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Anesthesia for the surgery of gastric cancer
ANESTHESIA FOR THE SURGERY OF GASTRIC CANCER* JAMES CIinicaI Professor
T.
GWATHMEY,
of OraI Surgery, New York University NEW
YORK,
T
HE agent and method for anesthesia in surgery of gastric cancer shouId be selected so that the effects of the agent or method may be excluded from the fina resuJts of the operation. Preliminary medication is of extreme importance and is but IittIe understood by surgeons generaIIy. It prevents psychic shock, increases the margin of safety, and according to anima1 experiments may prevent postoperative pathoIogic Iesions or a Iung in the lungs, i.e., pneumonia abscess. This has been proved very definiteIy in the laboratory. George BarcIay WaIIacet using 6 per cent ether in normaI saIine intravenousIy, proved that anesthesia is produced more quickIy, Iess ether is used, and the margin between compIete anesthesia and respiratory faiIure is widened, thus making anesthesia a safer procedure. The folIowing is a protoco1 of the experiment:
WITH PRELIMINARY MEDICATION Sept. 7, 191 j. 2:50 P.Xl. 0.5 cc. of 2 per cent morphine soIution. 3:10 6.05 cc. paraldehyde and 13.0 grams potassium bromide. Started intravenous ether adminis3:59 tration. 4:ors:i Complete anesthesia, using 87 cc. ether soIution. 4:095,; Respiratory faiIure, required 245 CC. more ether solution. University
and
BelIevue
* Read at a Round Table Conference
HospitaI
N. Y.
In both experiments the dog received exactIy the same amount of morphine sufficient to make it easy to handIe him. So this factor can be excIuded. It wiI1 be noted that without preIiminary medication I 34 C.C. of ether soIution was used to produce compIete anesthesia whiIe onIy 87 C.C. was necessary with preIiminary medication. Respiratory faiIure required onIy 99 cc. of ether when pre1iminar.y medication was not empIoyed,- as against 244 cc. of ether with DreIiminarv medication. showing that the a;imaI which had received preIiminary medication was safer and in better condition than the one which was not preIiminariIy medicated. The foregoing statement is a paradox. Some surgeons and anesthetists think that a patient’s safety is jeopardized by preIiminary medication. These experiments were fuIIy verified some years Iater by Charles W. Hooper and myseIf. The foIIowing resuIts represent a year’s work in which approximateIy 500 animaIs were empIoyed to determine the vaIue of preliminary medication in inhaIation anesthesia. This Iaboratory data verifies the results in cIinica1 experiments, i.e., that proper preliminary medication is equally as important as the termina1 anesthetic agent. The agents used were nitrous oxide, acetyIene, ethylene, propylene, and ether. Four animals were empIoyed for each experiment; two were given so much preIiminary medication that they did not move ten minutes Iater when pIaced in the gas chamber with the controls. AI1 were given the same anesthetic under preciseIy simiIar conditions. The controIs jumped around and struggIed against the anesthetic Y
DOG No. 20. WEIGHT 13 KILO 1vITHOCT PRELIMINARY MEDICATIOPG June 15. 1915. 10:30 A.\I. 0.5 cc. of z per cent morphine solution. Started intravenous ether adminisI I :34 tration. I I :38Li Complete anesthesia, using 134 cc. ether solution. I I ~42 Respiratory failure; required onIy 99 cc. more ether solution.
1 New York MedicaI CoIIege.
M.D.
on Cancer at the Fiftieth Anniversary 1934. 237
of the MemoriaI Hospital,
May 25,
238
A m&can
Journal of surgery
Gwathmey-Gastric
and died within eight to ten minutes; the animaIs which received the preIiminary medication feII asIeep with no excitement
Surgery
Anesthesia
FEBRUARY, 1936
was not unusua1 to find a partiaI ateIectasis and often massive ateIectasis invoIving one or more Iobes. The heart, kidneys and
Nitrous oxid g3 per cent, oxygen 7 per cent. FIG. I. No preIiminary medication. Air spaces filIed FIG. 2. Preliminary medication. Air spaces and bronchi with edematous fluid; perivascular edema; conclear; no perivascular edema or congestion. gestion.
Ether vapor 34 per cent, oxygen 66 per cent. FIG. 4. PreIiminary medication. FIG. 3. No preliminary medication. Massive ateIectasis normaI. and congestion; air spaces obliterated.
