ETHER ANAESTHESIA Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from 1842 - 1900* By BARBARA M. DUNCUM, D.Phil., Nuffield Department of Anaesthetics, University of Oxford

by touch. For the oil is greasy; the water not at Pre-anaesthetic History all so. Then preserve the separated oil for further The first man to give an unequivocal description use. of the distilling of ether from sulphuric acid and was Valerius Cordus,' about the year I540. The Properties of the Substance which has been Separated Cordus called ether "sweet oil of vitriol," and his "It has all of the properties of sulphur, but all of account of his method of preparing it and of its them are more pronounced because it penetrates properties (see Fig. I) has been translated by Guy liquids more easily, and hastens actions, which K. Tallmadge as follows: sulphur cannot do because it is impeded by its own solidity and dryness, by which it is less pene- "Take six fluid ounces of strong, very biting, trating. This, indeed, this oil can do better than thrice purified wine, and the same quantity of sour sulphur, wherefore it is especially valuable for all oil of vitriol. Mix in a-Venetian glass, and place in putrefactions in the body, and particularly for the a small gourd with a narrow mouth, and seal the plague. It draws the pus and mucus from the mouth with clay. Set aside thus for a whole lung in pleurisy, peripneumonia and hacking cough, month, or two. Then pour out into a gourd to for it may be securely taken internally, and without which should be immediately connected, and sealed any danger. It does not cause stones to form,Protected by copyright. by the heat of the fire, an alembic (that is, ein kolb either in the kidneys or in the urinary bladder; it mit einen angeschmeltzen helm), which we illustrate heals an exulcerated urinary bladder. Its dose below; now place in a small furnace and half cover is one or two drops, or three mixed in a moderate it with ashes. After this, apply a receiving vessel quantity of wine. It may be mixed, moreover, and carefully close the joint with clay, and extract into pills and electuaries made of sugar. It must the six fluid ounces of strong wine which you added. be carefully preserved, however. For only a little But, so that this may be done safely, place into a is got from a pound of sour oil of vitriol, and bath of Maria: thus the wine alone will ascend, because of the tenuity of its nature it easily eva- without the oil. WVhen you shall have extracted porates."2 in the bath the six fluid ounces of strong wine which had been added, place the residue in the The name cether seems first to have been applied furnace so that sand is heaped up to the middle to the liquid by August Siegmund Frobenius.3 part of the gourd, and, having applied a new, small, He demonstrated various of its properties, real empty receiving vessel, carefully seal the joint with and imaginary, before the Royal Society during clay. Now make a slow fire, and slowly extract February of the year I730. Among Frobenius's http://pmj.bmj.com/ all of the moisture which remains in the gourd, experiments on that occasion was one to show until no longer in the bottom, always liquid appears be best .. . using the greatest care and watchfulness that you "that this Ather may preserved so moderate the fire that the boiling liquid never under the Receiver in Vacuo, whereas on the reaches the tube of the alembic. . . Whexi you contrary, exposed to the open Air, its Parts soon have completed the slow extraction, at once remove evaporate, and its whole Bulk . . . vanishes." the receptacle, with its liquid, and you will see Upon which the Royal Society's reporter com- that it contains two substances, namely, an aqueous mented, "This experiment fail'd remarkably." In liquid and an oily, fatty one. You should separate another experiment with ether Frobenius showed on September 29, 2021 by guest. one from the other at once, however, so that no that "a little of it poured on the Surface of the aqueous substance remains in the oil, for that Hand, affects it with a Sense of Cold equal to that water spoils the oil. The oil itself generally floats the Contact of Snow, and blow upon it but upon the water, especially if the wine shall have from first been entirely extracted upon the bath, but once or twice with your Mouth, immediately your you can easily distinguish the oil from the water Hand becomes dry. Beware however of approaching a lighted candle with your Hand thus wet, lest it *Some of the material relating to inhalation anaesthesia take Fire and burn you"-to which account is contained in this article is based on Dr. Duncum's book, appended the comment, "Succeeded." The Development of Inhalation Anaesthesia with Special During the last decade of the eighteenth century, Reference to the Years I846-I900, now in course of publi- cation by the Oxford University Press for the Wellcome after Lavoisier had elucidated the true nature of Historical Medical Museum. respiration and had shown the part played in it October, I946 ETHER ANAESTHESIA, 1842-1900 281 Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from by oxygen and carbon dioxide, and after Priestley and a great depression of spirits; for many days had inhaled oxygen, a new therapeutic vogue came the pulse was so much lowered that considerable into being. This was pneumatic medicine, in fears were entertained for his life."'5 which various gases and vapours-among them These effects were quoted in I839 by the pharma- sulphuric ether-were inhaled in order to cure not cologist, Jonathan Pereira,6 and he recounted also only physical complaints, particularly pulmonary that "the chemist Bucquet, who died of schirrhus ones, but also such mental ailments as melancholy. of the colon, with inflammation of the stomach and Pneumatic medicine had its origins in part in the of the intestines generally, took, before his death, very brilliant circle of learned men centred in a pint of ether daily to alleviate his excruciating Birmingham, of whom Priestley was one. It cul- pains." minated in the founding by Thomas Beddoes, of Referring to the inhalation of ether vapour, the Pneumatic Institution at Clifton, Bristol. Pereira noted its use "in spasmodic asthma, Describing, for example, the method of inhaling chronic catarrh, and dyspnoea, whooping cough, ether devised by the physician R. J. Thornton, and to relieve the effects caused by the accidental about I795, Beddoes wrote: inhalation of chlorine gas." He stated that the "The manner of inhalation is very simple. Two physiological effects "have not been determined," tea-spoonfuls of ather are put into a tea pot. This and described how, after giving fifteen drops to a is held near a candle, and the thumb is put over young rabbit, its death took place within an hour. the spout. When the vapour begins to press on "The symptoms were indisposition to move, the thumb, it [the spout] is transferred to the apparent tendency to sleep, followed by incapacity mouth, and air is drawn into the lungs. This is of supporting the erect position, occasional con- repeated until the whole be consumed, or ease vulsive movements, grating of the teeth, and acquired."4 insensibility."

