Ether – As I See
Ether – As I See.
Dr R S Saxena
It is always painful to see the demise of an old faithful. I felt it when I found Diethyl Ether enlisted under the chapter “Agents and techniques no longer in common use” in the 1995 edition of Lees Synopsis pf Anaesthesia. I had heard the death-bell ringing earlier but could not anticipate that it will completely be out of existence. Till five years back or so one could get anaesthetic diethyl ether but it appears that production has now been completely stopped.
My association with the outstanding anaesthetic has been since 1956 is more than half a century old. Anaesthesia has transformed from an art to a perfect science-more perfect than any other discipline of medicine. In a natural sequence the “Shishi Wala doctor” ie the anaesthetist of the yore, has transformed himself to a better known and respected anaesthesiologist of today.
The first whiff of ether than I got was in June 1956 while assisting a senior resident to put a child under. Ethyl Chloride and ether were used in sequence over a yank heaver’s mask covered with 6-12 layers of gamgee from a distance I did not find the vapour disagreeable or irritating. As the concentration increased with putting in of a gamgee pad cutting down the leaks I observed the child straining and coughing. However, it did not last long because the induction was now taken over by the consultant, who with his experience, cut down the second stage and the child was quiet and breathing smoothly with long excursons. I still remember the consultant words “ Ab yeh ether pee sakta hai, koi paswah nahi.” He had converted the “open drop technique “ into a semi-open technique by putting a towel-hood over the mask. If only ether is used the induction lasts over twenty minutes in an adult. A good premedication, a slow and progressive increase in concentration and maintaining a good airway are the secrets of a good induction. No wonder, then, that anaesthesia was labeled as an art.
The availability of anaesthesia machines was restricted and its maintenance was a big problem. The teaching of the subject was restricted to Bombay, Calcutta, Hyderabad, Madras. Any student who wanted to pursue post-graduates studies had to come to these centres. Anaesthesia G.A Wither was restricted to G.A. Wither ether and regional in a few peripheral centres chloroform was still in use. A few anaesthetists were mixing ether and chloroform in various proportions viz C2E3. The mixture did not gain popularity; ether’s irritation prolonged the induction during which chloroform was real risky and could cause sudden cardiac arrest. Chloroform did its natural death due to its pharmacological shorteomings and emergence of better agents. Many of them have been used to reduce the irritation and induction time of ether. Of the inhalation agents available then, nitrous oxide, trilene and the costly imported agent Cydopropane were all tried but with a limited success. Nitrous oxide and cydopropane need a proper anaesthetic apparatus; so it was left to trilene and another ether (Divinyl ether) to improve the open drop induction. Vinesthene ie Divinyl ether gained some popularity in the U.K. The agent was not commonly available in India. Induction by trilene, because of its less irritant vapours was practiced. Due to its poor vapourisation, the open drop technique was restricted to children who were maintained on ether subsequently.
Intravenous induction with agents like thiopentone sodium and maintaining on open drop ether was also used by a few. Means for ventilating the patient were always kept ready because of a possible apnoea due to intravous thiopentone. Due to lack of expertise and an inherent fear of relaxants intubation was done with ether only, taking the patient into a deeper plane.
It would not be exaggerating facts to say that ether ruled supreme at this time. Chloroform, a keen competitor had started falling out of favour. The reign of ether in India lasted for over a century and a quarter. It goes mostly to the credit of dentists Horace Wells and T.W.G Morton to develop anaesthesia till the latter successfully demonstrated ether’s control of pain during removal of tumour by Dr J.C.Warren in Massachaisets General Hospital on Oct. 16,1846. Before this demonstration he had successfully administered ether vapour to a patient, Eben Frost, on Sept. 30,1846 for removing a tooth. Crawford William Long had successfully removed a tumour from the neck of a young man, much before Morton, on March 20,1842. The account of this pioneering research was not published for seven years. He was thus denied the credit which could have been his. It is not so well known that another dentist, Robinson, administered ether on Saturday, 19th Dec.1846, to Miss Lousdale and successfully removed some teeth. A book on ether’s pharmacological and clinical properties got published by John Snow in 1847-“On the inhalation of Ether Vapour. It is surprising that ether did not gain popularity in England till B/Joy Jeffries brought the American towel cone method of forcible induction in 1872. Two years later clover introduced his gas-ether sequence. Till then chloroform was used almost as a routine. Open ether was reintroduced in its land of origin by Prince in 1895. The credit of popularizing it in England goes to R.L.Tait a well known Birmingham surgeon and a former assistant to J.Y.Simpson who had introduced Chloroform into correctly clinical practice in 1847. If I remember Richard Gordon, an anaesthetist himself, and author of the famous Doctor in the House series, has written in one of his books that it is impossible for a doctor to kill anybody with ether anaesthesia unless he is a confirmed idiot. Scientifically speaking, John Snow, “On Chloroform and other anaestheties” in 1858 had expressed similar views “I hold it, therefore, to be almost impossible that a death from this agent (ether) can occur in the hands of a medical man, who is applying it with ordinary intelligence and attention.”