Lung tissue relatively
The work of CharIes W. Hooper, assisted by the author. From Autochrome photomicrographs in Nelson’s Looseleaf Surgery, Vol. I, page 514.
stage and survived the ether twenty to After the animals twenty-five minutes. were kiIIed they were immediateIy necropsied. Lung Iesions grossIy showing distension, edema and congestion were found in the animaIs that had not received preIiminary medication. In ether anesthesia it
Iiver showed no gross Iesions and they were not examined microscopicaIIy. MicroscopicaIIy the Iesions showed perivascuIar edema, diffused petechiae, aIveoIar spaces fiIIed with ffuid and bronchi containing edematous fluid. (Figs. I through 4.) On the other
hand,
the Iungs of the animaIs that
NEWsE~lEsvoL.XXXI,NO.2 Gwathmey-Gastric received preIiminary medication were reIativeIy normaI. Thousands of individuaIs anesthetised without preIiminary medication, have made uneventfu1 recoveries : however, the facts here presented may possibIy expIain certain fataIities which have hitherto been either unsoIved or charged to other causes. I refer especiaIIy to postoperative pneumonias. The preferred anesthesia for humans is the one which combines within itseIf both the preIiminary and termina1 anesthetic. Such an agent and method is oiI-ethercoIonic anesthesia. The patient is put to sIeep in his own bed; puIse and respiration remain more nearIy norma than with any inhaIation method. The recovery is in an analgesic state and without nausea and vomiting. The anesthesia is under compIete contro1 from start to finish, as in any inhaIation anesthesia, i.e., it is reversibIe and controIIabIe. The Iate CharIes BaskerviIIe,” in thousands of experiments in the Iaboratory, proved that whiIe ether boiIs at 34.6 degrees c., it does not escape vioIentIy from an oil-ether mixture (as does ethy1 chIoride-J. T. G.) when the mixture is heated higher, nameIy, to body temperature of 37 degrees c. The rate of separation of ether from the oiI quickIy acquires a definite and fairIy fixed speed. The significance of this conduct cannot fai1 to be of great importance, for by this means the proper content of ether may be maintained in the bIood to produce any desired physioIogica1 effect that has a quantitative reIation thereto, for exampIe the third or surgica1 state of anesthesia. If ether separated irreguIarIy from oi1, producing a deep anesthesia at one time and a light anesthesia at another, it wouId be a very unsafe procedure, but the amount of evaporation per minute never varies. The anesthesia is automaticaIIy maintained by certain inffexibIe physica Iaws of which the even evaporization is the principIe. The ether is practicaIIy outside the body when pIaced in the coIon, as no physioIogi* Professor and Director of the ChemicaI Laboratories of the CoIIege of the City of New York.
Surgery
Anesthesia
A mericanJournal of Surgery 239
ca1 effect occurs unti1 the ether evaporates from the oi1 and is absorbed by the bIood. This occurs at the rate of 1.25 dram every five minutes. The frigid condition in the coIon caused by evaporation of the ether from the oi1 cooIs the mixture and coIon and retards the evaporation. This process continues automaticaIIy unti1 a11 the ether has Ieft the oi1. When ether is taken up by the smaI1 bIood vesseIs surrounding the coIon, it is carried through the Iiver by the greater circuIation and on to the heart. From there it is pumped into the Iungs. By this time it is moistened and thoroughly warmed to the body temperature, so that there is no irritation to the Iungs. No pneumonias have been reported with this form of anesthesia. The coIor of the face suggests thorough oxidation at a11 times. The physiologica baIance between the puIse and respiration is never disturbed, as is usua1 with inhaIation anesthesia. Laboratory experiments in the Department of HeaIth of New York City by Dr. WiIIiam H. Park show that the baciIIus coIi is kiIIed within two and a haIf minutes exposure of oil-ether. In cancer surgery, where anatomica knowIedge and patience are at a premium, in order to obIiterate compIeteIy a11 traces of the disease, with this method of anesthesia the surgeon can more nearIy approximate the idea1 and disregard the eIement of time. It is especiaIIy appropriate for gastric cancer. SUMMARY
Ether-oi1 with preIiminary medication is the anesthesia of choice for the folIowing reasons :(I) Psychic impuIses are removed. (2) Patient is ready for operation without undue Ioss of time. (3) Postoperative awakening is in a state of anaIgesia and without pain. (4) Nausea and vomiting are ehminated. (5) Leisure for carefu1 surgica1 dissection is permitted without added discomfort or danger to the patient. (6) Ether-oil anesthesia is safer than inhaIation anesthesia.
