CHAPTER III
Anesthesia for Men Wounded in Battle
Henry K. Beecher, M. D.
The selection of an anestheticagent, the technique of administration employed, and the competence ofadministration of the anesthetic are matters of the greatest importance in thepeacetime practice of surgery. They are doubly important in the surgery ofcombat-incurred injuries. The relationship between anesthesia and shock isparticularly close in operations performed upon seriously wounded men, not onlybecause of the frequent occurrence of shock after wounding but also because, ifit is not already present, anesthesia can be, and often is, a precipitatingfactor in its development. It is entirely possible for an unwisely selected orincompetently given anesthetic to precipitate such profound shock in a woundedman whose status was previously not unsatisfactory that a compensatedcirculatory system is transformed into a state of decompensation. All of themechanisms of this process, although not yet fully clarified, were sufficientlywell understood when the United States entered World War II for theconsiderations which determined the acceptability or unsuitability of availableanesthetic agents to be clearly comprehended and to be translated intoappropriate action by all anesthetists who cared for wounded men.
HISTORICAL NOTE
It is indicative of the lack of emphasis placed uponanesthesia in World War I that the section dealing with it in the officialhistory was written by a surgeon, Col. George W. Crile, MC.1The specialty was not represented in The Surgeon General's Office, andconsultants in anesthesia were not appointed for service either overseas or inthe United States. Few of the points of view presented in the summary whichfollows could be substantiated at the beginning of World War II, but thematerial is presented because of its historical interest.
Nitrous oxide-oxygen anesthesia-Inthe first year of the First World War, according to the official history, theparamount value of nitrous oxide-oxygen anesthesia was clearly demonstrated byAmerican anesthetists attached to the Western Reserve University unit, whichworked at the American Ambulance at Neuilly, France. Satisfactory anesthesiacould be obtained with this agent in operations on seriously wounded men,whatever their degree of exhaustion. When the unit returned to America, one ofthe nurse-anesthetists
1Crile, George W.: Anesthesia. In The Medical Department of the United States Army in the World War. Washington: U. S. Government Printing Office, 1927, vol. XI, pt. 1, pp. 166-184.
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remained in France, at the special request of French andEnglish medical officers, to give instruction in the technique of nitrous oxideadministration.
The early enthusiasm for nitrous oxide-oxygen anesthesiacontinued for a considerable period.2 Conclusions adopted by theInter-Allied Surgical Conference at its second session, in Paris, in 1917, reaffirmed the confidence felt init by the delegates present, who represented England, Belgium, France, Italy,Japan, Portugal, and Serbia. It was the consensus of the conference that thisform of anesthesia (combined with local anesthesia) was the method of choice intraumatic shock, in amputations, and in gas gangrene. Ether was the secondchoice. Local anesthesia was preferred for cerebral injuries. Chloroform wasregarded as dangerous, and spinal anesthesia was reported as giving varyingresults.
When Base Hospital No. 4 (the Lakeside unit), which was the firstbase-hospital unit of the United States Army to be called into service after theUnited States entered the war, left for France, it was equipped with what wasassumed to be an adequate supply of nitrous oxide and with sufficient apparatusfor its administration. During the summer of 1917, surgeons of the unit hadopportunities at a British base hospital in Rouen and at British casualtyclearing stations in Flanders to test the comparative advantages of nitrousoxide, ether, and spinal anesthesia. English and French medical officers becameinterested in securing adequate supplies of nitrous oxide, and it was soonevident that what the Lakeside unit had brought over would not be sufficient forits own needs. The English supply was totally inadequate. The difficulty wassolved by the appropriation by the American National Red Cross of funds for theconstruction of a plant for the production of nitrous oxide. Various delaysensued, and it was not until the early summer of 1918 that the plant was in operationin France and was manufacturing the gas at the rate of 125,000 gallons every 8hours.
It was generally acknowledged that nitrous oxide-oxygen anesthesia gave lesssatisfactory muscular relaxation than either ether or chloroform, that itrequired expensive and cumbersome apparatus for its transportation and administration, that it cost more than other anesthetics, that it was technically themost difficult to administer of all the anesthetics then available, and that itwas dangerous in inexpert hands. These disadvantages, however, were thought tobe outweighed by its advantages, including the following: It was quick in actionand pleasant to take; recovery was immediate, without nausea; food could betaken soon after recovery; transportation was possible soon after recovery; lessnursing care was required; such complications as bronchitis, pneumonia, andnephritis did not follow it; and, finally, nitrous oxide was thought to bestrongly protective against the shock of surgery. It was particularly favoredfor short operations but was regarded as equally suitable for long
2Surgery at theBase. Compilation of Responses by Base-Hospital Staffs to Questionnaire Sent Outby Research Committee. Questionnaire Prepared by Brig. Gen. J.M.T. Finney andCol. G. W. Crile. Compilation of Responses Made by Maj. T. W. Burnett. War Med. 2: 1281-1350, February-March 1919.
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ones. If it did not bring about sufficient muscular relaxation in abdominaloperations, it could be supplemented by regional anesthesia.3
Ether and chloroform -In the chapter on anesthesia in The MedicalDepartment of the United States Army in the World War, ether and chloroform arediscussed under the same general heading.4 Both were thought to contributeactively to shock and exhaustion. Both, if given for any length of time, werethought to cause cytologic changes in the cells of the brain, the liver, and theadrenal glands identical with those resulting from other causes of exhaustion.Patients who did well under ether anesthesia were said to do poorly later. Itwas believed that ether tended to cause bronchopneumonia, especially inabdominal surgery performed in the winter; to be unsuitable in infectionsbecause it diminished, and even temporarily abolished, phagocytosis; to beunsuitable in shock because of its tendency to cause a fall in blood pressure;and to be responsible for a rather large diminution in the reserve alkalinity ofthe blood.
Spinal anesthesia-The tendency of spinal anesthesia to produce a fall inblood pressure was recognized in World War I, the decrease being most notable inpatients whose blood was greatly diluted and whose hemoglobin was low. On theother hand, this was stated to be the type of patient most in need of protectivenerve block. The practice was to attempt to overcome the fall in blood pressureby a preliminary blood transfusion. The disadvantage of psychic shock, arisingfrom the sights and sounds of the operating room and the patient's awareness ofwhat was happening, was recognized, but it was pointed out that thesedifficulties could be overcome by the administration of morphine or, better, byvery light nitrous oxide-oxygen anesthesia or partial ether anesthesia.
