Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from THE PRESENT POSITION OF ETHER ANAESTHESIA

By

JOHN ELAM, M.R.C.S., L.R.C.P. (General Practitioner)

Ether has been our good friend and trusted of his leaving the theatre. (The nature of the helper for one hundred years. operation has some influence.) But, to-day, some of our colleagues maintain Some reflexes return much sooner than con- that this drug should not be used, although many sciousness and after one hour's anaesthesia with experienced practitioners still consider ether to ether, the patient will usually be moving his head be one of the best anaesthetic agents. ten minutes from the time the anaesthetic is dis- This difference of opinion arises, I believe, continued. because of the absence of a clear differentiation I usually give as premedication atropineProtected by copyright. between the action of the anaesthetic drug and grs. 1 (hypodermically), and potassium bromide- that of the drug used as premedication before the chloral hydrate (for women 20-30 grains of each- operation. For example: One writer described for men, 30-40 grains of each, by mouth). From his "ether patients" as "returning to the ward, these drugs the patient obtains relief from anxiety snoring, sweating, and gurgling, with relaxed and, if kept waiting in the theatre ante-room, hypertonic muscular system, which results in poor usually falls asleep. Delay in recovering con- circulating blood volume . . . and stagnant sciousness and many of the undesirable post- anoxia," and as taking, on an average, over two operative complications, so often attributed to hours to recover consciousness. ether, are due to over-indulgence in the use of the Such is a picture, not of a patient arriving in barbiturate group of drugs, or of morphia. the hospital ward after an ether anaesthetic, but If we are to abandon the use of ether after one of a patient who has been given an overdose of hundred years of satisfactory experience with some powerful drug to allay his apprehension of this drug, we must be very sure that the drugs and his operation. methods of administration which we intend to http://pmj.bmj.com/ Before September, I939, I administered one of use, have in very truth some special advantage. the barbiturates to all my patients before operation. It is my purpose to show that, compared with But I found that many of them were a long time other drugs and techniques, ether remains to-day in recovering consciousness. This delayed recovery the best and the safest anaesthetic agent, and that threw a heavy burden on the nursing staff, and, the dangers and disadvantages of "Modern Anaes- with the advent of war, I was forced to abandon thesia"* do not justify our removal of ether from this form of premedication because of the shortage its place as our foremost anaesthetic drug. of nurses. on September 28, 2021 by guest. After discontinuing the use of the barbiturates, The Failure of "Modern Anaesthesia" to Improve I found that post-operative chest complications Post-Operative Results, or to Reduce Anaesthetic of Mortality were markedly reduced and the condition the The substitution of what is often called "Modern patients greatly improved. led to After deep ether anaesthesia without heavy Anaesthesia" for ether anaesthesia, has not premedication, the time of recovery from when the improvement in post-operative results, or to a fall anaesthetic is discontinued, until the patient in anaesthetic mortality. Indeed, Marston suggests regains complete consciousness of his surroundings, that 'modern anaesthesia" is associated with an averages twenty minutes per hour of etherisation. increasing number of risks. * By "Modem Anaesthesia" I mean those drugs and When light or moderate planes of ether anaes- techniques now used in place of ether, such as Intravenous thesia are used, as for a hernia operation, the Anaesthesia, Spinal Analgesia, or Cyclopropane Anaes- patient will usually be conscious within ten minutes thesia, and certain other methods. POST-GRADUATE MEDICAL JOURNAL Octobey, .1946 Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from In a recent discussion at the Royal Society of of saliva and mucus. Not during deep anaesthesia. Medicine, many new agents and techniques were Boyd and others are doubtful whether there is described as having been used in the surgery of an increase in the output of respiratory tract the upper abdomen. fluids, and maintain that there is no evidence of It was a little surprising to find that the post- damage to the cilia lining of the respiratory tract. operative results mentioned, showed little, if any, Ether increases pulmonary ventilation, but in- improvement on those which we, general practi- creased pressure in the airway may be harmful, tioner anaesthetists, have been obtaining from the on occasions. use of ether. Negative pressure caused, for example, by the There has been a marked increase in the number use of too small an endotracheal tube, may cause of anaesthetic deaths reported to the Coroner pulmonary oedema. Bacteria inspired into the during the last twenty years. lungs during ether anaesthesia will grow un- In I92I-347 deaths under anaesthesia were inhibited by the body defences during the period reported to the Coroner. of unconsciousness. In I93I-723 deaths under anaesthesia were Liver.-Function decreased, returns to normal reported to the Coroner. in twenty-four hours. Bile secretion is probably In I94I-835 deaths under anaesthesia were decreased. Molitor does not believe that the reported to the Coroner. secretion of bile is decreased. Thus we find an increase in anaesthetic mortality Kidney.-The volume of urine is decreased during those years when new drugs and new and the renal function depressed, although the techniques were in great part displacing ether in effect of ether need not be feared in healthy operative surgery. subjects. Changes in the kidney function may To explain this upward trend in anaesthetic be due to the extra-renal action of the anaesthetic deaths, it is said that not only are more operations added to the operative procedures. performed to-day than was the case in former times, Heart.-The effect of ether on the heart of Protected by copyright. but that greater surgical risks are now accepted. the healthy patient is slight. There is, however, This statement is not true. Twenty-five years ago, an increase in the heart volume indicating relaxa- many hazardous* operations were performed tion of the heart tone. which are now rarely seen. The general condition Stomach and Intestines.-Movements decreased of patients coming to operation now is infinitely action passes off quickly in ten to fifteen minutes. better than was frequently the case in the past, Lymphatics.-Increased flow and absorption. and one seldom sees to-day those neglected cases Ether is not the deadly poison some anaesthetists of perforated gastric ulcer and intestinal obstruction would have us believe. which were once so common and which gave so much anxiety to the anaesthetist. And, in addition, we have to-day the tremendous advantage of Administration modem restorative measures. Ether can be administered:

(A) By Inhalation- http://pmj.bmj.com/ The Physiology of Ether Anaesthesia (I) By the open drop technique or- We do not know precisely how ether produces (2) From some apparatus such as- surgical anaesthesia, but it is known that ether (a) Clover's inhaler. has a depressant action and shields the brain from (b) Shipway's apparatus. damage by painful stimuli. (c) Oxford vaporiser. Central cortical activity is decreased and lower to other anaesthetics, e.g. nitrous The temperature regulating (3) Added pathways blocked. oxide oxygen (as in Boyle's ap- on September 28, 2021 by guest. centre is depressed and the voltage and frequency paratus).. of action potentials decreased. % Per rectum. The vasomotor centre is not directly affected. (B) The carotid sinus reflex is depressed, but ether (C) In combination with local analgesia or spinal stimulates breathing by reason of its action on analgesia. the respiratory tract. The bronchial muscles are relaxed. Salivation and lacrimation occur in the (i) Open Drop Ether early stages of ether anaesthesia, and, during light A protective pad of gauze with a centre hole is anaesthesia, there an increase in the secretion placed over the face. A wire mask covered with il one layer of house flannel is superimposed. Ethyl * How many of our young anaesthetists have seen the chloride is sprayed gently on to the mask until operation for the partial removal of the maxilla for cancer, and the performed under chloroform? regular automatic breathing is established Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from Octoberl, I1946 THE PRESENT POSITION OF ETHER ANAESTHESIA 271 ethyl chloride snore is heard. (At this stage the If a cautery or diathermy is to be used during pupils of the eyes will be dilated and there will the operation, chloroform should be placed in the be a characteristic squint.) second bottle, and the anaesthetic continued with Ether is then dropped on to the mask just fast gas-oxygen-chloroformn. enough to enable the individual drops to be distinguished. (B) Rectal Ether The administration of ether per rectum was (2) Ether Inhaler introduced by Gwathmey and is used chiefly in obstetric practice. It holds little advantage over There are many inhalers designed to administer inhalation methods for general surgery. ether, among which: (C) Ether Anaesthesia in Combination with Local (a) Clover's inhaler and or Spinal Analgesia (b) The Shipway apparatus have proved useful Harold Dodd and others advocate a technique in the past. of infiltration with local analgesia in combination (c) The Oxford vaporiser was designed to with the very lightest plane of ether unconscious- administer ether under difficult circum- ness. Undesirable effects of deep ether narcosis stances which might arise during war. are avoided and the dangers of local analgesia Definite and constant percentages of ether in air lessened. can be given, as the ether is kept at an unchanging However, it must be appreciated that local temperature by two surrounding jackets, one analgesia per se, will neither prevent circulatory holding crystalline* calcium chloride, and the complications nor reduce the incidence of post- other, hot water. operative pulmonary difficulties. To obtain a pleasant induction, the face-piece Two types of untoward reaction to local anal- of the apparatus is applied and one short. spray of gesia have been reported: Collapse and convulsions.Protected by copyright. ethyl chloride is then sprayed into an induction Sudden collapse may be the result of psychological bag about every two breaths until regular auto- reaction, or of an idiosyncrasy towards the local matic breathing is established. Then the indicator anaesthetic. The cause of convulsions is not clear, of the machine is turned to 10I5 and the bag but both types of reaction can be fatal. turned off. The required plane of anaesthesia is Sudden death from allergy to procaine has been thus quickly obtained. reported in the medical literature. Several workers Endotracheal ether can be administered from have found that the use of procaine (novocaine), this apparatus and there is a device for delivering inhibits the action of the "sulpha" group of drugs, oxygen. A bellows for inflating the lungs with to a considerable extent. Ether can also be admin- air or air-oxygen, is attached. istered to render a patient unconscious during As the ether vaporises losing heat, it borrows spinal analgesia, or to make it possible to con- the heat held by the molten calcium chloride. tinue a long operation if the effect of a single dose Thus the ether remains at a constant temperature of spinal analgesia should wear off. until all the molten calcium chloride is reconverted http://pmj.bmj.com/ into its crystalline form, that is for about two Is Ether Anaesthesia Obsolete for Casualty hours, so that there is no variation in the percentage or Military Surgery? of ether vapour in air. It has been stated that many practitioners who The Oxford vaporiser enables ether to be used had to treat air-raid and military casualties during in very hot climates. the war, came to the decision that ether anaes- thesia should be avoided, and that intravenous (3) Gas Oxygen Ether Sequence from the Boyle's pentothal was the anaesthetic indicated. My on September 28, 2021 by guest. Apparatus experience leads me to take a view which is in This apparatus has been in use for many years. strong opposition to this precept. In addition to the ether bottle a second bottle is For many years before the war I worked at a usually provided which can be filled with chloro- hospital which had to deal with a large number of form, vinesthene-ether mixture, or trilene. Vines- road accidents. During the war years, at this same thene-ether mixture is valuable both for obtaining hospital, we had our share of air-raid casualties. a smooth induction and for giving the anaesthetist and, after Dunkirk, of wounded soldiers. Ether the power to obtain extra muscular relaxation, anaesthesia gave excellent results in the surgical should this be required in a difficult case. treatment of such cases and I have come to believe * The crystalline calcium chloride takes up the heat that ether is the anaesthetic of choice for casualty from the hot water, being thus transformed into a molten surgery and that the use of the barbituxtes is shape. better avoided. Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from 272 POST-GRADUATE MEDICAL JOURNAL October, I946 The barbiturates administered intravenously venous barbiturates has no place in the surgical depress the respiration, lower the blood pressure, treatment of patients who are susceptible to shock. poison the heart muscle, and lead to delayed A possible explanation of the unsatisfactory recovery. These drugs cannot, on theoretical or results obtained by some anaesthetists, with ether practical grounds, be described as the agents of anaesthesia may be given by Dauna, who calls choice for anaesthetising the gravely injured attention to the unnecessary depth of many ether patient. It was my experience during the war anaesthetics, and Goldberg, who gives a warning that light ether from the Oxford vaporiser did that anaesthetic difficulties and post-operative not appear to "upset" the patient any more than complications are increased by the pre-operative gas and oxygen, and endotracheal ether was use of morphia. found to be specially valuable for grave head Fordyce advocates the- use of ether for emer- injuries and severe burns. gency surgery, and Thomas remarks that ether Quick recovery of consciousness is an important has never failed to be utilised for overcoming the consideration when a hospital, often short of staff, failures of other methods. has to deal with a number of wounded persons. Revell holds that ethyl ether has been the By means of light ether anaesthesia, I was enabled standard comparison for other agents and remains to ensure that the patients became conscious in the reliable stand-by where muscular relaxation is the shortest possible time. When I administered required. Flagg, one of the world's most out- an intravenous barbiturate anaesthetic I found standing authorities in anaesthesia, after a personal that delayed recovery of the patient was a fre- experience of more than thirty years with ether quent complication and this added greatly to the as an anaesthetic agent, has decided that claims burdens of an overworked nursing staff. for other agents as basic routine cannot be sus- It is generally admitted that in a high proportion tained. He has found that every type of war or an intravenous can be carried out safely, efficiently, of patients who have received civilian surgery Protected by copyright. barbiturate anaesthetic, a period of excitement and with a minimum of morbidity and mortality, and irrationalism will ensue before full recovery of with ether. He feels that too many anaesthetists consciousness takes place. This is a most serious have tried too often to avoid the use of ether, and administrative consideration in any hospital. I the skill with which it might be used, is not so also found that even in the case of patients who much in evidence to-day as it should be. might be described as "good operative risks" a In his textbook, Flagg describes anaesthesia post-operative condition indistinguishable from by ether gas as the safest anaesthesia known. shock, not infrequently occurred after the use of Post-operative illness he believes is usually due to pentothal. anoxia. He also remarks that other anaesthetic My experience has also led me to believe that agents are seldom compared with ether at its the barbiturates are absolutely contra-indicated best. for those patients who have been badly burned or The comparison is usually with ether at its worst. scalded and for elderly patient, who have to undergo some emergency operation, especially that and the General http://pmj.bmj.com/ of supra-pubic cystotomy. Ether Anaesthesia A study of the medical journals has brought Practitioner confirmation of my opinion. For example- My own experience as a general practitioner Pask considers that insufficient attention has anaesthetist for over twenty years, has led me to been given to the possibilities of light ether nar- believe that ether, by the open drop technique, cosis, in cases of shock, and in the United States of from the Oxford vaporiser, or combined with America, the Mayo Clinic estimate ether as one other agents, as from a Boyle's apparatus, is by of the best anaesthetic agents that has ever been far the best anaesthetic agent for use by the general on September 28, 2021 by guest. introduced. practitioner. Many lives might be saved and Romberger and Beecher also hold ether in much distress avoided if general practitioners esteem, and Renow considers ether by the open would confine themselves to the use of this drug, method the anaesthetic of choice for war wounds leaving other agents and techniques to the full- of the abdominal viscera. Martin believes ether time professional anaesthetist. to be one of the safest agents for army surgical procedures; his findings were confirmed by other military observers, i.e., Martele, McCarthy, Anaesthetic Mortality Archer, Gould, Martin. McCarthy believes that I agree with the statement of Galley, that the ether remains the best and safest single agent use of unsuitable drugs in unsuitable surroundings for abdominal injuries, and considers that spinal by inexperienced administrators, plays no small ~anaesthesia or basal anaesthesia with the intra- part in causing the increased mortality already Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from October, I946 THE PRESENT POSITION OF ETHER ANAESTHESIA 273 noted. While it is usual to assess the value of the patient was probably.more uncomfortable but any anaesthetic agent or technique by the standard safer. These statistics are not very helpful, and I of immediate mortality, yet this is not the most think that Jarman points to the true cause of satisfactory method of evaluation. anaesthetic mortality-"The unskilled adminis- When skilled adniinistrators are in charge of the trator." He found on studying the details of over administration, the