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September 1998
Volume 62 |
Number 9
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| Development of
Rectal Analgesia |
Franklin B. McKechnie, M.D., Trustee
Wood Library-Museum of Anesthesiology
"Tobacco smoke has oft proved of use.
Nor proudly thou the potent herb refuse.
The enlivening fumes with watchful patience pour
Into the bowels thrice within the hour
If this should fail, tobacco clyster ply
Or other juice of equal energy."
From the times of antiquity, the rectum has been recognized
as a readily available and easily accessible pathway into the
body for the administration of drugs, food and fluids in cases
where the usual oral route cannot be used. This remains true,
especially in many pediatric cases. To have the child fall asleep
in the mother's arms, undergo surgery and then wake up in the
mother's arms with no memory of what took place in between, is
a goal well worth seeking as long as it can be carried out safely
and without complications.
Dioscorides, surgeon-botanist to Nero's army in the first
century recommended giving "wine of mandragora," the juice obtained
by boiling the roots of the Atropa-mandragora plant mixed in wine,
given per rectum to ease the pain of spear and lance wounds. Clysters
of all kinds (alcohol, opium, etc.) were used. The administration
of various opioids by rectum was well-known in the Middle Ages,
and it is presumed this technique was taught at the School in
Salerno.
In 1767, the Society of Amsterdam for the Recovery of
Drowned Persons recommended, among other more sensible treatments,
that tobacco smoke should be given rectally and, if that was not
successful, to make a clyster of tobacco juice and leaves and
push that into the rectum. In 1745, R.A. Mead, M.D., writing in
Mechanical Accounts of Poisons, stated, "There are many
accounts on record of those, who, after having been drowned for
many hours, have been brought back to life. This should certainly
encourage the use of all means of resuscitation to be used upon
such accident victims." He recommended blowing smoke into the
bowels, warming the body by shaking, rubbing, rolling, etc, and
possible venesection when the blood is warm enough to drip out
of the veins.
The following is a partial excerpt taken from "A Poetical
Version of the Rules of the Humane Society for the Recovery of
Drowned Persons" as printed in a magazine called the Cheap
Magazine, in May 1814.
"Let one the mouth and either nostril close
While through the other the bellows gently blows,
Thus the pure air with steady force convey,
To put the flaccid lungs again in play,
Should bellows not be found or found too late,
Let some kind soul with willing mouth inflate,
Then downward, though but lightly, press the chest
And let the inflated air be upward prest.
But should not these succeed, with all your care,
With vigor then to different means repair,
T obacco smoke has oft proved of use.
Nor proudly thou the potent herb refuse.
The enlivening fumes with watchful patience pour
Into the bowels thrice within the hour
If this should fail, tobacco clyster ply
Or other juice of equal energy."
Thus, we find that using the rectum as a route to introduce
various substances into the body was not a new approach at the
time (1846) that ether was discovered to have anesthetic qualities.
In fact, in a book published that same year as well as in a letter
to the Academie des Sciences dated January 4, 1847, Nickolai Ivanovich
Pirogoff, professor of clinical surgery at the Imperial Academy
of Surgery at St. Petersburg, Russia, reported on his usage of
ether given per rectum for surgical procedures. Pirogoff notes
that the advantages of the rectal approach are: 1) the respiratory
organs do not suffer at all (I believe that this may be in reference
to the high degree of tuberculosis prevalent at the time); 2)
etherization is completely independent of the will of the patient
and acts very promptly (within two to four minutes of injection,
one can smell ether on the patient's breath); 3) vomiting is reduced.
He goes on to say, "It seems to me that this method will completely
replace the pneumatic method, often disturbing and painful to
the sick. Operations done by the pneumatic method have been very
difficult, as, for example, several operations of the face, on
the mouth and above all, the operations on children, can now be
accomplished very easily by my method."
Others at this time also began to use rectal ether for
anesthesia. Roux made some experiments, as did Vincente y'Yhedo
and Marc Duprey. Although they were able to obtain fair-to-good
anesthesia, their complications apparently prevented this method
of using either pure ether or ether mixed in water and then pushed
into the rectum from becoming widespread. Such complications as
abdominal cramping, diarrhea and especially bloody diarrhea were
fairly common.
