THE

PRESENT POSITIONOF

ETHER ANAESTHESIA

By

JOHN ELAM, M.R.C.S., L.R.C.P.

(General Practitioner)

Ether has been our good friend and trustedhelper for one hundred years.

But, to-day, some of our colleagues maintainthat this drug should not be used, although manyexperienced practitioners still consider ether tobe one of the best anaesthetic agents.

This difference of opinion arises, I believe,because of the absence of a clear differentiationbetween the action of the anaesthetic drug andthat of the drug used as premedication before theoperation. For example: One writer describedhis "ether patients" as "returning to the ward,snoring, sweating, and gurgling, with relaxedhypertonic muscular system, which results in poorcirculating blood volume . . . and stagnantanoxia," and as taking, on an average, over twohours to recover consciousness.

Such is a picture, not of a patient arriving inthe hospital ward after an ether anaesthetic, butof a patient who has been given an overdose ofsome powerful drug to allay his apprehension ofhis operation.

Before September, I939, I administered one ofthe barbiturates to all my patients before operation.But I found that many of them were a long timein recovering consciousness. This delayed recoverythrew a heavy burden on the nursing staff, and,with the advent of war, I was forced to abandonthis form of premedication because of the shortageof nurses.

After discontinuing the use of the barbiturates,I found that post-operative chest complicationswere markedly reduced and the condition of thepatients greatly improved.

After deep ether anaesthesia without heavypremedication, the time of recovery from when theanaesthetic is discontinued, until the patientregains complete consciousness of his surroundings,averages twenty minutes per hour of etherisation.When light or moderate planes of ether anaes-

thesia are used, as for a hernia operation, thepatient will usually be conscious within ten minutes

of his leaving the theatre. (The nature of theoperation has some influence.)Some reflexes return much sooner than con-

sciousness and after one hour's anaesthesia withether, the patient will usually be moving his headten minutes from the time the anaesthetic is dis-continued.

I usually give as premedication atropinegrs. 1 (hypodermically), and potassium bromide-chloral hydrate (for women 20-30 grains of each-for men, 30-40 grains of each, by mouth). Fromthese drugs the patient obtains relief from anxietyand, if kept waiting in the theatre ante-room,usually falls asleep. Delay in recovering con-sciousness and many of the undesirable post-operative complications, so often attributed toether, are due to over-indulgence in the use of thebarbiturate group of drugs, or of morphia.

If we are to abandon the use of ether after onehundred years of satisfactory experience withthis drug, we must be very sure that the drugs andmethods of administration which we intend touse, have in very truth some special advantage.

It is my purpose to show that, compared withother drugs and techniques, ether remains to-daythe best and the safest anaesthetic agent, and thatthe dangers and disadvantages of "Modern Anaes-thesia"* do not justify our removal of ether fromits place as our foremost anaesthetic drug.

The Failure of "Modern Anaesthesia" to ImprovePost-Operative Results, or to Reduce AnaestheticMortalityThe substitution of what is often called "Modern

Anaesthesia" for ether anaesthesia, has not led toimprovement in post-operative results, or to a fallin anaesthetic mortality. Indeed, Marston suggeststhat 'modern anaesthesia" is associated with anincreasing number of risks.

* By "Modem Anaesthesia" I mean those drugs andtechniques now used in place of ether, such as IntravenousAnaesthesia, Spinal Analgesia, or Cyclopropane Anaes-thesia, and certain other methods.

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POST-GRADUATE MEDICAL JOURNAL

In a recent discussion at the Royal Society ofMedicine, many new agents and techniques weredescribed as having been used in the surgery ofthe upper abdomen.

It was a little surprising to find that the post-operative results mentioned, showed little, if any,improvement on those which we, general practi-tioner anaesthetists, have been obtaining from theuse of ether.

There has been a marked increase in the numberof anaesthetic deaths reported to the Coronerduring the last twenty years.

In I92I-347 deaths under anaesthesia werereported to the Coroner.

In I93I-723 deaths under anaesthesia werereported to the Coroner.

In I94I-835 deaths under anaesthesia werereported to the Coroner.

Thus we find an increase in anaesthetic mortalityduring those years when new drugs and newtechniques were in great part displacing ether inoperative surgery.To explain this upward trend in anaesthetic

deaths, it is said that not only are more operationsperformed to-day than was the case in former times,but that greater surgical risks are now accepted.This statement is not true. Twenty-five years ago,many hazardous* operations were performedwhich are now rarely seen. The general conditionof patients coming to operation now is infinitelybetter than was frequently the case in the past,and one seldom sees to-day those neglected casesof perforated gastric ulcer and intestinal obstructionwhich were once so common and which gave somuch anxiety to the anaesthetist. And, in addition,we have to-day the tremendous advantage ofmodem restorative measures.

The Physiology of Ether AnaesthesiaWe do not know precisely how ether produces

surgical anaesthesia, but it is known that etherhas a depressant action and shields the brain fromdamage by painful stimuli.

Central cortical activity is decreased and lowerpathways blocked. The temperature regulatingcentre is depressed and the voltage and frequencyof action potentials decreased. %

The vasomotor centre is not directly affected.The carotid sinus reflex is depressed, but etherstimulates breathing by reason of its action onthe respiratory tract. The bronchial muscles arerelaxed. Salivation and lacrimation occur in theearly stages of ether anaesthesia, and, during lightanaesthesia, there il an increase in the secretion

* How many of our young anaesthetists have seen theoperation for the partial removal of the maxilla for cancer,performed under chloroform?

of saliva and mucus. Not during deep anaesthesia.Boyd and others are doubtful whether there is

an increase in the output of respiratory tractfluids, and maintain that there is no evidence ofdamage to the cilia lining of the respiratory tract.Ether increases pulmonary ventilation, but in-creased pressure in the airway may be harmful,on occasions.