immediate mortality seems to I,000 deaths, that 8o per cent occurred when the be about the same, whatever the agent or method administration was in the hands of the newly qualified used. house officer. The general practitioner and the Griffiths supports this view and feels that it is newly qualified house officer would be wise to use the anaesthetist who.really creates a department only the safest anaesthetic agent-ether-in spite of anaesthesia. The Wisconsin School teach that of the attraction of other drugs. it is the anaesthetist and not the anaesthetic agent or technique which is of primary importance. Are "Modern Methods" Associated with It is, however, very generally admitted that ether has a greater margin of safety than any other Untoward Occurrences? drug. For example, if respiratory arrest occurs Apart from death, the administration of an under ether, the practitioner has ten times more anaesthetic is sometimes associated with extremely chance of re-establishing breathing than if it unpleasant complications. Untoward reactions do occurs under chloroform, and most anaesthetic occasion4ly follow the administration of ether, but deaths are caused in the first place by respiratory the possible disadvantages and complications of arrest. We might, with advantage, then, consider other drugs and methods are formidable and should certain published records. be borne in mind by the local doctor who, unlike Dealy gives us a record of the anaesthetic the London specialist, has to live in close proximity deaths in Queen's General Hospital, for five years, to his patients. Protected by copyright. 1936-I94I:- Intravenous anaesthesia has been associated with many troubles. Pallor, tachycardia and 19,529 anaesthetics were administered. extremely poor radial pulse frequently follow the 16,273 were inhalation, with 7 deaths, possibly administration of Pentothal. Thrombosis of a due to anaesthetic. vein, injection into an artery with tragic results, 3,193 were spinals, with 7 deaths, possibly due have been known to occur. Fall in blood pressure, to anaesthetic. excitement, local irritation, nausea, vomiting, 63 were rectal, with 4 deaths, possibly due headache, irritability of the throat, unrest and to anaesthetic. deplopnia, paralysis, polyneuritis, impairment of Waters and Gillespie have shown that death vision and albuminuria, and convulsions, have also during operation and anaesthesia has occurred in been reported, after intravenous anaesthesia. I in I,ooo cases, in a series of 250,000 cases, in five The general practitioner would be wise to con- teaching hospitals. sider his own position, should some of these compli- Kaye gives the statistics in a hospital in cations occur in one of his near neighbours. The http://pmj.bmj.com/ Melbourne from I9I9-I929. In a series of I3,400 same warning also applies to the use of spinal operations on in-patients it was found that i'6 analgesia, by the patient's own doctor. Spinal per i,ooo was the immediate mortality. analgesia has many ardent supporters to-day, but During the period I929-I934, in I7,757 opera- grave neurological complications do from time to tions I * 3 per I,000 was the mortality. time, follow the use of this technique. Permanent An analysis of one series of cases showed that incontinence, mental affliction, and muscular under ether anaesthesia in 8,999 cases there were palsies have been reported. 8 deaths. A question was recently asked in Parliament, on September 28, 2021 by guest. Under NO and ethylene in 2,555 cases I3 deaths. concerning a young soldier who, having survived Under spinal in 907 cases i death. an operation for hernia, under spinal analgesia, Under local and regional in 2,393 cases 4 deaths. died seven months later from paralysis and, Two deaths under local analgesiafortonsillectomy toxaemia. What would Dr. Jones have said to, were reported. the local Vicar's wife had this young man been Fors and Schwalm, compared results in 4,000 her son? Could he have expected to have retained cases of which 2,000 were given ether-2,000 were the confidence of his other patients, after such a given spinal. Mortality was 6 5 per cent for tragedy? spinal-6 8 per cent for ether. Pulmonary com- 'Quite recently, in my own county a young man plications were equal. was sent to a London teaching hospital for a, Professor Grey Turner, discussing "Modern cystoscopy. The patient, six months later, stiU Anaesthesia," believed that with older methods suffers from grave neurological sequelae. Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from 274 POST-GRADUATE MEDICAL JOURNAL October, I946 It cannot be maintained that these tragedies are Post-Operative Shock and Circulatory due to errors in the technique of administration because a few, a very few, highly skilled anaes- Complications thetists have been honest enough to record their It is sometimes stated that ether anaesthesia misadventures. Had all our colleagues been predisposes towards shock, and that when a equally frank, I doubt very much whether the condition of shock already exists, or may be pre-eminence of ether would be challenged to-day. expected to develop, the use of some more modern In assessing the value of ether, then, we must technique such as intravenous anaesthesia is consider whether the disadvantages of this anaes- preferable or indeed essential. thetic are greater than those associated with other Mallinson states that there is no room for drugs and techniques: Whether, in fact, weighed doubt ... that ether should be entirely avoided in the balance with new methods, ether has been in dealing with shocked and exsanguinated patients found wanting and its kingdom given to another. and advises the use of intravenous anaesthesia. The chief criticisms against ether are that it I have found that intravenous anaesthesia accen- leads to: tuates shock, even when given for the induction of anaesthesia, and sometimes leads to a fall in (I) Vomiting, following operation. blood pressure from which the patient appears to (2) Abdominal distension and paralytic ileus suffer for a considerable period of time. after operation. An Editorial in Current Researches tells us (3) Post-operative shock. that there were six times as many deaths under (4) Post-operative chest complications. intravenous in the United States of America's of consciousness. Army, as under any other anaesthetic. Is this (5) Delayed recovery then to be the technique of choice for war surgery?