It may not be out of context to mention the names of a few Indian ether enthusiasts in whose contact I have worked. One of them Dr P.J.Nawathe, J.J, Bombay Hospital, used ether in almost all the cases. He was very fond of its relaxation, safety and cost effectiveness. Dr. V.Bhargava, consultant in the same hospital was also fond of ether. In Amritsar, I saw Prof. Pritam Singh and his team using ether quite freely. This was done with the purpose of cutting down the dose of relaxation viz d Tubocurarine (Tubarine) & Gallamine (Flaxedil). These agents were found to be posing difficulties in reversal specially when bigger doses were used and also with Ph disturbances. Relaxants we use now viz Norcuron, atracurium etc are quite safe and easy to reverse. The status of the neuromuscular block was difficult to gauze then. Nerve stimulator does it quite easily now. Prof. Singh’s teacher Dr S K Bakshi who was practicing anaesthesia in undivided Punjab, was an ether enthusiast, and a good friend of Sir Robert Macintosh and used to call him Mac. In return he got addressed as Jaok. In Delhi Dr Satinder Singh and Dr P.D.Dhamija started his career in Sir Ganga Ram Hospital, Lahore, and retired finally from Sir Ganga Ram Hospital, Delhi. I used to call him a bridge between the neighbours and the two Ganga Ram Hospitals too used ether freely as well as Dr Fakir Chand Khandpur.
Sir R.R.Macintosh, who invented the curved laryngoscope in 1943 helped the cause of ether tremendously when he described the oxford vaporiser for the use of ether in 1941; which was later improved by the same Nuffield Department of Anaesthesia in 1956. It is used as a draw over vapouriser. When used with Oxford Inflating Bellows, it can safely be used for I.P.P.R. and allows the use of ether with relaxants under difficult peripheral conditions. I have myself used it for a Caesarean section in Yemen Arab Republic where it was lying as a junk as well as in S.J.H on numerous occasions. Sir, macintosh was once asked to anaesthetise a V.I.P. The media asked him “ What anaesthesia have you planned?” Without surgeon will be using the same old knife; I will use the same old ether,” That reflected his faith in ether.
Some of the Indian V.I.Ps too, had a taste of ether. Daughter and mother of a Prime Minister and self also a P.M whiffed the agent in Willingdon Hospital on 17th Feb.1960 for a kidney surgery, national poet Ram Dhari Singh “Dinkar” was administered ether a couple of years later. None of them had any complaint. By no means a V.I.P, but it did pose a ;problem for me I was asked by an E.N.T surgeon, a good friend of mine, to help him out by getting a hernia surgery done on his Pamrerian pup. I had no experience of anaesthetising a dog what to say of a small puppy. I cut a cigarette can to make a small mask. The puppy’s tender snout was put inside, covering the open end with 6 layers of gauze soaked previously with ethyl chloride. The puppy went under fast, ether was then used as in open drop technique, keeping a keen eye on respiration and colour of the blood. Relaxation was good and the vet found rapairing the hernia quite easy. Ether being a complete anaesthetic suited the occasion well. After this experience I could say with full confidence that open drop ether does not deserve the disdain as shown by the modern anaesthesiologist.
Macintosh visited Delhi and demonstrated his E.M.O with inflating bellows technique. He used air and ether even on lung surgery cases enriching the mixture with 500-1000ml of oxygen. An Indian, Brig. Rama Rao who worked in Army Hospital, Delhi, described a modification of E.M.O without getting the preset mixture diluted with oxygen. The modification was well accepted and appreciated. After thiopentone and non-depolarising relaxant patient was intubated with ether 5% in air initially, reduced to 2-3% subsequently. The risk of explosions so deadly feared with ether, has not been described with ether and air mixture even with concurrent use of diathermy. A trace of halothane administered from a small vaporiser during induction speeds it up.
Explosions have quite frequently been linked with ether but I was lucky not to have seen one in real practice. I did, on two occasions, see a blue ether flame burning on the O.T. floor without exploding. Ether vapour is twice as heavy as air, hence settles on floor. A Delhi surgeon, who worked as a Resident Anaesthetist during his student days, did cause a minor explosion by his cigarette but no damage was done to anybody in the O.T.