Negative pressure caused, for example, by theuse of too small an endotracheal tube, may causepulmonary oedema. Bacteria inspired into thelungs during ether anaesthesia will grow un-inhibited by the body defences during the periodof unconsciousness.Liver.-Function decreased, returns to normal

in twenty-four hours. Bile secretion is probablydecreased. Molitor does not believe that thesecretion of bile is decreased.Kidney.-The volume of urine is decreased

and the renal function depressed, although theeffect of ether need not be feared in healthysubjects. Changes in the kidney function maybe due to the extra-renal action of the anaestheticadded to the operative procedures.Heart.-The effect of ether on the heart of

the healthy patient is slight. There is, however,an increase in the heart volume indicating relaxa-tion of the heart tone.Stomach and Intestines.-Movements decreased

action passes off quickly in ten to fifteen minutes.Lymphatics.-Increased flow and absorption.

Ether is not the deadly poison some anaesthetistswould have us believe.

AdministrationEther can be administered:

(A) By Inhalation-(I) By the open drop technique or-(2) From some apparatus such as-

(a) Clover's inhaler.(b) Shipway's apparatus.(c) Oxford vaporiser.

(3) Added to other anaesthetics, e.g. nitrousoxide oxygen (as in Boyle's ap-paratus)..

(B) Per rectum.(C) In combination with local analgesia or spinal

analgesia.

(i) Open Drop EtherA protective pad of gauze with a centre hole is

placed over the face. A wire mask covered withone layer of house flannel is superimposed. Ethylchloride is sprayed gently on to the mask untilregular automatic breathing is established and the

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THE PRESENT POSITION OF ETHER ANAESTHESIAethyl chloride snore is heard. (At this stage thepupils of the eyes will be dilated and there willbe a characteristic squint.)

Ether is then dropped on to the mask just fastenough to enable the individual drops to bedistinguished.

(2) Ether InhalerThere are many inhalers designed to administer

ether, among which:

(a)(b)

(c)

Clover's inhaler andThe Shipway apparatus have proved useful

in the past.The Oxford vaporiser was designed to

administer ether under difficult circum-stances which might arise during war.

Definite and constant percentages of ether in aircan be given, as the ether is kept at an unchangingtemperature by two surrounding jackets, oneholding crystalline* calcium chloride, and theother, hot water.To obtain a pleasant induction, the face-piece

of the apparatus is applied and one short. spray ofethyl chloride is then sprayed into an inductionbag about every two breaths until regular auto-matic breathing is established. Then the indicatorof the machine is turned to 10I5 and the bagturned off. The required plane of anaesthesia isthus quickly obtained.

Endotracheal ether can be administered fromthis apparatus and there is a device for deliveringoxygen. A bellows for inflating the lungs withair or air-oxygen, is attached.As the ether vaporises losing heat, it borrows

the heat held by the molten calcium chloride.Thus the ether remains at a constant temperatureuntil all the molten calcium chloride is reconvertedinto its crystalline form, that is for about twohours, so that there is no variation in the percentageof ether vapour in air.The Oxford vaporiser enables ether to be used

in very hot climates.

(3) Gas Oxygen Ether Sequence from the Boyle'sApparatus

This apparatus has been in use for many years.In addition to the ether bottle a second bottle isusually provided which can be filled with chloro-form, vinesthene-ether mixture, or trilene. Vines-thene-ether mixture is valuable both for obtaininga smooth induction and for giving the anaesthetistthe power to obtain extra muscular relaxation,should this be required in a difficult case.

* The crystalline calcium chloride takes up the heatfrom the hot water, being thus transformed into a moltenshape.

If a cautery or diathermy is to be used duringthe operation, chloroform should be placed in thesecond bottle, and the anaesthetic continued withgas-oxygen-chloroformn.

(B) Rectal EtherThe administration of ether per rectum was

introduced by Gwathmey and is used chiefly inobstetric practice. It holds little advantage overinhalation methods for general surgery.

(C) Ether Anaesthesia in Combination with Localor Spinal Analgesia

Harold Dodd and others advocate a techniqueof infiltration with local analgesia in combinationwith the very lightest plane of ether unconscious-ness. Undesirable effects of deep ether narcosisare avoided and the dangers of local analgesialessened.

However, it must be appreciated that localanalgesia per se, will neither prevent circulatorycomplications nor reduce the incidence of post-operative pulmonary difficulties.Two types of untoward reaction to local anal-

gesia have been reported: Collapse and convulsions.Sudden collapse may be the result of psychologicalreaction, or of an idiosyncrasy towards the localanaesthetic. The cause of convulsions is not clear,but both types of reaction can be fatal.Sudden death from allergy to procaine has been

reported in the medical literature. Several workershave found that the use of procaine (novocaine),inhibits the action of the "sulpha" group of drugs,to a considerable extent. Ether can also be admin-istered to render a patient unconscious duringspinal analgesia, or to make it possible to con-tinue a long operation if the effect of a single doseof spinal analgesia should wear off.

Is Ether Anaesthesia Obsolete for Casualtyor Military Surgery?

It has been stated that many practitioners whohad to treat air-raid and military casualties duringthe war, came to the decision that ether anaes-thesia should be avoided, and that intravenouspentothal was the anaesthetic indicated. Myexperience leads me to take a view which is instrong opposition to this precept.For many years before the war I worked at a

hospital which had to deal with a large number ofroad accidents. During the war years, at this samehospital, we had our share of air-raid casualties.and, after Dunkirk, of wounded soldiers. Etheranaesthesia gave excellent results in the surgicaltreatment of such cases and I have come to believethat ether is the anaesthetic of choice for casualtysurgery and that the use of the barbituxtes isbetter avoided.