Spinal anesthesia was believed to be of special value whenlesions in the air passages rendered inhalation anesthesia inadvisable or whenthe prone position was necessary because of the nature of the wounds. It wasgranted that it was time consuming to administer, and its use in rush periodswas therefore not thought to be justified, on the ground that it would work ahardship to other patients awaiting operation, who might be subjected to therisk that anaerobic contamination could become gas gangrene. The statement thatone of the advantages of spinal anesthesia is that it does not require a trainedanesthetist to give it has a curious sound to modern ears.
Regional and local anesthesia-Regional and localanesthesia were regarded as of great value in many of the exigencies of warsurgery in World War I, especially in rush periods at the front, when it mightnot be practical to give nitrous oxide-oxygen anesthesia because of theapparatus required, and when prolonged periods of induction and recovery wouldnot be feasible. Even when inhalation anesthesia was available, local anesthesiawas regarded as preferable for the excision of damaged soft tissues, the removalof debris, the probing of soft tissues for retained missiles, the amputation offingers, the repair of scalp wounds, and intracranial operations. The chiefdisadvantage
3It should be emphasizedagain that the data on nitrous oxide anesthesia are presented for theirhistorical interest only. Neither clinical nor experimental evidence warrantedthe high favor accorded to this form of anesthesia.
4See footnote 1, p. 53.
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of local anesthesia was thought to be the possibility that it mightdecrease the resistance to infection of tissues which were alreadycontaminated.
Pre-anesthetic medication in World War I was limited to morphine.
MILITARY CONSIDERATIONS OF ANESTHESIA
When the United States entered World War II, anesthetists had at theirdisposal a wide range of agents and techniques. A number of these had beenintroduced since World War I, including ethylene, ethyl chloride, PentothalSodium (thiopental sodium) by the intravenous route, and endotrachealanesthesia. Equipment had been greatly improved. In particular, modern,efficient machines for gas anesthesia had been made possible by the developmentof the carbon dioxide absorption technique. This technique, although it had beendescribed in 1915, had not come into common use until the decade preceding WorldWar II. It permits measured amounts of anesthetic gases and oxygen to bedelivered to the patient, ether being added to the mixture in small quantitiesuntil the desired plane of anesthesia is reached. As the gases are expired, theypass through a canister containing a chemical absorbent, by means of whichexpired carbon dioxide is removed. The gases then pass into a rebreathing bag,and the patient, on inspiration, receives a warm mixture of anesthetic gases andoxygen or of vapor and oxygen.
The closed method of administering gas-oxygen and ether anesthesia has anumber of advantages. It greatly reduces the fire hazard, since all gases usedare contained in a closed circuit. It also reduces the cost of anesthesia, sincethe closed circuit conserves whatever agents are used. In addition, thistechnique permits the maintenance of intermittent positive pressure anesthesiaand also permits the anesthetist to control the patient's respiration at will.It is not too much to say that without this, and other, advances in anesthesia,the surgical progress accomplished in World War II would not have been possible.
The wide range of anesthetic agents and techniques available at the outbreakof World War II did not, of course, mean that all of them could be employedaccording to peacetime practices. In addition to the fact that medicomilitaryefficiency could be achieved only by the establishment of standardized methods,there were several other reasons why anesthetic agents, at least in forwardzones, were chiefly limited in World War II to ether, Pentothal Sodium, andprocaine hydrochloride:
l. The use of cumbersome equipment was undesirable because ofthe disproportionate amount of scarce shipping space which it occupied intransit to destinations overseas.
2. The use of such equipment was also impractical. Many times during thecourse of the war, hospital installations in forward areas, even 400-bedevacuation hospitals, had to evacuate their patients; tear down their equipment;move forward, often many miles, often over difficult, congested roads, andsometimes under fire; set up again and be ready to receive patients within 24
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hours after the first notification of the move. When suchmoves had to be accomplished, as well as under other military circumstances, itwas almost impossible to protect delicate, complicated apparatus from injury.Gas machines are delicately adjusted, and when they were handled roughly theywere likely, in a short time, to leak and to lose their serviceability.
3. The problem of logistics played a further part in the choice ofanesthestic agents in forward areas. Interruption of supply channels andconstantly changing supply routes soon convinced even anesthetists who hadstrong preferences for certain agents to the exclusion of others that they mustcontent themselves with fewer agents, preferably those which, when necessary,could be transported by hand and which could be administered, when necessary, byimprovised techniques and equipment.
4. The shortages of trained personnel for the administrationof anesthetics made it necessary, from the standpoint of safety, to limit theagents employed to those which could be given, without undue risk to thepatient, by physicians and nurses of limited experience in this field.
PERSONNEL
The outbreak of World War II found the whole United States with far fewertrained anesthetists than were needed for the practice of the specialty inpeacetime. The Army Medical Corps, which represented a cross section of Americanmedical personnel and practice, naturally reflected this shortage. Furthermore,because of the previous Army policy in regard to training medical officers asanesthetists, it was not until March 1939 that a 6-month course of instructionwas begun at the Mayo Clinic by the first medical officer to be designated forformal training in anesthesia since World War I. When he completed his course,he was replaced by another officer, and this limited policy was still in effectat the time of Pearl Harbor. While these officers were being trained, nursescontinued, as previously, to give inhalation anesthetics in the various Armyhospitals in the United States. Spinal, local, and regional anesthetics weregiven by the surgeon himself or by some other medical officer designated forthis purpose.
The Army shortage of trained personnel in anesthesia wasseriously reflected in the North African Theater of Operations, where the firstprolonged fighting against the western Axis powers took place. Of the 77physicians in the theater designated as specialists in anesthesia, only 10percent had been certified by the American Board of Anesthesiology. Fifteenpercent of the so-called specialists in anesthesia had been trained in courseswhich lasted from 1 to 3 months, and 20 percent had had no training at allexcept what they had obtained incidentally, during surgical residencies androtating internships.
