Reprint from Medical Century, January 15, 1894. NITROUS OXIDE ANESTHESIA. A FURTHER CONTRIBUTION TO THE SUBJECT OF NITROUS OXIDE IN GENERAL SURGERY. BY T. L. MACDONALD, M.D., WASHINGTON, D. C. PROF. SURGERY SOUTHERN HOMEOPATHIC MEDICAL COLLEGE, BALTIMORE. CHICAGO: MEDICAL CENTURY COMPANY 31 Washington Street. Reprint from Medical Century, January 15, 1894. NITROUS OXIDE ANESTHESIA. A FURTHER CONTRIBUTION TO THE SUBJECT OF NITROUS OXIDE IN GENERAL SURGERY. BY T. L. WASHINGTON, D. C. PROF. SURGERY SOUTHERN HOMEOPATHIC MEDICAL COLLEGE, BALTIMORE. CHICAGO: MEDICAL CENTURY COMPANY 31 Washington Street. NITROUS OXIDE ANESTHESIA. The continued use ot gas in general surgery, and a number of letters requesting answers to questions relating to this subject, are responsible for this article. I may be wrong about it, but since I have been using nitrous oxide I have a growing conviction that our anesthetics, as we usually employ them, have much to answer for in the production of surgical shock. This convic- tion is based entirely upon negative observations. 1 mean by that, the noticeable absence of shock after the use of gas. How frequently we carry our patients from the operating table to the bed, clammy and cold, or even reeking with perspira- tion and with a subnormal temperature, after the administration of ether or chloroform. Then to this is grafted the deathly nausea and vomiting which may continue for hours. Now I have thought that everyone of these undesirable symp- to the anesthetic and not to the clean, operative incision. Why, then, is it not rea- sonable to charge the anesthetic with, at least, the greater portion of the shock? What surgeon believes that such an incision and the usual mani> -testations that accompany it would produce symptoms with such frequency if it could be per- formed without an anesthetic? Whenever it is feasible do we not prefer to amputate or open an abdomen or a chest without a general anesthetic? The most tragic surgical scenes that I have ever witnessed were associated with thoracotomies, under ether or chloroform. As a result of this I have found (like many others, I presume) that I can cut my way freely into thy thorax without 4 shock. In this class of cases it is not the incision, etc., that produces the cold perspiration, the nau- sea and vomiting, and particularly the subnormal temperature. It is the anesthetic; and this propo- sition is strengthened by the fact that the above group of symptoms scarcely ever occur when the operation is performed without a general anes- thetic. General anesthesia produces shock by interfering with the physiological metabolism (Nicaise, Porter), the products of which not only beget a certain amount of toxemia but, at the same time, seem to clog the wheels of the excretive apparatus. The great degree of freedom from shock after the use of nitrous oxide makes that which accompanies the other anesthetics stand out the more prominently. In a recent report of sixty-five operated cases aged seventy years or more, ten died from shock and uremia. These were not all capital operations, either. One death resulted from so simple an operation as slitting up a fistula in ano. I cannot but believe that many of these deaths were due to the drug action of the anesthetics. Ten deaths from that number of aged patients is not such a bad record, but ten deaths from shock and uremia alone is far from what it should be. Of course others died from other causes. I have tried gas in patients of advanced age and cite a few illustrative cases. Mrs. S., aged seventy (apparently eighty), suf- fering from a carcinoma of the vagina. It was extirpated and the denuded area covered by sliding a flap from the left labium. Time, forty minutes. No nausea, vomiting or shock. Mrs. C., aged seventy-two, quite feeble. She had a distinct aortic regurgitation, marked ascites from multiple cysts of the ovaries and broad ligaments (which, by the way, had been pro- 5 nounced cured by a Christian scientist). The gas controlled her perfectly. The cysts were all removed except one, which was evacuated and stitched to the abdominal incision. Although she became somewhat weak after the sudden evacua- tion of the ascitic fluid the pulse and respirations were good when she was placed in bed. No nausea or vomiting. Mrs. F., aged seventy-three, thigh amputation No nausea or vomiting and scarcely a perceptible sign of shock. To such patients as these I give gas with a confidence that I never experienced be- fore. In all honesty, I expect to have some cases of shock after operations under gas anesthesia, but I have not seen any thus far. If one wishes to note the difference in the anes- thetics there is no better way than to give gas to some and ether to others during the same clinic. Then when all have been operated on, visit them in their rooms and wards. I was never so forcibly struck with the contrast as when I tried this. The post-operative condition of the gas patients is pleasant to perceive. The intellect is perfectly clear, the eye is bright, skin natural, pulse scarcely changed-in short they appear as though nothing had happened. Then compare this to the semi- stupor of the ether patient, the frigid and clammy skin, the ether-laden breath, the nausea, retching and vomiting and it is notorious that these latter symptoms have often frustrated the most skillful operative procedures. Although Porter claims that ether and chloro- form act merely by excluding the atmospheric air I cannot get away from the idea that the tis- sues are chemically damaged. Not only for hours but sometimes for two days the breath is still offensive with the fumes of ether, and during this time the patients are generally miserable. 6 Uremia is another complication which I think would be largely obviated by substituting gas for ether. Many a brilliant major operation has been followed by death, in a few days, from uremia. These are matters of deep regret to the surgeon, especially when the patient is pursuing an other- wise uncomplicated course. Freedom from respiratory irritation is another of the advantages in the use of nitrous oxide. I have, so far, seen no coughing or bronchial or laryngeal irritation resulting from its use. If it had no merit except that of saving time for the surgeon it should be thoroughly tested. One minute is usually sufficient to anesthetize a patient profoundly and they generally recover conscious- ness quite as quickly, occasionally ip less time. "In these most brisk and giddy paced times" the above fact is by no means an unimportant item. Another feature peculiar to gas is that the de- gree of anesthesia is out of proportion to the degree of unconsciousness. Sensation may be complely abolished and still cerebration be pos- sible. Patients have repeated to me remarks that have passed between myself and assistants, but were quite oblivious to pain. I believe this is one thing that reassures us, for (in a general way) we naturally feel that, despite anesthesia, the distance the patient has traversed from the basis of safety is usually in proportion to the degree of uncon- sciousness. In beginning my study of this subject I was anesthetized several times and fancied I knew all that was going on, but it must have been fancy, for when consciousness returned I could not form- ulate even the delusions that had passed through my brain. And so I frequently find patients who think they know all that was passing, and yet upon close questioning it is found that they know 7 little or nothing of what occurred. I can readily see how these startling medico-legal cases resulted from the administration of gas. Dentists have observed that a patient may be completely anesthetized without complete loss of muscular tone. I have remarked, and so have my assistants, that the patients are controlled much better after the first five minutes. I have been asked what class of cases I con- sidered the most suitable for gas. To this I would reply: bone surgery in adults. This is not from reasoning, but because in these cases it has given me perfect results. On account of the freedom from nausea and vomiting, it should be the ideal anesthetic in abdominal surgery. It ought to work equally well in bladder surgery. I still regard the matter somewhat from the position of the experimentalist and let the expe- rience and observations stand for what they are worth. Before closing it is but just to admit that nitrous oxide possesses two disadvantages; it is more expensive and less convenient than our ordinary anesthetics.