[From the American Practitioner and News, August 27,1892.] ON ANESTHESIA FROM ETHER:* Being Deductions from a Personal Experience of over Five Hundred Cases given in St. Catherine Hospital, Brooklyn, Harlem Hospital, New York City, and in Private Practice. By JAMES W. GUEST, M. D. The first few successful cases of etheriza- tion are apt to produce a feeling of safety for succeeding ones, but the more one is engaged in the daily administration of ether the more cautious and painstaking he will of necessity become. There are very few cases exactly alike. The marked differences and peculiarities become a frequent lesson to a careful and observant ad- ministrator. The differences'are best observed in the fol- lowing conditions of life: 1. Age. 2. Sex. 3. Size. 4. Temperament or education. 5. Health. 6. Disease. 1. Age. The older the subjects, save in in- fancy and early childhood, the harder is it for them to take and bear ether well as a rule. They have lost the vigor of early life, conse- quently have a diminished respiratory resist- ance, which is the essential point in a good and a safe etherization. The older the person the more pronounced the tendency to bronchitis, asthma, cardiac or renal lesions, every one of which adds to early and serious complications. The explanation, probably, that old people bear an anesthetic better than the middle aged is, that the proportion given is far less, and it is given with more care and precaution because they are old. With the above facts it would make statistics appear better. 2. Sex. There is no question but that women take and bear ether better than men, and that a less quantity will produce the same degree of anesthesia. This is explained by their being less full-blooded and less fleshy about the neck as a rule, and, most important, less given to alcoholism. Alcoholics are " bug-bears " to an- esthetists, and never have a typical anesthesia. The difficulty with which they are anesthe- tized is in a direct proportion to the amount of whisky they have imbibed, and the length of time spent in imbibing it. The older the alco- holic the longer and the more ether required to etherize him. 3. Size. Fat and short-necked people are good examples of the differences in taking ether. They are harder to anesthetize and to hold for any length of time under the influence of ether, both of which circumstances increase the danger. This is no doubt due to the differ- ent degrees of swelling of the tongue and the mucous membrane of the epiglottis and larynx, which occurs in cases not well taken. Some writers claim in subjects of obesity the mucous membrane is more prone to the action of irri- tants than in sparely-built people. This would appear, then, the reason why fat and short-necked people do not take or bear ether as well as the sparely-built, because the mucous membrane secretes more actively, and with the swelling of the adjacent parts of the "Read at the Thirty-seventh Annual Meeting of the Ken- tucky State Medical Society, May, 1892. 2 ON ANESTHESIA FROM ETHER. throat acts as a mechanical obstruction to the free entrance and exit of air. 4. Temperament or Education. Temperament is an important factor in the giving of ether. Even-tempered people, who are no doubt the bravest people, take it better than irritable ones. They are in a better condition, on ac- count of their self-possession and composure, to reason with, and to carry the reasoning into execution. Women are more even-tempered under sur- gical procedures than men, and will not re- sist the inevitable. Very seldom have I found it necessary with women to ask assistance in giving them ether. In most instances request- ing them not to make resistance was sufficient. Encouragement to take it well is more effect- ive usually than all else, for they all want to take it better than any one else ever did, and how easy to make them believe they are doing it. Talking, laughing, or crying are favorable in inducing etherization, for the patient freely expires, which is involuntarily followed by a deep inspiration, and the desired effect is soon obtained. The taking of food before operations is most deceptive, and the digestion of it will differ according to the temperament of the pa- tient. Some will eat a fairly good meal from four to six hours before an operation, and thor- oughly digest it. The more nervous and irri- table will eat sparingly of a supper the night previous, but will only partially digest it, and will throw up undigested matter the next day following the operation. I have often seen coffee or tea given four or five hours before an operation, yet be ejected from the stomach while the patient is coming out from the effects of the ether. A difference of importance in taking ether is marked in the sensitiveness of the fauces, as there is a dif- ference among patients in this respect. It is best to inquire before giving it if they have sensitive throats, for this is often a guide to giving it. The suffocation usually produced is more marked in hyper sensitive throats than in those less sensitive. In the majority of cases, how- ever, the pharynx is very sensitive to the fumes of ether, and the quicker you destroy that ex- treme sensitiveness, by pushing ether from the beginning, the better and safer will it be taken. By abolishing this sensitiveness as rapidly as possible, it prevents to a great extent the swell- ing