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POST-GRADUATE MEDICAL JOURNAL

The barbiturates administered intravenouslydepress the respiration, lower the blood pressure,poison the heart muscle, and lead to delayedrecovery. These drugs cannot, on theoretical orpractical grounds, be described as the agents ofchoice for anaesthetising the gravely injuredpatient. It was my experience during the warthat light ether from the Oxford vaporiser didnot appear to "upset" the patient any more thangas and oxygen, and endotracheal ether wasfound to be specially valuable for grave headinjuries and severe burns.

Quick recovery of consciousness is an importantconsideration when a hospital, often short of staff,has to deal with a number of wounded persons.By means of light ether anaesthesia, I was enabledto ensure that the patients became conscious inthe shortest possible time. When I administeredan intravenous barbiturate anaesthetic I foundthat delayed recovery of the patient was a fre-quent complication and this added greatly to theburdens of an overworked nursing staff.

It is generally admitted that in a high proportionof patients who have received an intravenousbarbiturate anaesthetic, a period of excitementand irrationalism will ensue before full recovery ofconsciousness takes place. This is a most seriousadministrative consideration in any hospital. Ialso found that even in the case of patients whomight be described as "good operative risks" apost-operative condition indistinguishable fromshock, not infrequently occurred after the use ofpentothal.My experience has also led me to believe that

the barbiturates are absolutely contra-indicatedfor those patients who have been badly burned orscalded and for elderly patient, who have toundergo some emergency operation, especially thatof supra-pubic cystotomy.A study of the medical journals has brought

confirmation of my opinion. For example-Pask considers that insufficient attention hasbeen given to the possibilities of light ether nar-cosis, in cases of shock, and in the United States ofAmerica, the Mayo Clinic estimate ether as oneof the best anaesthetic agents that has ever beenintroduced.Romberger and Beecher also hold ether in

esteem, and Renow considers ether by the openmethod the anaesthetic of choice for war woundsof the abdominal viscera. Martin believes etherto be one of the safest agents for army surgicalprocedures; his findings were confirmed by othermilitary observers, i.e., Martele, McCarthy,Archer, Gould, Martin. McCarthy believes thatether remains the best and safest single agentfor abdominal injuries, and considers that spinal~anaesthesia or basal anaesthesia with the intra-

venous barbiturates has no place in the surgicaltreatment of patients who are susceptible to shock.A possible explanation of the unsatisfactory

results obtained by some anaesthetists, with etheranaesthesia may be given by Dauna, who callsattention to the unnecessary depth of many etheranaesthetics, and Goldberg, who gives a warningthat anaesthetic difficulties and post-operativecomplications are increased by the pre-operativeuse of morphia.

Fordyce advocates the- use of ether for emer-gency surgery, and Thomas remarks that etherhas never failed to be utilised for overcoming thefailures of other methods.

Revell holds that ethyl ether has been thestandard comparison for other agents and remainsthe reliable stand-by where muscular relaxation isrequired. Flagg, one of the world's most out-standing authorities in anaesthesia, after a personalexperience of more than thirty years with etheras an anaesthetic agent, has decided that claimsfor other agents as basic routine cannot be sus-tained. He has found that every type of war orcivilian surgery can be carried out safely, efficiently,and with a minimum of morbidity and mortality,with ether. He feels that too many anaesthetistshave tried too often to avoid the use of ether, andthe skill with which it might be used, is not somuch in evidence to-day as it should be.

In his textbook, Flagg describes anaesthesiaby ether gas as the safest anaesthesia known.Post-operative illness he believes is usually due toanoxia. He also remarks that other anaestheticagents are seldom compared with ether at itsbest.The comparison is usually with ether at its worst.

Ether Anaesthesia and the GeneralPractitioner

My own experience as a general practitioneranaesthetist for over twenty years, has led me tobelieve that ether, by the open drop technique,from the Oxford vaporiser, or combined withother agents, as from a Boyle's apparatus, is byfar the best anaesthetic agent for use by the generalpractitioner. Many lives might be saved andmuch distress avoided if general practitionerswould confine themselves to the use of this drug,leaving other agents and techniques to the full-time professional anaesthetist.

Anaesthetic MortalityI agree with the statement of Galley, that the

use of unsuitable drugs in unsuitable surroundingsby inexperienced administrators, plays no smallpart in causing the increased mortality already

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THE PRESENT POSITION OF ETHER ANAESTHESIA

noted. While it is usual to assess the value ofany anaesthetic agent or technique by the standardof immediate mortality, yet this is not the mostsatisfactory method of evaluation.When skilled adniinistrators are in charge of the

administration, the immediate mortality seems tobe about the same, whatever the agent or methodused.

Griffiths supports this view and feels that it isthe anaesthetist who.really creates a departmentof anaesthesia. The Wisconsin School teach thatit is the anaesthetist and not the anaesthetic agentor technique which is of primary importance.

It is, however, very generally admitted thatether has a greater margin of safety than any otherdrug. For example, if respiratory arrest occursunder ether, the practitioner has ten times morechance of re-establishing breathing than if itoccurs under chloroform, and most anaestheticdeaths are caused in the first place by respiratoryarrest. We might, with advantage, then, considercertain published records.

Dealy gives us a record of the anaestheticdeaths in Queen's General Hospital, for five years,1936-I94I:-

19,529 anaesthetics were administered.16,273 were inhalation, with 7 deaths, possiblydue to anaesthetic.

