COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD RD85.R2 HX64067319 _96 Ether-oil rectal ane /F/'HER-OIL RECTAL ANES- THESIA; SOME THEORET- L^ CONSIDERATIONS. BT H. CLIFTON LUKE, M.D., NEW YORK: Anesthetist to St. Luke's Hospital. REPRINTED FROM THE MEDICAL RECORD May 9, 1914 WILLIAM WOOD & COMPANY NEW YORK .■Hf /?/)ys-'^ M, intlifCttpofllfttilork CoIIegt of ^fjpjiirians anb g>nrgeons Hibrarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/etheroilrectalanOOIuke to CO LU ETHER-OIL RECTAL ANESTHESIA; SOME THEORETICAL CONSIDERATIONS. By H. CLIFTON LUKE, M.D., NEW YORK. ANESTHETIST TO ST. LUKE'S HOSPITAL. The administration of ether per rectum has once more taken on a certain degree of popularity, the present advocates of the method using it in the form of an oil-ether enema. The results here, in the hands of experienced anesthetists, have been variable, some praising, others disfavoring the method. There are some theoretical objections, hov^ever, to the procedure, and it is the purpose of these remarks to deal with the subject chiefly from this viewpoint. The usual technique, omitting special refine- ments, is in brief as follows: Effort is made to thoroughly cleanse the intestinal tract, especially the large intestine, beforehand; a hypodermic in- jection of morphine, sometimes in combination with atropine or hyoscine, is usuallj^ given one- half hour before injecting the ether; the mixture of ether and oil (olive oil being mostly used), con- taining about seventy-five per cent, ether in adult cases, is given in a single dose of six to eight ounces by volume very slowly through a small catheter Copyright, William Wood & Company. 1 into the lower bowel. This is injected about thirty minutes before operation, the patient being in bed until the unconscious state is reached. If surgical anesthesia is not obtained in thirty to forty min- utes, more ether is injected per rectum or admin- istered for a brief time by inhalation. Can we say that this method is founded on a good scientific basis? In other words, is it exact or accurate? The administration of ether, to be exact within a reasonable meaning of the term, should have the dosage, or amount administered, under direct control, which in turn exercises a fairly definite influence on the dose or amount ac- tually absorbed. This fundamental requirement does not appear to be fulfilled here: (1) because the entire dosage is estimated, and placed in the in- testine for absorption before essential information is acquired by the anesthetist regarding, (a) length of time the operation will take (which is often impossible to know), (b) the patient's resistance, susceptibility, or even special idiosyncrasy to the drug; (2) because a portion or all of the mixture may be expelled and lost, in which event an estima- tion of the amount still retained would be largely guesswork; (3) since there is also a small chance of error if the mixture is given in the usual man- ner by pouring through an open-topped funnel ; over a period of five minutes material loss by evap- oration could occur. Then, in reference to the important question of dose there also appears to be considerable uncer- tainty, and the reasons for this are: (1) the influ- ence of the inaccurate dosage as pointed out above ; (2) the patient's age would have a bearing on the rate of absorption, a given quantity of ether prob- ably entering the blood stream in young people, in considerable less time than it -would in those past middle life; (3) position of the solution in the large intestine has, undoubtedly, a marked influ- ence on the rate of absorption. It is impossible to know just how high it goes in any particular case, which adds to the uncertainty; but it seems highly probable that in some cases reverse persistalsis may take place carrying the mixture into the cecum, making its recovery, in case of over dosage, prac- tically impossible and materially increasing the rate of absorption. Practical proof of this possibility is shown in Stewart's case where a lead pencil, in- serted into the rectum, soon reached the cecum from which it had to be removed. Also in Chapin's work on babies where ic-ray examinations showed, after low injections of bismuth solution, that this material practically always reached the cecum. Le- Wald further states that low rectal injections of bismuth solution pass into the ileum in about 10 per cent, of cases due to incompetency of the ileo- cecal valve, and that in over 90 per cent, the solu- tion reaches the cecum. That this factor has an important practical side is evidenced by the fact that the Trendelenburg position (the necessity for which cannot always be foretold) is considered by some to contraindicate the use of the method; (4) pathological conditions of the rectum, sigmoid, or descending colon might strongly retard or increase the absorption; (5) an excessive amount of ether is probably absorbed (a) because the induction period is prolonged (frequently requiring one-half to three-quarters of an hour), which is due to the slow absorption, the mixture having not yet reached a very high position in the intestine. Likewise, in the administration by inhalation of vapors of insuf- ficient strength, patients can be given excessive quantities of ether without obtaining surgical anes- thesia, whereas a much smaller amount expediently administered gives the desired result in very much less time; (6) since olive oil is said to hold the ether in close combination and give it up slowly, absorption may continue for a considerable time after operation and delay the recovery, as there is no way of determining how much of the mixture still remains in the intestine after the passage of tubes or irrigation; (6) the varying amount of in- testinal surface exposed to the action of the mix- ture; (7) the claim for even and constant evapora- tion of ether from the mixture would hardly seem valid, for many surgical cases run more or less severe temperatures, the influence of which toward increasing the absorption must be considerable in view of the low boiling point of ether. Among other theoretical objections would be the possibility of a special form of toxemia from ab- sorption; for a powerful solvent is placed im- mediately before it is to enter the blood stream, in direct contact with a variable amount of highly toxic intestinal material. Does it not seem possible, therefore, that definite quantities of toxines may thus be assisted to re-enter the circulation? If so an extra burden is placed upon the eliminative functions, and the vitality of the patient suffers accordingly. Furthermore, the mode of reaching the vital centers by the anesthetic is circuitous, it having to first enter the venous