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Ellison C. Pierce, Jr., M.D.,
Associate Clinical Professor of Anaesthesia, Harvard Medical School,
Chairman Emeritus, Department of Anaesthesia, Deaconess Hospital,
Boston, MA
The first day I administered anesthesia as a resident
in training was on July 1, 1954, in one of the gynecology operating
rooms at the Hospital of the University of Pennsylvania. The instructor
was James Eckenhoff, simply a wonderful teacher. Years later, in
a lecture given before the Royal Society of Medicine on the importance
of leadership, he discussed its role in promoting safety. (5)
What was it like to practice anesthesia in 1954?
How safe did it seem? The department at Pennsylvania was a major
proponent of cyclopropane anesthesia but the other available agents
included diethyl ether, divinyl ether, ethylchloride, trichlorethylene,
nitrous oxide, ethylene, and on rare occasion, chloroform. Use of
intravenous thiopental was common as was rectal anesthesia with
a variety of agents such as tribromoethanol (Avertin), paraldehyde,
or chloral hydrate. Single dose and continuous spinal anesthesia
with procaine or tetracaine were widely employed, even for upper
abdominal surgery.
Intravenous solutions were seldom begun until
after the patient was asleep. Cyclopropane induction was usually
performed with only the agent and oxygen. With ether, the patient
was given 100% nitrous oxide for several minutes. The resultant
hypoxia plus the addition of carbon dioxide to the circuit produced
hyperventilation, hastening ether uptake. Induction frequently was
time consuming. Anesthesia for tonsillectomy was with open drop
ether and no endotracheal tube. I clearly remember one incident
when Dripps, demonstrating ether induction to a group of medical
students, saw his patient, a strapping young male, sit up and climb
off the table.
At Barnes Hospital in St. Louis, where I had been
a surgical intern, the time required for ether induction, before
I could prep the patient, was often 30 minutes or more. Impatience
with this vexing delay was one of the factors that pushed me into
becoming an anesthesia resident. Some of the surgeons at Barnes
performed thyroidectomies while the nurse anesthetist gave only
thiopental, total doses approaching two or more grams. These patients,
of course, slept for a considerable period after surgery. Dripps,
in contrast to Beecher at the Massachusetts General Hospital, encouraged
use of the recently available neuromuscular blocking drugs, d-tubocurare,
succinylcholine, gallamine, and decamethonium. However, prolonged
blockade with decamethonium was common; since we had no ventilators
it fell upon the residents to ventilate the patient's lungs postoperatively
in the, then new, recovery room, using an anesthesia machine.
Intubation of the trachea was not common, except
when necessary as in anesthesia for thoracic surgery. Even thyroid
resection was performed with a mask; I remember worrying about having
a finger cut if the surgeon slipped with his knife. When residents
were allowed to intubate the trachea, more often than not the tube
had no cuff; rather the pharynx was stuffed with gauze. If the anesthetist
did want a cuffed tube it was necessary to insert the cuff over
the end of the endotracheal catheter. As you can well imagine it
was not unusual for the cuff to be dislodged, sometimes to remain
in the trachea.
What of the anesthesia machines? At Pennsylvania
several models were used, including Ohio, Heidbrink, and Forreger
with its water manometer. No resident was ever fully inducted into
the club until he had opened the oxygen valve on a water manometer
Forreger with the flowmeter previously left fully on, thus blowing
water all over the operating room. There were no piped gases; the
tanks on the machine were, therefore, all important.
What of intraoperative monitoring? It was not
much different from the days of John Snow who in the 1850's had
encouraged observation of the pulse, respirations, and pupils. The
only additional techniques in common use were the Riva Rocca blood
pressure measurement and occasionally, in pediatric patients, a
precordial stethoscope. EKGs were unavailable except under the most
rare circumstance, when an old mahogany Sanborn machine would be
wheeled into the operating room from the EKG station. However, it
almost never worked because of the effect electrical interference
had on the stylet. I never saw a blood gas obtained in a clinical
setting, since they could only be determined in a research laboratory
using the Van Slyke manometric apparatus. Cardiac arrest, not an
unusual occurrence, was treated with open thoracotomy; closed chest
compression had not evolved. Defibrillation was with alternating
current.
While at Pennsylvania I well remember the arrival
of the first machine with Lucien Morris' copper kettle. Suddenly
residents were able to give 60% ether instead of struggling with
warm water around the glass vaporizer trying to reach an ether concentration
of 5%. As a result, the incidence of ether overdose skyrocketed.
Almost every Monday afternoon at the complications conference there
was at least one presentation of near arrest. Moreover, in those
days, in all anesthesia departments I am sure, when a patient did
not survive, the families were simply told that "old Joe"
just didn't tolerate the anesthesia, "too bad".
By today's standards cardiac anesthesia was particularly
primitive. Since there were no plastic intravenous catheters, a
number 14 metal needle was inserted in the dorsum of each foot where
the likelihood of dislodgement was less than in the arm. Monitoring,
again, consisted of Riva Rocca blood pressure measurement, observation
of respiration, and a finger on the pulse. Often blood pressure
could be obtained only by observing oscillations. Electrocardiography
was rarely attempted. Thomas Cannard, one of our staff anesthesiologists,
built the first permanent EKG machine in our operating rooms from
a kit.
Recovery rooms were by that time in use in many
American hospitals but they were small and primitive. They were
not to be found in the United Kingdom or Europe. If a patient were
cyanotic it was difficult to know whether it was central cyanosis
or a result of peripheral vasoconstriction due to shivering. Some
anesthetists, to make the differential diagnosis, would scratch
the chest with a needle, observing whether the resultant bleeding
was bright or dark red blood.
Anesthesia machines were certainly less safe than
today. Heidbrink flowmeters with disc floats were difficult to read
accurately because the calibration was too small. There was no standardized
arrangement for the gas flowmeters; the oxygen flowmeter was sometimes
on the left side, sometimes in the middle and sometimes on the right.
Pin indexing was new; not all machines had been fitted with the
pins. Moreover, sometimes the pins were dislodged, allowing attachment
of the wrong tank. This situation was a set-up for catastrophe because
each machine often had cylinders of oxygen, nitrous oxide, cyclopropane,
ethylene, carbon dioxide, and helium. Ventilators were not available
except for primitive ones with a single pressure setting or foot
operated bellows.
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