(6) Laryngeal spasm during the induction, and Even in relatively minor surgery performed underProtected by copyright. operation. intravenous anaesthesia, I have found that patients (7) Ether convulsions. often appear collapsed after an operation such as (8) That it is a toxic drug upsetting physiological would give no cause for worry under other methods balances. of anaesthesia. Harris, Richards, and others report some- what similar experiences. Ether-even deep ether Vomiting anaesthesia, is less likely to contribute to that Vomiting occurs in about 6o per cent of all condition known as shock, than the non-volatile etherised patients and can be reduced by preventing drugs for which-such extravagant claims have been the swallowing of ether-laden saliva, and by made. keeping the depth of the anaesthetic strictly to The medical journals contain numerous re- the plane required by the operation. But vomiting ferences to the association of intravenous anaes- may also be a distressing complication of both thesia with shock, and to the dangers which may spinal analgesia and intravenous anaesthesia, as be encountered when the barbiturates are adminis- http://pmj.bmj.com/ many observers have shown. tered (intravenously or otherwise), to the shocked Waters found that nausea or vomiting occurred casualty. Minnitt and Gillies consider that in in 50 per cent of cases after ether and 39 per cent haematogenic shock, stagnant anoxia will be after cyclopropane. aggravated by the barbiturates, but that in neuro- It is better to have a patient who vomits even genic shock, they are not contra-indicated. for forty-eight hours, than a patient who lies quiet Woodhall, Madan and Crooke, Morris and and still in the mortuary, or a patient who leaves Bowler report unsatisfactory condition of patients, hospital crippled for life from some injury to his following the administration of the barbiturates. on September 28, 2021 by guest. central nervous system. Chivers and Evans give a word of caution, and Marston considers that recovery may be retarded and the effects of shock increased by deep basal Abdominal Distension narcosis. Saklad and others believe that the Abdominal discomfort and distension may occur intravenous barbiturates have no place in the after ether anaesthesia, but the post-operative surgery of the shocked casualty and recommend administration of morphine is helpful in over- ether anaesthesia. coming this distressing condition, which is not The Editor of Anesthesiology issues a warning confined to those patients who have been given to war-time anaesthetists, that untoward compli- ether. Waters found that distension developed cations may follow the administration of intra- in i6 - 5 per cent of cases after ether and I3-5 per venous anaesthesia to the shocked battle casualty. cent after cyclopropane. Moon78 found that the barbiturates facilitate the Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from October, I946 THE PRESENT POSITION OF ETHER ANAESTHESIA 275 development of shock in experiments on animals cause of post-operative pneumonia. The most and that dogs under barbiturate anaesthesia important factor, however, is post-operative and develop spontaneous shock. pre-opera.tive nursing care, and the general hospital Beecher, McCarrell and Evans* found that there ward. By far the most disappointing feature of was no significant delay in the onset of shock our new health service, is the omission to condemn caused by bleeding when the barbiturates were and abolish the general hospital ward. Far more used, as against ether. patients lose their lives following operation, from "Shock" is the surgeon's and the anaesthetist's being nursed in a large general ward, than from greatest anxiety, and up to the present time no any other cause. anaesthetic technique has been discovered which There was a number of investigations in will remove this dangerous complication from its military hospitals during the war to try to find association with major surgery. out why there was such a high incidence of chest Adams quotes Reynolds, Veal and Chapman, complications, following hernia operations. It as finding that the heart muscle is poisoned under was found that the anaesthetic agent used made continuous Pentothal. Beecher agrees. little difference, but the technique of pre-operative Minnitt and Gillies call attention- to the sedation was important. Bird and others agree possible dangers of the non-volatile agents in with the findings of the investigations described. elderly subjects or in shock. Flagg feels that there is no danger in the use If we decide that intravenous anaesthesia is to of ether, properly administered, even in pulmonary be avoided in cases where shock is present or is tuberculosis, and refers to the opinion of the expected to occur, we have as alternatives to the Director of the New York State Tuberculosis use of ether anaesthesia: Hospitals, who found that no ill effect resulted from the administration of ether to tuberculous (i) Trilene or vinesthene anaesthesia. subjects. Murphy supports this belief. Protected by copyright. (2) Cyclopropane anaesthesia. Beecher anaesthetised with ether I47 patients (3) (a) Spinal analgesia, or suffering from pulmonary tuberculosis, with ex- (b) Local analgesia, with or without some cellent results. method of producing unconsciousness. Balbage and others state that even when no Are these methods and combinations so satis- inhalation anaesthetic agent is used, there is factory that the use of ether has become obsolete? certainly no lessening of the incidence of chest Vinesthene is an excellent anaesthetic but is at complications, following operation. present yery difficult to obtain and is associated Griffiths listed pulmonary complications fol- with some disadvantages, although these are not lowing:- numerous. The combination of vinesthene with A. ether, known as V.A.M., is a most valuable anaes- Upper abdominal surgery under- thetic. Trilene added to nitrous oxide and oxygen, is satisfactory for many operations, but fails to (i) General anaesthesia as 9 45 per cent give adequate muscular relaxation in some cases. (2) Regional anaesthesia as I5 I5 per cent http://pmj.bmj.com/ A combination of cyclopropane with spinal (3) Combined anaesthesia as 25 per cent analgesia, or cyclopropane with local analgesia, has been found valuable. A comparison of the B. last-mentioned techniques as against ether anaes- and those following lower abdominal surgery thesia will be made later when we have to consider under- the choice of an anaesthetic for grave major opera- (i) General anaesthesia as 4 per cent tions of long duration requiring complete muscular on September 28, 2021 by guest. relaxation. Shock is particularly likely to occur (2) Regional anaesthesia as IO-3 per cent under such conditions. (3) Spinal anaesthesia as I5 per cent and remarked on the important part played by Post-operative Chest Complications pre- and post-operative sedation. There is incontestable evidence to-day that In another report on abdominal operation on ether plays no part in the production of post- patients with chronic respiratory infection, acute operative chest complications. Over-premedica- post-operative pulmonary complications occurred tion with sedative drugs, among which the bar- in- biturates are the worst offenders, is a common I3 5 per cent of cases after ether. I7 5 per cent of cases after cyclopropane. * They were referring to the observations of Essex, 39-5 per cent of cases after spinal, Seely, and Mann, that shock from intestinal manipulation is delayed under barbiturate anaesthesia, as against ether. where no pre-operative infection existed. Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from 276 POST-GRADUATE MEDICAL JOURNAL October, 1946 Acute post-operative complications were re- our discussion on the physiology of ether anaes- ported in- thesia. 5 * 8 per cent of cases after ether. / 4 9 per cent of cases after cyclopropane. 7*5 per cent of cases after spinal. The Use of Ether for Extensive Surgery Stewart believes endotracheal ether the best It remains now to decide whether ether should anaesthetic for upper abdominal surgery. Many be used for long and extensive operations requiring other authorities agree that general anaesthesia absolute muscular relaxation for their completion, with ether is of little importance in the causation and often associated with a high degree of surgical of post-operative chest complications. Jones and shock. Burford report four cases of collapse of the lung Three methods are available for such operations: under cyclopropane anaesthesia; a method thought (i) Deep ether or chloroform* anaesthesia. to be particularly suitable when chest compli- (2) Spinal analgesia (with or without uncon- cations are to be expected. sciousness). It is now established that regardless of the (3) A combination of local analgesia with some anaesthetic agents used, the incidence of post- method of producing unconsciousness, such operative chest complications increases with the as cyclopropane anaesthesia. increase of duration of the anaesthesia, with increase in depths of anaesthesia and with increase Deep ether anaesthesia by the endotracheal route in of has been used for many years, with excellent results. grade surgical risk. That difficulties and disadvantages are attached to Delayed Recovery of Consciousness this method, no one ,will deny. But with other techniques specially grave and tragic complica- Delayed recovery of consciousness has been tions, never encountered with ether anaesthesia,Protected by copyright. stated to occur after ether anaesthesia, but it has may be met with. been shown that this complication is due not to the use of ether anaesthesia per se, but to the practice of administering powerful sedative drugs Spinal Analgesia before operation. Referring to spinal analgesia, Flagg warns us that "extremely serious post-operative complica- Laryngeal Spasm tions never seen in general anaesthesia, are to be Laryngeal spasm occurs during the induction reckoned with," and practitioners submitting their period, in heavy smokers and alcoholics. It may patients to these risks must clearly understand also occur during the course of an operation owing that they are very real and not imaginary. It to some action on the part of the surgeon. Pre- has been stated that complications are due to medication with morphia seems to predispose to errors in technique, but this is clearly not the case. this troublesome condition. But laryngeal spasm Grave damage to spinal cord, meningitis, respira-

is also a frequent and sometimes a very grave tory arrest, and collapse have been reported. http://pmj.bmj.com/ complication of intravenous anaesthesia, because Apgar found that in 6o per cent of cases, if not quickly overcome, it may be fatal. the state of the circulation was unsatisfactory. There were four cases of irreversible shock and Ether Convulsions one case of severe neurological reaction, in a Ether convulsions are always associated with series of 422 patients to whom spinal analgesia sepsis and are usually seen in children. The fre- was administered. quency of their occurrence is said to be one in In two other series reported by Pappen, McCul- ten thousand cases. I believe, having myself loch, and others, respectively, very serious compli- on September 28, 2021 by guest. lost patients from this cause, that convulsions are cations were met with. due to anoxia and can be avoided by preventing Moorhead found that in war surgery, spinal the slightest trace of oxygen shortage during the analgesia has a place, but after-headache and operation. It must be remembered that con- bladder involvement are complications. vulsions occur under other agents and techniques. Hames, Simpson, and Bradford also encoun- The Australian Society of Anaesthetists pub- tered untoward reactions. lish a report of such cases received in reply to a Meningitis is reported by Aikenhead and questionnaire. Kremer. Kremer quotes Siebert, Livingstone, and others, as having had similar experiences. A General Poisoning of the Whole Body * Because of the prejudice at present existing against That the human body can well withstand the chloroform anaesthesia, the use of this drug will not be administration of ether has already been shown in discussed. Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from October, I946 THE PRESENT POSITION OF ETHER ANAESTHESIA 277 Downing met with two cases of collapse of substances, sometimes with a fatal result. In my intervertebral discs, and Co Tui and others own county, a strong healthy young woman died, found local nervous tissue changes following spinal without any apparent cause, immediately after a analgesia, in experiments on animals. Caesarean operation, performed under procaine Kazman, Baker, and others, mention grave analgesia. neurological sequelae (death of one patient seven It is a great ordeal for a patient to endure a long months after spinal, from damage to cord), and operation while fully conscious, and some method Van der Post reports three disturbing cases of producing unconsciousness is usually adopted. under light percalie-(two deaths, one narrow Because cyclopropane is a non-toxic gas and can escape), while Power adds his quota to the list be used with a high percentage of oxygen, it of misadventures. would appear to be the ideal anaesthetic agent McNeil Love writes of ocular palsies and for this purpose. permanent incontinence. VWhile we are considering the value of a technique Fairclough recently called attention to the in which its use seems particularly indicated, we high incidence of sixth nerve palsies. Such might with profit discuss the advantages, the dis- palsies were also reported from Manchester in a advantages, and the peculiarities of this valuable discussion at the Royal Society of Medicine, drug. A few particularly gifted individuals can thirteen cases being noted between August, I932, obtain from cyclopropane alone a relaxation which and March, I934. is beyond criticism, but many practitioners add Lundy adds other complications to the already ether to the cyclopropane, or make use of novo- alarming and formidable list, while Eid reports caine infiltration of the field of operation to enable a new and remarkable complication recently. the surgeon to work in comfort.