Diethyl ether, eldest of its family, is a drug of considerable antiquity. According to Dudley Buxton its original discovery is attributed to Djaber Yeber, an Arabian Chemist, synthesised later by Valeruis Cordus in 1540 and named as oleum vitrioli dulce. Ether is related chemically to water H-0-H and also alcohol where H of R-O (H) is replaced by another R. C2H5OH is ethyl alcohol; if we replace H by another C2H5 we get diethyl ether C2H5OC2H5. Ether is said to be simple when both “R’s” are of the same group when R radicals are of different groups a mixed ether is formed. Pharmacologists have thus synthesised about 700 halogenated hydrocarbons. Out of these, only a few had the pharmacological properties to be honoured on the anaesthetists trolly. To name a few ethers we may recall Methoxyflurous (Penthrane), Enflurane (ethrane, Alyrane), Isoflurane (Forane, Aerrane, Nederane), an isomer of enflurane, Desflurane and Sevoflurane. Of the halogenated compounds list will not be complete till wename halothane which is 2 bromo-2-chloro-1,1,1 trifluoroethane and thus not an ether.
The American discovery of ether spread fast over the world. The first European demonstration took place just nine weeks later in London. The lucky chance followed so soon because of the friendship between Bigelow of Boston and Boot of London. Bigelow sent a detailed letter of Morton’s successful ether administration. Boot lived and practiced in Gower Street, close to University College Hospital, who informed the surgeon Liston. On Monday 21st December 1846 Liston operated on three cases under ether anaesthesia administered by squires, using an apparatus specially designed for the occasion (India did not lag behind and ether anaesthesia entered the country from Calcutta).
The enterprise of dental profession in introducing anaesthesia is thus well established. The speciality having been formed, was subsequently nursed, nurtured and developed by its first specialist, John Snow in the Great Britain. He met an early death at the age of 45 years and carried out all the good work to establish his new-born speciality firmly in the last twelve years of his life. In 1847 he published his first book “On the Inhalation of Ether”. Chloroform and ether shared honours at this time; friline, though excelled in analgesia, lacked in relaxation and could not be used as a sole anaesthetic, cyclopropane being very costly and an imported item had only a few indications and was sparingly used.
I clearly remember having anaesthetized a 92 years old relative of the H.O.D of Orthopaedics in J.J.Hospital, Bombay. He was induced by a sleep dose of thiopentone, taken deep by open drop ether intubated and maintained on open drop ether with a 500ml per minute flow of oxygen under the mask. The S.P nailing lasted about an hour. The patient made an uneventful recovery. The surgery was assisted by Dr Sheroo Bharucha who later joined Irarin Hospital as Dr Mrs Kohli. An other case that I remember is of our own colleague. Late Dr G.C.Saxena approached one with the request that I should not intubate him for the stripping of his varicose veins in the legs. The surgery got prolonged and lasted over five hours. The induction was with thiopentone, gas, oxygen and halothane. I was forced to add a trace of ether to deepen the anaesthesia to achieve a cushion and avoid see-saw of planes, after an hour of halothane anaesthesia, he opened his eyes while bandages were being applied and had no nausea and vomiting post-operatively. The addition of ether successfully offset the two major disadvantages of halothane i.e. respiratory depression of cardiovascular depression. Hudon in 1958 had reported the use of mixture. Various combinations were tried and 2:1 halothane: ether (68:32 to be precise) were found stable and non flammable. The mixture behaved like and additive compound or an azeotrope. This adadvantae was, however, not supported by later research.
Be that as it may. I remember my first encounter with ether in Delhi was in 1958 when I joined the then Willingdon Hospital (now Dr R.M.L Hospital). The first person to greet me was Dr (Mrs) Vimla Mehra, Dr H.P.Varma took me to the ground floor O.T and asked me “Are you familiar with ether insufflation” I was not. He introduced me to endopharyngeal insufflation of ether, N2O/O2 mixture for tonsillectomy in children. Boyle-Davis gag was used to depress the tongue, tension being regulated by rope hanging down from a hook about 10ft above the mixture being delivered at the gas port. The Patient was taken deep into IIIrd stage plane II anaesthesia, put in Rosen’s position and surgery allowed without intubation. The set up looked impressive, anaesthesia did not take long and a long list could be completed fast. The surgeon used to remark “I am more under than you” It is a different storey that my wife would smell my clothes and would not come near. However, I and the surgeon enjoyed a good post-lunch siesta from experience I have learnt that ethyl chloride rather sequence is the best way to achieve blind intubation. A little CO2 (500ml/min) to deepen the respiration, not very light anaesthesia (IIIrd stage, plane I or II) good curve of the red rubber tube and a proper positioning of the head and neck are the secret of success. I have so far not failed at blind intubation. An other innovation I took a fancy for is flagg’s can. At the Safdarjang Hosptial they were using it for small surgical procedures in children but could also be used on adults. I consists of a tin can with several openings on the top containing ether. The endotracheal tube is connected to the top. The patient breathes air-ether mixture as per his tidal volume depending on the depth of anaesthesia. Ayre’s T Piece and its Jackson Rees modification can successfully be used for maintenance of anaesthesia with ether or other agents. It is light and has no values.
