ?ird me?od ( induc+ regional an/hesia--fir/ recomm5d$ by ,hack5bru*--:i* is wor? m5tion1 is by ! production ( a r+ ( infiltration ar\nd a p]iph]al "p1 su* z a f+]1 or ar\nd & und]nea? a tum\r4 ,by ?is means ! n]ve fibres are caught up by ! an/hetic & _! conductivity int]rupt$ z !y ent] ! area to be op]at$ ^u4 ,9 deal+ ) su* conditions z a l>ge lipoma1 or an umbilical h]nia1 x may be possible to avoid ! use ( an excessive am\nt ( an/hetic solution by employ+ ?is me?od4 ,me?ods ( ,application ( ,infiltration & ,regional ,an/hesia4 ,x is sometimes /at$ t local an/hesia %\ld be limit$ to small & sup]ficial op]ations1 b ) a k ( anatomy & ( ! correct te*nique1 !re are few op]ations :i* ! surgeon _c und]take ) ?is =m ( an/hesia4 ,if we rememb] t ! mortality f ! an/hetic is practically nil1 x is obvi\s t x is (t5 ! duty ( ! op]ator to give ! pati5t ! *oice ( local an/hesia4 ,9 urg5t conditions 9 :i* ! adm9i/ration ( a g5]al an/hetic w\ld be att5d$ ) great dang]1 x is (t5 a life-sav+ measure4 ,ei!r infiltration or regional an/hesia may be us$ alone2 9 "s cases x is conv5i5t to comb9e ! two me?ods4 ,op]ations on ! ,upp] ,extremity4 ,regional an/hesia is sometimes employ$ 9 op]ations on ! upp] extremity 9 conditions1 su* z diabetic gangr5e or advanc$ c>diac disease1 :]e a g5]al an/hetic is contra-indicat$4 ,9 simil> conditions 9 ! l[] extremity1 sp9al an/hesia is usually pref]r$1 ?\gh x is q possible to an/hetise ! l[] limb by block+ ! sciatic1 femoral1 & lat]al cutane\s n]ves ) a local an/hetic4 ,crile lays great /ress on ! block+ ( n]ves ) a local an/hetic dur+ op]ations on ! limbs z a means ( prev5t+ %ock1 ev5 :]e a g5]al an/hetic is be+ employ$4 ,! effect ( ! local an/hetic is to prev5t ! impulses :i* produce %ock f pass+ up to ! high] c5tres4 ,only ^? me?ods :i* are appli$ to ! upp] extremity ne$ special description4 ,,an,,/hesia ,,( ,,! ,,:ole ,,arm4--,! n]ves ( ! upp] extremity are all d]iv$ f ! bra*ial plexus except ! int]co/o-bra*ial4 ,?is n]ve1 :i* is ! lat]al cutane\s bran* ( ! second int]co/al1 crosses ! axilla & pi]ces ! deep fascia on ! m$ial side ( ! arm4 ,x supplies ! sk9 on ! dorsal "p ( ! m$ial aspect ( ! upp] arm4 ,! lat]al cutane\s bran* ( ! ?ird int]co/al n]ve sometimes crosses ! axilla also1 & rea*es ! m$ial side ( ! arm4 ,injection ( ! bra*ial plexus produces complete analgesia ( ! %\ld] & entire arm1 & is p>ticul>ly suit$ to high amputations & dis>ticulations at ! %\ld]4 ,if ! area suppli$ by ! int]co/o-bra*ial is encroa*$ ^u1 ?is c be an/hetis$ by infiltration ) a few drams ( solution inject$ subcutane\sly along ! floor ( ! axilla f its lat]al & po/]ior bord]s4 ,,me?od4--,! injection may be intraneural or p>aneural4 ,! intraneural is made aft] expos+ ! plexus by an incision "u infiltration an/hesia f ! junction ( ! middle & l[] ?irds ( ! /]no-ma/oid to ! union ( ! middle & lat]al ?irds ( ! clavicle4 ,x is f\nd ly+ on ! scal5us m$ius & ea* ( its bran*es is sep>ately inject$ ) a few drops ( #e p] c5t4 solution ( novoca9e conta9+ a few drops ( adr5al9 to ! ounce4 ,! p>aneural injection is less satisfactory1 s9ce ! n]ves are too l>ge to be readily p5etrat$ 9 effective quantities by ! an/hetic solution1 & s9ce !re are num]\s ve9s 9 ! neighb\rhood into :i* ! solution may be accid5tally inject$ ) dang]\s results4 ,! injection is usually made above ! clavicle4 ,9 ?is region ! plexus lies ma9ly above & to ! lat]al side ( ! ?ird "p ( ! subclavian art]y1 ! l[e/ trunk ly+ directly beh9d ! vessel z x re/s on ! fir/ rib4 ,! position ( ! art]y is fir/ localis$ ) ! f+] by its pulsations1 & ! sk9 & subcutane\s tissue infiltrat$ imm$iately above ! mid-po9t ( ! clavicle4 ,f ?is po9t a long f9e ne$le1 unatta*$ to ! syr+e1 is pass$ d[nw>ds1 backw>ds1 & m$ially 9 ! direction ( ! second or ?ird ?oracic sp9e4 ,! di/ance to :i* ! ne$le p5etrates v>ies f #b to #d c4m4 ,:5 ! plexus is rea*$ a slight radiat+ pa9 is felt d[n ! di/ribution ( ! radial or m$ian n]ve4 ,at ?is po9t ! ne$le is held /ation>y1 ! syr+e atta*$1 & ! injection made4 ,! reason = n atta*+ ! syr+e e>li] is t %\ld ! art]y be ent]$1 blood w fl[4 ,?is accid5t is ( little consequ5ce1 ! ne$le be+ )drawn slightly & introduc$ a little m lat]ally4 ,ab\t #aj c4c4 ( a #b p] c5t4 solution ( novoca9e & adr5al9 is inject$2 ! ne$le is !n slightly )drawn & a fur!r #aj c4c4 inject$ 9 ! neighb\rhood4 ,an/hesia occurs 9 f ?ree to fifte5 m9utes4 ,illu/ration3 ,,fig4 #eb4--,po9t at :i* ! ne$le is introduc$ 9 p>aneural injection ( bra*ial plexus4 ,! individual n]ves ( ! upp] limb c be readily inject$4 ,! m$ian c be expos$ at ! b5d ( ! elb[ = an intraneural injection1 or a ne$le may be pass$ "u ! t5don ( ! palm>is longus at ! wri/ = a p>aneural injection4 ,! uln> c be easily rea*$ z x lies on ! po/]ior aspect ( ! m$ial epicondyle ( ! hum]us = a p>aneural or intraneural injection4 ,! sup]ficial radial c be rea*$ = a p>aneural injection ab\t two in*es above ! wri/ to ! lat]al side ( ! t5don ( ! bra*io-radialis 7sup9ator longus74 ,! injection is made into ! deep fascia1 & c>ri$ across ! lat]al bord] ( ! =e>m = ab\t an in*1 to ensure rea*+ all ! bran*es ( ! n]ve4 ,! m$ial antibra*ial 7int]nal7 cutane\s c be block$ on ! front ( elb[ by a p>aneural injection ab\t half an in* m$ial to ! biceps t5don1 & ! lat]al antibra*ial cutane\s 7musculo-cutane\s7 at a correspond+ po9t on ! o!r side ( ! t5don4 ,,an,,/hesia ,,( ,,! ,,arm ,,bel[ ,,! ,,elb[4--,9 op]ations bel[ ! elb[1 9 conditions 9 :i* a g5]al an/hetic is n p]missible1 z 9 diabetes1 nephritis or advanc$ c>diac disease1 a full an/hesia c be obta9$ by intraneural injection ( ! m$ian1 uln>1 & radial 7musculo-spiral7 n]ves1 comb9$ ) p>aneural injection ( ! m$ial & lat]al antibra*ial cutane\s4 ,! m$ian & radial are ea* expos$ by an incision "u infiltration an/hesia1 ! radial be+ expos$ 9 ! groove betwe5 ! bra*ialis & bra*io-radialis4 ,! infiltration to expose ! m$ian n]ve usually blocks ! ant]ior bran* ( ! m$ial antibra*ial cutane\s4 ,to make c]ta9 t ! po/]ior bran* is also an/hetis$1 x is advisable to inject a little an/hetic solution ov] ! front ( ! m$ial epicondyle4 ,! intraneural injection into ! uln> n]ve c (t5 be made )\t expos+ x4 ,,an,,/hesia ,,( ,,f+]4--,! p>aneural me?od appli$ to ! digital n]ves at ! root ( ! f+] gives p]fect results4 ,a circle ( an/hetic solution is fir/ inject$ r\nd ! root ( ! f+]4 ,! ne$le is !n pass$ ?r\gh ! infiltrat$ sk9 on ea* side ( ! f+]1 & a few drops ( p] c5t4 novoca9e solution inject$ ar\nd ! n]ves4 ,complete an/hesia ( ! f+] results 