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The development, impact and use of anaesthesia in World War One.

Introduction

As we ready ourselves to acknowledge the 100th anniversary of ANZAC Day and the landing of the Australian and New Zealand troops in Gallipoli, it brings to mind how anaesthesia was delivered to the injured troops during those trying times.

During World War One (WW1) in particular there were major anaesthetic developments and influences that paved the way to the specialty we see today.

What we know from the history texts is that the Gallipoli campaign lasted a total of 260 days. There were 14,000 New Zealand troops who landed on Gallipoli, with 4852 New Zealand servicemen wounded and a further 2721 killed. (A Guide to ANZAC Day for New Zealanders).

This article pays tribute to the men and women who provided anaesthesia in the World War One battlefield hospitals and offers a brief overview of the impact and development of anaesthetics and the role of medical personnel with the soldier as the patient.

Injuries came to the Casualty Clearing Station quick and fast. The way in which men were triaged and then treated was essential for a successful outcome and was altered throughout the war to accommodate the large numbers of injured men and to improve systems as a whole.

With multiple casualties arriving quickly and at different times of the day, there was a need to ensure they were treated quickly and efficiently. It was therefore essential that an effective triage system was put in place at the receiving field hospital. Injuries were predominately from trauma, resulting from being shot by the then new machine guns. Many patients required many further surgeries, from amputations to contentious surgical debridement (Anderson, n.d).

McDonald (2014) states that in order to deal with the thousands of wounded men, a system of battlefield evacuation and treatment was put in place. Stretcher bearers took the wounded from trenches to a dressing station and then to a casualty clearing station sited some kilometres from the front. Here the men received treatment including surgery and anaesthesia.

Kovac (2007) states that the anaesthetic techniques used during WWI depended on the patient's general wellbeing, the surgery and anaesthesia factors. Solders were young, (on average between the ages of 18-20), they were in good physical condition and with few medical problems. In the early 1900s smoking was a very popular 'pastime'. This was no different in the trenches, with many soldiers smoking quite heavily (Kovac, 2007).

Smoking was one problem, however, that affected the anaesthetic requirements of the surgical patient as it was found that lung disease was common among the young soldiers. The other issue that affected the choice of anaesthetic agent used for surgery was that many soldiers were subjected to shell shock and nervous exhaustion as a result of days and nights under bombardment in the trenches. These men in particular had hyper sensitive sympathetic nervous systems which evidenced "excitability" thus requiring more anaesthetic agents than other patients. Pain and suffering was something well known to wounded soldiers.

Personnel

During WWI there were no rules or restrictions on who could administer anaesthetics to patients, with nurses and clergymen alike often administrating anaesthetics without any formal training. Courington and Calverly (1986) quote one nurse: "I spent most of my time giving anaesthetics. I had no right to be doing this, of course, but we were simply so rushed..... I went on giving anaesthetics because no one else could be spared to do it."

Anaesthesia during these times fell under the realm of surgery and was not seen as a speciality in its own right as it is today.

Two doctors helped to take the first steps to remedy the shortage of qualified people capable of providing anaesthesia. Dr George Crile took up the challenge to train nurses in the safe administration of anaesthetic to patients as did Dr Arthur Guedel who also actively taught hundreds of individuals on the safe administration of ether to surgical patients during WW1.

As a result of this basic training, specialty trained specialists and nurses began to replace the ad hoc medical officers in administering anaesthesia. Due to a shortage in medical officers, more nurses were trained to provide this service. Both new Zealand and Australian nurses stepped up to take on this role, including the training of new staff. The British army provided a three month training programme for Australian, New Zealand and British nurses in the use of chloroform and ether. This led the way to a formal recognition of the role of Nurse Anaesthetist, which is still a career path for Registered Nurses available today in countries such as Australia, the United States of America and in the United Kingdom.

In WW1 specialist anaesthetist posts were created which allowed the specialist to focus on blood transfusions, fluid resuscitation and cardiac resuscitation which were all relatively new concepts and not well researched. Metcalfe (2005) states that these factors were vital to treat and avoid shock.

Anaesthetics

Anaesthesia had not changed significantly in the 60 years prior to WWI, but many basic techniques and principles of anaesthesia were established during the war time period (Bullingham, 2014). Various anaesthetic methods had been developed before WWI and all of the following were available in field hospitals.

Lee (2003) states that "the journey began when it was realised that the current understanding of anaesthetics and the devices available for its use was insufficient to treat the injured."

Nitrous Oxide

Nitrous oxide also known as 'laughing gas' was discovered in 1775 by 18th-century English theologian, dissenting clergyman, natural philosopher, chemist, educator and Liberal political theorist Joseph Priestley (1773-1804).

In 1844 nitrous oxide inhalation was used by Horace Wells for the removal of teeth with the idea of pain relief by gas inhalation. It is a stable, colourless, slightly sweet smelling gas used as an inhalation anaesthetic. A 50-50 mixture of oxygen and nitrous oxide is used to induce anaesthesia without loss of consciousness.

