Anesthetics in Use
During the Civil War
Use of Sulphuric Ether and
Chloroform
Edited from the medical textbook
Handbook of Surgical Operations,
U. S. A. Medical Department, 1863,
(in this collection) written during the Civil War by
Stephen Smith,
M.D.:
ANESTHETICS
The anesthetics in general use
are sulphuric ether and chloroform.
Sulphuric Ether.- — This agent is
liable to adulteration, by sulphurous acid, alcohol, volatile oils,
and by oxidation; it may be rendered purer by agitation with lime
water, and afterwards separating it by decanting.
Method of Administration.—The
following practical remarks on the administration of ether were made
by a Committee appointed by the Boston Society for Medical
Improvement to investigate the alleged dangers from inhalation of
ether :
Ether should never be given from
any inhaling apparatus. The best medium of its administration is a
bell-shaped sponge, large enough to cover in the nose, mouth, and
chin; but it is difficult to find one of sufficient size and close
enough in texture, or without such numerous apertures at the root as
to admit too freely the atmospheric air. A sponge of this sort,
moreover, being as expensive as rare, is seldom used outside of
hospitals. A stiff towel, properly folded, may be substituted, and
has the advantage of being always at hand; as it may be left behind,
the surgeon does not carry away with him the annoying odor of an
impregnated sponge. It is desirable that the towel should be a new
one, and of pretty good size. It is to be taken just as it comes
from the laundry, and not unfolded further than to display it in the
dimensions of about ten inches by five; by folding down two of the
corners in such a way that they shall lap over each other a little,
and securing them by stout pins, a cone will be made which fits the
face admirably. The thick layers of towelling will hold sufficient
ether, and its texture will prevent a too free dilution of the
anesthetic by the atmospheric air, provided the apex and seam of
the cone are carefully and tightly closed, either by pins or the
fingers. As the cone becomes collapsed by saturation, it should from
time to tune be opened, and kept in shape by distending it with the
hand. Unless these details are attended to, and especially the
closure of the apex of the cone, the induction of anaesthesia will
be uncertain and protracted.
In anything so porous as a towel
or sponge, the difficulty is to exclude enough air; for while its
adequate admission to the lungs during etherization is essential to
the life of the patient, its too free entrance not only delays
anaesthesia, but induces a condition of excitement, both mental and
physical. The importance of excluding the air, as above stated, is a
point not generally appreciated, but the necessity of it has long
been known to those most accustomed to the use of ether, as shown by
the " chemise" with which, in hospital practice, a too porous sponge
is often covered to expedite the etherization of a rebellious
patient. Ether should be poured lavishly on the towel or sponge, an
ounce or two at a time, especially at the commencement of
inhalation. Although it may be wasted, too much, as far as safety is
concerned, cannot be used. A small quantity poured on hesitatingly
and timidly, as is sometimes done, has the same effect as a too free
dilution of the vapor with air, producing simply intoxication and
its accompanying excitement without anaesthesia; whereas a large
amount, though the cough and choking sensation which the greater
volume of vapor produces may cause the patient to resist and
struggle, is certain to bring about a satisfactory condition of
insensibility.
Phenomena of Etherization.—A
strong, full-blooded man is pretty sure to resist the approaches of
anesthesia under any circumstances. This may sometimes be overcome
by warning him beforehand of such a possibility, and inducing him to
resolve not to struggle; the last impression on his mind influences
him even in his stupor. The same thing is liable also to happen with
almost all patients just before complete anesthesia takes place,
but the ether rarely requires to be suspended. Occasionally the
respiration becomes embarrassed during the period of excitement,
partly from the struggle itself, and partly perhaps from the
increased flow of saliva, which is a common phenomenon of
etherization, or from the position of the tongue or head of the
patient, and a condition may sometimes show itself characterized by
lividity, rigidity, and convulsive motions of the extremities.
Although alarming to the inexperienced, the state is in fact devoid
of danger, provided the ether be momentarily suspended; this being
done, the refusal to breathe soon gives place to a long-drawn
inspiration, and in most instances complete insensibility
immediately ensues. In such a case it is interesting to observe how
readily the spasm yields, and how complete is the muscular
relaxation which follows the free respiration of air unmixed with
ether.