9 a few m9utes4 ,,9 ,,! ,,l[] ,,limb injection ( individual n]ves is r>ely employ$1 z an/hesia is easily obta9$ by ! me?od ( sp9al analgesia4 ,! lat]al cutane\s c be inject$ z x lies imm$iately m$ial to ! ant]ior sup]ior iliac sp9e em]g+ f "u cov] ( ! +u9al ligam5t4 ,?is proc$ure may be useful 9 obta9+ sk9 grafts1 ! grafts be+ tak5 f ! ant]o-lat]al aspect ( ! ?igh4 ,amputations 9 ! middle ?ird ( ! ?igh h be5 p]=m$ by inject+ ! sciatic1 ! po/]ior cutane\s 7small sciatic71 ! femoral 7ant]ior crural71 & ! lat]al cutane\s at ! root ( ! limb4 ,! obturator n]ve is difficult to f9d & an/hetise 9 su* cases4 ,op]ations bel[ ! knee c be pa9lessly p]=m$ by ?is me?od ( an/hesia4 ,op]ations on ! ,neck4 ,,tra*eotomy4--,?is op]ation is conv5i5tly & safely p]=m$ "u infiltration an/hesia4 ,! an/hetic solution is inject$ 9 ! usual way 9 ! l9e ( ! incision d[n to ! tra*ea b n into x1 z ! tra*ea itself is ins5sitive to pa94 ,,goitre4--,a p>5*ymat\s or ad5omat\s goitre c be readily remov$ "u local an/hesia1 ?\gh ! adm9i/ration ( e!r by intra-tra*eal insufflation is usually to be pref]r$4 ,! pr9cipal n]ve supply to ! field ( op]ation is d]iv$ f ! c]vical plexus1 ^: bran*es become sup]ficial ab\t ! middle ( ! po/]ior bord] ( ! /]no-ma/oid4 ,an intrad]mal injection may be made fir/ at ?is po9t1 & a long] ne$le !n pass$ d[n to ! po/]ior bord] ( ! muscle1 & an area ( infiltration produc$4 ,f ?is po9t ! ne$le is direct$ fir/ upw>ds & !n d[nw>ds r\nd ! m>g9 ( ! goitre s z to produce a zone ( infiltration4 ,! same proc$ure may be repeat$ on ! opposite side1 s t ! :ole gl& is surr\nd$ ) a zone ( infiltration ) a special depot ( solution ar\nd ! bran*es ( ! c]vical plexus4 ,:]e only "o lobe is involv$1 x is suffici5t to c>ry ! injection d[n 9 ! middle l9e aft] "o side has be5 encircl$4 ,:5 ! %ea? has be5 incis$ & ! surface ( ! gl& expos$1 ! i/hmus is infiltrat$ & divid$4 ,! affect$ half ( ! gl& is !n roll$ outw>ds1 & ! atta*m5ts betwe5 ! po/]ior aspect ( ! gl& & ! l>ynx & tra*ea are infiltrat$1 special att5tion be+ paid to ! upp] pole4 ,! re/ ( ! op]ation c !n be c>ri$ out pa9lessly4 ,,exoph?almic ,,goitre may also be op]at$ ^u "u local an/hesia aft] a prelim9>y hypod]mic injection ( morphia & scopolam91 ?\gh _m op]ators pref] a g5]al an/hetic on acc\nt ( ! n]v\s /ate ( ! pati5t4 ,9 bad cases a proc$ure :i* is (t5 ( great value is ligature ( ! sup]ior ?yroid art]y on bo? sides "u local an/hesia4 ,aft] ligature ( ! vessels a colloid deg5]ation takes place 9 ! gl&1 & ! symptoms ( hyp]?yroidism subside4 ,aft] a delay ( two or ?ree mon?s x may be possible to c>ry out ! radical op]ation ) little or no dang]4 ,! incision is two & a half in*es 9 l5g?1 & crosses transv]sely ! c5tral "p ( ! ?yroid c>tilage4 ,! l9e ( ! incision is infiltrat$ ) novoca9 solution 9 ! ord9>y way1 & bo? sup]ior ?yroid art]ies expos$ & ligatur$4 ,op]ations on ! ,?orax4 ,! great] "p ( ! wall ( ! ?orax is suppli$ by ! int]co/al n]ves4 ,9 front ! supraclavicul> n]ves come d[n z f> z ! second int]co/al space or sometimes z f> z ! nipple1 & ! lat]al & m$ial ant]ior ?oracic n]ves supply ! pectoral muscles1 s5d+ a few twigs to ! ov]ly+ sk94 ,! long ?oracic n]ve ext5ds d[n ! side ( ! *e/1 supply+ ! s]ratus ant]ior4 ,! int]co/al n]ves c be block$ 9 ! region ( ! angles ( ! ribs & ! supraclavicul> by c>ry+ a l9e ( infiltration along ! clavicle4 ,! ant]ior ?oracic c be block$ by deep] injections4 ,9 ?is way ! great] "p ( ! *e/ wall & ! pleura c be an/hetis$4 ,,acute ,,empyema4--,?is op]ation %\ld always be p]=m$ "u local an/hesia4 ,exhau/ion f septic absorption & f ! antec$5t pneumonia or o!r disease1 ) ! dyspna f ! pressure ( ! pus on ! lung may r5d] a g5]al an/hetic highly dang]\s4 ,! me?od ( produc+ local an/hesia is simple & easily c>ri$ out4 ,a po9t is select$ on ! rib :i* is to be resect$ a %ort di/ance beh9d ! l9e ( ! incision & an intra-d]mal injection made ) a f9e ne$le4 ,a long ne$le is !n sub/itut$ & pass$ d[n to ! upp] bord] ( ! rib until x rea*es ! plane betwe5 ! ext]nal & int]nal int]co/al muscle1 ! injection be+ cont9u$ lightly z x advances4 ,:5 ! desir$ po9t is rea*$ "o or two drams ( ! solution are inject$4 ,! ne$le is !n slightly )drawn & pass$ to ! l[] bord] ( ! rib to rea* ! same plane & ! same proc$ure c>ri$ out4 ,! infiltration is !n c>ri$ along ! l9e ( ! incision or x may be made to pass obliquely upw>ds to ! rib above & obliquely d[nw>ds to ! rib bel[ s z to cat* up ! n]ves com+ f beh9d into ! area ( op]ation4 ,! an/hesia ( s(t p>ts1 bone1 & pleura is p]fect aft] ! above injection4 ,op]ations on ! ,abdom54 ,! ant]ior abdom9al wall1 includ+ ! ant]ior p>ietal p]itoneum1 is suppli$ by ! l[] six int]co/al n]ves1 ! la/ ?oracic n]ve1 & ! ilio-hypoga/ric & ilio-+u9al n]ves f ! fir/ lumb>4 ,x is a v int]e/+ & important fact t1 al?\gh ! p>ietal p]itoneum is exce$+ly s5sitive to t\* & pa91 ! visc]al p]itoneum & ! visc]a !mselves are ins5sitive4 ,:5 op]ations are p]=m$ "u local an/hesia ( ! abdom9al wall1 ! visc]a c be freely h&l$ or incis$ )\t ! pati5t exp]i5c+ ! slighte/ discom=t1 provid$ t ! p>ietal p]itoneum is n put ^u ! /ret* by traction on ! mes5t]y or o!r p]itoneal atta*m5t4 ,?us ! colon c be op5$ tw5ty-f\r or =ty-eight h\rs aft] be+ br\ght outside ! abdom9al wall )\t any an/hetic 9 ! op]ation ( colo/omy4 ,local an/hesia is !re=e well adapt$ to cases 9 :i* a small am\nt ( manipulation ( ! visc]a is requir$1 & :]e a g5]al an/hetic w\ld be dang]\s1 z 9 grave cases ( inte/9al ob/ruction & 9 cases ( c>c9oma ( ! sophagus ) weakness & loss ( fle% f />vation4 ,,ga/ro/omy4--,?is op]ation is commonly p]=m$ "u local an/hesia & may be tak5 z an illu/ration ( ! proc$ure employ$4 ,! incision is made ?r\gh ! middle ( ! left rectus & is ab\t two & a half or ?ree in*es long1 beg9n+ ab\t an in* bel[ ! co/al m>g94 ,an intrad]mal :eal is e/abli%$ at ! middle ( ! propos$ incision4 ,a long ne$le is ent]$ at ?is po9t & pass$ fir/ upw>ds & !n d[nw>ds 9 ! l9e ( ! incision1 infiltrat+ ! subcutane\s fat z x goes4 ,! ne$le is !n pass$ 9 ?r\gh ! ant]ior wall ( ! rectus %ea?1 ?is be+ easily recognis$ z a plane ( decid$ resi/ance4 ,! ne$le is advanc$ a little inside ! %ea?1 ! injection be+ cont9u$ z x advances4 ,! same proc$ure is repeat$ at v>i\s po9ts along ! l9e ( ! incision4 ,! extra-p]itoneal fat may be infiltrat$ 9 ! same way1 ! po/]ior wall ( ! %ea? be+ id5tifi$ z a deep] plane ( resi/ance & g5tly pi]c$4 ,?is /ep may be def]r$ until ! po/]ior wall ( ! %ea? has be5 expos$4 ,! infiltration may be complet$ by =m+ a l9e ( intrad]mal infiltration along ! l9e ( incision1 ?