T.
GWATHMEY,
of OraI Surgery, New York University NEW
YORK,
T
HE agent and method for anesthesia in surgery of gastric cancer shouId be selected so that the effects of the agent or method may be excluded from the fina resuJts of the operation. Preliminary medication is of extreme importance and is but IittIe understood by surgeons generaIIy. It prevents psychic shock, increases the margin of safety, and according to anima1 experiments may prevent postoperative pathoIogic Iesions or a Iung in the lungs, i.e., pneumonia abscess. This has been proved very definiteIy in the laboratory. George BarcIay WaIIacet using 6 per cent ether in normaI saIine intravenousIy, proved that anesthesia is produced more quickIy, Iess ether is used, and the margin between compIete anesthesia and respiratory faiIure is widened, thus making anesthesia a safer procedure. The folIowing is a protoco1 of the experiment:
WITH PRELIMINARY MEDICATION Sept. 7, 191 j. 2:50 P.Xl. 0.5 cc. of 2 per cent morphine soIution. 3:10 6.05 cc. paraldehyde and 13.0 grams potassium bromide. Started intravenous ether adminis3:59 tration. 4:ors:i Complete anesthesia, using 87 cc. ether soIution. 4:095,; Respiratory faiIure, required 245 CC. more ether solution. University
and
BelIevue
* Read at a Round Table Conference
HospitaI
N. Y.
In both experiments the dog received exactIy the same amount of morphine sufficient to make it easy to handIe him. So this factor can be excIuded. It wiI1 be noted that without preIiminary medication I 34 C.C. of ether soIution was used to produce compIete anesthesia whiIe onIy 87 C.C. was necessary with preIiminary medication. Respiratory faiIure required onIy 99 cc. of ether when pre1iminar.y medication was not empIoyed,- as against 244 cc. of ether with DreIiminarv medication. showing that the a;imaI which had received preIiminary medication was safer and in better condition than the one which was not preIiminariIy medicated. The foregoing statement is a paradox. Some surgeons and anesthetists think that a patient’s safety is jeopardized by preIiminary medication. These experiments were fuIIy verified some years Iater by Charles W. Hooper and myseIf. The foIIowing resuIts represent a year’s work in which approximateIy 500 animaIs were empIoyed to determine the vaIue of preliminary medication in inhaIation anesthesia. This Iaboratory data verifies the results in cIinica1 experiments, i.e., that proper preliminary medication is equally as important as the termina1 anesthetic agent. The agents used were nitrous oxide, acetyIene, ethylene, propylene, and ether. Four animals were empIoyed for each experiment; two were given so much preIiminary medication that they did not move ten minutes Iater when pIaced in the gas chamber with the controls. AI1 were given the same anesthetic under preciseIy simiIar conditions. The controIs jumped around and struggIed against the anesthetic Y
DOG No. 20. WEIGHT 13 KILO 1vITHOCT PRELIMINARY MEDICATIOPG June 15. 1915. 10:30 A.\I. 0.5 cc. of z per cent morphine solution. Started intravenous ether adminisI I :34 tration. I I :38Li Complete anesthesia, using 134 cc. ether solution. I I ~42 Respiratory failure; required onIy 99 cc. more ether solution.
1 New York MedicaI CoIIege.
M.D.
on Cancer at the Fiftieth Anniversary 1934. 237
of the MemoriaI Hospital,
May 25,
238
A m&can
Journal of surgery
Gwathmey-Gastric
and died within eight to ten minutes; the animaIs which received the preIiminary medication feII asIeep with no excitement
Surgery
Anesthesia
FEBRUARY, 1936
was not unusua1 to find a partiaI ateIectasis and often massive ateIectasis invoIving one or more Iobes. The heart, kidneys and
Nitrous oxid g3 per cent, oxygen 7 per cent. FIG. I. No preIiminary medication. Air spaces filIed FIG. 2. Preliminary medication. Air spaces and bronchi with edematous fluid; perivascular edema; conclear; no perivascular edema or congestion. gestion.
Ether vapor 34 per cent, oxygen 66 per cent. FIG. 4. PreIiminary medication. FIG. 3. No preliminary medication. Massive ateIectasis normaI. and congestion; air spaces obliterated.
