5. TRILENE
Trichloroethylene. Cl2C=CClH. Trade name: Trilene. A colourless, poorly volatile liquid with a smell not unlike that of chloroform.
Putney, London
‘John, how could you?! They have only just come back from the cleaners.’
‘Sorry, Mum. It was an accident.’
I looked with regret at the oily mark upon my trousers. I had only been cleaning my bike! I had tried to be especially careful. I really had not meant to get any grease on the trousers.
‘I’ll get it off with some Dabitoff.’
I enjoyed using Dabitoff. It was so convenient. You just unscrewed the cap and turned the small bottle upside down and the gauze got wet with the stuff and you could rub the mark off.
‘There isn’t any left in the bottle, John. I think you used it all up when you got oil on your jacket last week. You were cleaning your bike then too, weren’t you? You really must change into old clothes before you do jobs like that. We’ll ask Dad if he has anything in the surgery that would do. If not you’ll have to go out and buy some more.’
‘Yes. Mum.’
It turned out that my father thought that he did have something suitable.
‘Pop downstairs to the surgery, John, and open the glass door of the cabinet in the corner. You will see several bottles there on the shelf and one will be marked ‘carbon tetrachloride’. Bring it up. It will do the job splendidly. I think Dabitoff is just a trade name for the same stuff, though I am not sure.’
I found the bottle easily enough; it was labelled in big clear letters: CARBON TETRACHLORIDE. It was next to a smaller brown bottle which was labelled TRILENE with the word trichloroethylene underneath. I knew from my Greek lessons at school that tetra meant four and tri meant three, and I also knew that chlorine was a gas; I had not carried a gas mask all that time during the war without learning about chlorine! Anyway, the two names seemed rather strange and exotic.
I asked my father about them.
‘Trilene is a powerful anaesthetic, John. Dr McConnell uses it sometimes. Unfortunately they’ve put a blue dye[1] in it, which is a great pity, as it is a marvellous solvent and it would be grand for getting rid of grease spots on clothes, but the blue spoils it for that. Carbon tet. is good for cleaning clothes too, but it can’t be used as an anaesthetic[2] as it’s poisonous.’
The bottle of carbon tetrachloride was nearly empty but there was just enough to get the oily mark off the trouser leg. I breathed a sigh of relief.
The next time I cleaned my bike I did change into my old clothes first. When I discovered that there was no paraffin, which was what I usually used to clean the bicycle chain, I remembered what my father had said about Trilene. I waited till the coast was clear and crept quietly to the surgery where I poured some of the blue liquid into an empty jam jar. Back in the garden I put the dirty bicycle chain into the jar. The dirt and grease fell off the chain like magic, though the smell of the Trilene gave me a headache[3] which lasted most of the afternoon.
Guy’s Hospital
I really enjoyed helping to give the anaesthetics and I was constantly asking questions about the different agents. I saw Trilene used a lot.
Trilene itself was colourless, I was told, but they added a beautiful blue dye to it so it would not get mistaken for chloroform which had a similar smell.
The glass jar on the anaesthetic machine that they used for Trilene was smaller than the one they used for ether. You had to remember to put the cork into the hole at the top of the jar where you filled it, and, of course, you must not let the Trilene get into contact with the soda lime in the closed circuit or it would react to produce phosgene. Despite its lovely name this was very toxic and could produce nerve palsies afterwards.
Usually the anaesthetist would put the patient off to sleep with an injection of thiopentone, say 400-500mg, and then, if it was not a major operation, get the patient breathing a mixture of nitrous oxide, oxygen and Trilene. This might be chosen as the main anaesthetic or it might lead on to nitrous oxide, oxygen and ether.
‘What makes you decide whether to change over to ether or whether to stay with Trilene?’ I asked.
‘All sorts of things,’ I was told, ‘but most important is whether you need to soften up the muscles or not. Trilene isn’t at all good at reducing muscle tone. However when you add it to nitrous oxide it is very good for producing light levels of anaesthesia for operations like mastectomy or thyroidectomy, and for dentistry, or even neurosurgery. Those are the sort of operations where the surgeon really does not need any muscle relaxation. You need to be careful not to give too much of it, or the respiratory rate may get very rapid, though you can slow that down again with a little pethidine; also you may get heart arrhythmias, especially a very slow pulse which usually responds to some atropine; also if you give too much it may make the patients very sick when they wake up. The secret with Trilene is to be gradual during induction, to be modest with the dose during maintenance, and in a long case to turn it off in plenty of time as it is very slow on the way out again. We are using it a lot these days.’
The next patient, who was going to have her varicose veins dealt with, was already in the anaesthetic room waiting for them.
‘This lady is very suitable for a light Trilene anaesthetic,’ the anaesthetist said to me. ‘She is not too fat, there is nothing wrong with her heart and they don’t need any relaxation. Let’s go and get on with it.’