\gh ?is la/ /ep c (t5 be omitt$4 ,! abdom5 c !n be op5$ pa9lessly4 ,! only /ep 9 ! op]ation :i* may cause a little discom=t is ! traction :i* may be necess>y to br+ ! %runk5 /oma* d[n f "u cov] ( ! ribs4 ,! incision into ! /oma* is q pa9less4 ,,ga/ro-,,ent]o/omy c be p]=m$ "u local an/hesia1 ! only special /ep requir$ be+ infiltration ( ! meso-colon be=e x is p]=at$4 ,,app5dicectomy is n suitable1 z a rule1 = local an/hesia4 ,if ! ccum is fix$ or ! app5dix b\nd d[n by adhesions1 ! traction necess>y to br+ ! app5dix to ! surface causes consid]able pa94 ,9 ,,acute ,,ob/ruction1 :5 ! proc$ure ( ent]o/omy has be5 decid$ ^u ow+ to ! gravity ( ! pati5t's condition1 local an/hesia is (t5 ( great value4 ,! abdom9al wall is infiltrat$ 9 ! mann] describ$1 & a di/5d$ loop ( b[el br\ght to ! surface & sutur$ to ! p>ietal p]itoneum4 ,a ,paul's tube c !n be introduc$4 ,,+u9al ,,h]nia4 ,local an/hesia is specially suit$ to cases ( /rangulat$ h]nia1 b x may be employ$ 9 ! ord9>y case4 ,x %\ld be po9t$ out t sp9al an/hesia gives equally good results & is less tr\blesome to c>ry out4 ,! injection is comm5c$ ) a f9e ne$le a little beyond ! lat]al end ( ! propos$ incision4 ,an intrad]mal :eal is produc$ at ?is po9t1 a long ne$le introduc$ into ! subcutane\s tissue1 & ab\t half-an-ounce ( an/hetic solution inject$ 9 ?is position4 ,! ne$le is !n pass$ d[nw>ds & m$ially1 & ! subcutane\s fat infiltrat$ 9 ! l9e ( ! incision4 ,! ne$le is !n p>tly )drawn & aga9 advanc$ until x rea*es ! resi/ance ( ! aponeurosis ( ! ext]nal oblique4 ,?is is g5tly pi]c$ & ab\t half-an-ounce ( solution inject$ und]nea? s z to block ! ilio-hypoga/ric & ilio-+u9al n]ves4 ,9 mo/ cases ?is is all t is necess>y4 ,z additional precautions ! l9e ( incision may be infiltrat$ intrad]mally1 & an injection may be made ar\nd ! neck ( ! sac aft] x is expos$4 ,,femoral ,,h]nia4--,a femoral h]nia may be an/hetis$ by infiltration along ! l9e ( ! incision1 or by inject+ ar\nd ! circumf]5ce ( ! h]nia aft] ! me?od ( ,hack5bru*4 ,aft] ! sac has be5 expos$ & def9$1 x is necess>y to inject "s novoca9e solution ar\nd ! neck1 c>e be+ tak5 to avoid ! femoral ve9 :i* lies on ! lat]al side4 ,,umbilical ,,h]nia4--,local an/hesia is sometimes ( great value 9 deal+ ) umbilical h]nia1 especially if x is /rangulat$1 9 /\t pati5ts :o are bad subjects = a g5]al an/hetic4 ,! injection is be/ made ar\nd ! circumf]5ce ( ! h]nia4 ,sev]al intrad]mal injections are made at po9ts ar\nd ! swell+1 & ?r\gh ^! ! long ne$le c be introduc$ & ! deep] tissues infiltrat$4 ,if ! muscles are fairly well def9$ & c be felt1 !y may be infiltrat$ at ! comm5cem5t1 b x may be advisable 9 fat subjects to inject only ! subcutane\s tissues to beg9 )1 & to delay ! injection ( ! muscles & extra-p]itoneal fat until ! sac has be5 op5$ & a protect+ f+] c be introduc$ to gu>d ! inte/9es4 ,om5tal adhesions c be divid$ )\t caus+ pa94 ,if ! inte/9es are ext5sively adh]5t to ! sac x is bett] to infiltrate ! po9ts ( adhesion1 z ext5sive manipulation may cause cramp-l pa9s4 ,aft] ! circumf]5tial injection has be5 made 9 ^! cases1 x is be/ to wait = t5 or fifte5 m9utes be=e mak+ ! incision 9 ord] to all[ ! an/hetic solution to diffuse4 ,,suprapubic ,,cy/otomy4--,9 op]ations = dra9age ( ! bladd] local an/hesia is highly successful4 ,! sk9 & subcutane\s tissues are infiltrat$ 9 ! l9e ( ! incision4 ,! ne$le is !n c>ri$ betwe5 or ?r\gh ! recti muscles & sev]al drams inject$ into ! lay] ( fat 9 front ( ! bladd]4 ,x is unnecess>y to inject ! wall ( ! bladd] itself4 ,h,,morrhoids4--,9 pati5ts 9 :om !re is "s contra-indication to ! use ( a g5]al an/hetic ! removal ( hmorrhoids c be c>ri$ out q safely & pa9lessly "u local an/hesia4 ,a circumf]5tial injection is fir/ c>ri$ out r\nd ! muco-cutane\s junction4 ,x is be/ to />t ! infiltration ab\t an in* out f ! anus z ! sk9 imm$iately ar\nd ! anal orifice is extremely s5sitive4 ,! infiltration is made subcutane\sly1 & ea* re-ins]tion ( ! ne$le is made j %ort ( :]e ! previ\s injection /opp$4 ,:5 ! circumf]5tial injection has be5 complet$1 a f+] is pass$ into ! rectum1 & ! long ne$le introduc$ ?r\gh ! an/hetis$ area1 inject+ z x advances1 to a dep? ( ab\t #b in*es1 keep+ j outside ! sph9ct]s4 ,f\r su* injections are made1 "o on ea* side ( ! b[el1 "o 9 front & "o beh9d1 f #e to #aj c4c4 be+ inject$ 9 ea* position4 ,an/hesia results almo/ imm$iately & ! anal canal c be readily dilat$4 ,,! ,,tongue4--,= ! ,:itehead op]ation ( removal ( "o half ( ! tongue1 complete an/hesia c be obta9$ by ! infiltration me?od4 ,a long ne$le is introduc$ at ! tip ( ! tongue1 & ! injection c>ri$ 9 ! middle l9e to a po9t beh9d ! tum\r4 ,! muc\s membrane ( ! floor ( ! m\? & ! glosso-palat9e fold are infiltrat$1 & a la/ injection made across ! affect$ half ( ! tongue well beh9d ! tum\r4 ,! tongue c be an/hetis$ also by block+ ! l+ual n]ve ) a p>aneural injection4 ,! n]ve lies "u ! muc\s membrane ( ! m\? opposite ! la/ mol> too?4 ,if ! tongue is drawn well ov] to ! opposite side1 ! n]ve c be felt & ! injection made ar\nd x4 ,! only drawback to ?is me?od is t x does n an/hetise ! po/]ior ?ird1 :i* is suppli$ by ! glosso-ph>yngeal n]ve4 ,,op]ations ,,on ,,! ,,skull ,,& ,,bra9 c be readily p]=m$ by infiltration ( ! scalp4 ,9 ! lat] /ages ( ! rec5t w>1 a l>ge proportion ( op]ations on ! skull & bra9 7 p]=m$ "u local an/hesia4 ,! bra9 itself is ins5sitive to t\* & pa9ful /imuli1 & infiltration ( ! scalp is all t is necess>y4 ,a #a p] c5t4 solution ( novoca9e ) adr5al9 has be5 commonly employ$1 & is inject$ into ! subaponeurotic space s z to surr\nd ! field ( op]ation ) a wall ( an/hetic solution--! me?od ( ,hack5bru*4 ,! advantages are t hmorrhage is r$uc$ to a m9imum1 & ! head c be conv5i5tly & safely elevat$ & ! intra-cranial t5sion ?us r$uc$4 ,analgesia f ! ,application ( ,coca9e to ! ,eye or to a ,muc\s ,surface4 ,,= ,,op]ations ,,on ,,! ,,eye4--,analgesia is obta9$ by ! in/illation ( a few drops ( a #d p] c5t4 solution into ! conjunctival sac4 ,?is is repeat$ two or ?ree times1 & analgesia is obta9$ 9 five or t5 m9utes4 ,x may be necess>y to repeat ! in/illation dur+ ! c\rse ( ! op]ation4 ,,= ,,op]ations ,,on ,,! ,,nose1 ,,ph>ynx1 ,,or ,,l>ynx coca9e is commonly us$4 ,a #e or #aj p] c5t4 solution is employ$ & is m]ely pa9t$ on ! surface4 ,c>e mu/ be tak5 t su* /rong solutions are n swall[$4 ,,*apt] ,,xxi4 ,,sp9al ,,an,,/hesia4 ,sp9al ,an/hesia or ,analgesia1 consi/s 9 ! production ( analgesia 