Ether 65%+Olive oil 35% was given rectally 20ml mixture/stone of body weight. Anaesthesia lasted for 2-3 hours and was complete. It has been used in obstetrics, status asthmaticus and inducing anaesthesia in patients with cardiac decompensation. Ether has also been used intravenously by Pirogoff in 1847, a year after its introduction by Morton, A 2.5 to 5% solu. in normal saline or glucose is used. 12.5ml to 25ml of ether is shaken up in a bottle and warmed upto 90oF not more, 98.6oF being its B.P. Started slowly, later run in a stream. Recovery with this technique is fairly rapid.
The ether regime was severely dented by the introduction of relaxants, concept of triad of anaesthesia by the Liverpool group (Rees and Gray), its own pharmacological short comings, and a spurt of better compounds mainly its own derivative which came nearer to the concept of an ideal inhalational agent. The introduction of shorter and powerful analgesics and day care surgery put the last nail on the coffin aided by the temperature compensated precision controlled newer vaporisers. The concept of triad of anaesthesia got a further boost in the arm by the availability of better inducing agents much to the detriment of the use of Ether. I did not see Jackson-Rees using ether on a single occasion during the six months I worked with him in 1969.
Evaluating ether its main advantages are:-
(i) It was comparatively non-toxic than its peers.
(ii) It could give excellent relaxation without undue respiratory depression.
(iii) Respiratory depression, if it occurs, is not accompanied safely be reversed.
(iv) It’s safety is marvelous. It stands out when an unskilled anaesthetist is dealing
with an unfit patient in a difficult peripheral area.
The disadvantages of ether are:-
(i) Increases mucous secretion from the upper airway.
(ii) Upsets body chemistry.
(iii) Tendency to cause albuminurea.
(iv) Its explosiveness when comes in contact with sparks flames and hot surfaces
in a mixture of oxygen or nitrous oxide.
(v) Ether convulsions + ether eye.
It is interesting to observe how the enterprise and interest evoked by a speciality lead to the discovery of the anaesthetic use of ether. It is all the more surprising that this was followed by the birth of a new speciality. The human discovery of ether has been of great significance to the whole world. Inventions of such magnitude do not happen spontaneously. Necessity has again proved to be the mother of invention. Surgery has been going on from the times of Sushruta, who described the Indian method of rhinoplasty, he did not write a word about anaesthesia used. Surgeries performed then were of a superficial nature – fracture, cataract, amputation trephining or cystolithotomy. Simple techniques of hypnosis pressure over the nerves and blood vessels, cold locally, alcohol and herbal concoctions using poppy seeds were upto the task. So far the gastro-intestinal ingestion of the anaesthetic was the only route available. Ether opened the gates for subsequent routes i.e. inhalation, intravenous and combinations of other routes. Ether also gave birth to a new speciality of anaesthesia and spurred indirectly though, the interest of other scientists to discover the use of other agents, manufacture newer molecules and discover safer and comfortable techniques. A good example is newer potent analgesics and introduction of curare into the concept of “Balanced Anaesthesia.” Harold.R.Griffith used Intocostrin, a curare preparation to give surgical relaxation during anaesthesia. This must have seriously undermined the use of ether thereafter.
After serving the ailing humanity for well over a century ether, the old faithful, has gone out of use. All good things have to come to end. The satisfaction is that most of the agents replacing it are its own off springs ie substituted others.
I cannot imagine a single discipline of medicine which has not been benefited by the discovery of anaesthesia be it investigative, curative, diagnostic, pain relief or research work, helping patients of all ages.
We must thank ether and Morton, its discoverer, every year like this. This is the best way to salute and thank them. Even this will fall short of expressing our full gratitude.
References (ETHER – AS I SEE)
1. A synopsis of Anaesthesia - Editions – 1953, 1968, & 1995.
J. Alfred Lee, R S Atkinson
G.B. Rushman & N.J.H.Davis
2. Modern Practice in Anaesthesia - Frankis.T.Evans – Edition – 1954.
3. Principles of Anaesthesiology - Vincent J. Collins – Edition – 1966.
4. Text Book of Anaesthetics - R.J.Minnitt & John Gillies – 1944.
5. Buxton, D, - Anaesthetics:- Their uses and administration
- 1900.