We went into the anaesthetic room, where I said hello to the middle-aged woman lying peacefully on the trolley. I asked her if I could look at her arm. In the bend of her elbow there was a lovely big vein, seen easily through the skin even though I had not yet put a tourniquet on. Still I would do that now.
‘I’m just going to put this piece of rubber tubing round your arm, Mrs Frost, and tie it gently, like this. There, that’s not too tight is it. It makes the veins stand out nicely. Now just some thing cold and then a little needle prick.’
Having first wiped the skin with a swab soaked in surgical spirit I picked up the syringe of Pentothal and carefully thrust the point of the needle through the skin into the vein. Now, I knew, I must check that I had not put the needle into an artery by mistake; terrible things would happen if you injected Pentothal into an artery. Holding the syringe quite still I pulled gently on the plunger. A small jet of dark red blood came through the needle into the barrel of the syringe colouring part of the pale yellow solution of Pentothal a sunset crimson. I took the piece of rubber off her arm and gently felt the vein again to make sure that it was not pulsating as an artery would do. There was no pulse to be felt. I injected a small volume of the Pentothal, about half a cc, and paused.
‘Is that quite comfortable, Mrs Frost?’
‘Yes, thank you.’
I looked up at the anaesthetist, who nodded. The tests had been carried out properly and now we were sure that it really was a vein, and not an artery, it was safe to continue. I injected the rest of the Pentothal, a total of 8cc., which being a 5% solution contained 400 mg. I watched carefully as she drifted off to sleep. When her eyes closed I put out my hand and supported her chin. I knew that if you kept the chin up it would stop the tongue falling backwards and obstructing the airway as it did so. ‘Don’t forget to turn the gases on,’ the anaesthetist reminded me. I turned the knobs so that there was two litres a minute of oxygen flowing and six litres of nitrous oxide.
‘Now pop an airway in and put the mask on her face. That’s it. Fit it over the nose first and if it doesn’t cover the mouth properly it means you need a bigger mask.’
We soon had the patient breathing the nitrous oxide-oxygen mixture and now it was time for me to start gradually raising the lever at the side of the Trilene bottle. After twenty breaths or so I reached the top and I began to lower the plunger in stages till it was just above the level of the liquid.
‘That will do now,’ I was told. ‘You should never lower the plunger below the level of the liquid when you are using Trilene or you will get too strong a concentration, and the breathing will get too rapid and the pulse get irregular. Once the patient has settled you should reduce the amount of Trilene fairly drastically. I usually find that the patient stays settled if you put the lever at the second mark with the plunger up. If you do put the plunger into the liquid for a moment you will see that this is point the where the gases just start to come through the vaporiser, and that is all you need to maintain the anaesthetic. If you want to check that you still have some Trilene coming through you can disconnect the tubing for a moment and sniff it, but don’t do that too often or it will ruin your sense of smell for the rest of the day. I usually turn the Trilene off for ten minutes in every half an hour and in a really long case you want to turn it off altogether at least twenty minutes before the end, or even earlier. Now when you are watching the patient remember that it’s the breathing that’s important.’
Everything went very well except that I felt a bit light-headed and had a headache by the end of the case. I thought this was must be due to my breathing in the anaesthetic gases and vapours as, with a loud whistling, they came out of the expiratory valve just in front of me. Holding the mask as I was there seemed no easy way to avoid this. I mentioned it to the anaesthetist.
‘Oh, you soon get used to that’ I was told.
Nevertheless it was at least half an hour before I felt quite normal again.
A.D. 1957
I was very nervous about looking after a woman in labour. Luckily the midwife was a kind and capable person. She introduced me to Mrs Jones, the labouring mother, who was having her second child, and explained that I was the student who would be taking her blood pressure and generally helping to keep an eye on her, and giving her the Trilene to breathe if she needed it. The lady thought that she might very well need something later on as it had been very painful during her first labour.
The midwife showed me the Emotril machine.
‘They only started to let midwives use this a couple of years ago,’ she said. ‘But it works really well. We fill the machine by lifting up this piston so that we can pour Trilene into the small funnel, here. You can see the level of Trilene through the glass sight, here. There are two settings that can be used. This is the knob that you move to change it. I find that after ten minutes or so at the strong concentration the weak setting is enough for most people and it does not make them so sleepy. You must never hold the mask onto their face for them; they must do that for themselves. That way if they get too drowsy the mask just falls off.’
I nodded wisely. It sounded just a bit scary to me, though I had heard before of Trilene being given to relieve pain in a conscious patient. I knew it was used sometimes when a patient had intermittent painful spasms on one side of the face, something called trigeminal neuralgia, or tic doloreux if you felt like talking French!
‘What’s this dial for?’
‘That’s to check that the room is not too hot or too cold for the machine to work properly.’
