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.