ANAESTHESIA

BY

Lieutenant Colonel W. SCRIVEN, M.B.E

Royal Army Medical Corps

 

THE art and practice of anaesthetics in the Army has made great strides during the period of existence of the Royal Army Medical Corps.

 

Most of the advances have been made during the two Great Wars when the problems of anaesthesia for wounded men under active service conditions have produced new techniques and improvements in the established methods.

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In the early days of the. Corps existence,' anaesthesia was not regarded as a subject of much importance; to quote Major General J. W West, then a junior surgeon, "Any Medical Officer was considered as, suitably trained to give. a general anaesthetic and when the infrequent operation occurred in a Military Hospital, the surgeon had to ·search round for. some officer otherwise disengaged, who would administer the anaesthetic." Although the surgery in military hospitals of those days was not very enterprising, it Was not the operation but the anaesthetic which caused anxiety; chloroform was the only anaesthetic available, and deaths. tinder anaesthesia did occur. The Inexperienced anaesthetists were a sore trial to the surgeon; the, wait during induction was often long, the struggling of the patient great, and complete relaxation of the abdomen rare. Salivation, in spite of atropine was troublesome, and post-operative vomiting almost. universal. A few medical officers, mostly trained in Scotland, gave chloroform with a ~folded towel and a drop bottle most satisfactorily, but anxiety never ceased until the. patient was safely back in bed.

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During the South African War conditions such as those described above obtained; there were no specialist anaesthetists and little. equipment Chloroform was the agent used .and it was often' difficult to find a medical officer willing to act as an anaesthetist. It is interesting to note that in' 1904 an investigation was carried out to ascertain. whether deterioration occurred in chloroform exposed to hot climates on active service. Examples of chloroform from South Africa and from the China Field Force were, at the request of Army authorities, examined by Dr. F. W. Tunnidiffe, Professor of Pharmacology in King's College, London. After an exhaustive series of tests, it was found, that these samples of chloroform showed to change in properties

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In the years between the South African War and the First World War, various new methods of anaesthesia. were tried in' the Army . Local anaesthesia using B-eucaine and Adrenalin for minor operations was employed by Captain J. W.· Houghton in 1905 Spinal analgesia was first used in military practice in 1907 by Major C. G. Spencer and Captain J. W. Haughton at the Q.A. Military 'Hospital, Millbank. Stovain .was the agent used, according to Barker's original technique, and excellent operative conditions were obtained, though the incidence of  post-operative headache appears to have been relatively high Captain Houghton published a series of articles in the Journal .on· spinal Analgesia; in 1919 he used tropocaine in Sierra Leone and published further series of cases using Stovain in 1911, 1912. and 1913.

 

The absence of trained anaesthetists and the, difficulty of finding officers 'to administer general anaesthetics made the practice of the spine method highly acceptable to Army surgeons and made it possible for the to operate in out-of-the-way stations and on board ship without other trained assistants.

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During this period up to. 1914, ether came in to use in military hospitals in the United Kingdom and the Clover's inhaler was the apparatus employed. Mixtures of chloroform and ether. were used, and ethyl chloride was sometimes used for induction.

 

Though the Senior Course at the R.A.M. College produced medical officers specially qualified as surgeons, no attempt was made to have officers specially trained in anaesthetics and it was suggested in articles in the Journal in 1904 and 1905 that N.C:O.s of the corps should be trained in the administration of aesthetics, though there is no indication that this suggestion' was ever implemented.

 

In India, during the period up to the First World -War, chloroform was given by the open 'method and was the' general, anaesthetic mainly used, the official view being that ether would riot be effective in the hot weather, and the difficulties of transport and storage of ether was considered to make its use impracticable. An individual surgeon procured privately a Vernon Harcourt chloroform inhaler and used it with great improvement in the induction and maintenance of ,anaesthesia and in the postoperative condition of the patients. No trained anaesthetists were available in military hospitals, and anaesthetic duties had often to be delegated to members of the~ Indian Medical Department. Eventually, official objection's to 'ether were overcome, and it was supplied to military hospitals, but as no special apparatus for its administration was available, the open method had to be employed. Individual surgeons also used spinal analgesia with Stovain and local anaesthesia with B-eucaine providing their own apparatus as there was 'no official supply of such equipment.

 

During the 1914~18 War, much was learnt about anaesthesia for wounded men under active service conditions and notable advances were made.