9 ! l[] extremities & 9 ! l[] "p ( ! trunk by ! injection into ! sub>a*noid space ( an an/hetic drug :i* blocks ! sp9al n]ves z !y ent] & leave ! sp9al cord4 ,! cord ends at ! l[] bord] ( ! fir/ lumb> v]tebra & ! sub>a*noid space at ! second sacral v]tebra s t !re is a consid]able area into :i* ! injection may be made )\t risk ( injury to ! cord4 ,x is1 9 reality1 a special v>iety ( regional analgesia1 ! an/hetic be+ inject$ into t "p ( ! sub>a*noid space :i* is occupi$ by ! cauda equ9a4 ,! sub>a*noid space ( ! m$ulla sp9alis conta9s ! c]ebro-sp9al fluid & communicates above ) ! sub>a*noid space inside ! skull & ?r\gh ! =am5 ( ,mag5die1 ) ! v5tricul> sy/em ( ! bra94 ,! subdural space ( ! m$ulla sp9alis is m]ely a capill>y int]val4 ,at ! upp] end ( ! cauda equ9a ! n]ve trunks ( ! two sides are sep>at$ by a m$ian int]val--conta9+ only ! filum t]m9ale--:i* has be5 t]m$ ! cy/]na t]m9alis4 ,x is into ?is m$ian space t ! injection is made1 9 ord] to avoid w\nd+ ! n]ve trunks & to procure equal diffusion ( ! an/hetic to bo? sides ( ! middle l9e4 ,if ! injection is made among ! n]ve trunks on "o side1 a unilat]al an/hesia may result1 ! drug be+ prev5t$ f diffus+ freely to ! o!r side by ! pres5ce ( ! num]\s n]ves4 ,! ligam5tum d5ticulatum =ms an imp]fect scallop$ septum betwe5 ! po/]ior & ! ant]ior n]ve roots1 pass+ f ! surface ( ! cord to ! dura mat]4 ,! pres5ce ( ?is septum probably expla9s ! fact t ! motor n]ves are n affect$ ) ! same con/ancy & to ! same ext5t z ! s5sory roots4 ,te*nique4 ,! drug :i* is mo/ commonly employ$ 9 ! ,ed9burgh s*ool is ,tropacoca9e1 & ! results ( its use ) prop] te*nique are em95tly satisfactory4 ,! dose ( ! drug = mo/ purposes is #jg gramme4 ,small] doses are sometimes us$ b ! l>g] dose gives m con/ant an/hesia & appe>s to be well )9 ! limits ( safety4 ,! dose is dissolv$ 9 #a c4cm4 ( di/ill$ wat] & suffici5t sodium *loride add$ to make a solution isotonic ) ! c]ebro-sp9al fluid4 ,a conv5i5t me?od ( obta9+ ! drug is 9 glass amp\les1 ea* amp\le conta9+ "o dose1 :i* has be5 c>efully /]ilis$4 ,illu/ration3 ,,fig4 #ec4--,ne$le & syr+e = sp9al analgesia4 ,note ! %ort oblique "* ( ! po9t ( ! ne$le4 ,! syr+e & ne$le employ$ are illu/rat$ 9 ,fig4 #ec4 ,! po9t ( ! ne$le mu/ be %>p b %ort4 ,if a ne$le ) a long sl5d] po9t is employ$1 only "p ( ! po9t may ent] ! membranes2 a free fl[ ( c]ebro-sp9al fluid may !n take place1 b :5 ! injection is made "p ( ! an/hetic solution escapes outside ! membranes4 ,! ne$le %\ld he #c to #d in*es long & #a m4m4 9 diamet]4 ,a /ylet fits inside ! ne$le & prev5ts x f becom+ block$ dur+ ! introduction4 ,to prev5t ! possibility ( ru/+1 bo? ne$le & /ylet %\ld consi/ ( h>d nickel4 ,! b>rel ( ! syr+e mu/ consi/ ( glass s t ! appe>ance ( ! c]ebro-sp9al fluid c be se54 ,! ,record type is v satisfactory4 ,! syr+e usually suppli$ = sp9al analgesia has a capacity ( #b or #c c4cm41 b "o hold+ #aj c4cm4 is m useful4 ,syr+e & ne$le mu/ be c>efully /]ilis$ by boil+ 9 pla9 wat]2 any trace ( soda causes decomposition ( ! drug4 ,! amp\le conta9+ ! tropococa9e is /]ilis$ 9 a /rong antiseptic solution s z to avoid ! possibility ( contam9ation ( ! h&s :5 ! drug is be+ transf]r$ to ! syr+e4 ,me?od ( ,injection4--,! pati5t %\ld be giv5 a hypod]mic injection ( gr4 ( morph9e & gr4 ( scopolam9e an h\r be=e ! op]ation4 ,!re are a numb] ( m9or v>iations 9 ! me?od ( mak+ ! sp9al injection1 b limitations ( space =bid a discussion ( !oretical que/ions & ( ! relative m]its ( ! diff]5t proc$ures4 ,only "o me?od1 :i* has be5 f\nd safe & reliable1 w be consid]$ "h4 ,! injection is made 9 ! space betwe5 ! ?ird & f\r? lumb> sp9es1 ! objective be+ ! mid-l9e ( ! sub>a*noid space betwe5 ! two divisions ( ! cauda equ9a4 ,! position ( ! pati5t is su* t ! spaces betwe5 ! lumb> sp9es are op5$ up z widely z possible4 ,! mo/ conv5i5t plan is to h ! pati5t sitt+ on ! table ) ! head & %\ld]s b5t well =w>d 7see ,fig4 #ed47 ,if ! pati5t is unable to sit up1 ! injection may be made ) him ly+ on 8 side1 ) ! knees drawn up & ! %\ld]s b5t =w>d4 ,illu/ration3 ,,fig4 #ed4 ,position = ! injection4 ,! cross indicates ! po9t at :i* ! lumb> puncture is made--ab\t half an in* f ! m$ian plane & 9 ! space betwe5 ! ?ird & f\r? lumb> sp9es4 ,! sk9 ( ! back is c>efully /]ilis$2 pa9t+ ) t9cture ( iod9e s]ves admirably4 ,! amp\le conta9+ ! tropacoca9e is op5$1 & ! drug suck$ into ! syr+e ?r\gh a sp>e cannula4 ,! load$ syr+e is !n plac$ on a /]ile t[el at ! back ( ! pati5t4 ,) a little practice !re is no difficulty 9 mak+ ! lumb> puncture4 ,! f\r? lumb> sp9e is locat$ by not+ ! level ( ! highe/ po9t on ! iliac cre/--?is may be indicat$ by an assi/ant4 ,a l9e jo9+ ! highe/ po9ts on ! two iliac cre/s w pass ?r\gh ! tip ( ! f\r? lumb> sp9e4 ,:5 ?is process has be5 c>efully id5tifi$1 ! ne$le is introduc$ half-an-in* to "o side ( ! m$ian plane & midway betwe5 ! ?ird & f\r? sp9e4 ,"s surgeons pref] to g 9 exactly 9 ! middle l9e to make sure ( ent]+ ! middle ( ! sub>a*noid space1 b 9 ?is position ! t\gh supra-sp9\s & int]sp9\s ligam5ts are met )1 & to avoid ! resi/ance ( ^! x is be/ to keep a %ort di/ance out f ! m$ian plane4 ,by c>efully not+ ! direction ( ! ne$le1 ! cy/]na t]m9alis c always be ent]$4 ,! ne$le is pass$ =w>ds1 v slightly upw>ds1 & slightly m$ially s z to hit (f ! c5tre ( ! sub>a*noid space4 ,z ! ne$le passes ?r\gh ! ligam5tum flavum1 !re is a sudd5 dim9ution ( resi/ance & imm$iately aft]w>ds ! po9t ( ! ne$le lies 9 ! sub>a*noid space4 ,! passage ( ! ne$le ?r\gh ! membranes is sometimes accompani$ by a slight prick+ pa94 ,! /ylet is )drawn at ?is /age & ! c]ebro-sp9al fluid usually trickles out drop by drop4 ,! syr+e is pick$ up1 c>efully empti$ ( air bubbles1 & fitt$ on to ! ne$le4 ,! pi/on is )drawn until ! syr+e is fill$ ) c]ebro-sp9al fluid1 :i* mixes freely ) ! an/hetic solution1 & ! cont5ts !n sl[ly inject$4 ,! #aj c4cm4 syr+e is to be pref]r$ = ?is purpose z x is ess5tial to mix ! tropacoca9e ?or\ghly ) ! c]ebro-sp9al fluid4 ,if ! small] syr+e is us$1 x %\ld be refill$ ) c]ebro-sp9al fluid & empti$ a second "t s z to ensure ?or\gh diffusion ( ! drug4 ,! ne$le is !n )drawn & ! puncture seal$ ) collodion4 ,! injection %\ld nev] be made until a free fl[ ( c]ebro-sp9al fluid is obta9$1 s9ce ?is is ! only c]ta9 indication t ! ne$le has ent]$ ! sub>a*noid space4 ,if failure is met ) 9 ! space betwe5 ! ?ird & f\r? sp9es1 ! int]sp9\s space above or bel[ %\ld be tri$4 ,aft] ! injection has be5 complet$ ! pati5t is plac$ flat on 8 back & !n l[]$ into ! ,tr5del5burg position4 ,analgesia appe>s fir/ 9 ! scrotum & p]9eum1 ext5ds d[n ! m$ial side ( ! leg to ! foot1 !n appe>s on ! front ( ! leg1 & travels up to ! gro9 & ! l[] "p ( ! abdom54 ,! progress ( ! analgesia is te/$ f "t to "t by lightly p9*+ or prick+ ! sk91 ! pati5t's eyes be+ scre5$4 ,:5 ! analgesia rea*es ! level ( ! nipples1 ! pati5t is rais$ into ! horizontal position & ! ! op]ation may be comm5c$4 ,"s surgeons object to ! l[]+ ( ! head z r5d]+ p>alysis ( ! respiratory c5tre f upw>d diffusion ( ! drug m likely4 ,if tropacoca9e is us$ 9 ! dosage indicat$ & ! table elevat$ :5 ! an/hesia rea*es ! nipple l9e1 !re seems to be little risk ( ?is complication4 ,if analgesia is only desir$ 9 ! l[] extremity1 ! l[]+ ( ! table may be omitt$2 b if a good an/hesia is desir$ above ! level ( ! gro91 x %\ld always be c>ri$ out4 ,analgesia is complete 9 five or t5 m9utes z a rule4 ,! duration v>ies f ?ree-qu>t]s ( an h\r to an h\r & a half4 ,if a prelim9>y hypod]mic injection ( morph9e & scopolam9e has be5 giv51 ! pati5t lies quietly & pati5tly until ! op]ation is complet$4 ,9 "s cases ! pati5t actually drops (f to sleep f ! effects ( ! morph9e4 ,x is n uncommon to obs]ve a tempor>y nausea & fa9tness ab\t fifte5 or tw5ty m9utes aft] ! injection has be5 made1 & x is good practice to give ! pati5t a little br&y & wat] at ?is /age4 ,complications & ,aft]-,effects4 ,a great deal has be5 writt5 9 ! pa/ ) reg>d to unpleasant results ( sp9al analgesia1 b mo/ ( ^! w\ld appe> to h be5 ! result ( faulty te*nique or ( ! use ( an impure or irritat+ drug4 ,:5 tropacoca9e is us$ 9 ! mann] describ$1 ! usual result is t1 except = occasional nausea & fa9tness at ! comm5cem5t1 ! pati5t has a com=table1 pa9less op]ation1 & a recov]y :i* is unm>r$ by ! sickness & o!r di/ress+ symptoms :i* are s common aft] g5]al an/hesia4 ,dea?s h be5 record$1 & ^! h be5 ascrib$ to ! drug hav+ travell$ too high & br\ght ab\t p>alysis ( ! respiratory c5tre 9 ! m$ulla oblongata4 ,too mu* importance has probably be5 ascrib$ to ^! fatal cases4 ,!y h be5 mo/ common 9 pati5ts greatly enfeebl$ by %ock1 old age1 or debilitat+ illness1 :o are liable to die dur+ ! op]ation :atev] an/hetic is us$4 ,?\s&s ( cases h be5 record$ )\t a dea?1 & 9 ! h&s ( surgeons ( skill & judgm5t fatal cases are almo/ unkn[n4 ,an occasional complication is sev]e heada*e :i* may p]si/ = a week or long]4 ,o!r complications are all exce$+ly r>e2 p>alysis ( ! lat]al rectus muscle ( ! eyeball or ( o!r ocul> muscles has be5 record$1 & is probably due to toxic bye-products :i* are ! result ( impurity ( ! drug4 ,p]si/5t nausea & p>alysis ( ! bladd] & rectum & ev5 ( ! l[] extremities h also be5 record$1 b are to be reg>d$ z ! greate/ r>eties1 & probably due to impurity ( ! an/hetic4 ,indications4 ,sp9al analgesia may be us$ = any op]ation at or bel[ ! level ( ! umbilicus4 ,excell5t an/hesia is obta9$ = ! op]ation = radical cure ( umbilical h]nia1 b an/hesia above ?is level is n s con/ant1 & is reg>d$ by _m au?orities z unsafe4 ,! proc$ure is ( special value 9 cases 9 :i* a g5]al an/hetic is unsafe3--7#a7 ,9 old enfeebl$ pati5ts suff]+ f /rangulat$ h]nia1 enl>g$ pro/ate1 disease ( ! female pelvic organs1 & o!r conditions :]e an/hesia is necess>y bel[ ! umbilicus4 7#b7 ,9 pati5ts :o are already suff]+1 or :o are likely to suff]1 f sev]e %ock4 ,! drug has ! same effect on ! n]ve trunks ( ! cauda equ9a z on ! p]iph]al n]ves--x causes block+ ( ! c5tripetal s5sory impulses :i* are su* a pot5t factor 9 ! causation ( %ock4 7#c7 ,9 diabetic gangr5e sp9al analgesia is ! safe/ =m ( an/hesia to employ4 ,contra-,indications ,*ildr5 up to ! age ( f\rte5 or s are apt to be fright5$1 & sp9al analgesia is bett] avoid$ except 9 special cases4 ,x is contra-indicat$ also 9 septic conditions on acc\nt ( ! possibility ( septic m5+itis result+ f meta/asis ( ! infection1 ! drug hav+ possibly ! action ( l[]+ ! vitality ( ! cord & m5+es4 ,9 tub]culosis & syphilis x is bett] avoid$ = ! same reason4 ,x %\ld n be us$ :]e organic disease ( ! sp9al cord or bra9 is already pres5t4 ,analgesia ,produc$ by ,freez+4 ,a transi5t analgesia c be produc$ by freez+ ! sk94 ,an e!r spray 0 =m]ly employ$1 b 0 f\nd to be tr\blesome & inconv5i5t4 ,! mo/ conv5i5t proc$ure consi/s 9 freez+ ! "p by means ( a spray ( e?yl *loride4 ,?is drug is suppli$ 9 a glass cyl9d] ) a v f9e outlet s t x breaks up into a f9e spray z x escapes4 ,! cyl9d] is held ab\t #h or #aj in*es f ! pati5t's sk91 & pressure appli$ ) ! ?umb to a /opcock on ! neck ( ! cyl9d]4 ,"u ! influ5ce ( ! heat ( ! h& ! liquid escapes 9 a f9e jet :i* imp+es on ! pati5t's sk94 ,freez+ takes place 9 a few seconds1 ! froz5 pat* becom+ h>d & :ite4 ,! freez+ c be ha/5$ by bl[+ on ! sk94 ,?is me?od is only suitable = ! op5+ ( small abscesses & o!r proc$ures requir+ a v %ort an/hesia4 ,! an/hesia is v imp]fect1 & only la/s = a few seconds4 ,_m pati5ts appe> to h z mu* pa9 ) ?is =m ( an/hesia z )\t x4 ,,app5dix ,i4 ,,"s ,,exp]im5tal ,,obs]vations ,,by ,,! ,,au?or ,,^u ,,! ,,physical ,,facts ,,( ,,e!r ,,evaporation4 ,! app>atus 0 v simple4 ,x consi/$ ( a pump :i* w\ld propel air t[>ds ! e!r bottle2 a glass bottle conta9+ e!r1 ! ro( ( :i* 0 pi]c$ by two tubes1 "o ( :i* c>ri$ ! air f pump to bottle1 & ! o!r f bottle to a ,wall]'s tube1 :]e x 0 collect$4 ,! p]c5tage ( e!r 9 ! air 0 !n e/imat$ by ,wall]'s gravimetric me?od4 ,! e!r j> /ood 9 a wat] ba? :i* c\ld be ei!r left o!rwise empty or fill$ up ) wat] ( kn[n temp]ature4 ,! foll[+ tables %[ "s ( ! results4 ,9 ea* case1 ! air 0 propell$ = five m9utes1 by :i* "t ! cool+ effect ^u ! e!r 0 v m>k$2 ! figures giv5 are av]ages tak5 f sev]al obs]vations4 ,,table ,a4 ,,air ,,bl[+ ,,ov] ,,surface ,,( ,,e!r4 ---------------------------------------- ------------------------------- ,temp]ature ( ,quantity ( ,rate ,temp]ature ,ba? 7,fahr47 e!r be=e ( ( e!r ,p]c5tage be=e exp]im5t4 exp]im5t4 pump4 7,fahr47 at endobta9$4 ( exp]im5t4 ---------------------------------------- ------------------------------- #ge #ajj c4c4 #cj #ej ,f4 #abg #he #ajj c4c4 #cj #eb ,f4 #abh #ge #ajj c4c4 #ij #de ,f4 #hg #he #ajj c4c4 #ij #de ,f4 #hh ,no wat] 9 ba? #ajj c4c4 #cj #cb ,f4 #hb ,no wat] 9 ba? #ajj c4c4 #ij #bc ,f4 #ed ,no wat] 9 ba? #bjj c4c4 #cj #ch ,f4 #if ,no wat] 9 ba? #bjj c4c4 #ij #bi ,f4 #ff ---------------------------------------- ------------------------------- ,,table ,b4 ,%[+ increas$ p]c5tage obta9$ by 8bubbl+ ?r\gh0 in/ead ( 8bl[+ ov]0 e!r-- ,,wat] ,,ba? ,,at #ge ,,fahr4 ,quantity ( e!r4 ,rate ( pump4 #ajj c4c4 #cj ,air bl[n ov] surface ( e!r gave p]c5tage ( e!r #abh ,air bubbl$ ?r\gh e!r #bch ,,table ,c4 ,%[+ am\nts ( e!r vaporis$ at v>y+ pump rates4 ,9 ea* case1 ! temp]ature ( ! wat] ba? 0 #ge1 & ! initial am\nt ( e!r 0 #ajj cc4-- ,pump ,am\nt ( ,e!r ,rate4 ,vaporis$4 #cj #cj c4c4 #ij #ch c4c4 ,^! exp]im5ts ju/ify "o 9 draw+ ! foll[+ conclusions3-- #a4 ,! effect ( a wat] ba? has a m>k$ effect 9 increas+ ! /r5g? ( ! vap\r yield$1 b small v>iations 9 ! temp]ature ( ! ba? 7z betwe5 #ge & #he ,fahr47 h b little effect4 #b4 ,if e!r is vaporis+ quickly1 x _c pick up heat f ! wat] ba? z quickly z x is los+ its own heat4 ,?