of the mucous membrane, the coughing and vomiting, which are almost sure to follow from a slow and irritating administration. For this reason, if for no other, should near rela- tives be excluded from the room, for their presence and anxiety will involuntarily cause a slower administration from an innate desire to appear more humane. And, too, it increases the danger by allowing the long-continued irri- tating effect of the ether to more thoroughly arouse the activity of the salivary glands, and stimulates also deglutition, coughing, nausea, and vomiting. By an effort of the will anesthesia can be either advanced or delayed, so it is of the great- est importance to first gain the confidence of your patient, and thus you can accomplish more. I have noticed the sense of suffocation less- ened very much at times by explaining to the patient to expect it, but to remember that it is only a feeling with no harmful effect. It is wonderful how far this remembrance will some- times be carried by patients; often until they are in a good condition to fall an easy victim to an increased amount rapidly given. Education and refinement are positive aids to a good and quick anesthesia. The contrast in hospital and private practice is well marked. In private practice, among the educated and refined, you gain the confidence and co-opera- tion of the patient. In hospital practice among the laboring classes, where the word experiment is never fully lost sight of, you seldom gain the full confidence of the patient, and less often his co-operation. In reference to the special senses, I have no- ticed the sense of hearing to be the last to suc- cumb to ether. Patients will oftentimes tell afterward of some word spoken after a supposed loss of con- sciousness. In one instance a young man, while under ether, and while the operation was in progress, heard me tell the operator his pulse was 110. There could be no mistake about this, as it was the only time the pulse-rate was ON ANESTHESIA FROM ETHER. 3 asked or given during the entire operation. In- sensibility to the part was lost, yet his hearing and memory were not affected. The question of stimulation before an oper- ation is an important one. As generally rec- ognized, stimulant doses of whisky or brandy are most essential before giving chloroform. It being a heart depressor, even from the begin- ning, we can readily see the advantage in giv- ing a stimulant before. But with ether I believe stimulants are contra-indicated, because we are adding rapid heart stimulants to a greater one, ether-thereby overstimulating and taxing the heart in the beginning, when it is not indi- cated or necessary. Overstimulation of the heart from any cause has long been recognized as an injury, which can but weaken its action after a time. 5. Health. When the heart and respiration are good, especially the respiration, there is no danger in pushing the ether rapidly for the brief period while going under it; though when fully under its influence this method, if con- tinued, would become a serious danger. The danger is mostly in the discrimination to accu- rately judge when the patient is fully under it. One of the greatest aims of an anesthetist is to prevent secretion and accumulation of mucus in the patient's throat; and the more rapidly ether is given the less mucus there will be. After a slow etherization, with great secre- tion and accumulation of mucus in the throat, and stertorous breathing to follow, it becomes necessary to keep the inferior maxilla forcibly pushed forward throughout the operation, much to the discomfiture of operator and adminstra- tor. To torture a patient for twenty or thirty minutes trying to give ether slowly and safely (?) and painlessly (?) is a sad sight, and is not unlike the Frenchman's method of cutting his dog's ears off, namely, "little by little, so as not to hurt much." Reflex swallowing, cough- ing, and vomiting are sure signs of incomplete anesthesia, and, unless accompanied by cyanosis and difficult breathing, show that the ether should be pushed. When once under its influence just enough should be given to keep the reflexes in abey- ance. This requires but little. If the reflexes are allowed to return, the inconveniences of coughing and vomiting are not only most annoy- ing to the operator, causing delay and disar- rangement in his work, but increase the danger to life. Not a few cases of death are due to inhaling suddenly the vomited matter. The reflexes should be anticipated and prevented by a deeper narcosis. I do not believe patients are ordinarily benefited by allowing them to "come out for a minute" during an operation, as advocated by many, because the increased quantity of ether given necessary to again put them under it is more harmful than a mild con- tinuance of it throughout the operation. In regard to position, patients take an anes- thetic better when the head is lower than the body. This position predisposes to a cerebral hyperemia, which is more favorable than a cere- bral anemia, and, too, the trachea is freer from obstruction. Nelaton, Sims, and others believe chloro- form poisoning is principally due to a cerebral anemia. This must be true also of ether. Never is a patient's condition alarming with flushed cheeks and pink ears, therefore it is best and safest to predispose to a cerebral hy- peremia. The breathing is better and the aera- tion of the blood more complete, as shown by the color of the face. Anesthetics should never be continued on a pillow, yet it is best often to commence them on one; for all people intuitively believe they can breathe better with the head elevated. How easy after they are unconscious to slide the pillow out and arrange any little detail. 