Beddoes added a warning that "the vapour of Protected by copyright. aether is inflammable in air." The Trial of Ether as an Anaesthetic . After Humphry Davy's demonstrations at the At the time when Pereira wrote, and during the Pneumatic Institution (of which he became Super- next few years, the inhalation both of intendent in I798, at the age of nineteen) that and of ether vapour not for therapeutic reasons inhaled nitrous oxide-in addition to other, more but as a form of entertainment was extremely weighty, physiological considerations-was capable popular, especially in the United States of America. of inducing a state which was both pleasurable to Indeed, in May I846, the Lancet quoted the the subject and entertaining to onlookers, the Western Journal in which "Dr. Miller calls attention "laughing gas" was very frequently inhaled for to the pernicious effects of the inhalation of this amusement's sake. vapour [ether]-a habit which seems to prevail A similarity in the effects of nitrous oxide and among young persons in some districts of the of ether vapour when inhaled was pointed out in United States."7 i8i8 in the Journal of Science, of which Michael Such an ordinary gathering and its very unusual Faraday was then editor. results were described by the young general http://pmj.bmj.com/ practitioner Crawford Williamson Long: "When the vapour of ether mixed with common air is inhaled, it produces effects very similar to "In the month of Dec. I84I, or in Jan. I842, the those occasioned by nitrous oxide. A convenient subject of the inhalation of nitrous oxide gas was method of ascertaining the effect is obtained by introduced in a company of young men assembled introducing a tube into the upper part of a bottle at night in the village of Jefferson, Ga., and the containing ether, and breathing through it; a party requested me to prepare them some. I in-