The small number of physicians available for assignment to anesthesia in theMediterranean (North African) Theater of Operations was compensated for by anumber of substitutions and shortcuts:
1. Although shortages in personnel seldom seriously slowed downthe care
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of casualties, the possibility was always a constant anduncomforta threat. When the situations arose, dentists, as had been arrangedpreviously, helped out voluntarily.
2. A good many medical officers who had had little, if any, specialpreparation in anesthesia were also pressed into service.
3. Aidmen, under close supervision, sometimes gave anesthetics in times ofstress in forward areas. This was not a desirable expedient. These men, becauseof their earnest application to their duties, often rendered good service, but,in general, this was not a satisfactory plan.
4. Continuous training of nurses was practiced. Four general hospitals wereemployed for this purpose in the Mediterranean theater. They were more suitablefor supervised training in anesthesia than were forward hospitals.Theoretically, the course of training was 3 months. Actually, how long thestudent remained depended upon how long she could be spared from her unit. Oftenthis was only 2 months, and sometimes it was only 1 month.
5. Schools of anesthesia were supplemented by individual training given inthe various units in the theater. In a number of instances, the unusualabilities possessed by anesthetists in affiliated units working at the rear wereutilized in the training of anesthetists to be sent to forward areas.
Surveys made in certain evacuation, station, and general hospitals in theMediterranean theater in September 1944 showed that the relationship betweenpersonnel administering anesthesia and the surgical load varied widely (table3). The assignments, for obvious reasons, were made according to the function ofthe hospital. Evacuation hospitals naturally required the greatest concentrationof personnel in the forward areas. Field hospitals, in which newly woundednontransportable men were cared for, and which had a 100-bed capacity perplatoon, were usually staffed by four auxiliary surgical teams. Each of theseteams included an anesthetist, who was usually a physician, and the setup wassuch that two operating tables could be kept in continuous use day and night.Occasionally, when the load was particularly heavy, three or four operatingtables could be used at the same time in a single platoon, but this arrangementcould not be maintained for very long.
As a working principle, it was found best to assign theablest anesthetists to the combat zone. Here there were the greatest demands onnative intelligence, judgment, resourcefulness, and technical ability. Inpractice, this principle could not always be applied, because physicians inunits associated with affiliated schools and hospitals could not readily bedetached from them. It was undoubtedly true that surgery undertaken in stationand general hospitals in rear areas required at least as much judgment, skill,and training on the part of the anesthetists as were required in forward areas,but it was equally true that the circumstances under which surgery was done inforward areas put a particularly heavy tax upon these qualities andqualifications.
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TABLE 3.-Provisionof anesthetic personnel in sample evacuation, general, and station hospitals inMediterranean theater (September 1944)
EQUIPMENT
The portable Heidbrink and McKesson anesthetic machines issued by the Armywere of the standard type used in all civilian hospitals. The Beecher
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machine5 was designed especially for military use. As earlyas 1941, the Subcommittee on Thoracic Surgery of the Committee on Surgery of theNational Research Council, with a vivid recollection of the high death ratewhich followed wounds of the thorax in World War I, had attacked this problemfrom various aspects, with the idea of developing methods of making earlytranspleural intervention practical. Patients with wounds of the thoraxfrequently do not tolerate delay in transportation to distant hospitals. At thesame time, successful forward surgery could not usually be done in the absenceof positive pressure in the airway. The problem, from the standpoint ofanesthesia, was therefore twofold: (1) To devise a simple anesthesia apparatuswhich would be light, compact, and easily carried by hand; and (2) to constructit in such a manner that positive pressure could be developed with it, withoutdependence on tanks of oxygen, the provision of which, it was then thought,would be impractical in forward areas of active combat.
The machine designed to meet these requirements (figs. 8, 9, and 10)consisted of the following parts: A foot bellows, with air intake well above thefloor; an air reservoir bag; an air-reducing valve and a reducing valve arrangement which permitted the use of compressed oxygen when it was available;
5Beecher, H. K.: An Easily Transportable Apparatus for Anesthesia With orWithout Compressed Oxygen. Especially Designed for Positive Pressure Anesthesiain Thoracic Surgery Under Military Conditions. War Med. 2: 602-608, July 1942.
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FIGURE 9.-Transportable anestheticapparatus in carrying case and set up.
a safety blowoff valve; an ether-vaporizing bottle with a string wick, topromote rapid volatilization of ether; a face mask; and a breathing bag with ato-and-fro soda-lime filter (Waters' type for the removal of excreted carbondioxide). At the distal end of the soda-lime canister was an adjustable vent,which was chiefly used when room air was employed. An intake tube 3 feet long,which could be attached to the operating table, maintained the air intake of thefoot bellows at a considerable distance above the floor so that no floor
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FIGURE 10.-Administration of ether in simplified closedsystem in evacuation hospital in Italy, 1944.
dust was taken up. The parts of the machine made of rubber were preferablymade of conductive rubber. The machine permitted the maintenance of positivepressure in the airway when this was necessary, but at the same time could be soadjusted as to allow the gradual escape of air from which part of the oxygen hadbeen extracted during respiration.
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Several changes were made in the original model after it was tested in actualuse. It was found that the foot bellows could be dispensed with because oxygenwas available in forward as well as rear areas. It was also found advantageous to add a dropper of the oil-cup type, to enrichthe ether atmosphere. Finally, the machine was further simplified by eliminationof the flow meter, which was not really necessary for the air or oxygen used inmaintenance. If the breathing bag was kept adequately filled and if care wastaken to see that the patient's blood was always of good color, nothing else wasneeded beyond the respiratory excursions adequate to remove carbon dioxide.
This machine was carried, by hand when necessary, in a compact containermeasuring 10 by 10 by 19 inches(fig. 9). The container was large enough to contain additional supplies,including a laryngoscope (Eversole) with the battery in the handle, and 2 extra light bulbs for it; 2rubber intratracheal tubes (Magill, #29 and #32); anaspiration bulb and catheter (Flagg) for clearing out the bronchi; a smallpacket of the agent used for induction, usually Pentothal Sodium; and 2 cans of ether (1 pound each).When the container was fully loaded, the total weight was 25 pounds. The machine itself was sosmall that it occupied little space in a crowded operating tent, and it was sosimple and durable that there were few parts to get out of order and fewopportunities for leakage. An additional advantage was that it required onlysmall amounts of critical materials for its manufacture.