No further mention of rectal ether is mentioned until
1884 when Molliere, following the suggestion of Alex Yverson,
M.D., of Copenhagen, Denmark, employed the method at 1'Hotel Dieu
de Lyons and gave it much merit. He placed the ether in a bottle
and heated it to the boiling point and thus, by expanding itself,
it was pushed into the rectum. No raw ether was intentionally
administered, however, because this was heated above the boiling
point and condensed in the rectal catheter; it gave rise to irritation,
bloody diarrhea, etc. An interesting side observation in reading
the papers published at that time is the wide range of seeming
inaccuracies and the reporting of diametrically opposite results.
It would appear that the results reported were dependent on whether
the author was in favor of this method or against it. For example,
Hunter (New York Medical Record, 1884) reported six cases and
stated, "The method in question promises, in my opinion, to effect
a radical improvement in the method of administering ether." He
also gives the following advantages: 1) the small quantity of
ether use; 2) absence of unpleasant sensations; 3) rapidity of
onset and; 4) lack of struggling. He also notes that it is of
"decided value even if it is only to be used as a preliminary
step to the usual method." He reported no complications.
Weir and Bull (New York Medical Record 1884) reported
seven cases: all had either simple or bloody diarrhea and one
case collapsed postoperatively. Apparently, there was little communication
concerning methods of anesthesia or the use of ether by rectum,
for in 1905, John Cunningham, M.D., reported in the Boston
Medical & Surgical Journal that as house officer at Boston
City Hospital, he had not heard of it. The idea came to him when
he noticed that fluids were being given rectally and he thought,
why not ether? Abner Post, M.D., whetted his interest, and he
proceeded to develop an apparatus from which only the ether vapor
would be allowed to enter the bowel. He also realized the importance
of a good rectal cleansing the night before and the morning of
surgery. He recognized too, that rectal gas had to be released
in order to prevent dilution and by so doing was able to produce
a faster and smoother course. Cunningham also found that by allowing
only the vapor of ether to enter the bowel, the incidence of diarrhea
and particularly bloody diarrhea was essentially nil. It is interesting
to note that very often ether would be administered by mask until
the patient was "asleep" and then the rectal solution was given
for the surgical procedure.
This is not to say there were no complications. One in
particular was repeated but not explained. The incidence of death
seemed to be related to patients being kept under rectal anesthesia
for two hours or more resulting in several deaths. For example,
in Kadjan's Clinic in St. Petersburg, there were 308 cases and
three deaths reported.
There is no question that Cunningham's insistence of an
empty bowel and either ether-air or ether-oxygen vapor only be
used were much safer than heretofore.
The next major advance was in 1913 when James Taylor Gwathmey,
M.D., introduced the use of oil as the proper substance to mix
with ether. Initially using carron oil, he very shortly changed
to olive oil. The advantages that he gave for using this mixture
were: 1) no mask and, therefore, no fear; 2) no expensive apparatus;
3) lessened after-effects; 4) greater relaxation; 5) wide margin
of safety; and 6) more even plane of anesthesia. This was no doubt
due to the oil mixture releasing its ether at a steadier rate
than air or water. It is therefore more controllable, but as later
pointed out, once a set dose has been given, it is difficult to
retrieve. Despite other advances, Gwathmey continued to use his
oil-ether mixture of analgesia in obstetrical cases occasionally
mixing in quinine or alcohol, paraldehyde, magnesium sulfate or
latex. Lathrop pointed out and Gwathmey confirmed that his mixture
worked well because of the following: 1) the constant rate of
evaporation; 2) the distension of the colon causing less to be
absorbed; 3) cooling of the mixture as the ether evaporates; and
4) the difference between the absorptive powers of the colon and
the eliminative powers of the lungs.
In the constant search for better, safer and faster means
of producing a satisfactory anesthetic for surgery, many drugs
have been developed. Probably the first to find widespread use
following ether in oil was the introduction of Avertin in 1929.