stimulating effect is at first perceived at the epi- formed them I had not the requisite apparatus for on September 29, 2021 by guest. glottis, but soon becomes very much diminished, a preparing or preserving the gas, but that I had an sensation of fulness is then generally felt in the article (sul. ether) which would produce equally head, and a succession of effects similar to those exhilarating effects and was as safe. The company produced by nitrous oxide. By lowering the tube were anxious to witness its effects, the ether was into the bottle, more of the ether is inhaled at each introduced and all present in turn inhaled. They inspiration, the effect takes place more rapidly, were so much pleased with its effects that they and the sensations are more perfect in their afterwards frequently used it and induced others resemblance to those of the gas.... to do the same, and the practice soon became quite "It is necessary to use caution in making experi- fashionable in the county and some of the conti- ments of this kind. By the imprudent inspiration guous counties. of ether, a gentleman was thrown into a very "On numerous occasions," Long added, "I lethargic state, 'which continued with occasional inhaled ether for its exhilarating properties, and periods of intermission for more than thirty hours, would frequently, at some short time subsequent 282 POST-GRADUATE MEDICAL JOURNAL October, I946 Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from to its inhalation, discover bruised or painful spots diverted by a valve in the mouthpiece, and escaping on my person which I had no recollection of causing into the apartment is thus prevented from vitiating and which I felt satisfied were received while the medicated vapour."9 under the influence of ether. I noticed my friends while etherized ieceived falls and blows which I The fact that this inhaler (which was io cm. in believed were sufficient to produce pain on a diameter) was held in the administrator's warm person not in a state of anaesthesia, and on ques- palm, which automatically aided the vaporisation tioning them they uniformly assured me that they of the ether, was an accidental but a very important did not feel the least pain from these accidents. point in its favour. Observing these facts I was led to believe that anaesthesia was produced by the inhalation of Very soon after Morton's public demonstration, ether, and that its use would be applicable in various distinguished men in Boston sent word of surgical operations."8 the great surgical innovation, etherisation, to their friends in the Old World. How Long then, in March I842, poured ether on The first to receive the news in England was to a folded cloth and caused the boy, James Francis Boott, of Gower Street, London, and he Venable, to inhale the vapour so that he became and a dentist named Robinson lost no time in sufficiently insensible to allow two small tumours administering ether to a young lady for the extrac- to be painlessly removed from his neck is well tioni of a tooth. Boott also passed on the news known. So also is the not dissimilar sequence of to the surgeon, Robert Liston. events which, in December i844, led Horace Wells An eye-witness named Forbes described how, to conceive and put into practice the idea of on December 22, I846, inhaling nitrous oxide to obtund the pain of dental "in the theatre of University College Hospital, extractions. That he should have failed to produce Mr. Liston amputated the thigh of a man previously satisfactory anaesthesia in his patient during the narcotised by inhalation of the ether vapour. demonstration at the Massachusetts General Hos- Shortly after being placed on the operating tableProtected by copyright. pital in Boston, arranged through his former dental the patient began to inhale [from an apparatus partner, W. T. G. Morton, was a piece of extremely prepared by Squire (Fig. 2)], and became apparently bad luck. insensible in the course of two or three minutes. When in the summer of I846 Morton himself The operation was then commenced, and the limb decided to experiment in obtunding the pain of was removed in what seemed to us a marvellously short space of time-certainly less than a minute, tooth extractions, it is not so very. surprising that the patient remaining, during the incisions and the he should have chosen sulphuric ether as his tying of the arteries, perfectly still and motionless. anodyne agent. Indeed, he had actually used While the vessels were being secured, on being liquid ether in I844, at the suggestion of his spoken to he rose partially up (still showing no former chemistry tutor, C. T. Jackson, -as a local signs of pain) and answered questions pyt to him application to deaden pain in a tooth. in a slow drowsy manner. He declared to us that In his first clinical trial of etherisation, when on at no part of the operation had he felt pain, though September 30, I846, he painlessly extracted Eben he seemed partially conscious; he had heard some Frost's aching tooth, Morton poured the ether on words, and felt that something was being done to his limb. He was not aware, till told, that the http://pmj.bmj.com/ to a folded cloth. He had for some time past limb was off, and when he knew it, expressed great been trying to adapt various pieces of apparatus gratification at having been saved from pain."iO for administering ether and, not finding the folded cloth method entirely satisfactory, he In France the first trial of etherisation was made redoubled his efforts to devise a satisfactory by the surgeon, J. F. Malgaigne, towards the inhaler. middle of January i847. He described at a At the very last minute before his all-important me.eting of the Academie de Medecine in Paris, demonstration of etherisation at the Massachusetts how-having no such inhaler as was used in on September 29, 2021 by guest. General Hospital, on October i6th, Morton, with America and England-he took a simple tube into the assistance of the Boston physitian, Augustus which he put some ether and then introduced the A. Gould, designed and had made "a small two- end of it into the patient's nostril, the other nostril necked glass globe" to contain an ether-soaked being plugged. "I took care," said Malgaigne, sponge. H. J. Bigelow, who was present at the "that inspiration took place with the mouth closed, demonstration on October i6th, described the expiration with the mouth open."'1" Several of working of the inhaler as follows: Malgaigne's colleagues subsequently followed his "One aperture admits the air to the interior of example in making their patients inhale ether the globe, whence, charged with vapour, it is drawn. vapour through one or both nostrils. Others through the second into the lungs. The inspired preferred to use the American and English types air passes throug-h the bottle, but the expiration is of sponge-filled flask. October,- I946 ETHER ANAESTHESIA, 1842-1900 283 Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from In the meantime Morton had taken out a patent "He (Dr. Snow) was getting an instrument made to cover the use of etherisation and its adriinistra- which would enable the surgeon, merely by placing tion by any such means as his inhaler. At the it in a basin of water, warmed or cooled to a given Massachusetts General Hospital, John Mason temperature, to administer an atmosphere of any Warren in February I847 decided, in view of the strength he wished, and by this means to gain patent, to abandon the use of any inhaler and correct experience to guide him in future."'l4 instead to pour t14e ether directly on to a small A week later Snow showed his first ether inhaler bell-shaped sponge which was then held firmly at the Westminster Medical Society; and during over the patient's nose and mouth.'2 the spring of I847 he continued to improve it This procedure proved so simple and so effective (see Fig. 3a). One of the biggest of these improve- that it was widely adopted in the United States. ments was the adoption of a valved facepiece Indeed, from that time until the close of the (see Fig. 3b) (based on a valveless facepiece nineteenth century, a sponge or a sponge enclosed invented by Francis Sibson) instead of the usual in a folded towel was there the method of adminis- mouth-tube and nose-clip. tration almost exclusively used. Notwithstanding the fact that some adminis- In this way the Americans had found a means of trators were beginning to master the technique of avoiding the worst difficulties of etherisation; but etherisation, when Professor J. Y. Simpson, in in Great Britain and on the European Continent November I847, described the simplicity with anaesthesia was becoming less and less satisfactory which the far more potent anaesthetic, , as inhalers grew more conplicated. Summarising could be administered from a folded cloth, the use the common faults of these early inhalers John of ether was immediately and generally discarded. Snow, famous to-day as the first specialist anaes- In England ether anaesthesia was neglected thetist, wrote: during the next twenty-five years; on the Continent of Europe as a whole, it remained in disrepute

