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Chapter 3

Contents

CHAPTER III

Anesthesia for Men Wounded in Battle

Henry K. Beecher, M. D.

The selection of an anesthetic agent, the technique of administration employed, and the competence of administration of the anesthetic are matters of the greatest importance in the peacetime practice of surgery. They are doubly important in the surgery of combat-incurred injuries. The relationship between anesthesia and shock is particularly close in operations performed upon seriously wounded men, not only because of the frequent occurrence of shock after wounding but also because, if it is not already present, anesthesia can be, and often is, a precipitating factor in its development. It is entirely possible for an unwisely selected or incompetently given anesthetic to precipitate such profound shock in a wounded man whose status was previously not unsatisfactory that a compensated circulatory system is transformed into a state of decompensation. All of the mechanisms of this process, although not yet fully clarified, were sufficiently well understood when the United States entered World War II for the considerations which determined the acceptability or unsuitability of available anesthetic agents to be clearly comprehended and to be translated into appropriate action by all anesthetists who cared for wounded men.

HISTORICAL NOTE

It is indicative of the lack of emphasis placed upon anesthesia in World War I that the section dealing with it in the official history was written by a surgeon, Col. George W. Crile, MC.1 The specialty was not represented in The Surgeon General's Office, and consultants in anesthesia were not appointed for service either overseas or in the United States. Few of the points of view presented in the summary which follows could be substantiated at the beginning of World War II, but the material is presented because of its historical interest.

Nitrous oxide-oxygen anesthesia-In the first year of the First World War, according to the official history, the paramount value of nitrous oxide-oxygen anesthesia was clearly demonstrated by American anesthetists attached to the Western Reserve University unit, which worked at the American Ambulance at Neuilly, France. Satisfactory anesthesia could be obtained with this agent in operations on seriously wounded men, whatever their degree of exhaustion. When the unit returned to America, one of the 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 and English medical officers, to give instruction in the technique of nitrous oxide administration. 

The early enthusiasm for nitrous oxide-oxygen anesthesia continued for a considerable period.2 Conclusions adopted by the Inter-Allied Surgical Conference at its second session, in Paris, in 1917, reaffirmed the confidence felt in it by the delegates present, who represented England, Belgium, France, Italy, Japan, Portugal, and Serbia. It was the consensus of the conference that this form of anesthesia (combined with local anesthesia) was the method of choice in traumatic shock, in amputations, and in gas gangrene. Ether was the second choice. Local anesthesia was preferred for cerebral injuries. Chloroform was regarded as dangerous, and spinal anesthesia was reported as giving varying results.

When Base Hospital No. 4 (the Lakeside unit), which was the first base-hospital unit of the United States Army to be called into service after the United States entered the war, left for France, it was equipped with what was assumed to be an adequate supply of nitrous oxide and with sufficient apparatus for its administration. During the summer of 1917, surgeons of the unit had opportunities at a British base hospital in Rouen and at British casualty clearing stations in Flanders to test the comparative advantages of nitrous oxide, ether, and spinal anesthesia. English and French medical officers became interested in securing adequate supplies of nitrous oxide, and it was soon evident that what the Lakeside unit had brought over would not be sufficient for its own needs. The English supply was totally inadequate. The difficulty was solved by the appropriation by the American National Red Cross of funds for the construction of a plant for the production of nitrous oxide. Various delays ensued, and it was not until the early summer of 1918 that the plant was in operation in France and was manufacturing the gas at the rate of 125,000 gallons every 8 hours.

It was generally acknowledged that nitrous oxide-oxygen anesthesia gave less satisfactory muscular relaxation than either ether or chloroform, that it required expensive and cumbersome apparatus for its transportation and administration, that it cost more than other anesthetics, that it was technically the most difficult to administer of all the anesthetics then available, and that it was dangerous in inexpert hands. These disadvantages, however, were thought to be outweighed by its advantages, including the following: It was quick in action and pleasant to take; recovery was immediate, without nausea; food could be taken soon after recovery; transportation was possible soon after recovery; less nursing care was required; such complications as bronchitis, pneumonia, and nephritis did not follow it; and, finally, nitrous oxide was thought to be strongly protective against the shock of surgery. It was particularly favored for short operations but was regarded as equally suitable for long

2Surgery at the Base. Compilation of Responses by Base-Hospital Staffs to Questionnaire Sent Out by Research Committee. Questionnaire Prepared by Brig. Gen. J.M.T. Finney and Col. 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 abdominal operations, it could be supplemented by regional anesthesia.3

Ether and chloroform -In the chapter on anesthesia in The Medical Department of the United States Army in the World War, ether and chloroform are discussed under the same general heading.4 Both were thought to contribute actively to shock and exhaustion. Both, if given for any length of time, were thought to cause cytologic changes in the cells of the brain, the liver, and the adrenal glands identical with those resulting from other causes of exhaustion. Patients who did well under ether anesthesia were said to do poorly later. It was believed that ether tended to cause bronchopneumonia, especially in abdominal surgery performed in the winter; to be unsuitable in infections because it diminished, and even temporarily abolished, phagocytosis; to be unsuitable 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 of the blood.