 

'In a short survey of this nature, it is not possible to deal with all the details of the Techniques evolved; the subject has been very adequately dealt with by Captain H. P. Crampton in the 'Medical History of the War." For the first two months of the 1914-18 War, chloroform was the only anaesthetic available' for medical units in the field, but after this ether and other agents, were procurable.

 

In the early part of this war, before the establishment of Casualty Clearing Stations, a certain amount of surgery had to be undertaken in Field Ambulances, and chloroform supplied' in sealed glass tubes was useful on account of its portability. - To quote Dr. Ashley Daly: '

 

"It was soon learned (1) that prolonged deep ether or chloroform anaesthesia had a bad effect on a shocked or septic patient.

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(2) that spinal analgesia was dangerous and must be avoided in these· cases; ,

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(3) the danger of operating on' a shocked .patient without resuscitation equipment;

 

(4) the, value of blood pressure readings in estimating the degree of shock present."

 

A notable advance was the introduction 'in 1916" ,of Dr. (later Sir Francis} Shipway's well-known warm 'ether apparatus, by means of, which warmed ether and/or chloroform vapour could be delivered. to the patient using oxygen or air to· vaporize these agents. This compact and convenient apparatus was extensively used in Casualty Clearing Stations and  hospitals throughout the war.

 

The patients, then, as now, were nearly all heavy cigarette smokers and ether by the open method tended to produce a high incidence of post-operative pulmonary complications, which was considerably reduced after the introduction of the "warmed ether vapour" method. . Ether· was also administered by means 'of the Clover's inhaler and to a limited extent by the rectal and intravenous routes.

 

In 1916, nitrous oxide and oxygen became available and were administered by the Boyle's apparatus. It was soon found that, in skilled hands, this, was the method' of choice for use on the severely wounded and shocked patients or toxic .patients with gas gangrene: small quantities of ether could be added if required, especially during induction, and it was of great' importance to ensure that there was no limitation of the oxygen supply.

 

After adequate preoperative resuscitation, transfusion, warmth, etc., .these patients came through prolonged and serious operations and post-operative effects were markedly: reduced. Owing to difficulties in the supply of gas and the scarcity of skilled Administrators, this method had often to be reserved for selected cases.

 

Spinal analgesia with Stovain was found to be followed by a dangerous fall in blood pressure, and its use in forward medical units was soon abandoned entirely . Stovain and Novocain were used in Base hospitals for spinal analgesia for amputation through the lower' extremity, though' spinal methods were not on the whole favoured by surgeons.

 

Local anaesthesia by infiltration' with Novocain was used by some operators either alone, or combined with light general anaesthesia with, nitrous, oxide and oxygen. Successful use of local methods was made in a Special Head Unit at the Base under the direction of the late Colonel Sir Percy Sargent. Towards the end of the war the endotracheal administration' of anaesthetic vapours by the insufflation method was introduced and proved invaluable in dealing with facio-maxillary cases.

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As regards personnel, up to 1916' there were no specially trained " anaesthetists, anaesthetics Were administered by any medical officer available, in a medical unit. Then special anaesthetists' wen! appointed on the staffs of Casualty Clearing Stations as members of surgical teams; none of these officers appointed were regular officers of the Corps. In 1918 some two hundred nursing sisters, having been specially trained as anaesthetists, became available for service in Casualty Clearing Stations and many. of them became very skillful; they also freed a corresponding number of medical officers for duty at the front where there was a serious shortage of the latter.

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To quote from the "Medical History of the War," "The art of administering anaesthetics was greatly developed during the war with immense benefit to the patient and the surgeon. The increased supply of special apparatus contributed very greatly to this result arid the administration of warm ether vapour and of gas and oxygen instead of chloroform saved many lives.

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In the years between the World Wars, anaesthesia in the Army progressed more or less pari passu with anaesthesia in civil practice, though there was often a time lag between the introduction of new agents and their issue as an official supply and, in some cases, anaesthetists purchased their own drugs and equipment in order to keep up to date

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In India, however, things remained as they had been before the 1914-18 War: chloroform, ether by open' method, and nitrous oxide). and air. Were considered by· the Government .of India to be modern and adequate methods of anaesthesia . It was not till the 19308 that modern. anaesthetic apparatus became an official supply, and even in 1934 a Vernon Harcourt: chloroform inhaler was produced with great pride by an Indian store-keeper as modern equipment.