"When the inhalation of ether was first com- Protected by copyright. menced, the inhalers employed consisted generally until the last decade of the nineteeth century; even of glass vases containing sponge, to afford a surface in Boston it was for a short time discarded. for the evaporation of the ether. Both glass and Besides the Americans in the Northern States of sponge being very indifferent conductors of caloric, the Union, only the surgeons of Lyons-and the interior of the inhalers became much reduced following their example, the surgeons of Naples- in temperature, the evaporation of ether was very soon returned to the use of etherisation, after much checked, and the patient breathed air much colder than the freezing point of water, and con- deaths from chloroform had begun to occur. In taining very little of the vapour of ether. On the Austrian Empire, and in Vienna in particular, this account, and through other defects in the a compromise was made, and mixtures containing inhalers, the patient was often very long in becoming chloroform and ether in varying proportions, were insensible, and, in not a few cases, he did not preferred to the use of either agent alone. become affected beyond a degree of excitement and It seems probable that the reason why the inebriety."13 surgeons of Lyons returned so readily to the use Inhalers intended to overcome these defects had of ether was because, before the introduction of been produced, but until the principles laid down chloroform anaesthesia, they had been using an http://pmj.bmj.com/ by Snow himself began to be appreciated, designers effective methQd of etherisation. This was Roux's often showed themselves more remarkable for sac, "a bag, made like a lady's reticule, its opening ingenuity than for insight into the problems of being dilated or contracted by the drawing or ether vaporisation and inhalation. loosing of the strings around it, and lined by a pig's At a meeting of the Westminster Medical Society bladder. ... In using this apparatus, the mouth on January i6, I847, Snow read a paper on the and nostrils are both placed in the sac drawn over