3,193 were spinals, with 7 deaths, possibly dueto anaesthetic.63 were rectal, with 4 deaths, possibly due

to anaesthetic.Waters and Gillespie have shown that death

during operation and anaesthesia has occurred inI in I,ooo cases, in a series of 250,000 cases, in fiveteaching hospitals.Kaye gives the statistics in a hospital in

Melbourne from I9I9-I929. In a series of I3,400operations on in-patients it was found that i'6per i,ooo was the immediate mortality.During the period I929-I934, in I7,757 opera-

tions I * 3 per I,000 was the mortality.An analysis of one series of cases showed that

under ether anaesthesia in 8,999 cases there were8 deaths.Under NO and ethylene in 2,555 cases I3 deaths.Under spinal in 907 cases i death.Under local and regional in 2,393 cases 4 deaths.Two deaths under local analgesiafortonsillectomy

were reported.Fors and Schwalm, compared results in 4,000

cases of which 2,000 were given ether-2,000 weregiven spinal. Mortality was 6 5 per cent forspinal-6 8 per cent for ether. Pulmonary com-plications were equal.

Professor Grey Turner, discussing "ModernAnaesthesia," believed that with older methods

the patient was probably.more uncomfortable butsafer. These statistics are not very helpful, and Ithink that Jarman points to the true cause ofanaesthetic mortality-"The unskilled adminis-trator." He found on studying the details of overI,000 deaths, that 8o per cent occurred when theadministration was in the hands of the newly qualifiedhouse officer. The general practitioner and thenewly qualified house officer would be wise to useonly the safest anaesthetic agent-ether-in spiteof the attraction of other drugs.

Are "Modern Methods" Associated withUntoward Occurrences?

Apart from death, the administration of ananaesthetic is sometimes associated with extremelyunpleasant complications. Untoward reactions dooccasion4ly follow the administration of ether, butthe possible disadvantages and complications ofother drugs and methods are formidable and shouldbe borne in mind by the local doctor who, unlikethe London specialist, has to live in close proximityto his patients.

Intravenous anaesthesia has been associatedwith many troubles. Pallor, tachycardia andextremely poor radial pulse frequently follow theadministration of Pentothal. Thrombosis of avein, injection into an artery with tragic results,have been known to occur. Fall in blood pressure,excitement, local irritation, nausea, vomiting,headache, irritability of the throat, unrest anddeplopnia, paralysis, polyneuritis, impairment ofvision and albuminuria, and convulsions, have alsobeen reported, after intravenous anaesthesia.The general practitioner would be wise to con-

sider his own position, should some of these compli-cations occur in one of his near neighbours. Thesame warning also applies to the use of spinalanalgesia, by the patient's own doctor. Spinalanalgesia has many ardent supporters to-day, butgrave neurological complications do from time totime, follow the use of this technique. Permanentincontinence, mental affliction, and muscularpalsies have been reported.A question was recently asked in Parliament,

concerning a young soldier who, having survivedan operation for hernia, under spinal analgesia,died seven months later from paralysis and,toxaemia. What would Dr. Jones have said to,the local Vicar's wife had this young man beenher son? Could he have expected to have retainedthe confidence of his other patients, after such atragedy?'Quite recently, in my own county a young man

was sent to a London teaching hospital for a,cystoscopy. The patient, six months later, stiUsuffers from grave neurological sequelae.

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274 POST-GRADUATE MEDICAL JOURNAL October, I946It cannot be maintained that these tragedies are

due to errors in the technique of administrationbecause a few, a very few, highly skilled anaes-thetists have been honest enough to record theirmisadventures. Had all our colleagues beenequally frank, I doubt very much whether thepre-eminence of ether would be challenged to-day.

In assessing the value of ether, then, we mustconsider whether the disadvantages of this anaes-thetic are greater than those associated with otherdrugs and techniques: Whether, in fact, weighedin the balance with new methods, ether has beenfound wanting and its kingdom given to another.The chief criticisms against ether are that it

leads to:

(I) Vomiting, following operation.(2) Abdominal distension and paralytic ileus

after operation.(3) Post-operative shock.(4) Post-operative chest complications.(5) Delayed recovery of consciousness.(6) Laryngeal spasm during the induction, and

operation.(7) Ether convulsions.(8) That it is a toxic drug upsetting physiological

balances.

VomitingVomiting occurs in about 6o per cent of all

etherised patients and can be reduced by preventingthe swallowing of ether-laden saliva, and bykeeping the depth of the anaesthetic strictly tothe plane required by the operation. But vomitingmay also be a distressing complication of bothspinal analgesia and intravenous anaesthesia, asmany observers have shown.Waters found that nausea or vomiting occurred

in 50 per cent of cases after ether and 39 per centafter cyclopropane.

It is better to have a patient who vomits evenfor forty-eight hours, than a patient who lies quietand still in the mortuary, or a patient who leaveshospital crippled for life from some injury to hiscentral nervous system.

Abdominal DistensionAbdominal discomfort and distension may occur

after ether anaesthesia, but the post-operativeadministration of morphine is helpful in over-coming this distressing condition, which is notconfined to those patients who have been givenether. Waters found that distension developedin i6 - 5 per cent of cases after ether and I3-5 percent after cyclopropane.

Post-Operative Shock and CirculatoryComplications

It is sometimes stated that ether anaesthesiapredisposes towards shock, and that when acondition of shock already exists, or may beexpected to develop, the use of some more moderntechnique such as intravenous anaesthesia ispreferable or indeed essential.