Anesthesia could be induced with this apparatus by the so-called straightether method at least as conveniently as by the open cone method. Civilianexperience had shown that induction with nitrous oxide was satisfactory intranspleural surgery, but nitrous oxide was seldom available at the fieldhospital level. Pentothal Sodium was sometimes used for induction in etheranesthesia, but this agent was not safe, even for this limited purpose, inseriously wounded men (p. 72).
Although one of the reasons the Beecher machine had been devised was to makethoracic surgery feasible without the use of compressed oxygen, this did notmean, of course, that oxygen was not used when it was available (fig. 11). As amatter of fact, and contrary to expectations before the war, oxygen was suppliedat most forward installations. If the amounts available were limited, it couldbe added in small quantities to the room air in the system during the period thepleura was open. If, for instance, the pleura was open for 30 minutes, theaddition of 9.5 liters (2.5 gallons)of compressed oxygen aided greatly in maintaining ideal operating conditions.Compressed oxygen was thus conserved, and a little was made to go as far aspossible. When compressed oxygen was not available, a constant flow of room airwas maintained through the apparatus. When the system was constantly flushed inthis manner, it was not necessary to use the soda-lime carbon dioxide absorbent.
Although the Beecher machine was devised specifically for usein thoracic surgery, experience in the combat zone proved its usefulness for anyother type of operation in which inhalation anesthesia was employed. It couldalso be used for the administration of oxygen and for artificial respiration.
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ANESTHETIC AGENTS
The pattern of anesthesia had been clearly established bySeptember 1944 inthe North African (Mediterranean) Theater of Operations, where there had beenactive and often intensive combat since November 1942. Ether had emerged as the agent of choice for operation onseriously wounded soldiers, and its corresponding merits in men who were betterrisks had also become evident. Local anesthesia had been shown to be inadequatefor major procedures and was not well tolerated by apprehensive, badly woundedmen, who frequently had multiple wounds and who sometimes were in great pain.Intravenous anesthesia with Pentothal Sodium had its first valid trials inmilitary surgery during the fighting in North Africa. After a proper regimen forits use had been established and limitations and contraindications had beendetermined, it was found to be admirably suited for the needs of war surgery.
In the following sections, the advantages and disadvantages of the variousanesthetics and techniques available at the outbreak of World War II are brieflydiscussed from the standpoint of their use in combat zones. In station andgeneral hospitals, there were no special problems of anesthesia becauseconditions in them approximated those in civilian hospitals.
Spinal Anesthesia
When spinal anesthesia was first introduced, its tendency tocause a fall in blood pressure was so significant and so serious that its usewas almost discontinued. Then it was found that vasoconstrictor drugs couldcontrol this effect, though the most potent vasoconstrictors could not maintainlevels of safety in patients who had suffered severe trauma and had lost largeamounts of blood.
Spinal anesthesia was additionally undesirable for anotherreason. When it is used, the vasomotor fibers are the first to be paralyzed andthe last to recover. The area over which this effect occurs is larger than thearea over which the pain response is eliminated, since to interrupt vasomotorcontrol requires a lower concentration of whatever agent may be employed than isrequired to interrupt pain sensation. Spinal anesthesia therefore breaks down animportant body defense against shock by the interruption of vasomotor control,which is one of its integral effects.
In spite of these well-known disadvantages, many surgeonscontended in the first years of the war that spinal anesthesia was desirable inmilitary surgery. Many American surgeons argued for its employment, in spite ofthe data concerning its risks and inefficiency which came in from areas ofcombat early in the war, on the ground that errors of administration couldaccount for the unsatisfactory results.
Studies reported from the Massachusetts General Hospital6in 1943
6Beecher,H. K.: The Choice of Anesthesia for Seriously Wounded Patients. J. A. M. A. 121899-903, 20 Mar. 1943.
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effectively answered these arguments. These studies were carried out in twoseries of patients with perforated peptic ulcers. The patients, chiefly men, ofan average age of 44 years, were seen within 30 minutes to 40 hours of the accident, and allwere submitted to the same well-standardized reparative operation. One group wasoperated on under spinal and the other under ether anesthesia. Whether theadministration was by widely experienced anesthetists or by beginners, a fall inblood pressure was observed twice as frequently when spinal anesthesia was used.
Spinal anesthesia had a limited use early in the fighting in the NorthAfrican theater, but its popularity decreased as it came to be appreciated thatthere were few indications for its employment in forward areas. One reason forlimiting its use in these areas was the difficulty of preserving sterility ofequipment in the field. A more potent argument was the poor tolerance of freshlywounded men for it, as indicated by the tendency of the blood pressure to fallwhen it was used. The condition of the circulation, always precarious in afreshly wounded man, deteriorated rapidly when it was employed, and eventuallyfew surgeons or anesthetists, whatever their practices and preferences mighthave been in civilian life, recommended its use in forward areas, even inlightly wounded men. It always had, of course, a considerable and proper use inhospitals to the rear.
A survey of 12 hospitalsin September 1943 showedthat, since November 1942, spinalanesthesia had been used in almost 20 percent of the operations inforward hospitals. A second survey, in August 1944, showed that in the interveningperiod it had been used in only 3 percentof operations in forward hospitals. Further analysis showed that this proportionwas composed largely of emergency appendectomies and other operations notrelated to warfare. The sharp decrease in its use indicated, as already noted,both a realization of and an acceptance of the fact that spinal anesthesia isusually a poor choice in badly wounded men and may, indeed, be a major error.
Local (Regional) Anesthesia
Local anesthesia must always be considered when a noninflammable anesthetic is required or when surgery must be carried out on traumatized and exsanguinated patients for whom it would be adequate. The English experience early in the war, however, showed that the moderate discomfort and psychologic trauma associated with its use made this type of anesthesia poorly tolerated by seriously wounded men who were aware of their condition and surroundings. In their hands, as later in American hands, it was sometimes useful for minor surgical procedures on phlegmatic or apathetic subjects, but appraisal of the patient's possible tolerance for occasional discomfort and other inconvenience was an essential preliminary to the decision to employ it.