vaporisation of ether, in which he is reported to them, and inhalation goes on with the ether vapour on September 29, 2021 by guest. have said that given off from sponges soaked in ether, and placed "the great effect of temperature over relations of in the bladder.''l5 atmospheric air with the vapour of ether, had Before the inhalation of ether was superseded by apparently been overlooked in the construction that of chloroform, a few interesting experiments and application of the instruments hitherto used. on rectal etherisation were made in the laboratory ... The operators did not at present know the and clinically. In France Marc-Dupuy, injecting quantity of vapour they were exhibiting with the liquid ether mixed with water into the rectums of air; it would vary immenselyS according to the dogs, found that anaesthesia was rapidly estab- temperature of the apartment." lishe,d and caused but slight inflammation of the Snow gave a table setting out the volumes of rectal mucous membrane. He came to the con- ether vapour which, at different temperatures, one clusion that this method of rectal administration hundred cubic inches of air would contain. was likely to prove safer than inhalation of the 284 POST-GRADUATE MEDICAL JOURNAL October, 1946 Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from vapour.16 In Russia, the surgeon, Nikolai Ivano- extremely desirable to obtain an anaesthetic agent vich Pirogoff, after experimenting on animals, which shall be capable of producing the requisite evolved a satisfactory method of introducing ether insensibility, and yet is not so dangerous in its vapour into the rectums of his patients. After operation as chloroform. washing out the rectum, he introduced into it one "Ether, to a certain extent, fulfils these condi- end of a rubber catheter, the other end being tions, but its odour is disagreeable, it is slow in its connected to a small container surrounded by a operation, and gives rise to greater excitement than warm water-jacket, so that the liquid ether put chloroform. The committee therefore concur in into it should be immediately vaporised. He the general opinion which in this country has led claimed that anaesthesia was established in from to the disuse of ether as an inconvenient anaes- three to five minutes and that there were no thetic." undesirable after effects.17 As a compromise the committee suggested that The intravenous injection of ether, also, was mixtures of chloroform and ether should be used, tried on dogs, but the results were not very and in particular recommended the A.C.E. mixture encouraging. The physiologist, P. J. M. Flourens,18 which consisted of one part alcohol, two parts in I847, found that the dogs became "drunk" but chloroform, and three parts ether.2' not insensible, and Thomas Nunneley, of Leeds, Although such mixtures did not immediately two years later reported only that after the injection become popular, a few people began to use a of sulphuric and of acetic ether "the symptoms chloroform and ether sequence, inducing anaes- preceding death, and the appearance presented thesia with the more easily-manageable agent afterwards, do not differ materially from those chloroform, and maintaining it with the safer caused by inhalation."'9 Although P. C. Ore, of agent ether. Not long after the introduction of Bordeaux, used the intravenous injection of nitrous oxide into English dental practice in i868, hydrate successfully in a few cases during the early J. T. Clover began to use his famous "gas and eighteen-seventies, it was not until I909, after ether" anaesthesia.22 Protected by copyright. Ludwig Burkhardt had devised a satisfactory An unsuccessful attempt to arouse English method of administering ether intravenously, that interest in ether as the sole anaesthetic, adminis- this method of anaesthesia was adopted in practice. tered by the American method, was made by J. Warrington Haward, in i87I.23 In the following year, however, B. Joy Jeffries, an ophthalmic The Interim Period surgeon from Boston, Massachusetts, came to While Lyons and Naples remained, during the London to attend a conference. He also came eighteen-fifties and sixties, the only two cities in determined to convince the English chloroformists Europe where ether as the sole anaesthetic was of the error of their ways. regularly used in preference to chloroform, in i86i Jeffries opened his campaign by reading a paper Thomas Jones gave ether a re-trial at St. George's on "Ether in Ophthalmic Surgery," in which he Hospital in London. described the American procedure: Some years afterwards he wrote:

"A towel rolled into a cone, with a napkin or http://pmj.bmj.com/ "Although it was administered on a large conical sponge pushed to the top of the inside, is all we sponge (a very objectionable mode), I succeeded in need to pour our ether on, whilst our fingers can almost all cases in producing the necessary degree mould it over any mouth and nose...... Now of narcotism. It was given for several capital if the patient is warned that the ether will choke operations, and in cases requiring careful dis- him, and told when this occurs to take long breaths section, such as herniae, with complete success. to relieve it, and not struggle and endeavour to In the following year I discontinued its use, how- push away the sponge, many will go to sleep quietly ever, in the operating theatre, on account of the and without trouble to themselves or the surgeon. inconvenience occasioned to those present, by the . . . When the patient, whether old or young, on September 29, 2021 by guest. smell of the vapour, and from the time it took in struggles, alid asks for a respite and fresh air, do some cases to get the patient under its influence. not yield. Hold them down by main force, if I, however, continued its use in cases which necessary, and at any rate, keep the sponge tight were considered unsafe for chloroform, such as for over the mouth and nose till they finally take long those in a state of collapse from severe accidents."20 breaths and then go off into ether-sleep."24 In I864 the committee appointed by the Royal The London chloroformists were a little startled Medical and Chirurgical Society, to investigate by Jeffries's methods, but at the same time they the physiological action of chloroform anaesthesia, were comeplled to recognise the fact that, given in made its report. As a result of comparative this way, ether could be a very efficient anaesthetic series of experiments, using chloroform and,ether, agent. the following conclusion was reached: "It is . . . During the autumn of I872 the British Medical October, I1946 ETHER ANAESTHESIA, 1842-1900 285 Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from Association, through the medium of its journal, anaesthesia had been adopted independently by encouraged anaesthetists to make a fresh trial of the surgeon, Oscar Wanscher, of Copenhagen. etherisation, and by I873 the revival of its use was He administered ether both rectally,28 by a method well-established in England. which was in principle that used by Pirogoff in I847, and by inhalation, using an inhaler based on The Use of Ether Anaesthesia Re- Ormsby's, but without any air inlet or sponge, the liquid ether being poured straight into the bag.29 established A colleague of Wanscher's, Axel Yversen, visiting During the first few months of the revived use Lyons in I884, asked the surgeon, Daniel Molliere, of etherisation, variants of the American method whether he administered ether rectally. This of enclosing a sponge in some kind of cone-made, prompted Molliere to try the rectal route and his for example, from a folded towel, from felt, or from success attracted some attention in the United cardboard-were by far the most commonly used, States. In a leading article, the Boston Medical and this was to be expected. But gradually the and Surgical Journal in May i884,30 stressed the English preference for mechanical inhalers began particular usefulness of rectal etherisation in leaving to reassert itself. Unlike the inhalers of I847, the surgeon a clear field in operations involving which aimed at diluting each breath of ether the head and neck. It was this consideration, vapour with atmospheric air, the majority of also, which led D. W. Buxton to develop his own inhalers designed during the eighteen-seventies method of rectal etherisation about i890.31 made use of re-breathing. Of these inhalers the As for Wanscher's method of inhaling ether, his two best-remembered to-day are Clover's "portable first convert to it outside Denmark was the regulating inhaler"25 (see Fig. 4), and Ormsby's gynaecologist Landau, of Berlin, whose clinic inhaler26 (see Fig. 5), which were first described in Wanscher visited during the early part of I890. the medical joumals early in- I877. In August I890, the Tenth International Con-