\gh n %[n 9 ! tables1 ! actual loss ( temp]ature on ! wat] ba? 0 small--ab\t #b degrees ,fahr4 dur+ ! five m9utes exp]im5t4 #c4 ,! m =cible ! bla/ ( air bl[n ov] or ?r\gh ! e!r1 ! less ! p]c5tage ( e!r yield$4 ,table ,c %[s t ?is loss ( p]c5tage is n comp5sat$ = by an increase 9 ! total am\nt vaporis$4 ,( c\rse1 ^! results only apply to ! case ( a /rong curr5t ( air4 ,if ! curr5t ( air 7 v small1 ! e!r c\ld pick up heat z fa/ z x p>t$ ) x1 & )9 mod]ate degrees a little increase ( ! air /ream w\ld increase ! total am\nt ( e!r vaporis$ )\t r$uc+ ! p]c5tage /r5g?4 ,^! results are ( "s practical importance 9 connection ) s-call$ 8vap\r an/hesia0 z giv5 = in/ance by ,%ipway's in/rum5t 7page #ij71 & 9 devis+ & us+ ! e!r *amb]s ( intratra*eal app>atus4 ,,app5dix ,,ii4 ,,! ,,p]c5tage ,,/r5g? ,,9 ,,op5 ,,e!r4 ,hewitt & ,syme 7,lancet1 #bg? ,jan4 #aiab7 e/imat$ ! p]c5tage ( e!r obta9able f an op5 mask ) v>y+ mat]ials & quantities ( ! drug4 ,! results are tabulat$ bel[3-- ,a4--,a ,,:ole ,,mask ,,j ,,moi/4 ,mat]ial /ret*$ ,numb] ( ,p]c5tage on mask4 lay]s4 obta9$4 ,gauze #d #aa #h #aad #ab #aa ,flannel #a #hj #b #hj ,l9t #a #ajj ,b4--,,:ole ,,mask ,,wet4 ,gauze #d #ab #h #acd #ab #adj ,flannel #a #hj #b #hj ,l9t #a #hj ,by excessive d\*+ ! obs]v]s 7 able to obta9 #ag p] c5t4 ,9 ^! results1 air & e!r vap\r 7 drawn by a pump ?r\gh ! mat]ial to imitate ! inspiration1 b no attempt seems to h be5 made to imitate expiration4 ,! effect ^u ! mat]ial us$ ( moi/ure cond5s$ f ! expir$ air is n tak5 into acc\nt 9 ^! exp]im5ts4 ,?is is a s]i\s hiatus 9 ! argum5t1 p>ticul>ly z reg>ds l9t4 ,?is mat]ial 9 actual use rapidly becomes q sodd51 & e!r w n vaporise f x prop]ly4 ,9 spite ( ?is fault1 ^! obs]vations may probably be tak5 z be+ reasonably accurate4 ,) !m may be comp>$ ! figures ( ,k>l ,connell1 :o1 work+ ) q accurate me?ods1 e/imat$ ! p]c5tages ( e!r necess>y to induce & ma9ta9 an/hesia3-- ,p]iod ( ,an/hesia4 ,p]c5tage4 ,fir/ #e m9utes 7i4e4 induction7 #ah ,next #be #ad ,next #cj #ab ,next #fj #abh 8,bad0 subjects on ! av]age requir$ an extra #d p] c5t4 dur+ fir/ half h\r1 feeble pati5ts requir$ #b p] c5t4 less4 7,j\rnal ( ! ,am]ican ,m$ical ,association1 #bbnd ,m>* #aiac74 ,,app5dix ,,iii4 ,,! ,,action ,,( ,,an,,/hetics ,,^u ,,! ,,blood4 ,! ,blood ,gases 9 ,an/hesia4 ,buckma/] & ,g>dn] 7,j\rnal ( ,physiology1 vol4 xli41 p4 #bdf71 analys$ ! blood gases 9 v>i\s /ages ( *lor(orm an/hesia1 & "s ( _! results are %[n bel[ 9 tabul> =m4 ,!y %[ a v def9ite r$uction 9 ! oxyg5 cont5t ( ! blood4 ,s f> z "o ga!rs f ! text ( ! pap]1 ! animals 7 n subject$ to any consid]able trauma dur+ ! progress ( ! an/hesia1 s t ! figures arriv$ at ) reg>d to ! ,,co#b cont5t d n be> ^u ! ,acapnia "q4 ,if !re 0 no trauma1 !re w\ld be no deep brea?+1 & a r$uction ( ,,co#b c\ld n be expect$4 ---------------------------------------- --------------------------------------- ,av]age volume 9 ,av]age composition c4c4 p] #ajj c4c4 p] c5t4 ,relation ( blood ( gas ( -----------------------------------,o#b to ,,co#b ,,co#b,o#b,nitr4,,co#b ,o#b,nitr4 ---------------------------------------- ----------------------------------- ,normal cats4 #bejgacfj #ajj #fcb #cdbh #beb #a to #ahd ,reflexes j re-appe>+ #bijbaadi #acc #fejf #bedd #bhg #a to #bee ,reflexes j disappe>+ #bieg #ggh #bae #fiad #ahag #eji #a to #ch #bnd ,/age ,an/hesia #cfjj #had #adi #gabg #afab #bie #a to #dcb ---------------------------------------- ----------------------------------- ,o!r ,blood *anges 9 ,an/hesia4 ,hamburg] & ,ew+ 7,j\rnal ( ! ,am]ican ,m$ical ,assoc4 #aijh7 exam9$ ! blood *anges incid5tal to surgical an/hesia4 ,_! results may be cond5s$ z foll[s3-- ,nitr\s ,oxide4--,hmoglob9 is n p]man5tly decreas$ & no anmia foll[s ! adm9i/ration4 ,hmolysis is n increas$4 ,! coagulation "t ( ! blood is n always affect$ 9 ! same direction4 ,usually x is slightly increas$4 ,e!r4--,! hmoglob9 is slightly r$uc$ & anmia p]si/s = sev5 to t5 days4 ,hmolysis is n h[ev] mat]ially increas$4 ,!re is "s evid5ce ( blood inspissation4 ,! coagulation "t is m>k$ly increas$4 ,*lor(orm4--,! hmoglob9 is r$uc$ & a di/9ct anmia produc$4 ,hmolysis is def9itely increas$4 ,!re is a slight increase 9 ! coagulation "t4 ,,index4 ,a ,abdom9al op]ations1 ix1 #g local an/hesia 91 #ahg ,abdom9al muscles1 rigidity (1 #ai ,abnormalities ( an/hesia1 m9or1 #ch major1 #adj ,acapnia1 #aj1 #bi1 #ci ,accid5ts ( an/hesia1 #adj ,acetonuria1 #aec ,acidosis1 #aec ,ad5oids1 #abg1 #aff 9 /atus lymphaticus1 #adh ,adr5al91 #age dang] (1 ) *lor(orm1 #aac1 #aff ,a$5tul\s pati5ts1 #bc ,aft]-effects ( an/hetics1 see ,sequelae ,ages1 dosage ( morphia at v>i\s1 #de selection ( an/hetic at v>i\s1 #afd ,air%aft1 natural1 #if ,airway1 natural1 #ae1 #ca1 #aad1 #ade artificial1 #bc ,alcoholics1 an/hesia 91 #b1 #hg1 #ajc1 #acg1 #afe ,alkaloids1 #ab1 #dc1 #hh1 #ajc ,aneurysm1 #ef ,anoci-association1 #aa ,anoxmia1 #ae ,arm1 managem5t ( 9 an/hesia1 #aeg regional an/hesia (1 #aha ,art]ies1 sp\t+ (1 x1 #cg ,art]io-scl]osis1 #ef1 #afg ,artificial respiration1 #adf ,asphyxia1 #ae ,a!tosis1 #ch ,atrop9e1 #dc1 #de1 #aab1 #adg ,au] & ,meltz]1 #if ,b ,b>? #c-way tap1 #ej ,bic>bonate ( soda 9 acidosis1 #aef ,bladd]1 reflexes f1 #ci1 #afh local an/hesia 9 op]ations ^u1 #aij ,bli/]+1 by *lor(orm1 #aji ,blood1 *anges 91 dur+ an/hesia1 #bjg sp\t+ (1 f cut art]ies1 x1 #cg ,blood-pressure1 9 natural sleep1 #a 9 %ock1 #f 9 asphyxia1 #ag 9 nitr\s oxide1 #df 9 e!r1 #ge 9 *lor(orm1 #aaj 9 e?yl *loride1 #abb cl9ical obs]vation (1 #cg ,bl[+ respiration1 #cd1 #hi ,boo?by1 on e!r p]c5tages1 #ii ,boyle1 ,mr ,leon>d1 #gj ,bra*ial plexus1 n]ve block+ 91 #aha ,bra91 see ,n]v\s ,sy/em local an/hesia = op]ation ^u1 #aia ,brea?-hold+1 #cd1 #aab1 #aad ,brea?