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A hundred years ago: C.E.-ethyl chloride-chloroform sequence

By G.A.H. Barton, M.D., M.R.C.S., &C.,

Anaesthetist to the N.W London Hospital; Anaesthetist to the Throat Hospital, Golden Square, &c.

By G.A.H. Barton, M.D., M.R.C.S., &C.,

Anaesthetist to the N.W London Hospital; Anaesthetist to the Throat Hospital, Golden Square, &c.

Extracted from the September 1907 issue of The Practitioner

The following remarks are a brief record of some inductions of chloroform, and C.E. anaesthesia brought about with the assistance of ethyl chloride. I have been using ethyl chloride in this connection for the past two or three years. The sequence, which I have finally adopted, I call the C.E. ethyl chloride, chloroform, or C.E., ethyl chloride, C.E., sequence, as the case may be, and this paper is based on the notes of 200 consecutive cases of these sequences.

I am not claiming any great amount of originality for this idea of using ethyl chloride in the induction of chloroform anaesthesia. I have no doubt that all of us have adopted it, in some manner or another, at different times; altogether, I suppose I have used ethyl chloride in this connection some 400 times, and it was only after trying various methods that I appreciated the advantages of the one which I am about to describe, and set to work to secure notes on a series of consecutive cases.

I wish to lay some stress on the circumstance that these cases are consecutive, and not selected. Had I selected my cases of this sequence, I believe that I could have produced a series of nearly flawless inductions. All cases, in which a chloroform or C.E. anaesthesia appeared desirable, were submitted to this induction, unless ethyl chloride was for some reason distinctly contra-indicated, and I may say that this occurs rarely in my practice.

In the early days of ethyl chloride, I tried, in a few cases, a simple ethyl chloride-chloroform sequence, giving ethyl chloride in the usual manner, and then going on with chloroform. This however, I soon abandoned, and now only use, in a few cases, like short operations on the nose or throat, where I sometimes help out my ethyl chloride, as it were, by going on with the Junker apparatus, no real chloroform anaesthesia being developed in most cases. In order to explain my reasons for abandoning this particular method, I must first point out what advantages I hoped to gain using ethyl chloride.

My principal reasons for adopting any innovation in the induction of anaesthesia are the following: increased comfort for the patient, saving of time, and increased safety and precision.

Now the majority of chloroform patients, in general surgery, are women and children, and for them the anaesthetic has very real terrors, which the clapping on of a closely fitting mask and the sudden exhibition of a concentrated vapour only intensify. Time is saved no doubt in most cases, but not always, owing, in my hands at any rate, to some lack of precision in this method.

As to safety, I think that this is rather decreased than increased by presenting chloroform vapour to a patient with exaggerated breathing, and lungs full of ethyl chloride vapour and re-breathed air, also that there are pitfalls for the unwary in the symptoms produced by the passage from the ethyl chloride to the chloroform anaesthesia.

For these reasons, then, I gave up the simple ethyl chloride, chloroform sequence, and am of opinion that it is an unsafe procedure, unless the chloroform is inhaled from a Junker's apparatus, or from some form of regulating inhaler.

Having observed in the ethyl chloride, ether sequence, the advantages of an early gradual exhibition of the ether, thereby getting the patients under the combined vapours, instead of first anaesthetising them with ethyl chloride alone, I determined, so far as possible, to apply a similar method to chloroform inductions.

The only apparatus I use is a chloroform mask and a folded towel. One word I may say about the mask, hardly necessary, perhaps, to anaesthetists; the mask should be of such dimensions that there is no risk of its coming into contact with the patient's nose during the second stage of this procedure, when the towel may be pressed closely around it. There is no much danger of any other part of the face becoming scorched, as the amount of C.E. used is too small to run down the sides, but this risk can be obviated by using one of the modifications of Schimmelbush's mask, if thought desirable. I frequently, but not invariably, insert a prop before commencing. In strong muscular men, in whom there is likely to be much jaw spasm, and in all operations on the upper air passages, I think it advisable.

The sequence consists of three stages, and anaesthesia should be, and generally is, present at the end of the second.

In the first stage, the patient inhales C.E. mixture from the mask, the quantity varying from one to three drams, according to age and physique. After a little time, varying from half a minute to one and a half minutes, I spray on ethyl chloride from 3 to 7 c.c., and apply the towel closely over all. This is the second stage. It ends with the loss of the corneal reflex, generally lasting from a quarter to one and a half or two minutes. The towel is now removed, and the third stage entered upon. It simply consists in maintaining a proper degree of anaesthesia by means of the C.E. mixture or chloroform. A little judgment and practice soon enable one to steer the middle course, and, without overdosing, to give patients sufficient to prevent any return of consciousness.

Taking everything into consideration, I have got to like the sequence, and now adopt it as my routine practice. There is undoubtedly a great saving of time, with nothing to unduly alarm a nervous patient. It suits children admirably, they are generally under in between one and two minutes, with the minimum of discomfort.

By watching the behaviour of the patient during the second stage, one very quickly has a rough guide to the dosage of chloroform suitable to the case later on. There is no danger of the patient merely falling into a condition of anaesthetic slumber, especially if the operation commences, as it should, at the end of the second stage. Owing to its precision, I think it safer than the ordinary method of inducing anaesthesia on a mask.

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