At the time when the English were thus en- gress of Medicine was held in Berlin, and in theProtected by copyright. thusiastically rediscovering the advantages of ether course of the proceedings the American pharma- anaesthesia, France and Germany were recovering cologist, Horatio C. Wood, read a paper on from the effects of the Franco-Prussian War, and anaesthesia, in which he emphasised, with statistical it seems likely that this was a strong reason why details, the far greater safety of etherisation as the general revival of etherisation on the European compared with chloroform anaesthesia.32 This Continent was delayed for more than fifteen years paper made a great impression upon the Germans, longer. and Ernst Gurlt was commissioned by the German In I877, however, the surgeon, Gustave Julliard, Surgical Society to compile independent statistics of Geneva, after a death from chloroform had relating to the safety of the two agents. These occurred in his practice, abandoned the use of that were published annually.33 anaesthetic and adopted ether. He administered Gurlt's results weighed heavily in favour of it from a large, wire frame, the outside of which ether, and by I894, as an outcome of his investi- was covered with waxed cloth to make it imper- gation, a number of German surgeons were trying meable to air, the inside with surgical gauze on to ether anaesthesia either by Julliard's method or http://pmj.bmj.com/ which the ether was poured. This mask was by Wanscher's. Following the German example, subsequently modified by F. L. Dumont, of Berne, about I895 a few French surgeons, the Lyonnais who added a hinged, inner frame (to allow soiled apart, began tentatively to use ether.34 gauze to be changed more easily) and attached a The last major development in ether anaesthesia rosette of flannel to the gauze to receive the dose which had its beginnings during the first fifty of ether (see Fig. 6). The mask did not fit the years of anaesthetic practice was the adoption of face accurately, and when it was desirable to the open drop method. deepen anaesthesia a folded towel was laid round As long ago as i862 Thomas Skinner,35 of Liver- on September 29, 2021 by guest. the rim to reduce the amount of air filtering in. pool, had introduced the use of a small, wire face- But as inl any case the carbon dioxide accumulating mask, covered with woollen fabric, on to which under it was considerable, it was also necessary chloroform was dropped from a specially adapted to turn the mask aside from the face at intervals bottle; and this simple and effective method had throughout administration, as is shown in Fig. 6.27 proved popular, particularly in Germany. The use of Julliard's method of etherisation In I874 the American, 0. H. Allis, had introduced slowly spread northward into south Germany, the use of what he claimed was an open ether and it was adopted in particular by Bruns and inhaler.36 It consisted of a leather cover, shaped Garre, at Tubingen, during the late eighteen- rather like a detachable shirt-cuff, enclosing a eighties. similarly shaped, oval, metal cage, its internal At the beginning of the eighteen-eighties ether space being occupied by layers of bandage threaded 286 POST-GRADUATE MEDICAL JOURNAL October, I946 Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from across and across round the bars of the cage. One I902, that chest complications, far from being of the open ends of this inhaler was applied to the primarily due to the anaesthetic, were associated patient's face, and through the opposite end ether with certain types of surgery in which post- was dropped on to the stretched layers of bandage. operative pain deterred the patient from ridding There was, however, a considerable dead-space in himself of bronchial secretions by coughing.40 this inhaler. Furthermore, the specialist anaesthetist was un- It was not until some twenty years later, about known on the European Continent, and the I895, that another American, L. H. Prince, of amount of skill shown by the inexperienced young Chicago, thought of adapting for etherisation the house surgeons, to whom the task of administering open drop method used for chloroform anaesthesia. chloroform or ether -was relegated, was often "During the past two years," he wrote in. I897, inadequate. From the early eighteen-nineties on- "I have been using an ordinary Esmarch's chloro- wards a reasonably satisfactory way out of this form mask for administering ether, and have found difficulty was found-the surgeons themselves that, as a rule, it answers the purpose very well prepared a painless operating field. This they did indeed, with the single exception that the small either by adopting Schleich's method of infiltration surface area delays the production of complete anaesthesia or, after I899, by using Bier's spinal in