Spinal anesthesia-The tendency of spinal anesthesia to produce a fall in blood pressure was recognized in World War I, the decrease being most notable in patients whose blood was greatly diluted and whose hemoglobin was low. On the other hand, this was stated to be the type of patient most in need of protective nerve block. The practice was to attempt to overcome the fall in blood pressure by a preliminary blood transfusion. The disadvantage of psychic shock, arising from the sights and sounds of the operating room and the patient's awareness of what was happening, was recognized, but it was pointed out that these difficulties could be overcome by the administration of morphine or, better, by very light nitrous oxide-oxygen anesthesia or partial ether anesthesia.

Spinal anesthesia was believed to be of special value when lesions in the air passages rendered inhalation anesthesia inadvisable or when the prone position was necessary because of the nature of the wounds. It was granted that it was time consuming to administer, and its use in rush periods was therefore not thought to be justified, on the ground that it would work a hardship to other patients awaiting operation, who might be subjected to the risk that anaerobic contamination could become gas gangrene. The statement that one of the advantages of spinal anesthesia is that it does not require a trained anesthetist to give it has a curious sound to modern ears.

Regional and local anesthesia-Regional and local anesthesia were regarded as of great value in many of the exigencies of war surgery in World War I, especially in rush periods at the front, when it might not be practical to give nitrous oxide-oxygen anesthesia because of the apparatus required, and when prolonged periods of induction and recovery would not be feasible. Even when inhalation anesthesia was available, local anesthesia was regarded as preferable for the excision of damaged soft tissues, the removal of debris, the probing of soft tissues for retained missiles, the amputation of fingers, the repair of scalp wounds, and intracranial operations. The chief disadvantage

3It should be emphasized again that the data on nitrous oxide anesthesia are presented for their historical interest only. Neither clinical nor experimental evidence warranted the 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 might decrease the resistance to infection of tissues which were already contaminated. 

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 their disposal a wide range of agents and techniques. A number of these had been introduced since World War I, including ethylene, ethyl chloride, Pentothal Sodium (thiopental sodium) by the intravenous route, and endotracheal anesthesia. Equipment had been greatly improved. In particular, modern, efficient machines for gas anesthesia had been made possible by the development of the carbon dioxide absorption technique. This technique, although it had been described in 1915, had not come into common use until the decade preceding World War II. It permits measured amounts of anesthetic gases and oxygen to be delivered to the patient, ether being added to the mixture in small quantities until the desired plane of anesthesia is reached. As the gases are expired, they pass through a canister containing a chemical absorbent, by means of which expired carbon dioxide is removed. The gases then pass into a rebreathing bag, and the patient, on inspiration, receives a warm mixture of anesthetic gases and oxygen or of vapor and oxygen.

The closed method of administering gas-oxygen and ether anesthesia has a number of advantages. It greatly reduces the fire hazard, since all gases used are contained in a closed circuit. It also reduces the cost of anesthesia, since the closed circuit conserves whatever agents are used. In addition, this technique permits the maintenance of intermittent positive pressure anesthesia and 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 outbreak of World War II did not, of course, mean that all of them could be employed according to peacetime practices. In addition to the fact that medicomilitary efficiency could be achieved only by the establishment of standardized methods, there were several other reasons why anesthetic agents, at least in forward zones, were chiefly limited in World War II to ether, Pentothal Sodium, and procaine hydrochloride:

l. The use of cumbersome equipment was undesirable because of the disproportionate amount of scarce shipping space which it occupied in transit to destinations overseas.

2. The use of such equipment was also impractical. Many times during the course of the war, hospital installations in forward areas, even 400-bed evacuation hospitals, had to evacuate their patients; tear down their equipment; move forward, often many miles, often over difficult, congested roads, and sometimes 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 such moves had to be accomplished, as well as under other military circumstances, it was almost impossible to protect delicate, complicated apparatus from injury. Gas machines are delicately adjusted, and when they were handled roughly they were likely, in a short time, to leak and to lose their serviceability.

3. The problem of logistics played a further part in the choice of anesthestic agents in forward areas. Interruption of supply channels and constantly changing supply routes soon convinced even anesthetists who had strong preferences for certain agents to the exclusion of others that they must content themselves with fewer agents, preferably those which, when necessary, could be transported by hand and which could be administered, when necessary, by improvised techniques and equipment.

4. The shortages of trained personnel for the administration of anesthetics made it necessary, from the standpoint of safety, to limit the agents employed to those which could be given, without undue risk to the patient, by physicians and nurses of limited experience in this field.

PERSONNEL

The outbreak of World War II found the whole United States with far fewer trained anesthetists than were needed for the practice of the specialty in peacetime. The Army Medical Corps, which represented a cross section of American medical personnel and practice, naturally reflected this shortage. Furthermore, because of the previous Army policy in regard to training medical officers as anesthetists, it was not until March 1939 that a 6-month course of instruction was begun at the Mayo Clinic by the first medical officer to be designated for formal 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 effect at the time of Pearl Harbor. While these officers were being trained, nurses continued, as previously, to give inhalation anesthetics in the various Army hospitals in the United States. Spinal, local, and regional anesthetics were given by the surgeon himself or by some other medical officer designated for this purpose.