 It should therefore be borne
in mind, that when there is muscular rigidity with lividity, the
suspension of etherization will transform this into the
relaxation of anesthesia. Persons of intemperate habits succumb
to ether slowly, and with greater reluctance and more opposition
than persons unused to intoxication. The pulse should be watched
by a competent person from the outset, and its failure, either
in strength or frequency, lead to more cautious use of the
ether. It must, however, be remembered, that in experiments with
anesthetics upon animals, the heart has been found to be the
ulttmum moriens; the respiratory movements, therefore, should
not be forgotten or neglected, but any slowness or irregularity
in the performance should at once receive attention. Ether is
not to be withheld from a patient to be operated on, even in a
state of collapse after severe accident, but great caution is
demanded in its use with patients who are near death from
chronic and exhausting disease, and who require operations.
 The best test of complete
etherization is the snoring of the patient; and no operation,
unless slight, should be undertaken until this symptom presents
itself. The relaxation of the muscles of the extremities may
occur without insensibility. The important distinction between
snoring and stertor is, however, to be borne in mind. Whilst the
former is caused only by the relaxation of the muscles of the
palate, the latter arises from spasm of the vocal cords and
partial closure of the rima glottidis, and thus becomes the
immediate forerunner of the train of symptoms already referred
to as indicative of partial asphyxia. Stertorous respiration
demands, therefore, a brief suspension of inhalation; one or two
inspirations of fresh air will, as already mentioned, almost
instantly dispel the symptom. Ether may be administered to
persons of all ages, from the new-born infant to the
octogenarian. There is, however, a condition prone to manifest
itself with children, especially those who, are weak, strumous,
or overgrown, which is due to its cumulative properties. It may
show itself after almost any degree of etherization, and is
characterized by a feeble pulse and slow respiration, not
passing off with the readiness usually marking the phenomena of
etherization. "With young persons a cautious inhalation of five
minutes will often induce an anesthesia of half an hour, an
effect wholly out of proportion to what the same amount of ether
would produce in an adult. This state is not a dangerous one,
and only requires time to dissipate its symptoms. Compression of
the chest will expel the fumes of ether being eliminated from
the pulmonary surface, and permit the entrance of a fresh supply
of oxygen to stimulate the circulation. The inhalation should
therefore be suspended at short intervals with children, and but
little ether given at a time."
Chloroform: Chloroform
may be adulterated with alcohol, oils, and ether. Alcohol can be
added without being detected by the smell, but may be detected
by dropping the chloroform into water, when it assumes a milky
appearance. Oils are detected by strong sulphuric acid, which
gives a yellowish or reddish brown color; the presence of ether
is detected by its readily burning when exposed to a flame. Pure
chloroform may be thus tested:—-When dropped on the hand it
evaporates without leaving the least smell or moisture behind;
it is free from color or opacity; it does not redden or bleach
litmus paper; it does not become opaque when dropped into water;
it does not coagulate the white of egg.
Administration: In the
administration of chloroform great care must be exercised. The
following judicious rules by
Prof.
Gross (System of Surgery) cannot be too carefully followed:
" 1st. During etherization
the patient may sit up with impunity, but this is not the case
during the inhalation of chloroform, owing, apparently, to the
greater relaxation of the muscles, and consequently, to the
greater difficulty in maintaining the circulation of the brain
through the influence of the heart's action. Not only should the
body be recumbent, but care should be taken to depress the head
and shoulders, bringing them nearly to a level with the trunk.
" 2d. An empty state of the
stomach is desirable for two reasons; first, because if
chloroform be given soon after a hearty meal it will be almost
certain to induce vomiting; and, secondly, because a crowded
condition of the organ interferes materially with the movements
of the diaphragm. Food must not be taken for at least four hours
before the exhibition; but, on the other hand, the interval
should not be too protracted, lest serious exhaustion result
from »he want of the necessary stimulus.
" 3rd. Care must be taken,
before the inhalation is commenced, that the patient's clothes
are sufficiently loose to prevent constriction of the chest and
abdomen. Any compression from this source would necessarily
impede the action of the diaphragm, and might thus become a
cause of mischief.
"4th. The importance of
having an abundance of atmospheric ah- during the inhalation of
an article so potent as chloroform, is self-evident; in
etherization this is of comparatively little consequence, but in
the exhibition of chloroform for surgical and obstetrical
purposes, it is absolutely indispensable to the safety of the
patient.
" 5th. The inhalation must be
effected gradually, not hurriedly, time being allowed to the
system to accommodate itself to the influence of the remedy,
thus avoiding the shock which might otherwise result to the
heart and brain. From six to eight minutes should usually be
spent in producing the full effects of the anaesthetic.