Indeed, sufficient evidence is available for the Local analgesia in combination with cyclo-Protected by copyright. searcher after truth to enable him to realise how propane anaesthesia has been found satisfactory grave is the responsibility of the anaesthetist for many lengthy and difficult operations. Cyclo- who decides on spinal analgesia as the method of propane is also administered to provide uncon- choice for his patients. sciousness in patients undergoing operations under The avoidance of shock is the usual reason given spinal analgesia. But it must be generally ac- by surgeons who choose spinal analgesia for long knowledged that this anaesthetic has some dangers and difficult operations and shock is a very serious and disadvantages. A curious condition known condition. But we have to-day very satisfactory as cyclopropane shock has been reported by methods of combating this deadly and little under- Kellog and Phillips. stood phenomenon, and in our anxiety to avoid Wilkins found that shock of a degree to cause shock we m4st not forget our resources, nor submit concern may develop in the immediate post- our patients to even greater dangers. It is cer- operative period, after cyclopropane anaesthesia, tainly open to question whether spinal analgesia at moderately deep levels. does help to avoid shock. While the use of spinal Cardiac irregularities have frequently been http://pmj.bmj.com/ analgesia is certainly justified when some special noted, but the addition of ether to cyclopropane advantage is to be gained, there can be no possible promptly abolishes these irregularities. Allergic excuse for the anaesthetist or the surgeon who response to cyclopropane has been known to occur. chooses this technique for relatively straight- In healthy patients subject to anaesthesia for forward operations such as appendicectomy, the upper abdominal surgery the tendency to cir- repair of a hernia, or even delivery with the mid- culatory complications is greater after cyclopropane wifery forceps, should some misadventure follow. than after ether. It is possible that primary Neither can the use of spinal analgesia by the cardiac failure of a type resembling that seen under on September 28, 2021 by guest. general practitioner or the "occasional anaes- chloroform may be the cause of certain unexplained thetist," be justified under any circumstances deaths on the table. whatever. This is the province of the professional Waters and Gillespie, discussing seven deaths anaesthetist, and the professional anaesthetist only under cyclopropane, consider that five of these (not the surgeon). were due to abrupt cardiac failure. Cyclopropane is of great value on some occasions. Its bad A Combination of Local Analgesia with qualities appear to be of such magnitude that Some Inhalation Agent, as for it cannot be safely accepted as- a substitute for ether, for most inhalation anaesthesia. It appears example Cyclopropane likely that its range of usefulness will be much Local analgesia is not entirely without its narrower than was first predicted. The use of dangers and disadvantages, as a number of persons this new agent in no way reduces the incidence of exhibit an allergic reaction to novocaine and similar chest complications. Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from

278 POST-GRADUATE MEDICAL JOURNAL October, I1946 Wirthe considers that it is definitely contra- If the anaesthetic is kept at as light a plane as is indicated in all cardiovasalar disorders and that possible, and heavy premedication with sedative ether still remains the best anaesthetic for use in drugs avoided, no trouble will be experienced with patients with heart disease. either mother or baby. Allen and others make note of cardiac irregu- I have given a great number of ether anaes- larities in experimental animals, and find the thetics for caesarean section and only lost one addition of ether beneficial in such cases. What baby, whose death had nothing to do with the greater compliment could be paid to our old friend anaesthetic. ether,- than that its addition to the anaesthetic Some authorities, indeed, *consider that the mixture should be found helpful in overcoming the administration of ether to the mother reduces birth shortcomings of our latest and most expensive shock to the baby. anaesthetic gas? It has been stated that a baby born under In fact, Mousel, Stubbs, and Kreiselman feel ether is less inclined to lose weight and recovers that the place of cyclopropane in anaesthesia its weight loss more quickly than a baby whose should be reviewed. This becomes all the more mother was given no anaesthetic drug. necessary as the advent of the use of curare will One word of warning is necessary, however. probably give us means for obtaining full muscular Ether should not be administered after a heavy relaxation under the light planes of ether anaes- meal, and no practitioner should leave his patient thesia our safest anaesthetic agent. alone in her home until she is conscious. A surprising number of deaths have been caused by obstetric patients inhaling vomited material and Ether in Midwifery choking when no assistance was immediately

For obstetric operations in country districts available. Protected by copyright. chloroform is sometimes the only anaesthetic which can be used, because of the danger of fire Relief of Pain in Labour or explosion, and accidents with chloroform in Ether analgesia can be administered by the domiciliary midwifery are few. inhalation method if due care is taken. The Ether is unquestionably the safest and best patient soon becomes accustomed to the smell of anaesthetic for the general practitioner to ad- ether and makes no objection to its use. The minister for a forceps delivery, the repair of the technique of administration is difficult and there perineum, or the removal of an adherent placenta. lies only a narrow gulf between analgesia, and a The vast majority of deliveries other than in our normal spontaneous delivery, and anaesthesia great cities still take place in the patient's own with all its possible complications. A more satis- home, with only a midwife to assist the doctor, factory method is that of Gwathmey who developed should some obstetric operation be necessary, and the rectal administration of ether during the war, ether can be safely left in the hands of a midwife, I9I4-I8. once the induction has been accomplished. McCormic describes a modified Gwathmey tech- http://pmj.bmj.com/ Stillbirths and neonatal deaths are frequently nique from which complete relief from pain is attributed to the use of ether in obstetrics, but obtained, which can be used in the patient's own Lund considers that prematurity, complications home, and from which there is no danger to of pregnancy, and the method of delivery, play a mother or child. greater part in the causation of neonatal asphyxia With a little co-operation this technique might than do the various inhalation agents used. be made available to mothers in our own empire. On the American continent, continuous caudal The of the woman in labour and our

