CONVULSIONS UNDER DEEP ANESTHESIA

FOSTER H. BOWMAN, M.D.

YONKERS, N. Y.

S EARS1 reported z cases of convulsions

under deep ether anesthesia. He re- viewed the Iiterature on the subject and

gave a resume of the opinions of various commentators on the cause of this condi- tion. The very fact that there are so many different causes ascribed for the condition, causes one to beIieve that there may be different types coming under the observa- tion of these different reporters, and the phenomenon observed by one may be entireIy different from that observed by another.

h/Iy own opinion is that there are at least three types of convuIsions occurring under anesthesia. Every surgeon has ob- served the convulsions of beginning ether or nitrous-oxide narcosis. These convuI- sions are of a coarse clonic type, in the case of nitrous oxide often becoming tonic with great danger of asphyxia. These convulsions are probabIy respiratory in origin and due to too rapid administration of the anesthetic, with backing up in the blood of excess carbon dioxide. UsuaIIy withdrawa of the anesthetic wiI1 suffice to stop the convulsion.

Then during the War there were re- ported a number of toxic deaths from ether. This, I believe, was found to be due to toxic impurities in the ether, and the source of contamination being found and eradi- cated, no further diff%uIty was experienced with ether. Convulsions, as I remember, were a prominent symptom in those deaths. I have never seen this type, but Iiterature contained innumerabIe refer- ences to it at that time.

However, there is a type of convulsion which occurs in deep ether anesthesia that I beheve bears very Iittle reIation to the foregoing. It usuahy occurs in ex-

i J. ,4. AI. A ., 100: I IS”, 1933.

tremely toxic patients and usuahy in young chiIdren. The course is something Iike this: The anesthesia is progressing very niceIy; there is no cyanosis or paIIor, the respira- tions are fuII and normaI, the pupils are contracted down in the third stage of narcosis. The anesthetist first feeIs a tightness in the muscIes of the throat as he hoIds the mask, and thinking that the patient is probabIy coming out, he usuahy looks at the pupiIs and finds them dilated. Then he is sure that the patient is coming out and gives more ether with the resuIt that the tightness increases. UsualIy he then notices a twitching of the eyeIids and possibIy of the eyebaIl, and facia1 muscles. FoIIowing that the convuIsions, in true epileptic fashion, spread to the muscIes of the arms, then the Iegs and finaIly the abdomen. If ether is given they are in- creased. Oxygen has no effect upon them whatever. Chloroform stops them immedi- ately. This type is probabIy due to an intense toxemia which acts as a sensitizing agent, and the ether, which normaIIy wouId be without effect, becomes enough of a

cerebra1 irritant to initiate the convulsion.

The foIIowing case iIIustrates this type:

The patient was a chiId two vears of age. The birth had been difhcuh, with”instrumenta- tion and the baby had been bottIe fed. tIow- ever there was no history of birth injury or convuIsions at any time. The baby had done we11 under a formula and was somewhat over norma weight with a rather pasty or waxy coIor to the skin. The bIood count was: red bIood ceIIs 5,115,ooo; Ieucoqtes 22,000;

poIvmorphonucIears 92 per cent; temperature 10&r.; respiration 50; puIse 140. The urine showed no kidney involvement and was norma in amount. The pediatrician found no evidences of thymus or other endocrine derangement. Four days previous to admission she became sick with nausea and vomiting and other signs

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296 American Journal of Surgery Bowman-ConvuIsions FEr3RUARY. 1934

of an intestina1 upset. There was no Iocalized The baby was very toxic but perfectIy rationa tenderness or rigidity unti1 the morning of unti1 about three o’cIock the foIIowing morning. admission. On admission there was no question She then began to show signs of cardiac failure, of an acute condition in the abdomen, probabIy with puImonary edema and finaIIy died about a ruptured appendix. On operation, done at four o’cIock. once, generahzed peritonitis was found with The convuIsions Iasted five minutes; tota a IittIe more exudate and reaction around time of anesthesia twenty minutes. the appendix than eIsewhere. The appendix was removed. WhiIe tying off the stump, the

Ether was from a newIy opened can of

phenomena just described began. Oxygen Squibb’s ether; onIy 2 ounces being used.

was given and removed and repeated. How- The remaining ether in the can was used

ever, no results were apparent. Withdrawing in the next operation without unusua1 resuIts.

the mask entireIy for a few minutes had no The anesthetic was given by an experienced

effect. Three times we attempted to resume and competent technician in a very carefu1

the ether and each time the convuIsions be- unhurried manner and by the open drip

came more severe. FinaIly chIoroform was method.

given and the convuIsions stopped instantIy. There was no cyanosis unti1 after the convuI-

The operation was finished under that anes- sions began.

thetic, with no return of the convuIsions. The organism on cuIture was found to be

There were no convuIsions after the operation. Streptococcus viridans.