It received great popularity because patients liked it. Children
and anxious adults were subjected to minimal psychic trauma. There
is no question that Avertin produced a quiet, trouble-free, cooperative
patient in most cases. However, Henry K. Beecher, M.D., reported
in 1938 on eight deaths possibly due to Avertin and, although
its early acceptance was quite good, it rapidly fell into disfavor.
During the following years until the present, a number of barbiturates
(e.g., Evipal Soluble, Amytal, Surital, sodium Pentothal and most
recently methohexital) were used rectally to quiet the anxious
pediatric patient prior to surgery. All were used as preoperative
analgesics; none were ever intended to be used as full anesthetics
like rectal ether.
The goal in the development of all these agents is to
be able to give a nonirritating substance by rectum (to avoid
needlesticks, face masks, vision of the operating room, etc.)
that will quickly and smoothly put an anxious pediatric patient
into a somnolent state. In addition, it would be nice to keep
side effects such as intestinal distension, defecation, diarrhea
and hiccups at an absolute minimum. Certainly, the drugs, the
patients and the doctors have striven for these ideals since 1847
and although not perfect, they have come a long way.
References:
- Livingston HM. Rectal Anesthesia. In: Hale DE. ed. Anesthesiology.
2nd ed. Philadelphia, PA: F.A. Davis Co.; 1963; 18:551-570.
- Scherlis L.. Poetical Version of the Rules of the Humane
Society for recovering drowned persons. Crit Care Med. 1981;
9(5):430-431.
- Compte Rendue de Sciences de l'Academie de Science: Lundi
4 Janvier, 1847:789.
- Cunningham JH. Rectal Anesthesia. N.Y. Med J. 1910; 91:904-909.
- Hunter JB. The Rectal Administration of Ether. The Medical
Record. 1884; 25:507.
- Weir RF. On the Danger of Inducing Anaesthesia by the Rectum.
The Medical Record. 1884; 25:508.
- Cunningham JH, Lahey FH. A Method of Producing Ether Narcosis
by Rectum with the Report of Forty-one Cases. Boston: M. &S.J.
1905; 152:450-457.
- Gwathmey JT. Oil-Ether Anaesthesia. Lancet. 1913; 185:1756.
- Lathrop W. Ether-Oil colonic anesthesia. JAMA. 1920; 75:82.
- Gwathmey JT. Anesthesia by Colonic Absorption of Ether and
Oil-Ether Colonic Anesthesia. In: Gwathmey JT. ed. Anesthesia.
New York: Macmillan Company; 1925:433-464.
- Gwathmey JT. Obstetrical analgesia; further study based on
more than 20,000 cases. Surg.Gynec.Obst. 1930; 51:190-195.
- Wood PM, Bickley RS. Observations on use of tribromethanol
(avertin). Am J Surg. 1936; 34:598-605.
- Jones AE. Basal Anesthesia: use of evipal soluble by rectum.
JAMA. 1938; 110:1419-1423.
- Beecher HK. Fatal toxic reactions associates with tribromethanol
anesthesia. JAMA. 1938; 111:122-129.
- Weinstein ML. Rectal Pentothal Sodium: A New Pre- and Basal
Anesthetic Drug in the Practice of Surgery. Anesth and Analg.
1939; 18(4):221-223.
- Burnap RW, Gain EA, Watts EH. Basal Anaesthesia in Children
Using Sodium Pentothal by Rectum. Anesthesiology. 1948; 9:524-531.
- Audenaert SM, Montgomery CL, Thompson DE, Sutherland J. A
prospective study of rectal methohexital, efficacy and side
effects in 648 cases. Anesth and Analg. 1995; 81(5):957-961.
- Maddox JK. "Avertin" Rectal Anaesthesia. Australia: Angus
and Robertson, Ltd. 1931:1.
- Resuscitation-An Historical Perspective. Wood Library-Museum,
Park Ridge, Illinois. 1976:2-3, 8-7, 17.
Franklin B. McKechnie, M.D., is retired
from private practice in anesthesiology and resides in Winter
Park, Florida. He served as ASA President in 1986.
E-mail the author.
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