some cases. I am having made a anaesthesia, and a little later still, regional anaes- mask, similar in principle to the Esmarch, with some modification in size and shape, that I feel thesia. confident will answer the purposes of both chlorofonn The example set in Germany was generally and ether administration, at least until something followed on' the Continent, and a similar systetn better is presented."37 had been adopted in the United States, although there the idea of training and employing specialists In America the open drop method of adminis- was at the same time growing in favour.41 tering ether was developed at the Mayo Clinic In Great Britain the Scots remained as they had during the first ten years of the present century, always been, content with chloroform. But to theProtected by copyright. and it was adopted in England about I908, an English professional anaesthetist at the close of early advocate being H. Bellamy Gardner. the nineteenth century, ether was still the anaes- During the opening years of this century open thetic of choice in major surgery. The Continental drop ether was independently adopted by one or and American highly technical methods of local two German surgeons, notably C. Hofmann,38 of and regional anaesthesia not unnaturally made Cologne, and Oscar Witzel, of Bonn.39 little appeal to him, trained as he was in the Despite this new development, German interest refinements of inhalation anaesthesia. Neverthe- in inhalation anaesthesia, and in ether anaesthesia less, he was not so much looking forwards as in particular, had been declining since about I895. backward-to chloroform anaesthesia. Whereas In the upper-abdominal surgery which German no important new type of inhaler had been surgeons were then increasingly undertaking, post- designed for ether since Clover and Ormsby had operative chest complications were extremely launched theirs in I877, the year I903 saw the liable to follow, and a ready explanation for their Harcourt inhaler which, by limiting the amount of occurrence appeared to lie in the use of ether chloroform in the inhaled mixture to a maximum http://pmj.bmj.com/ anaesthesia. This explanation was widely accepted of 2 per cent was, it was hoped, about to make although Campiche, of Lausanne, pointed out in chloroform anaesthesia safe at last. REFERENCES i. CORDUS, V. (I561), Annotationes in Pedacii Dioscoridis Anazarbei 22. Discussion. (I87I), Med. Times, Lond., 2, 604. de materia medica hIbros quinque. Strasbourg. ff. 228v., 22gr. 23. HAWARD, J. W. Ibid., 603. 2. TALLMADGE, G. K. (1925), Isis, 7, 409-10. 24. JEFFRIES, B. J. (I872), Lancet, 2, 24I-2. 3. FROBENIUS, A. S. (I729-30), Philos. Trans., 36,283-9. 25. CLOVER, J. T. (I877), Brit. Med. J., 1, 69. 4. BEDDOES, T., and WATT, J. (I796), Considerations on the Medicinal 26. ORMSBY, L. H. (I877), Lancet, 1, 2I81 Use of Factitious Airs. Bristol. 143. 27. DUMONT, F. L. (1903), Handbuch er aligemeinen und lokalen on September 29, 2021 by guest. 5. Note. (i8i8), Journal of Science, 4, 158-9. Anaesthesie. Berlin and Vienna. 37. 6. PEREIRA, J. (I839-40), The Elements of Materia Medica. London. 28. WANSCHER, 0. (I884), Trans. Int. Congr. Med., 2(v), i86. 2o6. 29. Editorial. (I884) Boston Med. Surg. J., 110, 45I. 7. Report. (i846), Lancet, 1, 605. 30. BUXTON, D. W. (I892), Anaesthetics: their Uses and Administration. 8. YOUNG, H. H. (I897), Johns. Hoph. Hosp. Bull., 8, i82, London. 86-8. 9. BIGELOW, H. J. (1847), Brit. Foreign Med. Rev., 13, 310. 31. DUMONT, F. L., op. cit. 42. lo. FORBES, -. (i847), Lond. Med. Gaz., 4, 38. 32. WOOD, H. C. (I89I), Trans. Int. Congr. Med., 1, 233. ii. Report. (I846-7), Bull. Aced. Mid., Paris, 12, 262-3. 33. GURLT, E. (I89I), Dtsch. Med. Wschr., 17, 599; Ibid. (i89z), 12. WARREN, J. C. (I897), Trans. Amer. Surg. Ass., 15, 1-25. 18, 735. 13, SNOW, J. (i858), On Chloroform and other Anaesthetics. London, 348. 34. CHAPUT, P., et al. (i895), Bull. Soc. Chirurgie, Paris, 21, 368. 54. Report. (X847), London. Med. Gaz., 4, i56. 35. SKINNER, T. (I862), Retrosp. Practical Med., 46, i85. I.5. Report. (1847), Lancet, 2, os2. 36. TURNBULL, L. (i88o), The Advantages and Accidents of Artificial I6. MARC-DUPUY, -. (1847), C.R. Acad. Sci., Paris, 24,605. Anaesthesia. London. 237. 17. PIROGOFF, N. I. Ibid., 789. 37. PRINCE, L. H. (i897), Chicago Med. Rec., 12, 232-40. x8. FLOURENS, P. J. M. Ibid., 482, 38, HOFMANN, C. (I902), Dtsch. Z. Chir., 65,403-I6. I9. NUNNELEY, T. (1849), Trans. Provincial Med. Surg. Ass., N.S. 4, 39. WITZEL, 0. (I902), Muinch. Med. Wschr. 49(ii), I993-4. 268. 40. CAMPICHE, P. (I902), Contribution d l'dtude de la narcose a l'dther. jo. JONES, T. (I872), Brit. Med. J., 2, 603. Geneva. boI-Io4. az. Report. ,(864), Mod.-chir. Trais., 47, 331. 4I. Editorial (2897), Med. Rec., N.Y., 51, 522. Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from