The Army shortage of trained personnel in anesthesia was seriously reflected in the North African Theater of Operations, where the first prolonged fighting against the western Axis powers took place. Of the 77 physicians in the theater designated as specialists in anesthesia, only 10 percent had been certified by the American Board of Anesthesiology. Fifteen percent of the so-called specialists in anesthesia had been trained in courses which lasted from 1 to 3 months, and 20 percent had had no training at all except what they had obtained incidentally, during surgical residencies and rotating internships.

The small number of physicians available for assignment to anesthesia in the Mediterranean (North African) Theater of Operations was compensated for by a number of substitutions and shortcuts:

1. Although shortages in personnel seldom seriously slowed down the care


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of casualties, the possibility was always a constant and uncomforta threat. When the situations arose, dentists, as had been arranged previously, helped out voluntarily.

2. A good many medical officers who had had little, if any, special preparation in anesthesia were also pressed into service.

3. Aidmen, under close supervision, sometimes gave anesthetics in times of stress in forward areas. This was not a desirable expedient. These men, because of 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 were employed for this purpose in the Mediterranean theater. They were more suitable for supervised training in anesthesia than were forward hospitals. Theoretically, the course of training was 3 months. Actually, how long the student remained depended upon how long she could be spared from her unit. Often this was only 2 months, and sometimes it was only 1 month.

5. Schools of anesthesia were supplemented by individual training given in the various units in the theater. In a number of instances, the unusual abilities possessed by anesthetists in affiliated units working at the rear were utilized in the training of anesthetists to be sent to forward areas.

Surveys made in certain evacuation, station, and general hospitals in the Mediterranean theater in September 1944 showed that the relationship between personnel administering anesthesia and the surgical load varied widely (table 3). The assignments, for obvious reasons, were made according to the function of the hospital. Evacuation hospitals naturally required the greatest concentration of personnel in the forward areas. Field hospitals, in which newly wounded nontransportable men were cared for, and which had a 100-bed capacity per platoon, were usually staffed by four auxiliary surgical teams. Each of these teams included an anesthetist, who was usually a physician, and the setup was such that two operating tables could be kept in continuous use day and night. Occasionally, when the load was particularly heavy, three or four operating tables could be used at the same time in a single platoon, but this arrangement could not be maintained for very long.

As a working principle, it was found best to assign the ablest anesthetists to the combat zone. Here there were the greatest demands on native intelligence, judgment, resourcefulness, and technical ability. In practice, this principle could not always be applied, because physicians in units associated with affiliated schools and hospitals could not readily be detached from them. It was undoubtedly true that surgery undertaken in station and 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 in forward areas put a particularly heavy tax upon these qualities and qualifications.


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TABLE 3.-Provision of anesthetic personnel in sample evacuation, general, and station hospitals in Mediterranean theater (September 1944)

EQUIPMENT

The portable Heidbrink and McKesson anesthetic machines issued by the Army were of the standard type used in all civilian hospitals. The Beecher


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machine5 was designed especially for military use. As early as 1941, the Subcommittee on Thoracic Surgery of the Committee on Surgery of the National Research Council, with a vivid recollection of the high death rate which followed wounds of the thorax in World War I, had attacked this problem from various aspects, with the idea of developing methods of making early transpleural intervention practical. Patients with wounds of the thorax frequently do not tolerate delay in transportation to distant hospitals. At the same time, successful forward surgery could not usually be done in the absence of positive pressure in the airway. The problem, from the standpoint of anesthesia, was therefore twofold: (1) To devise a simple anesthesia apparatus which would be light, compact, and easily carried by hand; and (2) to construct it in such a manner that positive pressure could be developed with it, without dependence 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 the floor; an air reservoir bag; an air-reducing valve and a reducing valve arrangement which permitted the use of compressed oxygen when it was available;

FIGURE 8.-Transportable anesthetic apparatus for administration of ether in simplified closed system with and without oxygen.

5Beecher, H. K.: An Easily Transportable Apparatus for Anesthesia With or Without Compressed Oxygen. Especially Designed for Positive Pressure Anesthesia in Thoracic Surgery Under Military Conditions. War Med. 2: 602-608, July 1942.


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FIGURE 9.-Transportable anesthetic apparatus in carrying case and set up.

a safety blowoff valve; an ether-vaporizing bottle with a string wick, to promote rapid volatilization of ether; a face mask; and a breathing bag with a to-and-fro soda-lime filter (Waters' type for the removal of excreted carbon dioxide). 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 the foot bellows at a considerable distance above the floor so that no floor


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FIGURE 10.-Administration of ether in simplified closed system in evacuation hospital in Italy, 1944.

dust was taken up. The parts of the machine made of rubber were preferably made of conductive rubber. The machine permitted the maintenance of positive pressure in the airway when this was necessary, but at the same time could be so adjusted as to allow the gradual escape of air from which part of the oxygen had been extracted during respiration.


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Several changes were made in the original model after it was tested in actual use. It was found that the foot bellows could be dispensed with because oxygen was available in forward as well as rear areas. It was also found advantageous to add a dropper of the oil-cup type, to enrich the ether atmosphere. Finally, the machine was further simplified by elimination of the flow meter, which was not really necessary for the air or oxygen used in maintenance. If the breathing bag was kept adequately filled and if care was taken to see that the patient's blood was always of good color, nothing else was needed beyond the respiratory excursions adequate to remove carbon dioxide.