6. Physics for the Anaesthetist - W.W.Mushin, Peter L. Jones - 1987 Macintosh, Mushin & Epstein
Dr R S Saxena
It is always painful to see the demise of an old faithful. I felt it when I found Diethyl Ether enlisted under the chapter “Agents and techniques no longer in common use” in the 1995 edition of Lees Synopsis pf Anaesthesia. I had heard the death-bell ringing earlier but could not anticipate that it will completely be out of existence. Till five years back or so one could get anaesthetic diethyl ether but it appears that production has now been completely stopped.
My association with the outstanding anaesthetic has been since 1956 is more than half a century old. Anaesthesia has transformed from an art to a perfect science-more perfect than any other discipline of medicine. In a natural sequence the “Shishi Wala doctor” ie the anaesthetist of the yore, has transformed himself to a better known and respected anaesthesiologist of today.
The first whiff of ether than I got was in June 1956 while assisting a senior resident to put a child under. Ethyl Chloride and ether were used in sequence over a yank heaver’s mask covered with 6-12 layers of gamgee from a distance I did not find the vapour disagreeable or irritating. As the concentration increased with putting in of a gamgee pad cutting down the leaks I observed the child straining and coughing. However, it did not last long because the induction was now taken over by the consultant, who with his experience, cut down the second stage and the child was quiet and breathing smoothly with long excursons. I still remember the consultant words “ Ab yeh ether pee sakta hai, koi paswah nahi.” He had converted the “open drop technique “ into a semi-open technique by putting a towel-hood over the mask. If only ether is used the induction lasts over twenty minutes in an adult. A good premedication, a slow and progressive increase in concentration and maintaining a good airway are the secrets of a good induction. No wonder, then, that anaesthesia was labeled as an art.
The availability of anaesthesia machines was restricted and its maintenance was a big problem. The teaching of the subject was restricted to Bombay, Calcutta, Hyderabad, Madras. Any student who wanted to pursue post-graduates studies had to come to these centres. Anaesthesia G.A Wither was restricted to G.A. Wither ether and regional in a few peripheral centres chloroform was still in use. A few anaesthetists were mixing ether and chloroform in various proportions viz C2E3. The mixture did not gain popularity; ether’s irritation prolonged the induction during which chloroform was real risky and could cause sudden cardiac arrest. Chloroform did its natural death due to its pharmacological shorteomings and emergence of better agents. Many of them have been used to reduce the irritation and induction time of ether. Of the inhalation agents available then, nitrous oxide, trilene and the costly imported agent Cydopropane were all tried but with a limited success. Nitrous oxide and cydopropane need a proper anaesthetic apparatus; so it was left to trilene and another ether (Divinyl ether) to improve the open drop induction. Vinesthene ie Divinyl ether gained some popularity in the U.K. The agent was not commonly available in India. Induction by trilene, because of its less irritant vapours was practiced. Due to its poor vapourisation, the open drop technique was restricted to children who were maintained on ether subsequently.
Intravenous induction with agents like thiopentone sodium and maintaining on open drop ether was also used by a few. Means for ventilating the patient were always kept ready because of a possible apnoea due to intravous thiopentone. Due to lack of expertise and an inherent fear of relaxants intubation was done with ether only, taking the patient into a deeper plane.
It would not be exaggerating facts to say that ether ruled supreme at this time. Chloroform, a keen competitor had started falling out of favour. The reign of ether in India lasted for over a century and a quarter. It goes mostly to the credit of dentists Horace Wells and T.W.G Morton to develop anaesthesia till the latter successfully demonstrated ether’s control of pain during removal of tumour by Dr J.C.Warren in Massachaisets General Hospital on Oct. 16,1846. Before this demonstration he had successfully administered ether vapour to a patient, Eben Frost, on Sept. 30,1846 for removing a tooth. Crawford William Long had successfully removed a tumour from the neck of a young man, much before Morton, on March 20,1842. The account of this pioneering research was not published for seven years. He was thus denied the credit which could have been his. It is not so well known that another dentist, Robinson, administered ether on Saturday, 19th Dec.1846, to Miss Lousdale and successfully removed some teeth. A book on ether’s pharmacological and clinical properties got published by John Snow in 1847-“On the inhalation of Ether Vapour. It is surprising that ether did not gain popularity in England till B/Joy Jeffries brought the American towel cone method of forcible induction in 1872. Two years later clover introduced his gas-ether sequence. Till then chloroform was used almost as a routine. Open ether was reintroduced in its land of origin by Prince in 1895. The credit of popularizing it in England goes to R.L.Tait a well known Birmingham surgeon and a former assistant to J.Y.Simpson who had introduced Chloroform into correctly clinical practice in 1847. If I remember Richard Gordon, an anaesthetist himself, and author of the famous Doctor in the House series, has written in one of his books that it is impossible for a doctor to kill anybody with ether anaesthesia unless he is a confirmed idiot. Scientifically speaking, John Snow, “On Chloroform and other anaestheties” in 1858 had expressed similar views “I hold it, therefore, to be almost impossible that a death from this agent (ether) can occur in the hands of a medical man, who is applying it with ordinary intelligence and attention.”