+1 deep 7see ,acapnia7 ,bron*itis1 #aej ,c ,c>bon-dioxide1 #aj1 #ah1 #bjf ,c>diac cyanosis1 #cg ,c>diac disease1 #ajg ,c>diac failure 7see ,syncope7 ,ca/ration1 an/hesia 91 #afi ,c4,e4 mixture1 #hd1 #acd1 #acg ,cells1 n]ve1 *anges 91 #e ,c5tripetal impulses1 #f ,*ildr51 #de1 #id1 #abe1 #afd ,*loretone1 #ic ,*loride ( e?yl 7see ,e?yl ,*loride7 ,*lor(orm1 adm9i/ration (1 #aac decomposition (1 #aji delay$ poison+ by1 #aec physiology (1 #aji ,*oice ( an/hetics1 #afb ,circulation1 obs]vation (1 x1 #cg 9 %ock1 #aj 9 asphyxia1 #ag 9 valv$ brea?+1 #bi 9 nitr\s oxide1 #df 9 e!r1 #ge 9 *lor(orm1 #aaj 9 e?yl *loride1 #abb 9 ,c4,e4 mixture1 #aca failure ( 7see ,syncope7 ,circumcision1 an/hesia 91 #afi ,cl>ke's app>atus1 #fi ,cl5*+ ( ,jaws1 #ae1 #bd ,cl9ical ph5om5a ( asphyxia1 #ah ( normal an/hesia1 #cc ,clos$ e!r1 #gh ,clos$ me?od1 features (1 #bi ,clov]'s inhal]1 #gh1 #ach ,coca9e1 #agj ,collapse 7see ,syncope7 ,conduction ( n]ve impulses1 #c ,connell1 ,k>l1 #ij1 #bje ,conjunctival reflex1 #ca1 #ce ,convulsions1 #ag ,corneal reflex1 #cb1 #ce ,crile1 ,pr(41 #e1 #i ,cr[+ respiration1 #af1 #afi night cr[+1 #adh ,cyanosis1 #ah1 #cg1 #ec ,cyl9d]s = nitr\s oxide1 #dc = oxyg51 #fd ,d ,dang]s ( *lor(orm1 ,pr(4 ,l4 ,hill ^u1 #abj ,dea?1 causes (1 #ag1 #aaj1 #adj1 #add1 #adh ,decomposition ( *lor(orm1 #aji ( e!r1 #gd ,deep brea?+1 #aj ,degrees ( an/hesia1 #ca ,d5tal an/hesia1 #ed1 #eg1 #abh1 #aca1 #afc ,dep? ( an/hesia1 #cf ,dextrose 9 acidosis1 #aef ,difficulties ( an/hesia1 major1 #adj m9or1 #ch ,dilatation ( pupils1 #e1 #ag1 #ce1 #ec1 #ff1 #abe1 #acf1 #ada1 #adc ,disease1 relation ( an/hesia to1 #aff acute infecti\s1 #afh ,dislocations1 an/hesia 9 r$uction (1 #afd ,dorsal position1 #aeg ,dosimetric me?od = *lor(orm1 #aad = e!r1 #ij ,dott1 ,mr ,n41 direct l>yngoscope1 #ajd ,d\*e me?od1 #bj ,dread 7see ,fe>7 ,drop bottles2 *lor(orm1 #aag e!r1 #hc ,drop me?od1 #cj1 #hc ,drugs = local & sp9al an/hesia1 #agj to #agd ,e ,emphysema1 #afg ,empyma1 #afg1 #ahg ,enema1 be=e op]ation1 #db ,e!r1 #gd1 et seq4 clos$1 #gh intratra*eal1 #if op51 #hc physiology (1 #ge rectal1 #ic w>m$ vap\r1 #ij ,e!r1 respiratory sequel (1 #aej ,e!r tremor1 #ch ,e?yl *loride1 #abb1 et seq4 comb9$ ) nitr\s oxide1 #abh freez+ an/hesia by1 #bjj ,euca91 #agd ,excitem5t 7see ,/ruggl+7 ,extraction ( tee? 7see ,d5tal ,an/hesia7 ,eye reflexes1 def9ition (1 #ca ,f ,face-d[n po/ure1 #aeg ,face1 adaptation ( masks to1 #ba1 #eb1 #hd ,face-pieces = nitr\s oxide1 #ea ,false an/hesia1 #da ,f>adism ( motor n]ves 9 an/hesia1 #c ,fat pati5ts1 #aeh1 #afe ,fatty *anges aft] an/hesia1 #aec ,fe>1 effects (1 #i prev5tion (1 #aa1 #dc1 #hh ,feeble pati5ts1 #afh ,f]guson1 ,dr41 ,w4 ,j41 #hg ,f+]s1 regional an/hesia =1 #ahd ,flame1 op51 dang]s (1 #gd1 #ajd ,=ceps1 tongue1 #bd ,food be=e an/hesia1 #db ,=eign bodies 9 ! l>ynx1 #af ,freez+ analgesia1 #bja ,fright 7see ,fe>7 ,g ,gags1 #be ,g>dn]1 ,mr ,bellamy1 #bc1 #bd1 #hc ,gas & air1 #ed ,gas & e!r1 #ach ,gas & e?yl *loride1 #abh ,gas-oxyg51 #fj ,gasp+1 #dj ,g5ito-ur9>y op]ations1 #afh ,glossotilt1 #bd ,glottis1 spasm (1 #af1 #bj1 #bf1 #aje ,goitre1 an/hesia =1 #afj1 #ahe ,goitre1 exop?almic1 #i1 #afg ,grey & ,p>sons on %ock1 #f ,guy1 ,dr ,wm41 #abh ,guy-,ross1 gas oxyg5 me?od1 #aca ,gwa?mey1 w>m$ e!r vap\r1 #ij oil-e!r1 #ic ,h ,hmorrhage1 z a factor 9 %ock production1 #i obs]vation (1 by an/heti/1 x1 #cg ,hmorrhoids1 local an/hesia =1 #aia ,h>c\rt1 ,v]non1 #aad ,head & neck op]ations1 position =1 #aeh ,head & neck1 rais+1 #aeb l[]+1 #aaj1 #ade extra pill[ 9 deep *e/$ pati5ts1 #aeg ,he>t1 failure 9 asphyxia1 #ag obs]vation (1 #cg action ( e!r ^u1 #ge ( *lor(orm ^u1 #aaj ( e?yl *loride ^u1 #abb failure (1 9 second>y syncope1 #add ,he>t disease1 an/hetics 91 #afg ,h5d]son1 ,y&ell1 #aj1 #bi ,h]nia1 local an/hesia 91 #ahi ,h]o91 #dd ,hewitt1 ,sir ,fr$]ick1 #bb1 #ej1 #fb1 #ha1 #acg ,hill's direct l>yngoscope1 #ajd ,hill1 ,pr(4 ,leon>d1 #aaa1 #abj ,hornabrook1 #hg1 #abc ,hydro*loric acid1 z an impurity 9 *lor(orm1 #aji ,hypnotics1 #ab1 #db ,hypod]mic m$ication1 #ab1 #db ,i ,impurities ( an/hetics1 #gd1 #aji1 #abb ,infiltration analgesia1 #age ,inhal]s1 ,clov]1 #gh ,cl>ke1 #fh ,guy1 #abh ,guy-,ross1 #acj ,hewitt1 #ej1 #fb1 #ha ,junk]'s1 #aae ,ormsby1 #ha ,pat]son1 #eh ,r5dle1 #ace ,inhibition1 vagal1 #aaa1 #adc ,inte/9al ob/ruction1 #ada1 #ahi ,intranasal surg]y1 #afj1 #aff1 #aib ,intratra*eal me?od1 #if ,kelly's in/rum5t =1 #ajj ,%ipway's1 #aja ,inv]sion1 ,leon>d ,hill's exp]im5ts ^u1 #aaj1 #aaa ,j ,jactitations1 #ec ,jaundice1 #aed ,jaws1 cl5*+ (1 #ae1 #bf fall+ back (1 #af op]ations ^u1 #aff managem5t (1 9 an/hesia1 #bc1 #he ,jo9ts1 an/hesia 9 dislocation (1 #afd ,junk]'s inhal]1 #aae ,k ,kidney1 position = op]ations ^u1 #afh ,kelly's intratra*eal in/rum5t1 #ajj ,l ,lab\r1 an/hesia 91 #dd1 #afi ,lane1 ,sir ,arbu?nott1 #ad ,l>yngeal /ridor1 #af1 #bj1 #bf1 #dj1 #afi ,levy1 ,goodman1 #aab1 #ade ,light an/hesia1 dang]s (1 9 *lor(orm1 #i1 #aab ,levy's views1 #aac ,light reflex1 #cb ,local an/hesia1 #agj et seq4 ,l[]+ ( head & %\ld]s1 #aaj1 #ade ,lumb> puncture1 site =1 #aif ,lungs1 v5tilation (1 by normal brea?+1 #if by intratra*eal me?od1 #ig ,lymphatism1 #adh ,m ,malcolm1 ,j4 ,d41 #i ,m>%all1 ,dr ,ge(frey1 #gj ,masks = *lor(orm1 #aaj = e!r1 #hb = p]halation me?od1 #bh ,massage ( he>t1 #adh ,me*anical asphyxia1 #ae ,meltz] & ,au]1 on intratra*eal me?od1 #if ,m5/ruation1 #afi ,micturition be=e nitr\s oxide1 #ea ,mixtures1 ,c4 ,e41 #hd1 #acd1 #acg ( nitr\s oxide & oxyg51 #fj ( nitr\s oxide & e?yl *loride1 #abh ,morph9e1 #ab1 #dc1 #aeb ,m\?1 brea?+ ?r\gh1 #bb ,m\?1 op]ations ^u1 #afe ,m\? props1 #bb ,mucus 9 air passages1 #dj ,musculo-spiral p>alysis1 #aeg ,muscles 9 an/hesia1 ix1 #c1 #ai1 #cd ,muscle tone1 #c1 #ai1 #ec ,n ,nasal brea?