Anaesthesia and real surgery

Ether comes from ethanol and concentrated sulphuric acid — both available from distilling and acids. Add strong alcohol slowly to acid held at about 130–140 °C, distil off the vapour, wash the distillate with dilute alkali and then water, dry it, and redistil: ether boils at 34.6 °C, so it comes over easily and will also evaporate from any container you leave open.

Store in a full, stoppered dark bottle in a cool place. Old ether forms peroxides; discard anything that has stood open. Ether is safer than chloroform in unskilled hands — chloroform kills by sudden cardiac arrest at doses close to the useful one — but it is violently flammable.

Every anaesthetic death is an airway or a dose that nobody was watching. The anaesthetist's job is not to administer the drug; it is to watch breathing continuously for the whole operation and to be free to act.

That person holds the jaw forward, keeps the tongue off the back of the throat, has suction or a swab ready for vomit, and counts respiration aloud at intervals so the surgeon hears it. They do not hold retractors, pass instruments or look at the wound. Position the patient so the head can be turned to the side instantly, and keep the stomach empty — no food for 6 hours, no water for 2 — before anything elective.

There is no fixed dose. Use an open mask — layered cloth over a wire frame — and drip ether onto it, starting with a slow drip and increasing gradually as the patient tolerates the smell.

Read the depth from the patient: excitement and irregular breathing is too light, and operating there causes vomiting and struggling. The plane you want has regular, automatic breathing, the eyelash reflex gone, the eyes central and the pupils mid-sized, and muscles relaxed. Slow, shallow or irregular breathing, a widening pupil, or blue lips mean stop, take the mask away and support breathing. Come up whenever the operation pauses, not at the end.

Pain control without cleanliness means the patient survives the operation to die of infection — and anaesthesia makes that worse by encouraging more operations.

So the whole of germ theory and antisepsis applies at full strength: instruments pressure-steamed at 121 °C for 15 minutes and unwrapped at the table; hands and forearms scrubbed 2–5 minutes; the skin of the site washed and then painted with alcohol or iodine; boiled linen around the field; as few people in the room as the work needs; and dressings sterile and left alone. Historically, antisepsis alone cut surgical mortality by more than half. Combined with anaesthesia it changes what surgery is for.

Transfusing incompatible blood kills fast — fever, back pain, dark urine, collapse. Group A, B, AB and O decide it. Group O is the emergency donor and AB the universal recipient — for red cells; whole group-O blood carries its own antibodies, so cross-match anyway.

Without typing serum, do the direct cross-match: a drop of the donor's blood mixed with a drop of the recipient's serum on a glass slide, side by side with a control, read under the microscope after a few minutes. Clumping means do not transfuse, ever, whatever the emergency. Collect into citrate to stop clotting, use it fresh, and stop the transfusion at the first sign of a reaction. Rhesus disease will show itself in later pregnancies before you can test for it — record every transfusion given to a woman who may bear children.

Most surgical deaths are blood loss and shock, not the incision. Watch for a rising pulse, falling urine output, cold pale skin, thirst and restlessness — a falling blood pressure is a late sign, not an early one.

Salt solution given intravenously is simple, cheap and saves lives: 9 g of clean salt per litre of distilled water, boiled, filtered, and given through boiled tubing and a needle. Anything injected must be pyrogen-free — distilled, freshly made, sterilised at 121 °C — or it causes rigors and fever of its own. Give 20 ml per kilogram and reassess. Where there is no intravenous route and the patient can swallow, oral rehydration works.

Surgeons who do not track their own results do not improve, and the ones who most need to know are the least likely to ask.

Keep a book with a line per operation: date, patient, procedure, anaesthetic, who gave it, duration, complications, outcome at 30 days. Total it by procedure every month. Review every death in the open, with the question what would have caught this earlier rather than whose fault was it. Publish the rates. The test that you have got this right is behavioural: people present early rather than as a last resort, which only happens when the figures are known and good.