Mallinson states that there is no room fordoubt . . . that ether should be entirely avoidedin dealing with shocked and exsanguinated patientsand advises the use of intravenous anaesthesia.I have found that intravenous anaesthesia accen-tuates shock, even when given for the inductionof anaesthesia, and sometimes leads to a fall inblood pressure from which the patient appears tosuffer for a considerable period of time.An Editorial in Current Researches tells us

that there were six times as many deaths underintravenous in the United States of America'sArmy, as under any other anaesthetic. Is thisthen to be the technique of choice for war surgery?Even in relatively minor surgery performed underintravenous anaesthesia, I have found that patientsoften appear collapsed after an operation such aswould give no cause for worry under other methodsof anaesthesia.

Harris, Richards, and others report some-what similar experiences. Ether-even deep etheranaesthesia, is less likely to contribute to thatcondition known as shock, than the non-volatiledrugs for which-such extravagant claims have beenmade.The medical journals contain numerous re-

ferences to the association of intravenous anaes-thesia with shock, and to the dangers which maybe encountered when the barbiturates are adminis-tered (intravenously or otherwise), to the shockedcasualty. Minnitt and Gillies consider that inhaematogenic shock, stagnant anoxia will beaggravated by the barbiturates, but that in neuro-genic shock, they are not contra-indicated.

Woodhall, Madan and Crooke, Morris andBowler report unsatisfactory condition of patients,following the administration of the barbiturates.Chivers and Evans give a word of caution, andMarston considers that recovery may be retardedand the effects of shock increased by deep basalnarcosis. Saklad and others believe that theintravenous barbiturates have no place in thesurgery of the shocked casualty and recommendether anaesthesia.The Editor of Anesthesiology issues a warning

to war-time anaesthetists, that untoward compli-cations may follow the administration of intra-venous anaesthesia to the shocked battle casualty.Moon78 found that the barbiturates facilitate the

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October, I946 THE PRESENT POSITION OF ETHER ANAESTHESIA 275

development of shock in experiments on animalsand that dogs under barbiturate anaesthesiadevelop spontaneous shock.

Beecher, McCarrell and Evans* found that therewas no significant delay in the onset of shockcaused by bleeding when the barbiturates wereused, as against ether.

"Shock" is the surgeon's and the anaesthetist'sgreatest anxiety, and up to the present time noanaesthetic technique has been discovered whichwill remove this dangerous complication from itsassociation with major surgery.Adams quotes Reynolds, Veal and Chapman,

as finding that the heart muscle is poisoned undercontinuous Pentothal. Beecher agrees.

Minnitt and Gillies call attention- to thepossible dangers of the non-volatile agents inelderly subjects or in shock.

If we decide that intravenous anaesthesia is tobe avoided in cases where shock is present or isexpected to occur, we have as alternatives to theuse of ether anaesthesia:

(i) Trilene or vinesthene anaesthesia.(2) Cyclopropane anaesthesia.(3) (a) Spinal analgesia, or

(b) Local analgesia, with or without somemethod of producing unconsciousness.

Are these methods and combinations so satis-factory that the use of ether has become obsolete?

Vinesthene is an excellent anaesthetic but is atpresent yery difficult to obtain and is associatedwith some disadvantages, although these are notnumerous. The combination of vinesthene withether, known as V.A.M., is a most valuable anaes-thetic. Trilene added to nitrous oxide and oxygen,is satisfactory for many operations, but fails togive adequate muscular relaxation in some cases.A combination of cyclopropane with spinal

analgesia, or cyclopropane with local analgesia,has been found valuable. A comparison of thelast-mentioned techniques as against ether anaes-thesia will be made later when we have to considerthe choice of an anaesthetic for grave major opera-tions of long duration requiring complete muscularrelaxation. Shock is particularly likely to occurunder such conditions.

Post-operative Chest ComplicationsThere is incontestable evidence to-day that

ether plays no part in the production of post-operative chest complications. Over-premedica-tion with sedative drugs, among which the bar-biturates are the worst offenders, is a common

* They were referring to the observations of Essex,Seely, and Mann, that shock from intestinal manipulationis delayed under barbiturate anaesthesia, as against ether.

cause of post-operative pneumonia. The mostimportant factor, however, is post-operative andpre-opera.tive nursing care, and the general hospitalward. By far the most disappointing feature ofour new health service, is the omission to condemnand abolish the general hospital ward. Far morepatients lose their lives following operation, frombeing nursed in a large general ward, than fromany other cause.There was a number of investigations in

military hospitals during the war to try to findout why there was such a high incidence of chestcomplications, following hernia operations. Itwas found that the anaesthetic agent used madelittle difference, but the technique of pre-operativesedation was important. Bird and others agreewith the findings of the investigations described.

Flagg feels that there is no danger in the useof ether, properly administered, even in pulmonarytuberculosis, and refers to the opinion of theDirector of the New York State TuberculosisHospitals, who found that no ill effect resultedfrom the administration of ether to tuberculoussubjects. Murphy supports this belief.

Beecher anaesthetised with ether I47 patientssuffering from pulmonary tuberculosis, with ex-cellent results.Balbage and others state that even when no

inhalation anaesthetic agent is used, there iscertainly no lessening of the incidence of chestcomplications, following operation.

Griffiths listed pulmonary complications fol-lowing:-

A.Upper abdominal surgery under-

(i) General anaesthesia as 9 45 per cent(2) Regional anaesthesia as I5 I5 per cent(3) Combined anaesthesia as 25 per cent

B.and those following lower abdominal surgeryunder-

(i) General anaesthesia as 4 per cent(2) Regional anaesthesia as IO-3 per cent(3) Spinal anaesthesia as I5 per cent

and remarked on the important part played bypre- and post-operative sedation.