This machine was carried, by hand when necessary, in a compact container measuring 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; 2 rubber intratracheal tubes (Magill, #29 and #32); an aspiration bulb and catheter (Flagg) for clearing out the bronchi; a small packet 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 so small that it occupied little space in a crowded operating tent, and it was so simple and durable that there were few parts to get out of order and few opportunities for leakage. An additional advantage was that it required only small amounts of critical materials for its manufacture.

Anesthesia could be induced with this apparatus by the so-called straight ether method at least as conveniently as by the open cone method. Civilian experience had shown that induction with nitrous oxide was satisfactory in transpleural surgery, but nitrous oxide was seldom available at the field hospital level. Pentothal Sodium was sometimes used for induction in ether anesthesia, but this agent was not safe, even for this limited purpose, in seriously wounded men (p. 72).

Although one of the reasons the Beecher machine had been devised was to make thoracic surgery feasible without the use of compressed oxygen, this did not mean, of course, that oxygen was not used when it was available (fig. 11). As a matter of fact, and contrary to expectations before the war, oxygen was supplied at most forward installations. If the amounts available were limited, it could be added in small quantities to the room air in the system during the period the pleura was open. If, for instance, the pleura was open for 30 minutes, the addition 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 as possible. When compressed oxygen was not available, a constant flow of room air was maintained through the apparatus. When the system was constantly flushed in this manner, it was not necessary to use the soda-lime carbon dioxide absorbent.

Although the Beecher machine was devised specifically for use in thoracic surgery, experience in the combat zone proved its usefulness for any other type of operation in which inhalation anesthesia was employed. It could also be used for the administration of oxygen and for artificial respiration.


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FIGURE 11.-Administration of ether with oxygen in simplified closed system in evacuation hospital in Italy, 1944.


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ANESTHETIC AGENTS

The pattern of anesthesia had been clearly established by September 1944 in the North African (Mediterranean) Theater of Operations, where there had been active and often intensive combat since November 1942. Ether had emerged as the agent of choice for operation on seriously wounded soldiers, and its corresponding merits in men who were better risks had also become evident. Local anesthesia had been shown to be inadequate for major procedures and was not well tolerated by apprehensive, badly wounded men, who frequently had multiple wounds and who sometimes were in great pain. Intravenous anesthesia with Pentothal Sodium had its first valid trials in military surgery during the fighting in North Africa. After a proper regimen for its use had been established and limitations and contraindications had been determined, it was found to be admirably suited for the needs of war surgery.

In the following sections, the advantages and disadvantages of the various anesthetics and techniques available at the outbreak of World War II are briefly discussed from the standpoint of their use in combat zones. In station and general hospitals, there were no special problems of anesthesia because conditions in them approximated those in civilian hospitals.

Spinal Anesthesia

When spinal anesthesia was first introduced, its tendency to cause a fall in blood pressure was so significant and so serious that its use was almost discontinued. Then it was found that vasoconstrictor drugs could control this effect, though the most potent vasoconstrictors could not maintain levels of safety in patients who had suffered severe trauma and had lost large amounts of blood.

Spinal anesthesia was additionally undesirable for another reason. When it is used, the vasomotor fibers are the first to be paralyzed and the last to recover. The area over which this effect occurs is larger than the area over which the pain response is eliminated, since to interrupt vasomotor control requires a lower concentration of whatever agent may be employed than is required to interrupt pain sensation. Spinal anesthesia therefore breaks down an important 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 surgeons contended in the first years of the war that spinal anesthesia was desirable in military surgery. Many American surgeons argued for its employment, in spite of the data concerning its risks and inefficiency which came in from areas of combat early in the war, on the ground that errors of administration could account for the unsatisfactory results.

Studies reported from the Massachusetts General Hospital6 in 1943

6Beecher, H. K.: The Choice of Anesthesia for Seriously Wounded Patients. J. A. M. A. 121 899-903, 20 Mar. 1943.


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effectively answered these arguments. These studies were carried out in two series of patients with perforated peptic ulcers. The patients, chiefly men, of an average age of 44 years, were seen within 30 minutes to 40 hours of the accident, and all were submitted to the same well-standardized reparative operation. One group was operated on under spinal and the other under ether anesthesia. Whether the administration was by widely experienced anesthetists or by beginners, a fall in blood pressure was observed twice as frequently when spinal anesthesia was used.

Spinal anesthesia had a limited use early in the fighting in the North African theater, but its popularity decreased as it came to be appreciated that there were few indications for its employment in forward areas. One reason for limiting its use in these areas was the difficulty of preserving sterility of equipment in the field. A more potent argument was the poor tolerance of freshly wounded men for it, as indicated by the tendency of the blood pressure to fall when it was used. The condition of the circulation, always precarious in a freshly wounded man, deteriorated rapidly when it was employed, and eventually few surgeons or anesthetists, whatever their practices and preferences might have been in civilian life, recommended its use in forward areas, even in lightly wounded men. It always had, of course, a considerable and proper use in hospitals to the rear.

A survey of 12 hospitals in September 1943 showed that, since November 1942, spinal anesthesia had been used in almost 20 percent of the operations in forward hospitals. A second survey, in August 1944, showed that in the intervening period it had been used in only 3 percent of operations in forward hospitals. Further analysis showed that this proportion was composed largely of emergency appendectomies and other operations not related 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 is usually 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 it regularly and have had special experience with it. In other hands, there is a considerable 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 the Mediterranean Theater of Operations in World War II. Finally, the soundest reason for the limitation of its use was the multiplicity of wounds usually present in each case. In these circumstances, it was not a practical method.