The technique of local anesthesia is not difficult for surgeons who use itregularly and have had special experience with it. In other hands, there is aconsiderable proportion of partial successes and actual failures. These difficulties made local anesthesia time consuming and furnished another sound
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reason for its limited use under combat conditions in theMediterranean Theater of Operations in World War II. Finally, the soundestreason for the limitation of its use was the multiplicity of wounds usuallypresent in each case. In these circumstances, it was not a practical method.
Harmful circulatory effects can occur from the use of too large amounts oflocal anesthetic agents or from their too rapid absorption. These undesirableeffects can be minimized by two precautions:
1. The addition of epinephrine hydrochloride (1:200,000 in the optimum finaldilution). This practice prolongs the anesthetic effect perhaps fivefold and atthe same time reduces the quantity of procaine hydrochloride needed. Vasoconstricting agents should not be used, however, in operations about thegenitals or on the fingers, toes, ears, or nose, because of the danger ofsloughs. They should not be employed when cyclopropane, chloroform, ethylchloride, or Avertin (tribromoethanol solution) are to be used, because of thedanger of ventricular fibrillation. Finally, they should be employed with greatcare, if at all, in patients with organic circulatory impairment.
2. Careful attention to dosage. Toxicity from the absorption of localanesthetic agents increases in geometric progression as the dosage is increased.Thus it is usually safe to give an able-bodied man 150 cc. of 1-percent procainesolution over a period of an hour but dangerous to give him 75 cc. of 2-percentsolution over the same period. Not more than 35 cc. of the 2-percent solutioncan be used with safety in the space of an hour.
Within the limitations and with the precautions specified, local and regionalblock, chiefly with procaine hydrochloride, proved useful in certainneurosurgical and maxillofacial operations, as well as in minor surgical procedures. It also had other uses. In the form of intercostal and paravertebralblock, procaine hydrochloride was useful in controlling pain in the traumatizedchest wall, with consequent improvement of the respiratory function, and inimproving the blood supply to an extremity. Peritoneal block under direct visionafter the abdomen was opened often improved relaxation of the abdominal wall tosuch a degree that only light general anesthesia was necessary.
When topical anesthesia was indicated, it was accomplished with Pontocaine (tetracainehydrochloride) or cocaine.
Chloroform
From the theoretical standpoint, chloroform has a number of advantages. Itcan be administered smoothly with a minimum of equipment. Its potency is sogreat that only low concentrations are needed in inspired air, and adequateoxygenation can be obtained from the atmosphere of the operating room. Itproduces excellent muscular relaxation. It is easily transportable, and it doesnot burn or explode.
These advantages are outweighed by a number of disadvantages and dangers. Theventricular fibrillation, central hepatic necrosis, and destruction of theconvoluted tubules of the kidneys which chloroform is capable of producing cancause death or serious and permanent disability. Its effect on the
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circulation is profoundly depressing. It slows the heartrate, weakens the strength of the cardiac contractions, reduces the cardiacoutput, and depresses the blood pressure. It also causes acidemia. Hepaticdamage produced by chloroform can be minimized by its administration with highconcentrations of oxygen in inspired air and by a diet high in protein andcarbohydrate; but these precautions are not always possible under conditions ofcombat, and they do not alter the possible effects of chloroform on thecirculation.
Chloroform had been practically discredited in civilian practice for manyyears before World War II, and its effects on the circulation are such thatthere would seem to be even less reason for using it in men wounded in battleand already suffering from circulatory impairment than in nontraumatic civilianpractice. It was therefore almost never used in the Mediterranean theater. Withthe other agents available, it was difficult to find a legitimate use for it,except when Pentothal Sodium, nitrous oxide, or a local anesthetic agent was notadequate and it was imperative to use a noninflammable agent.
The suggestion was made that chloroform be provided in small ampules foradministration by nonmedical personnel to wounded soldiers who had become manicin burning tanks and who might be more easily removed through the narrow escapehatch if they could be controlled. So far as is known, chloroform was not usedfor this purpose in any theater of operations.
Nitrous Oxide, Ethylene, and Cyclopropane
Nitrous oxide, ethylene, and cyclopropane all have the initial disadvantages,from the military standpoint, that they require steel cylinders for theirstorage and that they must be used with compressed oxygen.
Nitrous oxide and ethylene have undesirable metabolic effects if they areadministered without adequate oxygenation, which is a generally impossiblerequirement if a full surgical level of anesthesia is necessary. This is particularly true when nitrous oxide is used, since the high partial pressurerequired leaves little room for oxygen. The same is true, though to a lesserdegree, when ethylene is used. Satisfactory muscular relaxation cannot beproduced with either of these agents within the limits of safety.
Cyclopropane has deleterious effects on the heart and has apparently causeddeath from ventricular fibrillation in a considerable number of cases. Asidefrom. this effect, it seems to be better tolerated, from the circulatorystandpoint, by animals in shock or in impending shock than any of the otheranesthetic agents, with the possible exception of ethylene. Whether this is trueof human subjects in shock is not yet known.
Neither cyclopropane nor ethylene was issued to medical officers in theMediterranean theater. When nitrous oxide was available, it was occasionallyused for minor surgical procedures, such as painful changes of dressings. It wasalso occasionally used to supplement other forms of anesthesia, such asPentothal Sodium (with 50-percent oxygen), or for induction in ether anesthesia.It was useful for all of these purposes, but it was by no means indis-
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pensable. Nor did it rank in efficiency with ether, Pentothal Sodium, orprocaine hydrochloride.
Vinyl Ether
Vinyl ether acts rapidly and is readily transportable. Inspite of these advantages, it was not used extensively in any theater in WorldWar II because its advantages were outweighed by its disadvantages. It isdifficult to use satisfactorily without a closed rebreathing apparatus. It has atendency to cause laryngeal spasm, profuse salivation, muscular twitchings, andeven convulsions and liver damage. It is chemically unstable, and it is possiblethat the results just listed may be caused by that property.
Ether
Ether is undoubtedly the most useful anesthetic agent forgeneral purposes and under nearly all circumstances, including militarycircumstances. Its great potency permits an adequate supply of oxygen, even ifonly room air is available. Its straight induction in seriously wounded men isremarkably easy and is apparently not unpleasant for the patient, whether theopen-drop method is used, or, as is preferable, it is given by the closedmethod, with oxygen (fig. 11). Ether produces excellent muscular relaxation. Itis well established that even an impaired circulatory system tolerates prolongedether anesthesia well. A man in shock, in fact, seems to tolerate ether farbetter than an animal in shock.
