Thursday, January 26, 2017

From the Anals of Anesthesia History

This photo was snapped in 1909 and immediately piqued my curiosity. At first glance, I guessed that this must be an old school exercise device, perhaps an inversion table or tilt table, but further investigation revealed that it's a set up for the rectal administration of ether anesthetics. This sounds like a high risk technique bordering on medical misadventure based on the flammability and mucosal irritating nature of ether. Here is what some of the physicians of the time had to say about colonic ether.

"The fact that the intestinal mucosa is especially efficient in transfer of gases to and fro from the blood, prompted the colonic administration of ether. The head of the operating table is depressed after the patient is placed on the table. The afferent rectal tube is inserted past the bulb and efferent tube. The anesthetist then opens the efferent tube to allowing bowel contents, if any to escape. The etherization should then commence by forcing the ether mixture into the bowel by pressing on the bulb until an intracolonic pressure of 20 mm Hg is obtained. Every 15 minutes the efferent tube should be opened and the cycle repeated. The colon should be inflated with oxygen after venting the superfluous ether at the conclusion of the procedure."

The prep for this anesthesia was brutal. NPO for 24 hours prior to surgery. Cleansing enemas the evening before and again in the AM prior to surgery. I was trying to deduce the rationale for the Trendelenberg (head down position) of the OR table and came up with a couple of guesses. Ether was notorious for inducing cardiac arrhythmias. An old school trick for converting arrhythmias was to place the patient in Trendelenberg and tell them to hold their breath or possibly the position helped in the retention of the ether. Who knows?

I was curious as to the nature of the ether used and learned that an ether generator was used. This was a crude vaporizer that created etherization by passing room air or oxygen through the liquid ether. Who knows what they did with the ether vapor that was vented off via the "efferent tube" but somehow I suspect that it was just vented out a window. This was a common practice many years ago and one of the reasons ORs were always on the top floor of old  hospitals.

One of the early axioms in medicine was the more primitive the procedure, the more sophisticated the lingo describing the action. That must be how the "afferent" and "efferent" rectal tubes came about. The clever old docs hijacked a term describing the autonomic nervous system and applied it to their backside buffoonery.

I don't think their notion that the intestinal mucosa is an effective means of gas exchange is accurate. "The patient is desaturating...get that rectal tube hooked up to oxygen said no one!" There is very little gas exchange along the GI tract as anyone who has erroneously intubated the esophagus knows all too well.

Although butts and gas go together like tweedle dee and tweedle dumb this procedure was inherently dangerous because ether was so flammable. Another complication was (surprise) rectal bleeding. This procedure looks more like a colitis simulator than an anesthesia agent.

Anyhow, the next time I have surgery it's going to be a spinal or regional.


9 comments:

  1. LOL at the title of your post!

    And yet today folk today are being saved from the ravages of C. Diff. infection with fecal transplants...

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  2. They seriously did that to patients? No wonder people back then believed that being sent to the hospital was a death sentence. But also, I concur with Bobbie: excellent title for the post!

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  3. Coincidentally, I was just wondering about the mechanics of fecal transplants. Seems simple enough to me, find a healthy donor, add donor stool to an old metal enema can, fill with water or 0.9 saline and gently agitate while holding your nose. It's too hard to squeeze that donor stool through the small opening on those new fangled disposable enema bags. I always knew there would be a use for those old enema cans.

    I suspect hospitals have added all sorts of unnecessary steps to the fecal transplant just to jack up the price. Donor screening and cross match, specially certified transplant specialist to administer.. etc. Hospitals today are experts at taking something simple and making it complex to bring in the $$.

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    1. My friend had a fecal transplant. He used his sister's crap. Her crap was put into a capsule, and he swallowed the pill. These days you don't even have to know someone, just use a stool bank http://www.openbiome.org/home/

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  4. I got to thinking which can be dangerous for oldfools; since stool is primarily anaerobic micro organisms maybe the best approach would be a patient to patient set up similar to old school exchange transfusions. Give the donor an enema leave the tube in place and connect it to a rectal tube indwelling in the recipient. The donor injects so to speak the stool directly into the recipient. A large fenestrated drape between the donor and recipient would provide HIPPA mandated privacy.

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    1. My friend took his pill orally.

      Your method exposes the stool to oxygen and that will kill off 90% of the critters in the stool. I honestly don't see how putting the stool in a capsule is an addition of an unnecessary step. They screen for STDs and HIV. They don't want donors that have autoimmune diseases, they want poo that is free of markers of those diseases because the poo is often going to someone who already is immunocompromised and they don't need that added exposure. That's also because fecal transplants are used to treat a lot of things now, not just C. diff (which is amazingly easy to treat with a fecal transplant). These tests are important to prevent the donors from getting something instead of being treated for something, so I'm not sure why you'd assume they would be unnecessary.

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  5. You are absolutely right about the need for screening. I was curious as to why the acidity in the stomach did not kill the bacteria when taken orally and was light heartedly suggesting the exchange method, but I don't really know much about the subject. What I lack in current knowledge is made up by my foolishness so I'm not a good source for current information. Thanks so much for sharing your comments.

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  6. Very nice blog Sir

    You said, "The fact that the intestinal mucosa is especially efficient in transfer of gases to and fro from the blood, prompted the colonic administration of ether"
    I Agree with you.

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  7. Exceptionally pleasant blog Sir

    You stated, "The way that the intestinal mucosa is particularly productive in exchange of gasses back and forth from the blood, incited the colonic organization of ether"

    I Agree with you.

    ReplyDelete