Lung tissue relatively
The work of CharIes W. Hooper, assisted by the author. From Autochrome photomicrographs in Nelson’s Looseleaf Surgery, Vol. I, page 514.
stage and survived the ether twenty to After the animals twenty-five minutes. were kiIIed they were immediateIy necropsied. Lung Iesions grossIy showing distension, edema and congestion were found in the animaIs that had not received preIiminary medication. In ether anesthesia it
Iiver showed no gross Iesions and they were not examined microscopicaIIy. MicroscopicaIIy the Iesions showed perivascuIar edema, diffused petechiae, aIveoIar spaces fiIIed with ffuid and bronchi containing edematous fluid. (Figs. I through 4.) On the other
hand,
the Iungs of the animaIs that
NEWsE~lEsvoL.XXXI,NO.2 Gwathmey-Gastric received preIiminary medication were reIativeIy normaI. Thousands of individuaIs anesthetised without preIiminary medication, have made uneventfu1 recoveries : however, the facts here presented may possibIy expIain certain fataIities which have hitherto been either unsoIved or charged to other causes. I refer especiaIIy to postoperative pneumonias. The preferred anesthesia for humans is the one which combines within itseIf both the preIiminary and termina1 anesthetic. Such an agent and method is oiI-ethercoIonic anesthesia. The patient is put to sIeep in his own bed; puIse and respiration remain more nearIy norma than with any inhaIation method. The recovery is in an analgesic state and without nausea and vomiting. The anesthesia is under compIete contro1 from start to finish, as in any inhaIation anesthesia, i.e., it is reversibIe and controIIabIe. The Iate CharIes BaskerviIIe,” in thousands of experiments in the Iaboratory, proved that whiIe ether boiIs at 34.6 degrees c., it does not escape vioIentIy from an oil-ether mixture (as does ethy1 chIoride-J. T. G.) when the mixture is heated higher, nameIy, to body temperature of 37 degrees c. The rate of separation of ether from the oiI quickIy acquires a definite and fairIy fixed speed. The significance of this conduct cannot fai1 to be of great importance, for by this means the proper content of ether may be maintained in the bIood to produce any desired physioIogica1 effect that has a quantitative reIation thereto, for exampIe the third or surgica1 state of anesthesia. If ether separated irreguIarIy from oi1, producing a deep anesthesia at one time and a light anesthesia at another, it wouId be a very unsafe procedure, but the amount of evaporation per minute never varies. The anesthesia is automaticaIIy maintained by certain inffexibIe physica Iaws of which the even evaporization is the principIe. The ether is practicaIIy outside the body when pIaced in the coIon, as no physioIogi* Professor and Director of the ChemicaI Laboratories of the CoIIege of the City of New York.
Surgery
Anesthesia
A mericanJournal of Surgery 239
ca1 effect occurs unti1 the ether evaporates from the oi1 and is absorbed by the bIood. This occurs at the rate of 1.25 dram every five minutes. The frigid condition in the coIon caused by evaporation of the ether from the oi1 cooIs the mixture and coIon and retards the evaporation. This process continues automaticaIIy unti1 a11 the ether has Ieft the oi1. When ether is taken up by the smaI1 bIood vesseIs surrounding the coIon, it is carried through the Iiver by the greater circuIation and on to the heart. From there it is pumped into the Iungs. By this time it is moistened and thoroughly warmed to the body temperature, so that there is no irritation to the Iungs. No pneumonias have been reported with this form of anesthesia. The coIor of the face suggests thorough oxidation at a11 times. The physiologica baIance between the puIse and respiration is never disturbed, as is usua1 with inhaIation anesthesia. Laboratory experiments in the Department of HeaIth of New York City by Dr. WiIIiam H. Park show that the baciIIus coIi is kiIIed within two and a haIf minutes exposure of oil-ether. In cancer surgery, where anatomica knowIedge and patience are at a premium, in order to obIiterate compIeteIy a11 traces of the disease, with this method of anesthesia the surgeon can more nearIy approximate the idea1 and disregard the eIement of time. It is especiaIIy appropriate for gastric cancer. SUMMARY
Ether-oi1 with preIiminary medication is the anesthesia of choice for the folIowing reasons :(I) Psychic impuIses are removed. (2) Patient is ready for operation without undue Ioss of time. (3) Postoperative awakening is in a state of anaIgesia and without pain. (4) Nausea and vomiting are ehminated. (5) Leisure for carefu1 surgica1 dissection is permitted without added discomfort or danger to the patient. (6) Ether-oil anesthesia is safer than inhaIation anesthesia.