It may not be out of context to mention the names of a few Indian ether enthusiasts in whose contact I have worked. One of them Dr P.J.Nawathe, J.J, Bombay Hospital, used ether in almost all the cases. He was very fond of its relaxation, safety and cost effectiveness. Dr. V.Bhargava, consultant in the same hospital was also fond of ether. In Amritsar, I saw Prof. Pritam Singh and his team using ether quite freely. This was done with the purpose of cutting down the dose of relaxation viz d Tubocurarine (Tubarine) & Gallamine (Flaxedil). These agents were found to be posing difficulties in reversal specially when bigger doses were used and also with Ph disturbances. Relaxants we use now viz Norcuron, atracurium etc are quite safe and easy to reverse. The status of the neuromuscular block was difficult to gauze then. Nerve stimulator does it quite easily now. Prof. Singh’s teacher Dr S K Bakshi who was practicing anaesthesia in undivided Punjab, was an ether enthusiast, and a good friend of Sir Robert Macintosh and used to call him Mac. In return he got addressed as Jaok. In Delhi Dr Satinder Singh and Dr P.D.Dhamija started his career in Sir Ganga Ram Hospital, Lahore, and retired finally from Sir Ganga Ram Hospital, Delhi. I used to call him a bridge between the neighbours and the two Ganga Ram Hospitals too used ether freely as well as Dr Fakir Chand Khandpur.
Sir R.R.Macintosh, who invented the curved laryngoscope in 1943 helped the cause of ether tremendously when he described the oxford vaporiser for the use of ether in 1941; which was later improved by the same Nuffield Department of Anaesthesia in 1956. It is used as a draw over vapouriser. When used with Oxford Inflating Bellows, it can safely be used for I.P.P.R. and allows the use of ether with relaxants under difficult peripheral conditions. I have myself used it for a Caesarean section in Yemen Arab Republic where it was lying as a junk as well as in S.J.H on numerous occasions. Sir, macintosh was once asked to anaesthetise a V.I.P. The media asked him “ What anaesthesia have you planned?” Without surgeon will be using the same old knife; I will use the same old ether,” That reflected his faith in ether.
Some of the Indian V.I.Ps too, had a taste of ether. Daughter and mother of a Prime Minister and self also a P.M whiffed the agent in Willingdon Hospital on 17th Feb.1960 for a kidney surgery, national poet Ram Dhari Singh “Dinkar” was administered ether a couple of years later. None of them had any complaint. By no means a V.I.P, but it did pose a ;problem for me I was asked by an E.N.T surgeon, a good friend of mine, to help him out by getting a hernia surgery done on his Pamrerian pup. I had no experience of anaesthetising a dog what to say of a small puppy. I cut a cigarette can to make a small mask. The puppy’s tender snout was put inside, covering the open end with 6 layers of gauze soaked previously with ethyl chloride. The puppy went under fast, ether was then used as in open drop technique, keeping a keen eye on respiration and colour of the blood. Relaxation was good and the vet found rapairing the hernia quite easy. Ether being a complete anaesthetic suited the occasion well. After this experience I could say with full confidence that open drop ether does not deserve the disdain as shown by the modern anaesthesiologist.
Macintosh visited Delhi and demonstrated his E.M.O with inflating bellows technique. He used air and ether even on lung surgery cases enriching the mixture with 500-1000ml of oxygen. An Indian, Brig. Rama Rao who worked in Army Hospital, Delhi, described a modification of E.M.O without getting the preset mixture diluted with oxygen. The modification was well accepted and appreciated. After thiopentone and non-depolarising relaxant patient was intubated with ether 5% in air initially, reduced to 2-3% subsequently. The risk of explosions so deadly feared with ether, has not been described with ether and air mixture even with concurrent use of diathermy. A trace of halothane administered from a small vaporiser during induction speeds it up.
Explosions have quite frequently been linked with ether but I was lucky not to have seen one in real practice. I did, on two occasions, see a blue ether flame burning on the O.T. floor without exploding. Ether vapour is twice as heavy as air, hence settles on floor. A Delhi surgeon, who worked as a Resident Anaesthetist during his student days, did cause a minor explosion by his cigarette but no damage was done to anybody in the O.T.
