Licence: Public Domain Mark
Credit: Surgery / by John Allan Wyeth. Source: Wellcome Collection.
Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.
39/832 (page 27)
![Individuals who are naturally nervous and overexcitable, and children who are unable to control themselves^ are not suitable subjects for cocaine surgery. In all instances where a prolonged operation is undertaken under cocaine anses- thesia, a hypodermic of ^ of a grain of morphia is advised five or ten minutes before the infiltration is given. Morphia is not only an antidote to cocaine poisoning, but tends to allay anxiety. For the first injection into the skin a very delicate needle should be used. This should be shown to the patient, with the statement that there will be no pain beyond the initial prick of the needle, for it is very important, in order to retain the con- fidence of the subject throughout the operation, to minimize even the small pain of the initial puncture. In a timid and overexcitable subject, so important is it that implicit confidence be won at the very threshold of the operation, it is a wise precaution to deaden sensation of the initial morphia and cocaine punctures by applying a spray of ether from the Eichardson atomizer, or by holding a piece of ' ice to the skin for a few minutes. The hypodermic needle should be entered almost parallel with the surface of the skin to be anaesthetized, the point and shaft being scarcely hcncatli. the epidermis, for here the end organs of the sensory nerves are most successfully paralyzed with the minimum of sohition. When pressure is made upon the piston and three or four minims have been forced out, the skin is slightly distended, becomes pale, and is anajsthetized. It should then be further introduced to its full length, and more solution injected. It should now be withdrawn, a larger needle quickly substituted, and inserted through the edge of the anaesthetized area, and in the track of the ]iroposed incision. This should be repeated ad finem. The underlying fat in the field of operation should then be thoroughly infiltrated with the weaker 1-1000 solution heforc the shin is incised. Should a sensitive area be encountered, as when a blood vessel or nerve trunk comes in the line of dissection, one or two minims of the stock solution should be injected into or immediately about the nerve. When operating wpon the extremities it may, in certain conditions, be advisable to produce blood stasis by the use of the rubber tournicfuet. When this is done, the cocaine solution remains for the time being stagnant, and in actual contact with the sensory end organs. When the operation is finished, and when a consid- erable quantity has been used, it is a wise precaution not to remove the tourniquet and allow all the solution to be carried too rapidly and in too large volume into the general circulation. This can be avoided by loosening the tourniquet for about ten seconds, tiglitening it again for a minute, and repeating this through.five or ten minutes, thus giving an opportunity for the gradual distribution and elimina- tion of the cocaine. Cocaine infiltration, either free or in stasis, when properly done, does not inter- fere with the process of repair in the field of operation. Any variation from the technic above described will be given in connection with the operations in which the change may be deemed advisable. As heretofore stated, with these cocaine solutions properly employed, operations of the magnitude of thyroidectomy may be satisfactorily done. The Kochers of Berne have performed nearly two thousand thyroidectomies with no other anses- thetization than cocaine infiltration. All operations upon bone can be done with perfect insensibility after cocaine anassthesia, provided the periosteum is thoroughly infiltrated. All the abdominal viscera are entirely insensible to pain, and unless the mesentery be dragged upon, all explorations and extensive operations may be done with cocaine antesthesia. provided the peritonseum of the abdominal wall, which is exquisitely sensitive, be thoroughly anaesthetized. Qiiinia and Urea Hydrochloride has been demonstrated by Dr. H. Thibault, of Arkansas, to be a local anaesthetic of great value. Injected into and beneath the skin in the same way as advised for cocaine infiltration (a two-per-cent solution for the endermic and one-per-cent for the hypodermic injection), it rapidly produces analgesia, the anaesthetic effect lasting longer than that of cocaine. Ten grains dissolved in one ounce of normal salt is approximately a two-per-cent solution. It may be rendered entirely sterile by boiling just before using, and so far, in the large number of cases in which it has been successfully employed, no constitutional](https://iiif.wellcomecollection.org/image/b21203647_0039.jp2/full/800%2C/0/default.jpg)