blood and be con- ducted through the portal system before reaching the right heart and lungs. It would seem desirable to introduce an anesthetic into as clean and acces- sible a part of the body as possible where it may immediately enter the arterial circulation, and reach the nerve centers by the most direct course. The pulmonary route fully meets these requirements. The routine use of morphine is said to be necessary with the rectal method, which has the disadvantage of depressing the respiratory center and locking up the secretions; objections which here seem to have special import. Furthermore, the respiratory cen- ter cannot utilize its protective function against over-dosage in the rectal method, as it may in the inhalation methods where the administration is under direct control, because with the former de- pressed and superficial breathing does not auto- matically lessen the intake of ether, since the dosage is independent of this protection. In fact, the opposite appears to occur since the more ether absorbed the greater the respiratory depression and the less the respiratory interchange, resulting in retarded elimination with consequent cumulative ether effect. Lastly, that a normal anus should often be severely irritated in this procedure seems only natural to expect, and if a fissure or hemor- rhoids were present the outcome might be quite serious. The advantages of the oil-ether method outside of its simplicity seem to be more apparent than real. In fact, with the possible exception of selected cases of bronchoscopy, it is difficult to see any indi- cation for its use that cannot be as well and prob- ably more safely met by the modern pulmonary methods.' Its chief advantages are said to be found in surgery of the head and neck, since there is no hindrance to the operator in the way of anesthetic apparatus. The ordinary intratracheal catheter could not inconvenience the surgeon much, either, and the intratracheal method offers a much greater margin of safety to the patient, especially in sur- gery about the face, mouth, and neck, for several reasons; first, because it affords an efficient pro- tection against pneumonia of the aspiration type; second, because it provides a delicate and even con- trol of the ether dosage, enabling one to maintain a very light narcosis, and establish the coughing reflex at the close of the operation ; third, it further conserves the patient's vitality by providing perfect aeration, thus obviating any possibility of ob- structed breathing or necessity of packing off the throat, with the use of nasal tubes. In our series of intratracheal anesthesias we note that it has been employed forty times in operations about the head and neck (over half of which were resections of the upper and lower jaw and tongue and plastic procedures), without a single case of pneumonia or anesthetic complication, except one case of sub- cutaneous emphysema," which recovered. On the other hand, the only jaw resection we have done with the oil-ether method died with an aspiration type of pneumonia twenty-two hours after opera- tion. This patient, a fairly vigorous man of about fifty years, really never recovered from the anes- thetic, and was in a most profound state of narcosis for nearly six hours. Six ounces of ether and two ounces of olive oil were administered in the usual manner, and both before and after the operation was completed the colon was repeatedly irrigated without apparent benefit. This case is cited here simply to point out one of the method's shortcom- ings in this kind of work. Another advantage is said to be the very quiet type of anesthesia pro- duced, which is common in any method where there is a free air-way. But it must be remem- bered that most patients profoundly under ether behave in this manner. In a good ether anesthesia the depth of narcosis is intelligently and gradually varied to meet the operative requirements during the different stages of the operation. This would appear to be possible only when the dosage is under direct and definite control. In closing these remarks it may be well to men- tion some of the undesirable clinical features which must certainly be looked for in a method involving so many theoretical objections. The following are offered for consideration: (1) The rather ex- haustive and unpleasant experience accompanying any special rectal preparation, as required here; (2) the occasional necessity and inconvenience of preliminary and subsequent proctoscopic examina- tions, as a matter of safety and caution; (3) oc- currence during the induction period of cramps, with distressing sensations of fullness and pres- sure in the lower bowel, accompanied by desire for stool; varying degrees of anal irritation occuring early or late; (4) prolonged induction stage with frequent necessary recourse to the inhalation method; (5) any time after the first fifteen or twenty minutes' respiratory depression may rather suddenly or slowly appear, followed by arrested breathing, loss of muscular tone and diluted pupils, with the possibility of fatal syncope supervening; (6) the occurrence of mild to very severe grades of proctitis and colitis, these complications appearing in more aggravated forms where any pre-existent pathological condition is present; (7) delayed re- covery, which may be prolonged for many hours; (8) increased toxemia, dependent on a number of factors already discussed and which has recently been pointed out by Coburn.^ We believe that any method of administering ether to children, old people, or cases at any age where there is more than the average risk, that does not provide for immediate and definite control at all times, is certainly hazardous. It is also con- tended that any principle of administration which attempts to figure the dosage of ether on the basis of body weight is unscientific and impractical; be- cause the influence and importance of personal equa- tion in drug dosage is a matter of every day ex- perience, and in operative work there are a number of other factors which always play an important role in the amount of anesthetic required. To point out some of the theoretical shortcomings of a method does not necessarily condemn that pro- cedure; but by presenting the possibility of unde- sirable or dangerous symptoms and results, it may help to temper with conservatism the light-hearted manner in which many of these new propositions are taken up, especially by those who are inex- perienced. REFERENCES. 1. Janeway: "Intratracheal Anesthesia from the Standpoint of the Nose, Throat, and Oral Surgeon," Laryngoscope, 1913, XXIII, 1082. 2. Luke: Surg., Gynec, and Obst, 1913, XVI, 204. 3. 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