Nitrous oxide-oxygen mixtures became even more feasible as devices that accurately measured their concentrations became readily available. American specialist in anaesthesia Dr James Gwathmey designed equipment that delivered precision mixtures. Administering such a mix became a recognised skill as it was important to titrate the gases at different phases of the operation. The storage and transport of gas anaesthetics such as nitrous oxide was problematic as it was typically stored in glass bottles which was not practical on the WWI battle field, so its use was restricted to larger base hospitals.

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Ether

Many anaesthetic gases have been administered since the 1800s. The first anaesthetic using ether was administered on March 30, 1842 in the United States of America when Crawford Long administered the gas for the removal of a tumour from the neck of a Mr James M. Venable. This is the first known administration of a gas for surgical pain relief. (History of Anaesthesia Society, n.d.). However, as Long did not publish an account of this until December 1849, when it appeared in the Southern Medical and Surgical Journal, it was Boston dentist William Morton who was initially credited with being the first to use ether as an anaesthetic for a surgical procedure. Morton anaesthetised Edward Abbott in a surgical operating amphitheatre at Boston's Massachusetts General Hospital on October 16, 1846, allowing surgeon John Collins Warren to remove part of a tumour from Abbott's neck. Warren was the first dean of Harvard Medical School and the theatre was later named the Ether Dome.

Two months later the first recorded use of ether as an anaesthetic in Britain occurred at University College Hospital on December 21, 1846 by William Squire during a surgery conducted by Robert Liston. (History of Anaesthesia Society, n.d.).

Ether is a colourless, volatile liquid with a characteristic smell. Although not ideal for anaesthesia, it is safer than chloroform and more effective then nitrous oxide. Its unwanted side-effects include coughing, sore throat, painful red eyes, a headache, drowsiness, laboured breathing and nausea.

In World War One ether was used as the anaesthetic agent of choice in the Casualty Clearing Stations and was often administered using the Clover Method, the first portable ether inhaler. This piece of equipment was developed in 1877 by James Clover and although it has been modified in various ways, it is still in existence today.

An even simpler device for the inhalation of ether is Flagg's Can, a tin can with multiple perforations on its top is a simple ether inhaler was designed to be used in conjunction with an endotracheal tube (Bhargava, 2003). Flagg's Can was an ingenuity of World War One and was devised by Paluel J. Flagg.

Ether continues to be used in third world countries due to the simplicity of administration and the inexpensive cost of the drug (Bhargava, n.d.).

Chloroform

Chloroform Is a colourless sweet smelling dense liquid considered hazardous with a tendency to cause fatal cardiac arrhythmias. It was discovered In 1847 by Scottish Obstetrician, James Young Simpson.

In 1848 John Snow developed an inhaler that regulated the dosage, reducing the number of deaths from chloroform. It was administered using a drop method holding the mask one inch above the patients face. (Clarke, 1918).

Gas Combinations

Due to necessity, surgeons experimented in mixing various gases, typically combinations of chloroform and ether.

War surgeon Geoffrey Marshall stated that by using a gas / oxygen mix, mortality was reduced from 90 per cent down to 25 per cent (Lee, 2003).

Developments in Anaesthesia

Unfortunately during WWI casualties suffered severe pain. Often pain relief was not available or what was available was given intra muscularly (IM) and took time to take effect. This lead the way for new and better anaesthetics and technigues to be developed.

Medications such as morphine and atropine were often given IM as a preoperative medication. This was typically given 30 minutes before surgery with the aim of potentiating anaesthesia, minimising secretions and to assist in aiding a "quiet" postoperative recovery, allowing patients to sleep post-surgery (Kovac, 2007). It should be noted that the Recovery Room, or the Post Anaesthetic Care Unit (PACU) as it is known today, did not feature until the early 1940s. In war time, casualties were immediately returned post operatively to the surgical ward, often still asleep, to recover.

In 1903 the first synthetic local anaesthetic was developed along with other new regional anaesthesia techniques (numbing a specific area of the body). Only a few surgeons were using these techniques before WWI, as others had not had the opportunity to gain experience in administrating these types of anaesthesia. However, the war period gave that opportunity to practice and refine these techniques on a large number of wounded men.

Primitive endotracheal intubation techniques were used to admit gas directly into the lungs often without the administrator's full understanding of controlled ventilation or even the need for it. It was following WWI that adjunct airways and anaesthetic apparatus were discovered following what was learnt in war-torn times. For example Guedal Airways in 1920, Flagg Endotracheal Tubes in 1919, the Boyles anaesthetic machine in 1917 and publications such as Signs of Anaesthesia by Guedal was published (Lee, 2003)

Conclusion

The experience of WWI paved the road for future developments in providing for a safe perioperative experience. The war experiences led to the development and recognition of the important role of the Specialist Anaesthetist or Nurse Anaesthetists. The skills of anaesthesia administration, titration of gases combined with oxygen, medication administration to maintain anaesthesia and comfort through pain relief, blood transfusion, fluid resuscitation and airway management became specialist knowledge for the field of anaesthesia that still remains the foundation of anaesthesia practice today. The concept of equipment such as airway adjuncts (Guedal airways, endotracheal intubation), portable inhalers, and the Boyles Anaesthetic Machine, all developed from the war experience and although these have been modified and enhanced extensively from the original designs, these pieces of equipment are still in existence today.

