Choice of Anesthetic Technique for Surgery at the Front during World War I

Anesthesia techniques for World War I (WWI) surgeries depended on patient, surgery and anesthesia factors. WWI soldiers were young (18-20 years), in good physical condition and had few medical problems. Many soldiers were heavy smokers. Lung disease was common, making patients difficult to anesthetize with ether or chloroform. They were often very nervous, especially if they suffered from shell shock following life in the trenches. Most operations were short (a half hour to one hour). Local anesthesia with novocaine was used for minor operations and spinal anesthesia with stovain for operations on the pelvis or legs. Morphine and atropine were given 1M as preop meds a half hour before surgery to potentiate anesthesia, minimize secretions, and aid “quiet” postop recovery, allowing patients to sleep post-surgery. The type of general anesthetics available were chloroform, ether, ethyl chloride and nitrous oxide/oxygen mixtures, given either by open drop mask, Clover method, Shipway warm vapor apparatus or Loosley warm inhaler. A chloroform and ether combination was often used, with chloroform first followed by ether, using two separate masks. The first (Schimmelbush) mask for chloroform had a single layer of gauze. The second mask for ether had two layers of gauze. Using two separate masks, the danger of giving a mixture of unknown strength was avoided. One administered chloroform slowly by the drop method with the mask one inch above the patient’s face while quietly talking to the patient. If nervous, the patient was asked to count. After a minute or so, the first chloroform mask was lowered, resting on the face. This mask was then replaced by the second ether mask and drop ether applied until the gauze was saturated. Another method placed a towel folded two or three times over the mask leaving a space. This increased the concentration of vapor and allowed continuous application of ether. Patients rarely struggled and were ready for surgery in three to four minutes. The combination of chloroform and ether had very quick onset and was preferable to starting with ether alone. Afterward, most patients stated that chloroform was more pleasant and less irritating than ether. Ether was also given by the Clover method and Shipway warm vapor apparatus. Shipway was more commonly used and thought to be especially useful for long surgeries as it conserved body heat and was cost effective. Ethyl chloride and nitrous oxide were used for short surgeries, especially joint manipulation. These agents were helpful for strong, healthy young men who lived outdoors for long periods in trenches and subject to war strain (shell shock) and nervous exhaustion. These patients were believed to have hypersensitive sympathetic nervous systems with a greater tendency for “excitability”, requiring more anesthetic than other patients. Calm verbal encouragement was given during the first stage of anesthesia. It was impossible to judge solely by appearance how patients would behave under anesthesia. Some, even though quiet and sickly, took large quantities of anesthetic and became “excitable and troublesome.” Other “rough looking and vigorous soldiers” needed very little anesthetic.