In another report on abdominal operation onpatients with chronic respiratory infection, acutepost-operative pulmonary complications occurredin-

I3 5 per cent of cases after ether.I7 5 per cent of cases after cyclopropane.39-5 per cent of cases after spinal,

where no pre-operative infection existed.

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POST-GRADUATE MEDICAL JOURNAL

Acute post-operative complications were re-ported in-

5 * 8 per cent of cases after ether./ 4 9 per cent of cases after cyclopropane.

7*5 per cent of cases after spinal.Stewart believes endotracheal ether the best

anaesthetic for upper abdominal surgery. Manyother authorities agree that general anaesthesiawith ether is of little importance in the causationof post-operative chest complications. Jones andBurford report four cases of collapse of the lungunder cyclopropane anaesthesia; a method thoughtto be particularly suitable when chest compli-cations are to be expected.

It is now established that regardless of theanaesthetic agents used, the incidence of post-operative chest complications increases with theincrease of duration of the anaesthesia, withincrease in depths of anaesthesia and with increasein grade of surgical risk.

Delayed Recovery of ConsciousnessDelayed recovery of consciousness has been

stated to occur after ether anaesthesia, but it hasbeen shown that this complication is due not tothe use of ether anaesthesia per se, but to thepractice of administering powerful sedative drugsbefore operation.

Laryngeal SpasmLaryngeal spasm occurs during the induction

period, in heavy smokers and alcoholics. It mayalso occur during the course of an operation owingto some action on the part of the surgeon. Pre-medication with morphia seems to predispose tothis troublesome condition. But laryngeal spasmis also a frequent and sometimes a very gravecomplication of intravenous anaesthesia, becauseif not quickly overcome, it may be fatal.

Ether ConvulsionsEther convulsions are always associated with

sepsis and are usually seen in children. The fre-quency of their occurrence is said to be one inten thousand cases. I believe, having myselflost patients from this cause, that convulsions aredue to anoxia and can be avoided by preventingthe slightest trace of oxygen shortage during theoperation. It must be remembered that con-vulsions occur under other agents and techniques.

The Australian Society of Anaesthetists pub-lish a report of such cases received in reply to aquestionnaire.

A General Poisoning of the Whole BodyThat the human body can well withstand the

administration of ether has already been shown in

our discussion on the physiology of ether anaes-thesia.

The Use of Ether for Extensive SurgeryIt remains now to decide whether ether should

be used for long and extensive operations requiringabsolute muscular relaxation for their completion,and often associated with a high degree of surgicalshock.Three methods are available for such operations:(i) Deep ether or chloroform* anaesthesia.(2) Spinal analgesia (with or without uncon-

sciousness).(3) A combination of local analgesia with some

method of producing unconsciousness, suchas cyclopropane anaesthesia.

Deep ether anaesthesia by the endotracheal routehas been used for many years, with excellent results.That difficulties and disadvantages are attached tothis method, no one ,will deny. But with othertechniques specially grave and tragic complica-tions, never encountered with ether anaesthesia,may be met with.

Spinal AnalgesiaReferring to spinal analgesia, Flagg warns us

that "extremely serious post-operative complica-tions never seen in general anaesthesia, are to bereckoned with," and practitioners submitting theirpatients to these risks must clearly understandthat they are very real and not imaginary. Ithas been stated that complications are due toerrors in technique, but this is clearly not the case.Grave damage to spinal cord, meningitis, respira-tory arrest, and collapse have been reported.Apgar found that in 6o per cent of cases,

the state of the circulation was unsatisfactory.There were four cases of irreversible shock andone case of severe neurological reaction, in aseries of 422 patients to whom spinal analgesiawas administered.

In two other series reported by Pappen, McCul-loch, and others, respectively, very serious compli-cations were met with.Moorhead found that in war surgery, spinal

analgesia has a place, but after-headache andbladder involvement are complications.Hames, Simpson, and Bradford also encoun-

tered untoward reactions.Meningitis is reported by Aikenhead and

Kremer. Kremer quotes Siebert, Livingstone,and others, as having had similar experiences.

* Because of the prejudice at present existing againstchloroform anaesthesia, the use of this drug will not bediscussed.

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THE PRESENT POSITION OF ETHER ANAESTHESIA

Downing met with two cases of collapse ofintervertebral discs, and Co Tui and othersfound local nervous tissue changes following spinalanalgesia, in experiments on animals.Kazman, Baker, and others, mention grave

neurological sequelae (death of one patient sevenmonths after spinal, from damage to cord), andVan der Post reports three disturbing casesunder light percalie-(two deaths, one narrowescape), while Power adds his quota to the listof misadventures.

McNeil Love writes of ocular palsies andpermanent incontinence.

Fairclough recently called attention to thehigh incidence of sixth nerve palsies. Suchpalsies were also reported from Manchester in adiscussion at the Royal Society of Medicine,thirteen cases being noted between August, I932,and March, I934.Lundy adds other complications to the already

alarming and formidable list, while Eid reportsa new and remarkable complication recently.Indeed, sufficient evidence is available for thesearcher after truth to enable him to realise howgrave is the responsibility of the anaesthetistwho decides on spinal analgesia as the method ofchoice for his patients.The avoidance of shock is the usual reason given

by surgeons who choose spinal analgesia for longand difficult operations and shock is a very seriouscondition. But we have to-day very satisfactorymethods of combating this deadly and little under-stood phenomenon, and in our anxiety to avoidshock we m4st not forget our resources, nor submitour patients to even greater dangers. It is cer-tainly open to question whether spinal analgesiadoes help to avoid shock. While the use of spinalanalgesia is certainly justified when some specialadvantage is to be gained, there can be no possibleexcuse for the anaesthetist or the surgeon whochooses this technique for relatively straight-forward operations such as appendicectomy, therepair of a hernia, or even delivery with the mid-wifery forceps, should some misadventure follow.Neither can the use of spinal analgesia by thegeneral practitioner or the "occasional anaes-thetist," be justified under any circumstanceswhatever. This is the province of the professionalanaesthetist, and the professional anaesthetist only(not the surgeon).