The "needs must" requirements and opportunities in war time, gave a significant boost to the knowledge and practice of anaesthetics which in peace time may have taken much longer.

Rob Hawker is an Associate Clinical Nurse Manager in Middlemore Hospital's Post Anaesthetic Care Unit. After leaving school he enrolled for a Bachelor of Nursing degree at Christchurch Polytechnic Institute of Technology. But after just two days experience as a student nurse in the perioperative clinical setting, he was accepted onto a New Graduate Programme in operating theatres based at Middlemore Hospital. After working in a variety of specialities he was attracted to the Post Anaesthetic Care (PACU). He is a member of the Editorial Committee of The Dissector.

Johanna McCamish completed her Diploma of Nursing at Whitirea Polytechnic at Porirua in Wellington in 1991. After a year at the 40 bed private hospital (20 surgical 20 long term beds) at the Home of Compassion in Wellington, she moved to Singapore and worked at Tan Tock Seng Hospital (neuro surgical hospital) for 18 months. Returning to New Zealand Johanna took up a position as a staff nurse in the Otorhinogology (ORL) ward at Green Lane Hospital where she completed a Post Graduate certificate in this specialty. Transferring for a year to vascular radiology and then on to the cardiac intensive care unit, Johanna had a number of roles at Greenlane including Cardiac care coordinator and ORL Educator. In 2002 she took up a position at Middlemore Hospital in the Post Anaesthetic Care Unit (PACU) and continued to expand her nursing knowledge and skills by working in the Intensive Care Unit (ICU) and then taking on a position as the General Surgical Coordinator before returning to PACU in 2006. In 2008 Johanna commenced in a new role as Nurse Educator for the Middlemore and Manukau site PACUs which is where she is currently working. She is an active member of the Auckland -Northland Region PNC Committee, and is also a member of the Editorial Committee of The Dissector.

References

A Guide to ANZAC Day for New Zealanders. Significance of ANZAC Day, ANZAC Numbers. Accessed March 2, 2015 from: http://www.anzac.govt.nz/significance/ index.html

Anderson, J. (n.d). Wounding in World War One. Accessed March 2, 2015 from http:// www.bl.uk/world-war-one/articles/wounding-in-world-war-one

Bhargava, A.K., (n.d.). Medical Philately. Accessed March 2, 2015 from http://medind. nic.in/maa/t03/i4/maat03i4p339.pdf

Bhargava, A.K., (2003). Anaesthetic Devices (1900-1925). Indian J. Anaesth. 2003; 47 (4): 263-264.

Beecher, H. K. (n.d). Anaesthesia for men wounded in battle. Accessed on 31/1/2015 http://history.amedd.army.mil/booksdocs/wwii/surgeryinwwii/chapter3.htm

Bullingham, A. (2014 ). Advances in anaesthesia and resuscitation due to the Great War. Accessed 31/01/2015 http://conference.iceaustralia.com/asa14/pdf/ 2014-10-06_1300-1430_Alan_Bullingham.pdf

Clarke T. (1918). Anaesthetics in Military Hospitals, The British Medical Journal: 79-80. Accessed 31/01/2015.

Courington, F.W. & Calverley, R.K. (1986). Anaesthesia on the Western Front: the Anglo American experience in World War I. Anaesthesiology: 1986 Dec; 65(6):642-53.

Harris, K. (2013). Giving the dope: Australian Army Nurse Anaesthetists during World War I: Journal of Military and Veterans' Health, History 21; 3

Kovac, A. (2014). Anaesthesia aspects of base hospital #28: accessed 31/01/2015 www.kumc.edu/wwi/base-hospital-28/clinical-services/anesthesia.html

Kovac, A. (2007). Choice of anaesthetic technique for surgery at the front during World War I. Accessed 29/01/2015 http://www.asaabstracts.com/strands/asaabstracts/ abstract.htm;jsessionid=6D6388E4F49B6A8AA7BBF5A7843F1293?year=2007&i ndex=12&absnum=114

Lee, E. (2003). Silencing pain amidst the gunfi re, World War I and the development of Anaesthesia: Accessed 29/01/2015 https://www.cas.ca/English/Page/ Files/64_2003%20Medical%20Student%20Prize.pdf

McDonald, J. (2014). Anaesthesia on the western front 1914-1918. Accessed 29/01/2015 https://conference.iceaustralia.com/.../2014-10-06_1300-1430_Jane_ McDonald

Metcalfe, N. H. (2005). Military influence upon the development of anaesthesia from the American Civil War (1861-1865) to the outbreak of the First World War. Anaesthesia, 1213 - 1217.

Metcalfe, N. H. (2007). The effect of the First World War (1914-1918) on the development of British anaesthesia. European Journal of Anaesthesiology: 24(8):649-57.
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Title Annotation:WWI: 100th anniversary
Author:McCamish, Johanna; Hawker, Rob
Publication:The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation
Date:Mar 1, 2015
Words:2683
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