+1 #bc1 #aff ,naso-ph>yngeal cat>rh1 #aea ,nasal me?ods ( giv+ nitr\s oxide1 #eg ,nasal tube = ,junk]'s bottle1 #aai ,neck1 position (1 #bj relaxation ( muscles (1 #ba po/ure = op]ation ^u1 #aei tum\rs & inflammatory swell+s 91 #g1 #aff ,nephritis1 influ5ce (1 ^u *oice ( an/hetics1 #gg1 #afh ,n]v\s sy/em1 effects ( an/hetics ^u1 #b1 #ge ,n]ves1 p]iph]al1 unaffect$ by an/hetics1 #c ,n]ve block+1 #ab1 #agi ,night-cr[+1 #adh ,nitr\s oxide1 #df ) air1 #ed ) e!r1 #ach ) e?yl *loride1 #abh nasal1 #eg physiology (1 #df contra-indications to1 #ef ,nitr\s oxide & oxyg51 #h1 #ab1 #fj v>i\s sy/ems =1 #fg1 #gj1 #acj = use 9 major surg]y1 #gb ) e?yl *loride1 #aca ,o ,obesity1 #aeh1 #afe ,ob/ruction1 inte/9al1 #ada respiratory1 #ae1 #ada ,oil e!r1 ,gwa?mey's me?od (1 #ic ,oligmia 9 %ock1 #aj ,omnopon1 #dd ,op5 me?od1 def9ition (1 #bh *lor(orm1 #aag e!r1 #hc e?yl *loride1 #abc ,o',malley's te*nique = intra-nasal surg]y1 #afj ,ormsby's inhal]1 #ha1 #acg ,ov]-dosage1 #cf1 #aaj1 #add ) nitr\s oxide1 #ed ,oxyg51 r$uction 9 blood 9 an/hesia1 #bjf z a relief 9 asphyxia1 #bg to old pati5ts1 #afe ) nitr\s oxide 7see ,nitr\s ,oxide & ,oxyg57 ) nitr\s oxide & e?yl *loride1 #acj ,p ,p>alysis1 musculo-spiral1 #aeg ,patella reflex 9 an/hesia1 #c ,p]c5tages ( *lor(orm & e!r requir$ 9 an/hesia1 #f ( *lor(orm1 #aaa ( e!r1 #hf1 #ii1 #bja1 #bjd ,p]halation me?od1 def9ition (1 #bh e!r 7see op5 ,e!r7 ,ph5om5a ( an/hesia normal1 #cc abnormal1 #ch ( nitr\s oxide1 #eb ( e?yl *loride1 #abe ,p]ic>ditis z a cause ( dea? 9 an/hesia1 #afh ,phillip's artificial airway1 #bc1 #afj ,physics ( natural respiration1 #if ,physiology ( an/hetic drugs1 #a ( asphyxia1 #ag ( *lor(orm1 #aji ( e!r1 #ge ( e?yl *loride1 #abb ( nitr\s oxide1 #df ,ph?isis1 #afg ,pneumonia1 po/ an/hetic1 #aeg ,position 9 an/hesia1 #aeg ,positive pressure 9 nitr\s oxide1 #eb 9 nitr\s oxide & oxyg51 #ff ,po/-*lor(orm poison+1 #aec ,po/ an/hetic complications1 #aej ,pregnancy1 an/hesia 91 #afi ,prelim9>y hypod]mic m$ication1 #aa1 #dc1 #aeb ,prep>ation ( pati5t1 #db ,prim>y syncope1 #aaj1 #adc ,protection f %ock by g5]al an/hetics1 #h ,pulse1 rate 9 %ock1 #f cl9ical obs]vation (1 #cg ,pupil1 light reflex (1 #cb size (1 #ce 9 asphyxia1 #ag ,purg+ be=e an/hetics1 #dj ,q ,qu99e & urea hydro*loride1 #agd ,r ,rebrea?+ me?od1 #ah 9 nitr\s oxide1 #fh ,rectal adm9i/ration ( e!r1 #ic ,rectal sal9e1 #db ,reflexes z a cause ( %ock1 #d1 #f ord] ( disappe>ance (1 #c ,reflex1 conjunctival1 #ca1 #ce corneal1 #cb1 #ce light1 #cb1 #ce patella1 #c sk91 #cg ,reflex syncope1 #h1 #aab1 #ade ,regional an/hesia1 #agi ,r5al disease1 #afc ,r5dle's cone1 #ace ,repeat$ adm9i/rations1 #fj1 #aef ,respiration1 arre/ (1 #adb artificial1 #adf bl[+1 #cd1 #hi cr[+1 #af depress$1 #ci1 #dc effect ( morphia & *lor(orm ^u1 #dc1 #hf normal1 #cd ob/ruct$1 #ae1 #ada1 #aff ,respiration1 physics ( natural1 #if reflex arre/ (1 #ci ,respiratory abnormalities1 m9or1 #ci major1 #ada ,respiratory sy/em1 effects ( e!r ^u1 #gf aft]-effects ( an/hetics ^u1 #aej ,rigidity ( muscles 9 asphyxia1 #ai1 #ch1 #ci 9 second /age1 #cc ,s ,sal9e injections1 p] rectus1 #db subcutane\s1 #ad ,s*immelbus*'s mask1 #bh1 #aaf ,scopolam9e1 #dd1 #ajc ,second>y syncope1 #ag1 #ach1 #adc ,secretion ( mucus1 #dj1 #gf ( ur9e1 #afh ,s$atives1 #ab1 #db ,selection ( an/hetic1 #afb ,semi-op5 me?od1 #bh ,septic cases1 #i1 #fj1 #aef1 #afh ,sequel ( an/hesia1 #ajj ,sex1 relation to an/hesia1 #afe ,%ipway1 ,dr1 #ia1 #aja ,%ock1 #e diff]5ce betwe5 syncope &1 #adb ,%ort1 ,mr ,r5dle1 #aed ,sickness 7see ,vomit+7 ,sigh+1 #dj ,sight-fe$ ma*9es = gas-oxyg51 #gj ,signs ( an/hesia1 #cf1 #ec1 #fe ,silk1 ,dr ,j4 ,w41 #bc1 #hg ,s+le dose an/hetics1 #cj1 #afc ,sitt+ po/ure1 #ba1 #aeh ,sl[ respiration1 #ci ,spasm1 muscul>1 #ai ( jaw muscles1 #ae ( l>ynx1 #af1 #bf1 #afi ,specific gravity ( *lor(orm1 #aji ( e!r1 #gd ,sp9al an/hesia1 #aic ,/ages ( an/hesia1 #ca ,/>vation1 a cause ( %ock1 #i ( acidosis1 #aee ,/atus lymphaticus1 #adh ,/]tor1 #dj1 #ec ,/imuli f field ( op]ations1 #f ,/oma* tube1 be=e op]ation1 #ada ,/ova9e1 #agc ,/ridor1 #af1 #bf1 #dj ,/ruggl+1 #cd ,/ry*n9e1 #adg ,subcutane\s sal9e1 #ad ,swall[+1 movem5ts (1 #cc ,sylve/]'s me?od ( artificial respiration1 #adf ,syncope1 #adb ,syr+e = local an/hesia1 #agf = sp9al an/hesia1 #agf ,t ,tee?1 dang] ( dropp+ ( into l>ynx1 #af extraction (1 #ed1 #eg1 #abh1 #aca1 #afc ,tet]1 ,dr41 on nitr\s oxide & oxyg51 #fh ,?omson1 ,pr(4 ,alexis1 #ab1 #aeh ,?omson1 ,torrance1 on intratra*eal an/hesia1 #if ,?oracic op]ations1 local an/hesia 91 #ahf ,?ree-way tap = nitr\s oxide1 #ej1 #abh ,?yroid gl&1 see ,goitre ,"t = op]ations1 #db ,"t af=d$ by s+le dose an/hetics1 #afc ,tongue fall+ back (1 #af =ceps =1 #bd op]ations ^u1 #ig1 #aah1 #aff local an/hesia =1 #aia ,tonsils & ad5oids1 #abg1 #aff ,tra*ea1 mucus 91 #dj pressure ^u1 #ag ,tra*etomy1 #adb1 #ahe ,tremor1 e!r1 #ch ,tr5del5b]g po/ure1 #aeh ,tropacoca9e1 #agc ,turn]1 ,dr ,logan1 #abe ,u ,ur9e1 secretion ( prev5t$ by morphia1 #afh ,v ,vagus n]ve1 #aaj1 #ade ,valv$ me?od1 features (1 #bi ,vap\r me?od1 e!r1 #ij e?yl *loride1 #abe ,vaso-motor sy/em1 9 %ock1 #i 9 asphyxia1 #ag 9 nitr\s oxide1 #df 7& see ,physiology7 ,ve9s1 l>ge1 empty+ into he>t1 #aj engorgem5t (1 #bj1 #aea ,v5esection 9 syncope1 #adg ,v]onal1 #ab ,vici\s circle ( asphyxia1 #bj ,vital m$ull>y c5tres1 #c ,vomit+1 #adj1 #aeb imp5d+1 #ci1 #ada ,w ,w>1 anti-%ock1 measures 91 #aa lessons (1 #fa1 #aea ,w>m+ an/hetic vap\rs1 #fb1 #ij1 #aja ,w$ge = op5+ cl5*$ jaws1 #be ,)drawal ( an/hetic1 = /ridor1 #bf = brea? hold+ & /ruggl+1 #cd = syncope1 #ade ,,footnotes3 #a ,?is c be done to a v limit$ ext5t inde$ if ! ord9>y valves "h describ$ are us$4 ,see page #fh4 #b ,a safegu>d provid$ on "s ma*9es is a side lead f ! oxyg5 supply direct to ! facepiece :]eby pure oxyg5 c be giv5 if requir$4 #c ,! am\nt ( oxyg5 9 a cyl9d] is designat$ 9 t]ms ( cubic feet4 ,a cyl9d] :i* w\ld hold #ajj gallons ( ,n#b,o1 w conta9 #cj cubic feet ( oxyg54 #d ,9 ! figure ! ,clov] is %[n ) gas valves & #b-;gallon bag1 arrang$ = 8gas & e!r40 #e ,trans4 xvii4 ,int]nat4 ,m$4 ,cong4 ,sub-sect4 7vii47 ,"p i4 #f ,j\rnal ,am]4 ,m$4 ,assoc41 ,sept4 #aiac4 #g ,trans4 xvii41 ,int]nat4 ,m$4 ,cong4 ,sub-sec4 7vii471 ,"p i4 #h ,trans4 xvii41 ,int]nat4 ,m$4 ,cong41 ,sub-sec4 7vii471 ,"p ii4 #i ,trans4 xvii41 ,int]nat4 ,m$4 ,cong41 ,sub-sec4 7vii471 ,"p ,i4 #aj ,! /ud5t %\ld be c>eful to be sure t ! bulb is atta*$ to ! inlet pipe3 if by accid5t x be slipp$ on to ! outlet pipe1 ! fir/ compression ( ! bulb w eject a /ream ( liquid *lor(orm f ! in/rum5t4 #aa ,! au?or describ$ ?is me?od 9 a pap] read be=e ! ,scotti% ,bran* ( ! ,briti% ,d5tal ,association1 & aft]w>ds publi%$ 9 ! ,j\rnal ( ! ,association "u ! title 8,! ,ed9burgh ,sy/em ( ,d5tal ,an/hesia40 ,to ! use ( ?is t]m ,dr ,j4 ,h4 ,gibbs1 ( ,ed9burgh1 took /rong exception 9 a lett] to ! ,editor ( ! ,j\rnal4 ,! au?or has & _h no desire to convey ! impression t ?is sy/em 0 univ]sally us$ 9 ,ed9burgh1 b simply t x is ! me?od taught by ,dr ,guy1 ,dean ( ! ,s*ool1 to ! /ud5ts 9 ! ,extraction ,room4 ,transcrib]'s ,notes3 #a4 ,obvi\s pr9t]s'1 punctuation & spell+ errors h be5 correct$ sil5tly4 #b4 ,:]e hyph5ation is 9 d\bt1 x has be5 reta9$ z 9 ! orig9al4 #c4 ,"s hyph5at$ & non-hyph5at$ v]sions ( ! same words h be5 reta9$ z 9 ! orig9al4 #d4 ,sup]scripts are repres5t$ us+ ! c>et "*1 e4g4 ,dr4 or ,xxx4 #e4 ,italics are %[n z xxx4 #f4 ,bold pr9t is %[n z xxx4