A Combination of Local Analgesia withSome Inhalation Agent, as forexample Cyclopropane

Local analgesia is not entirely without itsdangers and disadvantages, as a number of personsexhibit an allergic reaction to novocaine and similar

substances, sometimes with a fatal result. In myown county, a strong healthy young woman died,without any apparent cause, immediately after aCaesarean operation, performed under procaineanalgesia.

It is a great ordeal for a patient to endure a longoperation while fully conscious, and some methodof producing unconsciousness is usually adopted.Because cyclopropane is a non-toxic gas and canbe used with a high percentage of oxygen, itwould appear to be the ideal anaesthetic agentfor this purpose.

VWhile we are considering the value of a techniquein which its use seems particularly indicated, wemight with profit discuss the advantages, the dis-advantages, and the peculiarities of this valuabledrug. A few particularly gifted individuals canobtain from cyclopropane alone a relaxation whichis beyond criticism, but many practitioners addether to the cyclopropane, or make use of novo-caine infiltration of the field of operation to enablethe surgeon to work in comfort.

Local analgesia in combination with cyclo-propane anaesthesia has been found satisfactoryfor many lengthy and difficult operations. Cyclo-propane is also administered to provide uncon-sciousness in patients undergoing operations underspinal analgesia. But it must be generally ac-knowledged that this anaesthetic has some dangersand disadvantages. A curious condition knownas cyclopropane shock has been reported byKellog and Phillips.Wilkins found that shock of a degree to cause

concern may develop in the immediate post-operative period, after cyclopropane anaesthesia,at moderately deep levels.

Cardiac irregularities have frequently beennoted, but the addition of ether to cyclopropanepromptly abolishes these irregularities. Allergicresponse to cyclopropane has been known to occur.In healthy patients subject to anaesthesia forupper abdominal surgery the tendency to cir-culatory complications is greater after cyclopropanethan after ether. It is possible that primarycardiac failure of a type resembling that seen underchloroform may be the cause of certain unexplaineddeaths on the table.Waters and Gillespie, discussing seven deaths

under cyclopropane, consider that five of thesewere due to abrupt cardiac failure. Cyclopropaneis of great value on some occasions. Its badqualities appear to be of such magnitude thatit cannot be safely accepted as- a substitute forether, for most inhalation anaesthesia. It appearslikely that its range of usefulness will be muchnarrower than was first predicted. The use ofthis new agent in no way reduces the incidence ofchest complications.

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POST-GRADUATE MEDICAL JOURNAL

Wirthe considers that it is definitely contra-indicated in all cardiovasalar disorders and thatether still remains the best anaesthetic for use inpatients with heart disease.

Allen and others make note of cardiac irregu-larities in experimental animals, and find theaddition of ether beneficial in such cases. Whatgreater compliment could be paid to our old friendether,- than that its addition to the anaestheticmixture should be found helpful in overcoming theshortcomings of our latest and most expensiveanaesthetic gas?

In fact, Mousel, Stubbs, and Kreiselman feelthat the place of cyclopropane in anaesthesiashould be reviewed. This becomes all the morenecessary as the advent of the use of curare willprobably give us means for obtaining full muscularrelaxation under the light planes of ether anaes-thesia our safest anaesthetic agent.

Ether in MidwiferyFor obstetric operations in country districts

chloroform is sometimes the only anaestheticwhich can be used, because of the danger of fireor explosion, and accidents with chloroform indomiciliary midwifery are few.Ether is unquestionably the safest and best

anaesthetic for the general practitioner to ad-minister for a forceps delivery, the repair of theperineum, or the removal of an adherent placenta.The vast majority of deliveries other than in ourgreat cities still take place in the patient's ownhome, with only a midwife to assist the doctor,should some obstetric operation be necessary, andether can be safely left in the hands of a midwife,once the induction has been accomplished.

Stillbirths and neonatal deaths are frequentlyattributed to the use of ether in obstetrics, butLund considers that prematurity, complicationsof pregnancy, and the method of delivery, play agreater part in the causation of neonatal asphyxiathan do the various inhalation agents used.On the American continent, continuous caudal

analgesia (the injection of large quantities of alocal anaesthetic, through the sacral hiatus intothe extra dural space), has of late gained muchpopularity and publicity.

Baptisti gives an admirable summary of thedangers and disadvantages of caudal analgesia.Numerous accidents and fatalities have beenreported and it is evident that for many years tocome, continuous caudal analgesia will have to berestrictedtothe practice of highly trained specialists,working in special hospitals.

In fact, I believe ether to be the method ofchoice for obstetric manipulations, and for cae-sarean section, when there is no danger of fire.

If the anaesthetic is kept at as light a plane as ispossible, and heavy premedication with sedativedrugs avoided, no trouble will be experienced witheither mother or baby.

I have given a great number of ether anaes-thetics for caesarean section and only lost onebaby, whose death had nothing to do with theanaesthetic.Some authorities, indeed, *consider that the

administration of ether to the mother reduces birthshock to the baby.

It has been stated that a baby born underether is less inclined to lose weight and recoversits weight loss more quickly than a baby whosemother was given no anaesthetic drug.One word of warning is necessary, however.