In due course Mrs Jones asked if she could try ‘the stuff’, as it was getting really painful. I passed the mask to her. When her next contraction started she held the mask to her face and breathed in deeply. She said afterwards that the smell was rather unpleasant, but that it helped her a lot, so that it was worth it.
I looked more closely at the machine. When the lady breathed in I could see through a glass window on top that a valve opened so that she was able to suck air through the Trilene chamber and on down the breathing tube to the mask. When she breathed out this valve closed again with a soft click and a hissing sound came from the expiratory valve at the other end of the breathing tube. I remembered from my time doing anaesthetics that this was called a draw over system. The knob you turned to change the strength of the vapour just provided a bigger hole through which to suck in ordinary air to dilute the air that had been through the chamber where the Trilene was. Very crafty! I could smell the Trilene vapour myself as it spilled into the room from the valve. Just like the dry cleaners, I thought.
‘She’s getting on really well,’ said the midwife. ‘I think she is nearly fully.’
As if to confirm what the midwife had just said, Mrs Jones cried out
‘I want to push. I want to push.’ And push she did. The houseman was summoned, for he was the person who was going to show me what to do now. I felt my heart pounding with excitement.
Mrs Jones was getting another contraction. She took a deep breath, held it, gritted her teeth and pushed down hard. I could see the baby’s head clearly now. It was covered with a mass of dark wet hair.
‘ Push hard now, Mrs Jones,’ said the houseman. ‘That’s good. Take a big breath and hold it. Now puuuuuuush, puuuuuuuush. That’s splendid.’ He turned to me.
‘The head is crowning nicely. Put your hand onto it and stop it popping out too quickly like a cork from a champagne bottle. That’s it. Slowly now, Mrs Jones. Stop pushing now, Mrs Jones, just pant without pushing, just pant. That’s it. Good.’
He put his hand on top of mine and together we delivered the baby’s head in a slow and controlled manner so that the changes of pressure inside the tiny skull were not too sudden as it slipped gently out of its mother’s body.
‘Well done, Mrs Jones. That was splendid. Your baby is nearly here. One more push. That’s it. Good, good. It’s a boy! Look, it’s a beautiful boy.’
He held the baby up so the mother could see. The babe gave a loud cry and the mother cried too with joy. I was ecstatic. I had just delivered my very first baby! Soon the cord was cut, and the baby wrapped up carefully and handed to its mother.
We waited for the placenta to be expelled. One good contraction and surely it would come, plump and purple, and knobbly like a cirrhotic liver. But what was this? I watched in amazement as a thin transparent membrane, bulging with fluid, ballooned out of the vulva.
‘What is this?’ I asked in an urgent tone of voice, which was tinged with a trace of panic. The houseman, who had walked a few steps away by this time, turned back to look.
‘Good Heavens,’ he said. ‘There must be another baby.’ And there was! Everyone but Mrs Jones was surprised. Later she said
‘The other mothers on the ward all said I was big enough for twins, even though the consultant felt my tummy yesterday and told me that I had a seven pound baby inside me. They told me he was wrong and that I must have two seven pounds babies there.’
Clearly they had been right!
I was slightly disappointed that I had not been allowed to deliver the second twin, but it had all happened so quickly. Anyway, if the truth be told, I had been rather overawed by it at the time, though no more so than the young, pretty redheaded nurse who had been watching. I had caught a glimpse of her earlier but now I had time to look at her more closely. She was stunningly attractive, with glorious red hair, a wide smile, enchanting freckles and twinkling eyes. I was a lost man the moment I saw her.
Taunton, Somerset
We felt comfortable in Taunton. It was such a charming county town. I had heard that it was snarled up with traffic throughout the summer, but in early autumn it was not too bad. Isabel and I both liked the flat which cost us four pounds a week; this included the services of Bessie who came and tidied for two hours on two mornings each week. She usually brought something for us from her vegetable garden and there were times, when money was tight, that Isabel fed us on runner beans alone for half the week. Of course, there was always cider to drink; the landlady’s sister owned the local cider factory and we were often given a flagon of Autumn Gold when we paid the rent.
I always enjoyed the gynae lists. You never knew what you would find inside the abdomen, even if it was only fibroids looking like knobbly potatoes.
All the middle-aged ladies who were admitted for hysterectomy seemed to have high blood pressure though clearly this did not matter very much. They all survived their surgery and when they were discharged from the hospital the gynaecologists sent them back to their GPs with the suggestion that they should go onto some long term treatment or be referred to medical outpatients. The consultants were not keen on anaesthetising patients who were on drugs to lower a high blood pressures for fear of aggravating the effects of the anaesthetic drugs, so there was little point in starting the treatment before their operations. I used to wonder if some of them might not have been cured of their heavy periods if their blood pressures had been lowered first but I never knew if this so, as it was never tried.