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Endotracheal anaesthesia by the insufflation method was in use in large military hospitals in the U.K. and an article on this method was published in the Corps Journal in 1929 by Major L. M. Routh. Later the methods of blind intubation and inhalation endotracheal anaesthesia came into general use by anaesthetic specialists.

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Avertin is first recorded as having been used in the Army in 1934 by Major, L. S. C. Roche, and in the same year intravenous barbiturates came into use in military, anaesthetic practice, a series, of fifty cases using evipan being published in the Corps Journal by Major K. P. McKenzie It was, however, in the training and status of  anaesthetists that' great strides were made in the years between the two world wars.

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The Senior Courses for officers at the R.AM. College, Millbank, were resumed after the war and anaesthetics was 'recognized as ,a special subject; in 1920, after Special training in civil hospitals, Captain R. Martyn Davies became the first Regular specialist in anaesthetics in the Corps.

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The speciality was not a popular one, as the number. of hospitals requiring 'a full-time anaesthetist at the time were few, and anaesthetists were only entitled to specialist pay when employed as such, and£ posted to one of the smaller military' hospitals, they remained General Duty officers. Still, a number of specialist officers were trained and, after the inception of the Diploma in Anaesthetics in 1935, a few Army specialists· were successful in obtaining this Diploma.

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The outbreak of the' second World War in 1939 saw an enormous expansion in the personnel of the Corps.

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Almost all the Regular anaesthetists were soon employed on non-professional' duties and a large number of skilled specialist anaesthetists came into the. Army from civil life.

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In 1941 Major Ashley Daly was appointed the first Adviser in Anaesthetics to the War Office with the rank of Lieutenant-Colonel, and in 1945 he was made Consultant Anaesthetist with 'the rank of Brigadier; the first anaesthetist ever to attain this rank in a' purely professional capacity. Under his wise guidance, the aesthetic service of the Army grew· "in wisdom and stature."

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Advisers in the Tank of Lieutenant-Colonel were appointed to overseas theatres of war, M.E.F., C.M.F., B.LA., etc., these officers being chosen from anaesthetists who were on the teaching staff of civil hospitals in peacetime.

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In 1944 Brigadier H. K. Ashworth was appointed as Consultant Anaesthetist to G.H.Q., India, and Advisers were appointed in each of the four command in India led one with H.Q., A.L.F.S.E.A. ' .

The appointment of these Advisers in Anaesthetics was of great importance in raising and maintaining the standard, of anaesthesia in the Army. The Adviser was usually in a position to tour forward medical units and Base hospitals in his, area, when he could make personal contact with anaesthetists and help them with their professional, and sometimes personal problems, and, stimulate their interest in .new techniques. An important part of the Adviser's duties was the' supervision of· the teaching of trainees, which was carried out in all overseas theatres. The morale of anaesthetists was greatly assisted. Because they felt they had someone "higher-up" looking after their interests and ready to help them with their personal problems.

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At the. Headquarters of the formation the Adviser had a close liaison with the Consultant surgeon and was able to help with, the posting and distribution of anaesthetists according to their ability.

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As regards the supply of anaesthetics, agents, and equipment, the specialized, knowledge of the Adviser enabled him to be a great assistance to administrative medical authorities.

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In the matter of the technical development of anaesthetics during the war, space does not allow of a detailed description of the intricacies of, the various methods. used. One cannot do better than quote' from the memorandum on anaesthesia written by Brigadier Ashley Daly in the "Field Surgery Pocket Book" (1944): "Since the last war (i.e. 1914-18) the problem of anaesthesia in the Field has been simplified by the introduction of new drugs and improved methods of administration of ,the older' agents. Chief among these innovations are the development of the intravenous' route, consequent upon the discovery of 'the various barbiturates, the use of agents such as cyclopropane and trilene, and the invention of a most useful machine, for giving definite percentages of ether and air known as the Oxford Vaporiser Number One.

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Considerable advances have also been made in . the technique of local anaesthesia and though its use in war surgery is chiefly to reinforce general anaesthesia, local blocks, e.g. brachial block, are useful in severe injuries of the hand, and intercostal block combined with bilateral splanchnic. block is occasionally used for an abdominal injury. Spinal analgesia has a very small place in the surgery of the wounded man.

