ANESTHESIA.
Particularly in women are we liable to error in this respect. Slight, tenderly nurtured women often readily bear the most painful operations without the slightest complaint, while robust and courageous-looking women react greatly on the least manipulation. Here two factors are always to be taken into account: the individual sensibility, which causes the patient to shrink against her will, and the influence of psychical causes. We frequently meet women who will bear with great courage long-continued and intense labor pains, and yet will cry out against slightly painful procedures. Thanks to Jackson's discovery, pain is lost at operations, and the indications for operation have been essen tially widened, and in gynecology it is often not a question of vital indi cations, but only of operations which are undertaken to allay-greater or less complaints.
Whenever possible we take care to make our procedures as painless as possible. The effect of great pain, indeed of the fear of pain, on the nervous system, may be followed by the most serious results, and if the use of chloroform were absolutely free from danger, then would it be re sorted to much more frequently. Since, however, narcosis very excep tionally ends fatally, besides being accompanied by a number of un pleasant effects, it should only be used under strict indication.
In general the indication for anesthesia lies in any procedure, opera tive or diagnostic, which is so painful or unpleasant as to offset the disa greeable effects and the dangers of narcosis. Such are the majority of injuries of the external genitals, and also examination in the presence of ulcers, fissures, persistent or contracted hymen, vaginismus. The vagina is generally but little sensitive, still the majority of plastic operations should be performed under anesthesia. In the majority of women the cervix is scarcely at all sensitive, and in the absence of inflammatory af fections it may be cut or cauterized without the slightest evidence of pain. In case of marked prolapse of the uterus, however, where the cer vix or its canal are operated upon, the pain involved is nearly always great. Anesthetics should also be used when we desire to cause relaxa
tion of the abdominal muscles for the purpose of palpation, in the exam ination by the rectum or urethra, in case of spasmodic stricture of the various orifices, in the reposition of displaced organs. General hyperes thesis of high degree necessitates anesthesia, and in case of very nervous women we can rarely accomplish much without chloroform.
We occasionally meet patients who are afraid of chloroform, but these are in the great minority, and frequently the mere thought that the oper ation will be rendered painless will influence in favor of it.
The same contra-indications to anesthesia exist in gynecology as in general surgery. Great weakness of the heart, as after profuse hemor rhage, fatty degeneration and acute diseases of the organ, are contra indications, as also diseases of the lungs, which interfere with the respira tory act, strums, many brain and arterial diseases. Otherwise anesthetics may be administered for operation and in nearly any position of the body, even in the knee-chest when we use a proper fixation apparatus, like that of Bozeman, for the patient.
Anesthesia should never be induced in the absence of a competent assistant, who should be supplied with the articles which might be needed in an emergency, such as tongue depressor, laryngeal catheter, medicinal restoratives. It is well also to have an induction battery at hand.
Of the large number of anesthetic means, only a very few are in gen eral use: chloroform, sulphuric ether, which latter is growing iu favor. Simpson, and Megar and Kaltenbach, advocated chlormethyl because it has no depressing effect on the heart; Ileckermann used bromethyl.
Chloroform (purified) is either used alone, or mixed with ether, and absolute alcohol. I am in the habit of using Billroth's mixture, three parts chloroform, and one part each ether and alcohol.