Diethyl ether, eldest of its family, is a drug of considerable antiquity. According to Dudley Buxton its original discovery is attributed to Djaber Yeber, an Arabian Chemist, synthesised later by Valeruis Cordus in 1540 and named as oleum vitrioli dulce. Ether is related chemically to water H-0-H and also alcohol where H of R-O (H) is replaced by another R. C2H5OH is ethyl alcohol; if we replace H by another C2H5 we get diethyl ether C2H5OC2H5. Ether is said to be simple when both “R’s” are of the same group when R radicals are of different groups a mixed ether is formed. Pharmacologists have thus synthesised about 700 halogenated hydrocarbons. Out of these, only a few had the pharmacological properties to be honoured on the anaesthetists trolly. To name a few ethers we may recall Methoxyflurous (Penthrane), Enflurane (ethrane, Alyrane), Isoflurane (Forane, Aerrane, Nederane), an isomer of enflurane, Desflurane and Sevoflurane. Of the halogenated compounds list will not be complete till wename halothane which is 2 bromo-2-chloro-1,1,1 trifluoroethane and thus not an ether.
The American discovery of ether spread fast over the world. The first European demonstration took place just nine weeks later in London. The lucky chance followed so soon because of the friendship between Bigelow of Boston and Boot of London. Bigelow sent a detailed letter of Morton’s successful ether administration. Boot lived and practiced in Gower Street, close to University College Hospital, who informed the surgeon Liston. On Monday 21st December 1846 Liston operated on three cases under ether anaesthesia administered by squires, using an apparatus specially designed for the occasion (India did not lag behind and ether anaesthesia entered the country from Calcutta).
The enterprise of dental profession in introducing anaesthesia is thus well established. The speciality having been formed, was subsequently nursed, nurtured and developed by its first specialist, John Snow in the Great Britain. He met an early death at the age of 45 years and carried out all the good work to establish his new-born speciality firmly in the last twelve years of his life. In 1847 he published his first book “On the Inhalation of Ether”. Chloroform and ether shared honours at this time; friline, though excelled in analgesia, lacked in relaxation and could not be used as a sole anaesthetic, cyclopropane being very costly and an imported item had only a few indications and was sparingly used.
I clearly remember having anaesthetized a 92 years old relative of the H.O.D of Orthopaedics in J.J.Hospital, Bombay. He was induced by a sleep dose of thiopentone, taken deep by open drop ether intubated and maintained on open drop ether with a 500ml per minute flow of oxygen under the mask. The S.P nailing lasted about an hour. The patient made an uneventful recovery. The surgery was assisted by Dr Sheroo Bharucha who later joined Irarin Hospital as Dr Mrs Kohli. An other case that I remember is of our own colleague. Late Dr G.C.Saxena approached one with the request that I should not intubate him for the stripping of his varicose veins in the legs. The surgery got prolonged and lasted over five hours. The induction was with thiopentone, gas, oxygen and halothane. I was forced to add a trace of ether to deepen the anaesthesia to achieve a cushion and avoid see-saw of planes, after an hour of halothane anaesthesia, he opened his eyes while bandages were being applied and had no nausea and vomiting post-operatively. The addition of ether successfully offset the two major disadvantages of halothane i.e. respiratory depression of cardiovascular depression. Hudon in 1958 had reported the use of mixture. Various combinations were tried and 2:1 halothane: ether (68:32 to be precise) were found stable and non flammable. The mixture behaved like and additive compound or an azeotrope. This adadvantae was, however, not supported by later research.
Be that as it may. I remember my first encounter with ether in Delhi was in 1958 when I joined the then Willingdon Hospital (now Dr R.M.L Hospital). The first person to greet me was Dr (Mrs) Vimla Mehra, Dr H.P.Varma took me to the ground floor O.T and asked me “Are you familiar with ether insufflation” I was not. He introduced me to endopharyngeal insufflation of ether, N2O/O2 mixture for tonsillectomy in children. Boyle-Davis gag was used to depress the tongue, tension being regulated by rope hanging down from a hook about 10ft above the mixture being delivered at the gas port. The Patient was taken deep into IIIrd stage plane II anaesthesia, put in Rosen’s position and surgery allowed without intubation. The set up looked impressive, anaesthesia did not take long and a long list could be completed fast. The surgeon used to remark “I am more under than you” It is a different storey that my wife would smell my clothes and would not come near. However, I and the surgeon enjoyed a good post-lunch siesta from experience I have learnt that ethyl chloride rather sequence is the best way to achieve blind intubation. A little CO2 (500ml/min) to deepen the respiration, not very light anaesthesia (IIIrd stage, plane I or II) good curve of the red rubber tube and a proper positioning of the head and neck are the secret of success. I have so far not failed at blind intubation. An other innovation I took a fancy for is flagg’s can. At the Safdarjang Hosptial they were using it for small surgical procedures in children but could also be used on adults. I consists of a tin can with several openings on the top containing ether. The endotracheal tube is connected to the top. The patient breathes air-ether mixture as per his tidal volume depending on the depth of anaesthesia. Ayre’s T Piece and its Jackson Rees modification can successfully be used for maintenance of anaesthesia with ether or other agents. It is light and has no values.
