_Gradual induction_ of anesthesia until the patient’s tolerance to chloroform is ascertained, is of cardinal importance.
Obstructed breathing developing during the induction of narcosis is apt to be due to _crowding_. If obstructed breathing becomes manifest later, that is, during the course of the operation, it may be due to _inhibitory reflex elicited by the surgeon_. Traction on the gall bladder or mesentery will sometimes evoke a peculiar noisy breathing which does _not_ mean that the patient is insufficiently under the influence of the anesthetic. The breathing becomes normal and unrestrained as soon as the surgeon desists from these vigorous manipulations.
_Probably the most common of mistakes is crowding the anesthetic._ The anesthetist becomes aware of faint, high pitched notes in the breathing—the beginning of obstructed respiration. He examines the lid and corneal reflex and these convince him that the patient is in the state of _superficial_ anesthesia. Naturally, he gives more of the anesthetic. To his great chagrin the breathing becomes progressively more stertorous. The cyanosis which was at first slight, deepens. The noisy breathing attracts the surgeon’s attention. The perspiring anesthetist is enjoined to push the jaw forward; but the spasm of the muscles is too great. The teeth are pried apart, barbarous instruments are brought into play to pull the tongue forward. The patient has not received sufficient air all this time—his face is slate-colored. The nasal or pharyngeal tube, tongue traction, oxygen, artificial respiration with rhythmic chest compression, stretching of the sphincter ani, all follow in an illogical onslaught, until finally a long deep breath is induced and the victim is resuscitated. The condition was one of _respiratory-collapse_. The cause was crowding of the anesthetic.
WHEN SHALL THE PATIENT BE DECLARED READY FOR OPERATION?
As soon as the first, unimpeded, snoring respirations are heard, the cleansing of the field of operation may begin. If the cleansing manipulations do not disturb the rhythm of the snoring respiration, the rate of the pulse does not increase and the patient makes no defensive movements, he is very likely already in the proper plane of anesthesia. Note is at once made of the state of the pupil and lid corresponding to this plane.