Harmful circulatory effects can occur from the use of too large amounts of local anesthetic agents or from their too rapid absorption. These undesirable effects can be minimized by two precautions:

1. The addition of epinephrine hydrochloride (1:200,000 in the optimum final dilution). This practice prolongs the anesthetic effect perhaps fivefold and at the same time reduces the quantity of procaine hydrochloride needed. Vasoconstricting agents should not be used, however, in operations about the genitals or on the fingers, toes, ears, or nose, because of the danger of sloughs. They should not be employed when cyclopropane, chloroform, ethyl chloride, or Avertin (tribromoethanol solution) are to be used, because of the danger of ventricular fibrillation. Finally, they should be employed with great care, if at all, in patients with organic circulatory impairment.

2. Careful attention to dosage. Toxicity from the absorption of local anesthetic 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 procaine solution over a period of an hour but dangerous to give him 75 cc. of 2-percent solution over the same period. Not more than 35 cc. of the 2-percent solution can be used with safety in the space of an hour.

Within the limitations and with the precautions specified, local and regional block, chiefly with procaine hydrochloride, proved useful in certain neurosurgical and maxillofacial operations, as well as in minor surgical procedures. It also had other uses. In the form of intercostal and paravertebral block, procaine hydrochloride was useful in controlling pain in the traumatized chest wall, with consequent improvement of the respiratory function, and in improving the blood supply to an extremity. Peritoneal block under direct vision after the abdomen was opened often improved relaxation of the abdominal wall to such a degree that only light general anesthesia was necessary.

When topical anesthesia was indicated, it was accomplished with Pontocaine (tetracaine hydrochloride) or cocaine.

Chloroform

From the theoretical standpoint, chloroform has a number of advantages. It can be administered smoothly with a minimum of equipment. Its potency is so great that only low concentrations are needed in inspired air, and adequate oxygenation can be obtained from the atmosphere of the operating room. It produces excellent muscular relaxation. It is easily transportable, and it does not burn or explode.

These advantages are outweighed by a number of disadvantages and dangers. The ventricular fibrillation, central hepatic necrosis, and destruction of the convoluted tubules of the kidneys which chloroform is capable of producing can cause death or serious and permanent disability. Its effect on the


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circulation is profoundly depressing. It slows the heart rate, weakens the strength of the cardiac contractions, reduces the cardiac output, and depresses the blood pressure. It also causes acidemia. Hepatic damage produced by chloroform can be minimized by its administration with high concentrations of oxygen in inspired air and by a diet high in protein and carbohydrate; but these precautions are not always possible under conditions of combat, and they do not alter the possible effects of chloroform on the circulation.

Chloroform had been practically discredited in civilian practice for many years before World War II, and its effects on the circulation are such that there would seem to be even less reason for using it in men wounded in battle and already suffering from circulatory impairment than in nontraumatic civilian practice. It was therefore almost never used in the Mediterranean theater. With the 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 not adequate and it was imperative to use a noninflammable agent.

The suggestion was made that chloroform be provided in small ampules for administration by nonmedical personnel to wounded soldiers who had become manic in burning tanks and who might be more easily removed through the narrow escape hatch if they could be controlled. So far as is known, chloroform was not used for 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 their storage and that they must be used with compressed oxygen.

Nitrous oxide and ethylene have undesirable metabolic effects if they are administered without adequate oxygenation, which is a generally impossible requirement if a full surgical level of anesthesia is necessary. This is particularly true when nitrous oxide is used, since the high partial pressure required leaves little room for oxygen. The same is true, though to a lesser degree, when ethylene is used. Satisfactory muscular relaxation cannot be produced with either of these agents within the limits of safety.

Cyclopropane has deleterious effects on the heart and has apparently caused death from ventricular fibrillation in a considerable number of cases. Aside from. this effect, it seems to be better tolerated, from the circulatory standpoint, by animals in shock or in impending shock than any of the other anesthetic agents, with the possible exception of ethylene. Whether this is true of human subjects in shock is not yet known.

Neither cyclopropane nor ethylene was issued to medical officers in the Mediterranean theater. When nitrous oxide was available, it was occasionally used for minor surgical procedures, such as painful changes of dressings. It was also occasionally used to supplement other forms of anesthesia, such as Pentothal 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, or procaine hydrochloride.

Vinyl Ether

Vinyl ether acts rapidly and is readily transportable. In spite of these advantages, it was not used extensively in any theater in World War II because its advantages were outweighed by its disadvantages. It is difficult to use satisfactorily without a closed rebreathing apparatus. It has a tendency to cause laryngeal spasm, profuse salivation, muscular twitchings, and even convulsions and liver damage. It is chemically unstable, and it is possible that the results just listed may be caused by that property.

Ether

Ether is undoubtedly the most useful anesthetic agent for general purposes and under nearly all circumstances, including military circumstances. Its great potency permits an adequate supply of oxygen, even if only room air is available. Its straight induction in seriously wounded men is remarkably easy and is apparently not unpleasant for the patient, whether the open-drop method is used, or, as is preferable, it is given by the closed method, with oxygen (fig. 11). Ether produces excellent muscular relaxation. It is well established that even an impaired circulatory system tolerates prolonged ether anesthesia well. A man in shock, in fact, seems to tolerate ether far better than an animal in shock.