Ether has, on the other hand, some undesirable properties. Itis irritating to the mucous membranes of the respiratory tract-though it hasnever been adequately demonstrated that this characteristic increases theincidence of respiratory complications or the number of deaths from them, whileconsiderable evidence suggests that the irritation which it causes is of noclinical importance. Ether also causes a considerable disturbance of metabolism,the blood sugar frequently being elevated from 100 to 200 percent.
In World War II, ether was the anesthetic of choice in the seriously wounded,whether the gravity of their injuries depended upon widespread tissuedestruction, penetration of body cavities, or severe hemorrhage from woundswhich in themselves might not otherwise have been of great consequence. Since itwas the anesthetic best tolerated by men in shock, it seemed reasonable to useit also in men who were less badly off. In the first months of fighting in NorthAfrica, it was not used as widely as it should have been, at least in forwardhospitals. The increase in its use in the second year of fighting may beunimportant statistically, but clinically it is of great significance, since itoccurred chiefly in the field hospitals, where the surgically important group ofpatients was treated. These were the men with wounds of the abdomen and thoraxand compound fractures of the femur.
An intelligent appraisal of anesthesia practices is notpossible without some knowledge of the type of surgery performed. The meretabulation of data (table 4) does not tell the full story. The true picture isbetter obtained from an
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analysis of the experience of auxiliary surgical groups, which had a wideexperience in forward surgery, particularly in the surgery of nontransportablepatients in field hospitals. In such an analysis, surgery of the abdomen andchest assumes greater importance than the tabulated data indicate. Of 15,925wounded men treated by the 2d Auxiliary Surgical Group, for instance, during theNorth African, Sicilian, and part of the Italian fighting, 1,628 (10.2 percent)had abdominal injuries, 1,502 (9.4 percent) had thoracic injuries with pleuralinvolvement, and 508 (3.2 percent) had thoracoabdominal injuries. Since the1,628 abdominal injuries included a number of cases in which exploration wasnegative, the thoracic injuries may be said to have been approximately asfrequent as abdominal injuries in the experience of this group, while thecombined total of thoracic and thoracoabdominal injuries exceeded the number ofabdominal injuries. The responsibility of the anesthetist in surgery of suchmagnitude is too evident to need elaboration.
Area | Number of operations | Site of major surgery | ||||||
Extremities | Abdomen | Chest |
| Ear, nose, throat | Miscellaneous | |||
Major | Minor | |||||||
|
| Percent | Percent | Percent |
| Percent | Percent | Percent |
Forward (field and evacuation) hospitals | 9,199 | 28.0 | 7.0 | 3.1 | 1.7 | 0.6 | 3.3 | 56.3 |
Rear (station and general) hospitals | 11,261 | 13.4 | 6.5 | .8 | 1.4 | 2.1 | 4.5 | 71.3 |
The Barbiturates
Civilian experience up to World War II showed that when thebarbiturates (Evipal Sodium (hexobarbital soluble) and Pentothal Sodium) wereused for major as well as minor surgery, the death rate, depending upon thequality of the clinic, was likely to be from 3 to 10 times higher than for etheranesthesia. At the Massachusetts General Hospital, where these agents arechiefly used for procedures on able-bodied adults which last less than an hour,8,000 consecutive anesthesias were administered with barbiturates with nodeaths.7 Early in the series, however, a number of lessons werelearned: That bad-risk patients tolerate these drugs poorly, except when theyare used in small amounts as supplements to other forms of anesthesia; that,even in these circumstances, a fall in blood pressure may occur during spinalanesthesia; and that patients with circulatory impairment tolerate fullbarbiturate anesthesia particularly poorly.
7See footnote 6, p. 65.
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Adequate studies have shown that intravenous anesthesia with barbiturates isassociated with two other outstanding hazards:
1. It causes a progressive loss, which finally becomes complete, of thesensitivity of the respiratory center to its normal chief stimulus, carbondioxide, the content of which in the blood may rise to depressant levels duringanesthesia with barbiturates.
2. When the normal respiratorydrive becomes impaired or disappears completely, a supplementary mechanism isnecessary to keep it going. A shift is therefore made from the normal drivingaction of carbon dioxide on the respiratory center to the action of anoxia onthe chemoreceptors, chiefly the aortic and carotid bodies.
Pentothal Sodium was provided in the North African Theater of Operations fromthe time of the first landings in November 1942. Its ready availability; thesimplicity and compactness of the equipment for its administration; the ease andsmoothness of induction, even by inexperienced physicians; and the apparentinfrequency of undesirable after effects-all made it a popular anesthetic drugunder combat conditions. These advantages tended to outweigh other importantconsiderations: That Pentothal Sodium is a powerful tool, that overdosage is noteasy to overcome, that the lethal dose varies within a wide range from onepatient to another, and that this form of anesthesia is definitelycontraindicated in certain types of injury and under certain circumstances.
The results of the casual acceptance of the advantages of Pentothal Sodiumwithout regard for its dangers and disadvantages, were apparent in the firstsurvey of anesthesia made in the theater, in September 1943. Sample data secured from 12hospitals showed that this agent had been used in 2,672 operations and that in 6of the fatalities which followed (1:450), deathcould be attributed only to anesthetic causes. Further investigation at otherhospitals produced similar data. Results throughout the theater, in fact, wereso bad that it was seriously proposed that this form of anesthesia be abandonedentirely, particularly since the experience in North Africa paralleled theexperience reported from Pearl Harbor.
A detailed analysis of the fatalities caused by Pentothal Sodium anesthesiain 1942-43 casta somewhat more hopeful light upon the situation. Two errors were outstanding,but both were readily correctible. The first was the use of this method ofanesthesia by completely inexperienced medical officers, many of whom seemed tohave the impression that all that was necessary was for the drug to be injectedinto a vein. The second error was the frequent use of this method in conditionsin which it was actually contraindicated and in which it should never have beenemployed. The impression derived from the analysis was that if these errorscould be corrected and the conditions of its administration controlled,Pentothal Sodium might prove to be, in practice, the ideal anesthetic forcertain types of injuries of warfare, just as it had always been in theory.