Ether should not be administered after a heavymeal, and no practitioner should leave his patientalone in her home until she is conscious. Asurprising number of deaths have been caused byobstetric patients inhaling vomited material andchoking when no assistance was immediatelyavailable.

Relief of Pain in LabourEther analgesia can be administered by the

inhalation method if due care is taken. Thepatient soon becomes accustomed to the smell ofether and makes no objection to its use. Thetechnique of administration is difficult and therelies only a narrow gulf between analgesia, and anormal spontaneous delivery, and anaesthesiawith all its possible complications. A more satis-factory method is that of Gwathmey who developedthe rectal administration of ether during the war,I9I4-I8.McCormic describes a modified Gwathmey tech-

nique from which complete relief from pain isobtained, which can be used in the patient's ownhome, and from which there is no danger tomother or child.With a little co-operation this technique might

be made available to mothers in our own empire.The neglect of the woman in labour and ournational attitude of indifference to her suffering,constitutes one of the gravest sociological scandalsof the present time.

Ether Anaesthesia in the AgedI have found ether satisfactory for elderly

patients, up to the age of 92. The elderly malepatient who is admitted to hospital with acuteretention of urine, due to prostrate enlargement,tolerates ether better than most other anaesthetics,except chloroform. The intravenous barbituratesare particularly deadly, and gas and oxygen isunsatisfactory for these patients. Indeed,

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THE PRESENT POSITION OF ETHER ANAESTHESIAHubbard goes so far as to say that there aremore deaths from nitrous oxide oxygen, in thehands of the so-called expert, than occur fromether, no matter by whom administered.

I work at a rate-supported hospital where wefrequently have to deal with patients between 8oand go years of age, who come to us for intestinalobstruction, or retention of urine. In one after-noon I administered ether successfully to fourpatients over 8o years of age, for serious operations.

I have experienced no anxiety with regard torenal function which could in any way be ascribedto the use of ether, and Collen and others havecast doubts on the accepted theory that etherper se, has a damaging effect on the kidney.

Beecher considers, however, that age is animportant factor in determining kidney responseto ether (p. 284).

Ether in Heart DiseaseWith the exception of vinesthene, ether is

quite as suitable as any other anaesthetic in casesof heart disease. Cyclopropane causes cardiacirregularities, and the barbiturates poison theheart muscle.

Local analgesia I believe to be unsatisfactory inpatients with a damaged myocardium. I recentlywatched the attempt to remove the tonsils froma patient whom, the cardiologists had stated, couldtolerate only local analgesia. The patient col-lapsed after the injections, before the operationstarted. Yet he underwent the operation quitesatisfactorily a week later under ether anaesthesia.

I was called one night to a maternity hospitaland told that a primagravida at full-term wassuffering from a coronary occlusion and was on thepoint of death. The consulting physician heldout no hope -of saving the mother's life, but it wasfelt that an attempt should be made to obtain alive baby, by caesarean operation. Oxygen-ether-chloroform sequence was administered; a live babywas born and the mother made a complete recovery.

It is high time that consulting physicians andcardiologists refrained from giving advice as tothe choice of an anaesthetic or its method ofadministration.

ConclusionsEther which has been the basic 'anaesthetic.

agent for general use for one hundred years,still retains its position as the safest and mostsatisfactory anaesthetic drug. Although new drugsand new techniques of administration have beendeveloped of recent years, these are associatedwith disadvantages of such magnitude that thepre-eminence of ether is not challenged. It isparticularly in the treatment of war casualtiesthat the use of ether has been deprecated.

Many practitioners have given us glowingaccounts of their successes from the use of modernanaesthesia in war surgery. They have been silenton their failures. It is only from the reports ofthe United States of America Army authoritiesthat we have learned of the not infrequent mis-adventures. During those years when new drugsand methods of administration have been replacingthe use of ether anaesthesia, there has been a greatincrease in the number of fatalities reported to thecoroner. It is untrue to say that this increase inmortality is due to the acceptance of greatersurgical risks.The general practitioner anaesthetist would be

well advised to choose ether as the anaestheticagent likely to give the best results in thoseoperations for which he is called upon to administerthe anaesthetic. Many modern anaesthetic tech-niques are outside the province of the generalpractitioner and are unsuitable for general use.The difficulties and limitations of anaesthetic

practice in provincial or -rural England are un-known to many practitioners, who never appearto take into consideration the conditions whichmay be met with in our vast Empire.

It may well be that in some London hospitals,as good, or even better results are obtained fromthe use of "modem, anaesthesia" as from etheranaesthesia. But while -some specially giftedindividual in some specially favoured surroundingsmay obtain excellent results from one or other ofthe newer methods now in use, yet for the greatmajority of medical practitioners who have toadminister an anaesthetic under whatever cir-cumstances may exist at the time of operation,ether remains and is likely to remain, the safestand the best anaesthetic agent.

I should like to take this opportunity of making aprotest against the lamentable fact, that many newlyqualified practitioners go out into the world withouteven having seen ether administered by the -opendrop method, or chloroform by any method at all.

There are many conditions under which openether may be the only possible method of adminis-tering an anaesthetic, and, in country practice,circumstances may be such that the practitionerhas no choice but to administer chloroform, amost excellent anaesthetic, the dangers of whichhave been wildly exaggerated.On occasions, chloroform may kill a patient,

but under no circumstances does this drug rendera strong young man or woman a permanentcripple or a jibbering idiot, which is far from beingthe case with some of our modern anaesthetictechniques.

Let the general practitioner anaesthetist remainfaithful to his well tried and trusted friend-ether.He will have no cause to regret his trust.

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