Ether has, on the other hand, some undesirable properties. It is irritating to the mucous membranes of the respiratory tract-though it has never been adequately demonstrated that this characteristic increases the incidence of respiratory complications or the number of deaths from them, while considerable evidence suggests that the irritation which it causes is of no clinical 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 tissue destruction, penetration of body cavities, or severe hemorrhage from wounds which in themselves might not otherwise have been of great consequence. Since it was the anesthetic best tolerated by men in shock, it seemed reasonable to use it also in men who were less badly off. In the first months of fighting in North Africa, it was not used as widely as it should have been, at least in forward hospitals. The increase in its use in the second year of fighting may be unimportant statistically, but clinically it is of great significance, since it occurred chiefly in the field hospitals, where the surgically important group of patients was treated. These were the men with wounds of the abdomen and thorax and compound fractures of the femur.

An intelligent appraisal of anesthesia practices is not possible without some knowledge of the type of surgery performed. The mere tabulation of data (table 4) does not tell the full story. The true picture is better obtained from an


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analysis of the experience of auxiliary surgical groups, which had a wide experience in forward surgery, particularly in the surgery of nontransportable patients in field hospitals. In such an analysis, surgery of the abdomen and chest assumes greater importance than the tabulated data indicate. Of 15,925 wounded men treated by the 2d Auxiliary Surgical Group, for instance, during the North 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 pleural involvement, and 508 (3.2 percent) had thoracoabdominal injuries. Since the 1,628 abdominal injuries included a number of cases in which exploration was negative, the thoracic injuries may be said to have been approximately as frequent as abdominal injuries in the experience of this group, while the combined total of thoracic and thoracoabdominal injuries exceeded the number of abdominal injuries. The responsibility of the anesthetist in surgery of such magnitude is too evident to need elaboration.

TABLE 4.- Sample distribution of surgical procedures in the Mediterranean (North African) campaigns (1943-44)

Area

Number of operations

Site of major surgery

Extremities

Abdomen

Chest


Central nervous system

Ear, nose, throat

Miscellaneous

Major

Minor

 

 

Percent

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 the barbiturates (Evipal Sodium (hexobarbital soluble) and Pentothal Sodium) were used for major as well as minor surgery, the death rate, depending upon the quality of the clinic, was likely to be from 3 to 10 times higher than for ether anesthesia. At the Massachusetts General Hospital, where these agents are chiefly used for procedures on able-bodied adults which last less than an hour, 8,000 consecutive anesthesias were administered with barbiturates with no deaths.7 Early in the series, however, a number of lessons were learned: That bad-risk patients tolerate these drugs poorly, except when they are used in small amounts as supplements to other forms of anesthesia; that, even in these circumstances, a fall in blood pressure may occur during spinal anesthesia; and that patients with circulatory impairment tolerate full barbiturate anesthesia particularly poorly.

7See footnote 6, p. 65.


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Adequate studies have shown that intravenous anesthesia with barbiturates is associated with two other outstanding hazards:

1. It causes a progressive loss, which finally becomes complete, of the sensitivity of the respiratory center to its normal chief stimulus, carbon dioxide, the content of which in the blood may rise to depressant levels during anesthesia with barbiturates.

2. When the normal respiratory drive becomes impaired or disappears completely, a supplementary mechanism is necessary to keep it going. A shift is therefore made from the normal driving action of carbon dioxide on the respiratory center to the action of anoxia on the chemoreceptors, chiefly the aortic and carotid bodies.

Pentothal Sodium was provided in the North African Theater of Operations from the time of the first landings in November 1942. Its ready availability; the simplicity and compactness of the equipment for its administration; the ease and smoothness of induction, even by inexperienced physicians; and the apparent infrequency of undesirable after effects-all made it a popular anesthetic drug under combat conditions. These advantages tended to outweigh other important considerations: That Pentothal Sodium is a powerful tool, that overdosage is not easy to overcome, that the lethal dose varies within a wide range from one patient to another, and that this form of anesthesia is definitely contraindicated in certain types of injury and under certain circumstances.

The results of the casual acceptance of the advantages of Pentothal Sodium without regard for its dangers and disadvantages, were apparent in the first survey of anesthesia made in the theater, in September 1943. Sample data secured from 12 hospitals showed that this agent had been used in 2,672 operations and that in 6 of the fatalities which followed (1:450), death could be attributed only to anesthetic causes. Further investigation at other hospitals produced similar data. Results throughout the theater, in fact, were so bad that it was seriously proposed that this form of anesthesia be abandoned entirely, particularly since the experience in North Africa paralleled the experience reported from Pearl Harbor.

A detailed analysis of the fatalities caused by Pentothal Sodium anesthesia in 1942-43 cast a somewhat more hopeful light upon the situation. Two errors were outstanding, but both were readily correctible. The first was the use of this method of anesthesia by completely inexperienced medical officers, many of whom seemed to have the impression that all that was necessary was for the drug to be injected into a vein. The second error was the frequent use of this method in conditions in which it was actually contraindicated and in which it should never have been employed. The impression derived from the analysis was that if these errors could be corrected and the conditions of its administration controlled, Pentothal Sodium might prove to be, in practice, the ideal anesthetic for certain types of injuries of warfare, just as it had always been in theory.