neglect on September 28, 2021 by guest. analgesia (the injection of large quantities of a national attitude of indifference to her suffering, local anaesthetic, through the sacral hiatus into constitutes one of the gravest sociological scandals the extra dural space), has of late gained much of the present time. popularity and publicity. Baptisti gives an admirable summary of the dangers and disadvantages of caudal analgesia. Ether Anaesthesia in the Aged Numerous accidents and fatalities have been I have found ether satisfactory for elderly reported and it is evident that for many years to patients, up to the age of 92. The elderly male come, continuous caudal analgesia will have to be patient who is admitted to hospital with acute restrictedtothe practice of highly trained specialists, retention of urine, due to prostrate enlargement, working in special hospitals. tolerates ether better than most other anaesthetics, In fact, I believe ether to be the method of except chloroform. The intravenous barbiturates choice for obstetric manipulations, and for cae- are particularly deadly, and gas and oxygen is sarean section, when there is no danger of fire. unsatisfactory for these patients. Indeed, October, I946 THE PRESENT POSITION OF ETHER ANAESTHESIA 279 Postgrad Med J: first published as 10.1136/pgmj.22.252.269 on 1 October 1946. Downloaded from Hubbard goes so far as to say that there are Many practitioners have given us glowing more deaths from nitrous oxide oxygen, in the accounts of their successes from the use of modern hands of the so-called expert, than occur from anaesthesia in war surgery. They have been silent ether, no matter by whom administered. on their failures. It is only from the reports of I work at a rate-supported hospital where we the United States of America Army authorities frequently have to deal with patients between 8o that we have learned of the not infrequent mis- and go years of age, who come to us for intestinal adventures. During those years when new drugs obstruction, or retention of urine. In one after- and methods of administration have been replacing noon I administered ether successfully to four the use of ether anaesthesia, there has been a great patients over 8o years of age, for serious operations. increase in the number of fatalities reported to the I have experienced no anxiety with regard to coroner. It is untrue to say that this increase in renal function which could in any way be ascribed mortality is due to the acceptance of greater to the use of ether, and Collen and others have surgical risks. cast doubts on the accepted theory that ether The general practitioner anaesthetist would be per se, has a damaging effect on the kidney. well advised to choose ether as the anaesthetic Beecher considers, however, that age is an agent likely to give the best results in those important factor in determining kidney response operations for which he is called upon to administer to ether (p. 284). the anaesthetic. Many modern anaesthetic tech- niques are outside the province of the general Ether in Heart Disease practitioner and are unsuitable for general use. With the exception of vinesthene, ether is The difficulties and limitations of anaesthetic quite as suitable as any other anaesthetic in cases practice in provincial or -rural England are un- of heart disease. Cyclopropane causes cardiac known to many practitioners, who never appear irregularities, and the barbiturates poison the to take into consideration the conditions which heart muscle. may be met with in our vast Empire. Protected by copyright. Local analgesia I believe to be unsatisfactory in It may well be that in some London hospitals, patients with a damaged myocardium. I recently as good, or even better results are obtained from watched the attempt to remove the tonsils from the use of "modem, anaesthesia" as from ether a patient whom, the cardiologists had stated, could anaesthesia. But while -some specially gifted tolerate only local analgesia. The patient col- individual in some specially favoured surroundings lapsed after the injections, before the operation may obtain excellent results from one or other of started. Yet he underwent the operation quite the newer methods now in use, yet for the great satisfactorily a week later under ether anaesthesia. majority of medical practitioners who have to I was called one night to a maternity hospital administer an anaesthetic under whatever cir- and told that a primagravida at full-term was cumstances may exist at the time of operation, suffering from a coronary occlusion and was on the ether remains and is likely to remain, the safest point of death. The consulting physician held and the best anaesthetic agent. out no hope -of saving the mother's life, but it was I should like to take this opportunity of making a felt that an attempt should be made to obtain a protest against the lamentable fact, that many newly http://pmj.bmj.com/ live baby, by caesarean operation. Oxygen-ether- qualified practitioners go out into the world without chloroform sequence was administered; a live baby even having seen ether administered by the -open was born and the mother made a complete recovery. drop method, or chloroform by any method at all. It is high time that consulting physicians and There are many conditions under which open cardiologists refrained from giving advice as to ether may be the only possible method of adminis- the choice of an anaesthetic or its method of tering an anaesthetic, and, in country practice, administration. circumstances may be such that the practitioner has no choice but to administer chloroform, a on September 28, 2021 by guest. Conclusions most excellent anaesthetic, the dangers of which Ether which has been the basic 'anaesthetic. have been wildly exaggerated. agent for general use for one hundred years, On occasions, chloroform may kill a patient, still retains its position as the safest and most but under no circumstances does this drug render satisfactory anaesthetic drug. Although new drugs a strong young man or woman a permanent and new techniques of administration have been cripple or a jibbering idiot, which is far from being developed of recent years, these are associated the case with some of our modern anaesthetic with disadvantages of such magnitude that the techniques. pre-eminence of ether is not challenged. It is Let the general practitioner anaesthetist remain particularly in the treatment of war casualties faithful to his well tried and trusted friend-ether. that the use of ether has been deprecated. He will have no cause to regret his trust.