J. Herbert Simpson
1885 The Lancet  
SIR,-The following is, I think, a good instance of the value of cocaine in small operations:-Miss B--, whose breast 1 removed for scirrhus in February, 1884, found a week ago that two small nodules of the disease, each about the size of a pea, very hard and painful, had appeared near the cicatrix of the operation wound. The nodules were about three inches apart. On January 23rd I injected three minims of a 4 per cent. solution of the hydro chlorate of cocaine on either side of one nodule; and,
more » ... f one nodule; and, finding that after waiting ten minutes there was no pain on pinching the part, I cut down and removed the nodule, having to make an incision an inch and a half long. The patient felt absolutely nothing of the operation until 1 inserted the sutures, and that, she said, was hardly to be called pain. After closing the wound I injected another three minims near the second nodule, and operated in the same way; and although a little pain was felt, owing, I believe, to my not having waited sufficiently long for the third injection to take effect, it was very trifling ; and from beginning to end this operation under cocaine was a decided success. There were no after-effects from the drug, and both wounds are healing by first intention. I am, Sir, faithfully yours, Hutchinson. From a careful perusal of the same I have come to the conclusion that ether should not be blamed for the unhappy termination in the case. The post-mortem examination, independent of the anaesthetic used, revealed causes quite sufficient to produce death-viz., " The lungs were found emphysematous and congested. There was bronchitis, with a quantity of mucus in the tubes. The lower lobes did not contain much air. At the upper part there was more oedema. Trachea congested, containing frothy secretion. Heart flaccid, right ventricle and auricle occupied by soft coagulum; great increase of fat on surface of the same, and very little muscular tissue." Mr. Hutchinson states that Dr. Turner, who made the autopsy, considered that death had been brought about by fatty heart combined with bronchitis and emphysema; an opinion with which I cordially agree. What I now wish to state is what I have stated repeatedly, and that is that all anaesthetics are dangerous, and will induce death if pushed too far ; but of all anaesthetics I believe ether, properly and judiciously administered, is the safest, for it will never produce syncope or failure of the heart's action, no matter how much is given. It will produce asphyxia, or failure of respiratory action; but, as this is a very slow process compared to the former, timely warning is given to the anaesthetist to anticipate and prevent any untoward result, whereas syncope comes on and ends with such rapidity that there is no time for remedies. I also maintain that when bronchitis or pleuro-pneumonia is present to any great extent, ether or any anassthetic is dangerous to use, and should not be administered. In the administration of such agents I would suggest-1. That all anaesthetists should understand the properties and dangerous effects of each anaesthetic administered. 2. That all administrators should be qualified physicians or surgeons, and that they should carefully and thoroughly understand the process and degrees of anæsthesia before undertaking the very grave duty and responsibility of placing a human being into the mysterious sleep of insensibility. 3. That previous to any anesthetic being administered, a careful and thorough examination of the thoracic cavity and its contents should be made, so as to detect, before it is too late, bronchitis or other pulmonary affection, as well as the condition of the heart. 4. That the administration of ether or any other anaesthetic should not be prolonged beyond the actual time required for the perform-ance of the surgical operation. This I think it right to mention, as in a recent visit to some London hospitals I observed that the administration of ether with my inhaler was continued long after, in my opinion, there was any necessity for its use. After the main steps of an operation are over, anaesthesia, in the majority of cases, need not be continued. 5. At the slightest approach of danger, such as lividity and pallor of the face, stertorous breathing, cessation of the respiratory action or pulse, the anaesthetic should be at once discontinued, and fresh air given to the patient; and even when he has come round, the anaesthetic should not be there and then again administered, even should it be necessary to postpone the operation. The continuance of an anaesthetic after such warning symptoms can only lead to the most unfavourable consequences. 6. That the person deputed to administer the anaesthetic should devote his entire attention to the anæsthesia of the patient and to nothing else. lIe should not attempt to look about him or observe the progress of the operation. When mishaps have occurred they have frequently been due to inattention on the part of the anæsthetist. A competent and careful anaesthetist is, in my opinion, as important, and vested with as much responsibility during an operation, as the operator himself. I am, Sir, yours
doi:10.1016/s0140-6736(01)82690-8 fatcat:frwt2bl52nc3xfzdnac4h2afae