6. Disease. The fear of valvular or func- tional troubles of the heart is very often over- rated. I have never seen a valvular diseased heart seriously affected by a proper administra- tion of ether, and believe the increased action is compensated by the additional strength given to it by the ether. I would hesitate more in giving ether in a diseased lung or kidney than in a diseased heart. In bronchitis an excessive secretion of mucus is already established and needs but little ether to augment the flow and early complicate the condition. In asthma it is not well taken, be- cause there is always a co-existence of bron- chitis. It relieves the muscular spasm of the bronchioles, but it increases the secretion of 4 ON ANESTHESIA FROM ETHER. mucus. This mucus is especially dense, and contains the Curschman spirals or molds of the bronchioles. In kidney lesions ether undoubtedly adds a low grade of inflammation, which is noticed in the increased amount of albumen following etherization. General Remarks. The after-effectsJrom ether are largely dependent upon the manner in which it was taken. If taken rapidly, without complications aris- ing, it is thrown off rapidly with usually no nausea or vomiting. If taken slowly, with a struggle, great secre- tion of mucus in the throat and stertorous breathing, it is thrown off slowly, with nausea and vom- iting almost sure to follow. Therefore the period of recovery is in proportion to the manner and time of the etherization. There is less shock after a quick etherization, because the patient takes less and is not exhausted from muscular efforts of a long resistance. There are two kinds of breath- ing that should never be con- founded, namely, the palatine and laryngeal. The palatine is produced by vibrations of the soft palate when the mouth is open, and is indicative of a safe anesthesia approaching a natural sleep. The laryngeal is always a dan- ger signal, and caused by the swelling of the mucous mem- brane of the pharynx and lar- ynx, and in sound approaching a crowing character as in croup, and indicating mechanical ob- struction. This is perhaps the only time when it is absolutely necessary to withdraw the ether and let the patient come out for a while until the swelling subsides. It is more important to watch the respiration than the pulse, for if the respiration is good the pulse will never fail first. Therefore it is more im- portant to employ artificial respiration first of all in accidents, and to rely chiefly upon it. Injections of respiratory stimulants are as es- sential as the cardiac, and of these strychnine and nitro-glycerine are the best. To a functional heart trouble it is an abso- lute aid in reducing the heart's action to a me- chanical regularity. The most apparent good results are those from a functional irregularity when the pulse becomes full and regular after a few minutes under ether. ON ANESTHESIA FROM ETHER. 5 In large accumulations of mucus in the throat I have found that by turning the patient's head to one side as far as practicable and compress- ing the alee nasi at each expiration and relaxing at each inspiration, a sufficient amount of mu- cus will be expelled from the mouth to allow a good respiration. In comparison to the time of administration of the two anesthetics, chlo- roform and ether, there is very little differ- ence. To give chloroform with safety requires as much time, ordinarily, as in giving ether. Of course if it is pushed, it is quicker in its action, but the danger is greatly increased. I believe statistics will show most of the deaths from chloroform occurred in the early stages, showing it can never be pushed in safety as can ether. With the exception of children, it is seldom chloroform is given to the surgical degree and borne well under five minutes, and more often longer. In the last one hundred cases of ether, given in private practice, I have averaged eight minutes per case. The slowest was sixteen, and the quickest three minutes. In regard to the various methods of giving ether it makes but little difference so you have the essential feature of confining it. The care- fulness and experience of the administrator be- ing the real safety, I use a very simple cone which I devised after experimenting with many kinds. It is a pamphlet, a towel, and two pins. It has to recommend it the following: 1. Perfect cleanliness, a new cone for each anesthesia. 2. Quickly made and always at hand. 3. Most inexpensive. 4. All the essential points for a good and safe anesthesia. It is made by spreading the towel out and placing the pamphlet at one end with a two- inch margin left for a grip over it. Grip each side by now folding the long edges of the towel in over the pamphlet. Turn the pamphlet over once, and you have lined the cone. Now fold the pamphlet sideways to the long axis of the towel and you have the cone complete, except the two ends not closed. Bring the long strip of the towel left over the sides of the cone for one revolution, and pin when you reach the end of the towel. Louisville.