The decision to continue the use of Pentothal Sodium as ananesthetic
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agent in the Mediterranean theater proved sound. A surveyconducted in 10 hospitals in the theater in September 1944, a year after thefirst survey, showed that only 2 deaths could be attributed to its effects in11,136 operations (1:5,550). In other words, during the period covered by thesecond survey, Pentothal Sodium, although it had been used in about 4 times asmany cases as during the first period, was responsible for only a third as manydeaths. The figures indicate the magnitude of the improvement which had beenachieved in the course of the year.
It should be emphasized again that this improvement occurredover a period in which the use of Pentothal Sodium had increased considerably.In September 1943, this agent had been used in over 2,500 (53 percent) of theoperations performed in the forward hospitals surveyed and in 1,462 (28 percent)of the operations performed in the station and general hospitals surveyed. InSeptember 1944, these proportions had risen, respectively, to 63 percent (6,721operations) and 48 percent (4,415 operations). A large part of the increasecould be explained by the widespread adoption of the practice of secondary woundsuture, a procedure for which this type of anesthesia approaches the ideal.
By this time, the indications and contraindications for Pentothal Sodiumanesthesia had been standardized. It was regarded as the optimum anesthesia notonly for delayed primary wound closure but also for any other procedure whichcould be performed within 30 to 45 minutes. If the duration of the operation wasunexpectedly increased, it was the practice to shift to ether. Pentothal Sodiumhad a wide use in evacuation hospitals but was seldom used in field hospitals,in which ether was the anesthetic of choice. Long experience in theMediterranean theater led to the almost universal view that Pentothal anesthesiashould never be used in the seriously wounded patient, whether he was in goodgeneral condition or not. In the early days, many fatalities apparently due toPentothal anesthesia occurred, and this contraindication became clear. It wasuseful for the induction of ether anesthesia in men in good condition but wascontraindicated for this purpose in poor-risk patients. It was alsocontraindicated in the following circumstances unless there was some overridingreason for its use:
1. When shock was present or impending.
2. When the intake or distribution of oxygen was impaired or in any wayjeopardized.
3. When an overdose of morphine had been given (p. 41).
4. When severe hemorrhage had occurred, or when the patienthad sustained penetrating wounds of the thorax or abdomen or a compound fractureof the femur. Ether was the anesthetic of choice for all such cases.
5. When inflammation was present in the region of the carotid body andcarotid sinus. Inflammation in this area apparently causes sensitization of thereflexes in it, and this phenomenon may explain the sudden deaths which sometimes occur under Pentothal Sodium anesthesia in wounds of the neck. PentothalSodium and other barbiturates are not highly effective in depressing these
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reflexes, and it was best to avoid possible trouble by resorting to anotheranesthetic. On the other hand, when compound fractures of the face made theadministration of an inhalation anesthetic impractical, Pentothal Sodium, inspite of its risks, might be the best choice for incision of a cervical abscessor some similar lesion. When it was employed in such cases, a number ofprecautions were taken: The patient was heavily atropinized before operation. Ifthe carotid sinus was found to be irritable, the operation was not begun untilat least 10 minutes had elapsed since the administration of Pentothal Sodium.Pressure on the carotids was carefully avoided, and, whenever it was feasible,they were blocked with a local anesthetic.
6. When gas gangrene was present. The contraindication to Pentothal Sodium inthis condition was based on the fact that the toxins elaborated produce suchsevere circulatory damage that the patient is, for all practical purposes, inshock. It is true that the skin temperature of the extremities rises underPentothal Sodium anesthesia, but the elevation does not necessarily imply abetter cellular oxygen supply. The elevation may be attributable to the effectof the anesthetic on the arteriovenous anastomoses. Investigations have shownthat the lymph flow is greatly reduced by barbiturate anesthesia, in comparisonwith local or ether anesthesia, and this observation might be construed asevidence that the oxygen supply of the tissues is impaired by it. Such an effectshould be avoided in clostridial myositis, in which oxygenation is alreadydeficient.
7. When the operative position or procedure seemed likely to interfere withthe airway or make artificial respiration difficult. If, for any reason,Pentothal Sodium had to be used in these circumstances, all the precautionssurrounding its use were sedulously observed. This form of anesthesia wasavoided, if it was at all possible, in operations which had to be carried out inthe face-down position and in operations for maxillofacial injuries involvingthe airway. If local anesthesia was inadequate, as it frequently was, thesepatients were best managed by ether anesthesia with endotracheal intubation.
8. When intracranial procedures were necessary. A skillful-or fortunate-anesthetist might sometimes employ Pentothal Sodium anesthesia withoutan accident, but, for a number of reasons, the risk was not regarded asjustified. Intracranial operations were usually of long duration. In a series of20 typical craniotomies performed in a combat zone in Italy, the averageoperating time was 109 ?11 minutes, exclusive of the time for induction ofanesthesia. Another reason for avoiding Pentothal Sodium anesthesia inintracranial surgery was the heavy blood loss, which was often a liter or moreby actual measurement. The respiratory depression and anoxia which may occurunexpectedly with this form of anesthesia introduced an entirely unjustifiablerisk. Anoxia produces immediate swelling of the brain, which can make anintracranial procedure difficult or impossible. Finally, the hic-coughing,laryngeal spasm, and straining occasionally encountered during this form ofanesthesia, or during recovery from it, were, as always, highly undesir-
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able in intracranial surgery. In most cases, therefore,Pentothal Sodium was avoided, and inhalation anesthesia with ether or localanesthesia with procaine hydrochloride was employed.
9. When severe burns had been sustained. Burned patients, forreasons which were never clarified, were found to tolerate Pentothal Sodiumanesthesia poorly. Perhaps the explanation was the great reduction of thecirculating blood volume which is characteristic of burns. Whatever the reason,the circulatory impairment from this cause is comparable to the effects ofhemorrhage, in which Pentothal Sodium is always contraindicated.