The decision to continue the use of Pentothal Sodium as an anesthetic


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agent in the Mediterranean theater proved sound. A survey conducted in 10 hospitals in the theater in September 1944, a year after the first survey, showed that only 2 deaths could be attributed to its effects in 11,136 operations (1:5,550). In other words, during the period covered by the second survey, Pentothal Sodium, although it had been used in about 4 times as many cases as during the first period, was responsible for only a third as many deaths. The figures indicate the magnitude of the improvement which had been achieved in the course of the year.

It should be emphasized again that this improvement occurred over 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 the operations performed in the forward hospitals surveyed and in 1,462 (28 percent) of the operations performed in the station and general hospitals surveyed. In September 1944, these proportions had risen, respectively, to 63 percent (6,721 operations) and 48 percent (4,415 operations). A large part of the increase could be explained by the widespread adoption of the practice of secondary wound suture, a procedure for which this type of anesthesia approaches the ideal.

By this time, the indications and contraindications for Pentothal Sodium anesthesia had been standardized. It was regarded as the optimum anesthesia not only for delayed primary wound closure but also for any other procedure which could be performed within 30 to 45 minutes. If the duration of the operation was unexpectedly increased, it was the practice to shift to ether. Pentothal Sodium had a wide use in evacuation hospitals but was seldom used in field hospitals, in which ether was the anesthetic of choice. Long experience in the Mediterranean theater led to the almost universal view that Pentothal anesthesia should never be used in the seriously wounded patient, whether he was in good general condition or not. In the early days, many fatalities apparently due to Pentothal anesthesia occurred, and this contraindication became clear. It was useful for the induction of ether anesthesia in men in good condition but was contraindicated for this purpose in poor-risk patients. It was also contraindicated in the following circumstances unless there was some overriding reason for its use:

1. When shock was present or impending.

2. When the intake or distribution of oxygen was impaired or in any way jeopardized.

3. When an overdose of morphine had been given (p. 41).

4. When severe hemorrhage had occurred, or when the patient had sustained penetrating wounds of the thorax or abdomen or a compound fracture of the femur. Ether was the anesthetic of choice for all such cases.

5. When inflammation was present in the region of the carotid body and carotid sinus. Inflammation in this area apparently causes sensitization of the reflexes in it, and this phenomenon may explain the sudden deaths which sometimes occur under Pentothal Sodium anesthesia in wounds of the neck. Pentothal Sodium and other barbiturates are not highly effective in depressing these


73

reflexes, and it was best to avoid possible trouble by resorting to another anesthetic. On the other hand, when compound fractures of the face made the administration of an inhalation anesthetic impractical, Pentothal Sodium, in spite of its risks, might be the best choice for incision of a cervical abscess or some similar lesion. When it was employed in such cases, a number of precautions were taken: The patient was heavily atropinized before operation. If the carotid sinus was found to be irritable, the operation was not begun until at 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 in this condition was based on the fact that the toxins elaborated produce such severe circulatory damage that the patient is, for all practical purposes, in shock. It is true that the skin temperature of the extremities rises under Pentothal Sodium anesthesia, but the elevation does not necessarily imply a better cellular oxygen supply. The elevation may be attributable to the effect of the anesthetic on the arteriovenous anastomoses. Investigations have shown that the lymph flow is greatly reduced by barbiturate anesthesia, in comparison with local or ether anesthesia, and this observation might be construed as evidence that the oxygen supply of the tissues is impaired by it. Such an effect should be avoided in clostridial myositis, in which oxygenation is already deficient.

7. When the operative position or procedure seemed likely to interfere with the airway or make artificial respiration difficult. If, for any reason, Pentothal Sodium had to be used in these circumstances, all the precautions surrounding its use were sedulously observed. This form of anesthesia was avoided, if it was at all possible, in operations which had to be carried out in the face-down position and in operations for maxillofacial injuries involving the airway. If local anesthesia was inadequate, as it frequently was, these patients 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 without an accident, but, for a number of reasons, the risk was not regarded as justified. Intracranial operations were usually of long duration. In a series of 20 typical craniotomies performed in a combat zone in Italy, the average operating time was 109 11 minutes, exclusive of the time for induction of anesthesia. Another reason for avoiding Pentothal Sodium anesthesia in intracranial surgery was the heavy blood loss, which was often a liter or more by actual measurement. The respiratory depression and anoxia which may occur unexpectedly with this form of anesthesia introduced an entirely unjustifiable risk. Anoxia produces immediate swelling of the brain, which can make an intracranial procedure difficult or impossible. Finally, the hic-coughing, laryngeal spasm, and straining occasionally encountered during this form of anesthesia, or during recovery from it, were, as always, highly undesir-


74

able in intracranial surgery. In most cases, therefore, Pentothal Sodium was avoided, and inhalation anesthesia with ether or local anesthesia with procaine hydrochloride was employed.

9. When severe burns had been sustained. Burned patients, for reasons which were never clarified, were found to tolerate Pentothal Sodium anesthesia poorly. Perhaps the explanation was the great reduction of the circulating blood volume which is characteristic of burns. Whatever the reason, the circulatory impairment from this cause is comparable to the effects of hemorrhage, in which Pentothal Sodium is always contraindicated.