Illustrations ETHER ANAESTHESIA, I842-1900 By BARBARA M. DUNCUM, D.Phil.

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FIG. i.-Valerius Cordus's description (circa. 1540) of the preparation and properties of sulphuric ether. ETHER ANAESTHESIA, 1842-1900 BARBARA M. DUNCUM, D.Phil. Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from

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[FIG. 2.-The inhaler used by Boott and Robinson in December, I846, [ for the first dental operation performed on an etherised patient in England. Protected by copyright. - A

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A. The Urn with its stopper, into which the ether is poured. B. Valve which admits the air. C. Contains sponge saturated with ether. D. Valve which opens at each Inspiration, and closes at each expiration. E. Ferule for regulating the quantity of atmospheric air admitted. F. Valve for the escape of expired air. G. Mouth-piece. H. Lower vase. S. Spring for closing the nose. FIG. 3.-Squire's Ether Inhaler (December, I846). Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from ETHER ANAESTHESIA 1842-1900 ... BARBARA M. DUNCUM, D.Phil. FIG. 4a.-Snow's Ether Inhaler (I847) assem- bled, showing: A, the carrying case, serving also as a water-bath; B, the vaporising cham- ber (see also Fig. 3b); C, opening into which was screwed the air-inlet tube D; E, opening above B, from which the flexible tube F, led the ether-air mixture to the facepiece G, in the MMCA.. floor of which can be seen the inspiratory flap- valve H; I, the facepiece removed (see also Fig. 4b); S, diagram of the vaporising cham- ber B, showing the direction of the air flow.

FIG. 4b.-Details of Snow's Ether Inhaler. The facepiece, showing how the expiratory flap-valve could be turned aside (position shown in dot- Protected by copyright. ted outline) further to dilute the ether-air mixture.

A bove.-The spirally coiled batHe- plate of the vaporising chamber which directed the current of air over the surface of the liquid. http://pmj.bmj.com/

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FIG. 6.-Ormsby's Ether Inhaler (I877). Diagram showing: B, bag; C, cage holding sponge, S; 0, opening of FIG. 5.-Clover's "Portable Regulating air-inlet tube, Fu; SI, slot in Fu, opened Ether Inhaler" (I877). or closed bv the slotted cap, Ca. Postgrad Med J: first published as 10.1136/pgmj.22.252.280 on 1 October 1946. Downloaded from ETHER ANAESTHESIA, 1892-1900 BARBARA M. DUNCUM, D.Phil.

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FIG. 7a. FIGS. 7a, b and c.-Dumont's modification of Julliard's Ether Mask, showing (a) the hinged, inner frame to hold in place the gauze and flannel rosette on to which the anaesthetic dose was poured; (b) the mask, with its impermeable cover, resting lightly on the face, and (c) the mask http://pmj.bmj.com/ turned aside during administration, to allow the accumulated exhaled mixture to escape. on September 29, 2021 by guest. SiPs=

FIG. 9.-Skinner's Chloroform Mask, I862, prototype of the FIG. 8.-Wanscher's Ether Inhaler, based upon Ormsby's. open drop mask.