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The importance of adequate resuscitation before surgery was undertaken on the wounded man was fully realized; the magnificent work' of the Blood transfusion units, which worked in close touch with the surgical teams, lightened the anxieties of the Field anaesthetists to a considerable extent.

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The adequate premedication of patients before anaesthesia was a matter of importance and was usually carried out by the transfusion officer in liaison with the anaesthetist,' care being taken not to administer morphia to a patient who had already received a heavy dose of this drug as part of first aid

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Omnopon and scopolamine were usually employed and When necessary were given intravenously.

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Of all the. anaesthetic techniques employed during the war, perhaps the ,most outstanding success was the use of pentothal sodium. It was used as the only anaesthetic for a large number of wounded men and almost as a routine induction before proceeding to an inhalation agent. Extreme caution was required in cases suffering from "shock," e.g. cases with abdominal wounds or extensive injuries of the limbs arid only very small amounts of pentothal were required for induction in the former and for induction and maintenance in the latter type: of case.

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In patients with extensive burns, such as were seen in the Western Desert campaigns, great caution was required when administering' pentothal, and where possible intravenous omnopon 'and morphia only was given in these cases:

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Oxygen was often given during pentothal anaesthesia, and nitrous oxide and oxygen' were used to supplement the pentothal anaesthesia in many cases.

 

The more severely wounded always came to the theatre with a blood, saline, or plasma transfusion set up and induction of anaesthesia was easily carried  out by injecting a small amount of pentothal solution through the rubber tubing of the transfusion apparatus. On many occasions when' et patient recovered consciousness after an extensive operation he would' enquire when the operation was to take place; what a contrast to the South African War!

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Endotracheal methods were used in 'appropriate cases by all anaesthetists and were especially valuable in faciomaxillary and in neurosurgical units.

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Cyclopropane was available for most chest and neurosurgical units, and in the later stages of the war was supplied to other surgical units also.

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The supply of 'gases, used in anaesthesia, nitrous oxide, and oxygen" presented considerable difficulties in overseas theatres of war when shipping space was limited and cylinders had to be returned to the U.K. for refilling. This difficulty was overcome to a large extent in the Italian theatre 'by obtaining large cylinders of nitrous oxide containing 3,000 gallons from which the small cylinders used professionally could be refilled. Oxygen, cylinders were refilled by the RA.O.C. with gas manufactured in Italy, and a natural source of carbon dioxide was found at Pompeii, from ,which cylinders for medical purposes were refilled. This service was organized by Lieut.-Colonel B. R .M. Johnson, Adviser in Anaesthetics, C:M.F., with the help of the R.A.D.C.,and the RE.M.E.·

As regards anaesthetic equipment, the field pattern Boyle's apparatus did good Service in all theatres of war and. was even packed in special containers for mule transport in the Burma campaign, but it was not sufficiently accurate for modern methods ,of anaesthesia. . The addition of a to-and-fro carbon dioxide absorber increased its sphere of usefulness.

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In 1944, a portable military. model of the American Heidrick apparatus was introduced, which was a great advance on the Boyle's apparatus.

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Mention must be made' of the great ingenuity and resource -shown by anaesthetists in all theatres of war in modifying existing machines to modern techniques and. even in constructing new apparatus. The container of the Service, respirator was utilized as. a carbon dioxide absorber and many other ingenious modifications were carried out with the willing help of the craftsmen of R.E.M.E. Also various types of apparatus for the continuous administration of pentothal sodium were devised by anaesthetists on active service.'

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So far post-war anaesthetic practice in the Army has maintained the high standard ‘reached during. the war and is equal to that reached in civil life.

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Military hospitals are equipped with modern apparatus, and up-to-date techniques, such as the use of curare, are employed by trained anaesthetists., It has been said that the "corner stones of modern surgery are asepsis and anaesthesia." Many of the: surgical 'procedures carried, out during the, war would have been impossible, had it not been for modern anaesthetic techniques, and the' skill and devotion of the anaesthetists who; often in circumstances of considerable danger and discomfort unobtrusively carried. out their duties and worthily upheld. the. traditions of the Royal Army Medical Corps.

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For most of the information contained in this survey, the author is greatly indebted to the following:

 

Major-General J. W. West, C.M.G., C.RE., F.RC.S .

 

Brigadier ''.Ashley Daly, Lieu R; Martyn Davies, M.D.; and

 

Colonel G.- D. Gripper.

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