Technique-When the use of Pentothal Sodium had become standardized in the 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 to minimize vagal reflexes. The dose (0.6 mg., gr. 1/100) was preferably administered subcutaneously about an hour before induction. A second injection of half the original 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) was given intravenously about 10 minutes before operation. When laryngeal spasm occurred during anesthesia, atropine was again given intravenously, in the same dosage, and without delay, no matter how shortly after the previous injection the emergency occurred.

3. While there was general agreement concerning the usefulness of atropine as a preoperative drug in Pentothal Sodium anesthesia, there was considerably less agreement in principle or practice about the preoperative use of morphine. For one thing, as pointed out elsewhere (p. 42), the reduction in the total quantity of Pentothal Sodium accomplished by the use of morphine had to be weighed against the possible dangers of overmorphinism in the injured man. For another, it was not altogether clear whether morphine heightened the activity of the laryngeal reflex, which was occasionally troublesome in Pentothal anesthesia. Nor was it altogether clear what part was played by morphine in the long depressions which sometimes followed the use of Pentothal Sodium. For these reasons, the administration of morphine was strictly individualized, and it was given before operation or withheld according to the needs of the special patient.

4. The injection was made by an anesthetist or a physician who had been trained in the technique (fig. 12). The patient was under constant observation, and the pulse rate, respiration, and blood pressure were recorded at frequent intervals. It was the neglect of such precautions, which are traditional with other agents, that accounted for the poor record of Pentothal Sodium when it was first used in the Mediterranean theater.

5. As a safety precaution, and always in long operations, oxygen was administered with Pentothal Sodium (fig. 13).


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FIGURE 12.-Administration of Pentothal Sodium anesthesia by nurse in evacuation hospital in Italy, 1944.

PRE-ANESTHETIC MEDICATION

Early in the North African fighting, it was found that men who had been seriously wounded in battle needed little pre-anesthetic medication and 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 southern France.

Atropine before ether anesthesia was usually given to cut down the flow of mucus and minimize the vagal reflexes. The latter objective was particularly important in certain types of operations, including operations on the thorax; within the abdomen, especially the upper abdomen; and on the neck when inflammation was present in the region of the carotids (p. 72). The dose (0.6 mg., gr. 1/100) could be repeated within an hour if necessary. Atropine was also useful, as already mentioned, when intravenous anesthesia with Pentothal Sodium was employed, to counteract 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 became troublesome, a second injection was usually employed and was given intravenously. 

Morphine was given with great caution or was withheld entirely. As pointed out elsewhere (p. 42), the peripheral circulation was always poor in


77

chilled and shocked wounded men, and the morphine usually given as a first-aid measure might not have been absorbed from the subcutaneous deposit. When resuscitation had been effected, and later when vasodilatation occurred in response to ether anesthesia, poisoning was always a possibility if the injection of morphine was repeated and the double dosage was taken up into the blood.

Morphine was given when local anesthesia was employed if pain or 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 to 3) about 45 minutes before operation. Morphine was also used when it was thought that pain was severe enough to interfere with the induction of anesthesia. It was 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. It was also used routinely in all thoracic operations in which the pleura was involved. Finally, it was employed routinely in any operation likely to exceed an hour in duration. Otherwise, it was used, as a general rule, only when the operative position was such that maintenance of a satisfactory airway was difficult. Endotracheal intubation had a far wider application on the level of the field hospital than on the level of other hospitals.

The preparation of seriously wounded patients for surgery always included a check on the availability of a bronchoscope, but the instrument was not employed routinely, even in open thoracic operations. If the airway could be kept clear by frequent aspiration through a catheter in the trachea, the simpler procedure was preferable, and bronchoscopy was resorted to only when this could not be done.

Some surgeons and anesthetists advocated the routine use of the bronchoscope at the end of all major operations. This practice was considered undesirable by the majority of medical officers in both groups for two reasons:

l. If the bronchoscope was introduced at this time, it was necessary either to maintain general anesthesia at a deep level for a longer time than was otherwise required, or the anesthesia had to be deepened for this purpose. Neither practice was desirable at the end of a trying operation, when the patient's condition might be poor.

2. If ether anesthesia was not maintained or deepened, topical anesthesia had to be employed for bronchoscopy. Under these circumstances, if the patient vomited during his reaction from general anesthesia, it was almost impossible to 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 constitutes an anesthetic death. In the Army, the decision could be more arbitrary. It was the usual practice to classify in this category any death which occurred without adequate explanation in the condition of the patient or in the operation performed and which followed a pattern characteristic of death under the particular agent employed.

The two surveys of anesthesia made in the Mediterranean Theater of Operations in September 1943 and September 1944 showed a total of 12 deaths attributable to anesthesia in 27,564 administrations of anesthetic agents. There was a considerable difference in the distribution of the fatal cases. There were 8 deaths in the anesthesias reported from the hospitals included in the 1943 survey, roughly 1:1,000, against 4 deaths in the 19,914 anesthesias reported from 10 hospitals in the 1944 survey, roughly 1:5,000. Clearly, as methods became standardized and experience increased, anesthesia became increasingly safer for the seriously wounded man.

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