Ether 65%+Olive oil 35% was given rectally 20ml mixture/stone of body weight. Anaesthesia lasted for 2-3 hours and was complete. It has been used in obstetrics, status asthmaticus and inducing anaesthesia in patients with cardiac decompensation. Ether has also been used intravenously by Pirogoff in 1847, a year after its introduction by Morton, A 2.5 to 5% solu. in normal saline or glucose is used. 12.5ml to 25ml of ether is shaken up in a bottle and warmed upto 90oF not more, 98.6oF being its B.P. Started slowly, later run in a stream. Recovery with this technique is fairly rapid.
The ether regime was severely dented by the introduction of relaxants, concept of triad of anaesthesia by the Liverpool group (Rees and Gray), its own pharmacological short comings, and a spurt of better compounds mainly its own derivative which came nearer to the concept of an ideal inhalational agent. The introduction of shorter and powerful analgesics and day care surgery put the last nail on the coffin aided by the temperature compensated precision controlled newer vaporisers. The concept of triad of anaesthesia got a further boost in the arm by the availability of better inducing agents much to the detriment of the use of Ether. I did not see Jackson-Rees using ether on a single occasion during the six months I worked with him in 1969.
Evaluating ether its main advantages are:-
(i) It was comparatively non-toxic than its peers.
(ii) It could give excellent relaxation without undue respiratory depression.
(iii) Respiratory depression, if it occurs, is not accompanied safely be reversed.
(iv) It’s safety is marvelous. It stands out when an unskilled anaesthetist is dealing
with an unfit patient in a difficult peripheral area.
The disadvantages of ether are:-
(i) Increases mucous secretion from the upper airway.
(ii) Upsets body chemistry.
(iii) Tendency to cause albuminurea.
(iv) Its explosiveness when comes in contact with sparks flames and hot surfaces
in a mixture of oxygen or nitrous oxide.
(v) Ether convulsions + ether eye.
It is interesting to observe how the enterprise and interest evoked by a speciality lead to the discovery of the anaesthetic use of ether. It is all the more surprising that this was followed by the birth of a new speciality. The human discovery of ether has been of great significance to the whole world. Inventions of such magnitude do not happen spontaneously. Necessity has again proved to be the mother of invention. Surgery has been going on from the times of Sushruta, who described the Indian method of rhinoplasty, he did not write a word about anaesthesia used. Surgeries performed then were of a superficial nature – fracture, cataract, amputation trephining or cystolithotomy. Simple techniques of hypnosis pressure over the nerves and blood vessels, cold locally, alcohol and herbal concoctions using poppy seeds were upto the task. So far the gastro-intestinal ingestion of the anaesthetic was the only route available. Ether opened the gates for subsequent routes i.e. inhalation, intravenous and combinations of other routes. Ether also gave birth to a new speciality of anaesthesia and spurred indirectly though, the interest of other scientists to discover the use of other agents, manufacture newer molecules and discover safer and comfortable techniques. A good example is newer potent analgesics and introduction of curare into the concept of “Balanced Anaesthesia.” Harold.R.Griffith used Intocostrin, a curare preparation to give surgical relaxation during anaesthesia. This must have seriously undermined the use of ether thereafter.
After serving the ailing humanity for well over a century ether, the old faithful, has gone out of use. All good things have to come to end. The satisfaction is that most of the agents replacing it are its own off springs ie substituted others.
I cannot imagine a single discipline of medicine which has not been benefited by the discovery of anaesthesia be it investigative, curative, diagnostic, pain relief or research work, helping patients of all ages.
We must thank ether and Morton, its discoverer, every year like this. This is the best way to salute and thank them. Even this will fall short of expressing our full gratitude.
References (ETHER – AS I SEE)
1. A synopsis of Anaesthesia - Editions – 1953, 1968, & 1995.
J. Alfred Lee, R S Atkinson
G.B. Rushman & N.J.H.Davis
2. Modern Practice in Anaesthesia - Frankis.T.Evans – Edition – 1954.
3. Principles of Anaesthesiology - Vincent J. Collins – Edition – 1966.
4. Text Book of Anaesthetics - R.J.Minnitt & John Gillies – 1944.
5. Buxton, D, - Anaesthetics:- Their uses and administration
- 1900.
6. Physics for the Anaesthetist - W.W.Mushin, Peter L. Jones - 1987 Macintosh, Mushin & Epstein
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