When the patient is very
feeble, or pale and.timid, it will be advisable to give him,
immediately before the operation, from half an ounce to an ounce
of brandy; and the dose may afterwards be repeated, if the
effect is obliged to be maintained for an unusual length of
time, sufficient consciousness being permitted for the
performance of deglutition. The best mode of administration of
chloroform is to pour the fluid upon a napkin or handkerchief
previously folded into a kind of cup-shaped hollow, and held
securely in the hand. Or, instead of this, a small, hollow
sponge may be used. As to the various inhalers that have been
devised for the purpose, they are all objectionable on account
of their inconvenience and the difficulty of obtaining a
sufficiency of atmospheric air. The patient having taken his
place upon the table, and emptied his lungs by a deep and
protracted expiration, the napkin, impregnated with a drachm of
chloroform, is held over the mouth and nose, at a distance of
about two inches, being gradually brought nearer and nearer
until it is within half an inch, beyond which it should not be
carried, the chest being at the same time regularly and
powerfully distended. On no account should the liquid be
permitted to come in contact with the surface, as it might thus
cause vesication.
All unnecessary conversation
is avoided, lest the attention of the patient should thereby be
unduly distracted. The assistant having charge of the
administration gives it his earnest and undivided care; wetting
the napkin from time to time with the fluid, and seeing that the
patient gets an abundance of air, his vigilance increasing as
the effects of the medicine become more and more apparent. As
soon as the sensibility is completely abolished, the operation
is commenced, a return to consciousness being prevented by
holding the napkin, wet with a small quantity of the vapor,
occasionally before the nose; and thus the impression is
maintained, steadily and cautiously, not only until the knife
has fully accomplished its object, but until the principal
arteries have been secured, and, in some cases, even until tht
dressings have been applied.
As soon as the inhalation has
been fairly entered upon, one of the attendants should
sedulously watch the state of the pulse, of the respiration, and
of the countenance. Any sudden failure in any one of these
should at once create alarm, and induce a suspension of the
operation, or provision for the admission of a greater quantity
of atmospheric air. I do not deem it necessary that a finger
should be constantly kept upon the pulse; for the color of the
face and the nature of the breathing will always sufficiently
indicate the effects which the anesthetic is exerting upon the
system, and thus afford abundant opportunity for preventing any
unpleasant occurrence.
The quantity of chloroform
required during an operation, and the time during which its
effects may be safely maintained, must, of course, vary
according to the exigencies of each particular case. In general,
from half an ounce to an ounce may be regarded as a fair
average^ but very frequently it takes three or even five times
that amount, depending upon the severity and duration of the
operation, and the susceptibility of the individual. In some
instances almost an incredibly small portion answers the
purpose. Children usually require comparatively little; and it
is well known that women are, as a general rule, more
susceptible to its influence than men. Persons exhausted by
hemorrhage are very easily affected by it, owing to the
rapidity of its absorption, and hence it should always be
administered to them with unusual care."
Dr. Simpson has advised that
chloroform be given by laying a handkerchief over the face, and
letting the chloroform fall on it drop by drop.
Resuscitation: The towel or
inhaler being removed, the patient's tongue should be drawn
forward with forceps or a tenaculum, fresh air admitted from the
door or windows, or induced by a fan, and artificial respiration
instituted. Stimulating applications to the surface, cold douche
to the head, and stimulating injections may be added. The main
reliance is on artificial respiration, and this is best kept up
by Marshall Hall's method as follows: " Turn the body gently,
and completely, on the side and a little beyond, and then on the
face, alternately; repeating these measures deliberately,
efficiently, and perseveringly, fifteen times in a minute, only
[when the patient reposes on the thorax, this cavity is
compressed by the weight of the body, and respiration takes
place; when he is turned on the side, this pressure is removed
and inspiration occurs]. When the prone position is resumed,
make equable but efficient pressure along the spine ; removing
it immediately before rotation on the side [the first measure
augments the expiration, the second commences inspiration]." As
soon as the patient can swallow, give brandy and ammonia.
Efforts at resuscitation should not cease until death is
evident.
A method of producing
artificial respiration has been introduced by Dr. Sylvester; it
consists in laying the patient on his back, drawing the tongue
forward, then carrying the arms slowly upwards over the head,
thus elevating the ribs by means of the pectoral muscles, and
inducing respiration; the arms are then brought down to the side
of the chest and slightly compressed against it; these movements
are to be repeated slowly as by the other method.
If a galvanic battery is at
hand it should be resorted to among other possible means of
restoring animation.
Esmarch ether - chloroform dripping bottle and kit
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Additional information on the Chisolm ether and
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