Technique-When the use of Pentothal Sodium had become standardized inthe Mediterranean theater, it was employed according to the following technique:
1. It was used in 2.5-percent solution.
2. Atropine was used routinely for preliminary medication tominimize vagal reflexes. The dose (0.6 mg., gr. 1/100)was preferably administeredsubcutaneously about an hour before induction. A second injection of half theoriginal amount was given intravenously just before the anesthetic was started.When the flow of casualties was heavy, this routine was not always practical,and the total dosage (0.6 mg., gr. 1/100) wasgiven intravenously about 10 minutes before operation. When laryngeal spasmoccurred during anesthesia, atropine was again given intravenously, in the samedosage, and without delay, no matter how shortly after the previous injectionthe emergency occurred.
3. While there was general agreement concerning the usefulness of atropine asa preoperative drug in Pentothal Sodium anesthesia, there was considerably lessagreement in principle or practice about the preoperative use of morphine. Forone thing, as pointed out elsewhere (p. 42), the reduction in the total quantityof Pentothal Sodium accomplished by the use of morphine had to be weighedagainst the possible dangers of overmorphinism in the injured man. For another,it was not altogether clear whether morphine heightened the activity of thelaryngeal reflex, which was occasionally troublesome in Pentothal anesthesia.Nor was it altogether clear what part was played by morphine in the longdepressions which sometimes followed the use of Pentothal Sodium. For thesereasons, the administration of morphine was strictly individualized, and it wasgiven before operation or withheld according to the needs of the specialpatient.
4. The injection was made by an anesthetist or a physician who had beentrained in the technique (fig. 12). The patient was under constant observation,and the pulse rate, respiration, and blood pressure were recorded at frequentintervals. It was the neglect of such precautions, which are traditional withother agents, that accounted for the poor record of Pentothal Sodium when it wasfirst used in the Mediterranean theater.
5. As a safety precaution, and always in long operations, oxygen wasadministered with Pentothal Sodium (fig. 13).
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FIGURE 12.-Administration of Pentothal Sodium anesthesia bynurse in evacuation hospital in Italy, 1944.
PRE-ANESTHETIC MEDICATION
Early in the North African fighting, it was found that menwho had been seriously wounded in battle needed little pre-anesthetic medicationand were better off without it (p. 43). This early experience was repeated,often under extremely adverse circumstances, at Cassino, on the Anzio beachhead,in the Po Valley, and all through the campaigns in northern Italy and southernFrance.
Atropine before ether anesthesia was usually given to cut down the flow ofmucus and minimize the vagal reflexes. The latter objective was particularlyimportant in certain types of operations, including operations on the thorax;within the abdomen, especially the upper abdomen; and on the neck wheninflammation was present in the region of the carotids (p. 72). The dose (0.6mg., gr. 1/100) couldbe repeated within an hour if necessary. Atropine was also useful, as alreadymentioned, when intravenous anesthesia with Pentothal Sodium was employed, tocounteract the laryngeal spasm which occasion-
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FIGURE 13.-Administration of Pentothal Sodium anesthesia with oxygen by medical officer in evacuation hospital in Italy, 1944.
ally occurred when this agent was used (p. 74). When spasm becametroublesome, a second injection was usually employed and was givenintravenously.
Morphine was given with great caution or was withheld entirely.As pointed out elsewhere (p. 42), the peripheral circulation was always poor in
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chilled and shocked wounded men, and the morphine usuallygiven as a first-aid measure might not have been absorbed from the subcutaneousdeposit. When resuscitation had been effected, and later when vasodilatationoccurred in response to ether anesthesia, poisoning was always a possibility ifthe injection of morphine was repeated and the double dosage was taken up intothe blood.
Morphine was given when local anesthesia was employed if painor considerable discomfort was present or seemed likely to ensue. In addition,Pentothal Sodium was given by mouth in divided doses of 90 to 180 mg. (gr. 1? to3) about 45 minutes before operation. Morphine was also used when it was thoughtthat pain was severe enough to interfere with the induction of anesthesia. Itwas given intravenously 5 or 10 minutes before operation, always in small doses.This method of administration was routine during periods of heavy action.
ENDOTRACHEAL INTUBATION AND BRONCHOSCOPY
Endotracheal intubation was employed routinely in all intracranial,maxillofacial, and abdominal operations performed under general anesthesia. Itwas also used routinely in all thoracic operations in which the pleura wasinvolved. Finally, it was employed routinely in any operation likely to exceedan hour in duration. Otherwise, it was used, as a general rule, only when theoperative position was such that maintenance of a satisfactory airway wasdifficult. Endotracheal intubation had a far wider application on the level ofthe field hospital than on the level of other hospitals.
The preparation of seriously wounded patients for surgeryalways included a check on the availability of a bronchoscope, but theinstrument was not employed routinely, even in open thoracic operations. If theairway could be kept clear by frequent aspiration through a catheter in thetrachea, the simpler procedure was preferable, and bronchoscopy was resorted toonly when this could not be done.
Some surgeons and anesthetists advocated the routine use ofthe bronchoscope at the end of all major operations. This practice wasconsidered undesirable by the majority of medical officers in both groups fortwo reasons:
l. If the bronchoscope was introduced at this time, it was necessary eitherto maintain general anesthesia at a deep level for a longer time than wasotherwise required, or the anesthesia had to be deepened for this purpose.Neither practice was desirable at the end of a trying operation, when thepatient's condition might be poor.
2. If ether anesthesia was not maintained or deepened, topical anesthesia hadto be employed for bronchoscopy. Under these circumstances, if the patientvomited during his reaction from general anesthesia, it was almost impossibleto prevent the aspiration of vomitus through the locally anesthetized airway.
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ANESTHETIC DEATHS
There is not always full agreement in civilian practice on what constitutesan anesthetic death. In the Army, the decision could be more arbitrary. It wasthe usual practice to classify in this category any death which occurred withoutadequate explanation in the condition of the patient or in the operationperformed and which followed a pattern characteristic of death under theparticular agent employed.
The two surveys of anesthesia made in the Mediterranean Theater of Operationsin September 1943 andSeptember 1944 showeda total of 12 deathsattributable to anesthesia in 27,564 administrations of anestheticagents. There was a considerable difference in the distribution of the fatalcases. There were 8 deathsin the anesthesias reported from the hospitals included in the 1943 survey, roughly 1:1,000, against4 deaths in the 19,914 anesthesias reported from 10hospitals in the 1944 survey,roughly 1:5,000. Clearly, as methods became standardized and experienceincreased, anesthesia became increasingly safer for the seriously wounded man.