The minor non-abdominal cases were dealt with by giving them gas, oxygen and Trilene but not until they had been softened up by giving them a large dose of thiopentone and a small dose of Flaxedil. Flaxedil was a relaxant drug and the dose was chosen to be just enough to reduce the tone of the muscles generally but small enough to leave the diaphragm, and therefore the breathing, unaffected. This was a simple way of doing things as long as the patient did not recover too quickly before the Flaxedil had worn off. If they awoke too soon and too crisply they felt frighteningly weak and would complain bitterly once they had recovered. So they all got a big premed of Omnopon and Scopolamine and enough Trilene to keep them sleepy for ten minutes or so, though this was still less Trilene than they would have had if they had not had the Flaxedil.
They used a lot of Trilene in Taunton. It had many advantages: it was cheap, it did not depress the circulation and the rapid breathing that occurred if you pushed it too hard was easily controlled by giving a small dose of pethidine. The Flaxedil had the additional advantage of being rather like atropine in that it increased the pulse rate and so prevented the bradycardia that sometimes occurred with Trilene.
Although I spent the daytime working with the older anaesthetists it was Arthur, the registrar, and Hoppy, a locum member of the junior staff, who to taught me how to deal with the emergency cases, or who at least advised me how to deal with them, for I had, after the first ten days, mostly to get on with it unsupervised.
Officially Hoppy was no longer needed now that I had arrived, but he refused to leave, and somehow he persuaded them to continue to pay him for another two weeks. He was a remarkable individual who would stalk the wards of the hospital during the early evenings looking for patients who would benefit from vigorous suction, through a bronchoscope, of the phlegm in their lungs that they were too weak to clear for themselves. It was certainly eccentric behaviour as far as Taunton was concerned but nonetheless it was clearly in the patients’ interests.
Arthur was a thin young man with a wistful smile, whose three cars, including a Red Label Bentley, had only one tax disc between them - after all he could only drive one of them at a time, and how did he know which one he would be able to start in the morning? Arthur became the source of most of my knowledge.
‘Arthur, I don’t understand when its better to use Trilene than Fluothane. Can you tell me?’
‘Well, its like this. Trilene is a wonderful drug if the patient’s circulation is at all dodgy. It doesn’t drop the blood pressure like Fluothane. I use it for all the old ladies who need their hips pinned. You give them a small dose of thiopentone and then keep them asleep with a touch of Trilene added to some nitrous oxide. You can turn the Trilene off half the time. It is also very useful in keeping patients sleepy after short operations when you have used some Flaxedil; that way they don’t complain of feeling weak if the Flaxedil has not worn off by the end of the operation. Fluothane is better at taming strong men, though you mustn’t use it if they are going to inject adrenaline.’
Although I tackled some pretty ill patients on my own at the end of my first week as an anaesthetist, these were cases which were on the normal daytime operating list and which were left for me to deal with as the consultant had to leave at five o’clock to go the nursing home down the road.
‘You know what to do now, don’t you?’ I was told. ‘Just carry on.’
And carry on I did, successfully anaesthetising a jaundiced 76 year old mad for a laparotomy, and then a diabetic for his piles.
My first real emergency case occurred on my tenth day. There was a call to the Obstetric Department for an EUA (examination under anaesthesia) for a lady who was bleeding and might have placenta praevia, i.e. the placenta might be in the wrong place and be in the way of a normal delivery. If it was then they would proceed to Caesarean Section immediately. There was no one else available so I was sent to do the best I could.
As I walked down the corridor I tried to remember what Hoppy had told me: you gave atropine and Pentothal and Scoline in that order; you watched closely and as soon as the muscles of the face started to twitch you put the laryngoscope into the mouth and quickly lifted the larynx up towards the ceiling so that if any fluid came up from the stomach you had got the opening of the larynx above the level of the fluid; you had to continue lifting the larynx so that it was always ahead of the fluid which might still be rising; you had to get the tube down the trachea and the cuff blown up before you ran out of space into which the larynx could be lifted; it was no good worrying too much about the teeth as if you were slow the fluid from the stomach might get down the trachea into the lungs. Success depended on speed and sleight of hand. It sounded really scary.
Luckily it all went well. When the first dose of Scoline wore off I gave a second, but smaller, dose and repeated this as necessary every five or six minutes. I kept her asleep with 75% nitrous oxide. At the end of the operation I turned her on her side and removed the tube once I was sure that the last dose of Scoline had worn off.
‘You have a lovely baby boy,’ I told the new mother as she opened her eyes. She responded by vomiting copiously. Gosh, I thought, I’m glad that that did not well up into her mouth while I was trying to intubate her.
I talked about it to Arthur later on. He said
‘I always put a large bore stomach tube down before I put them off to sleep. If I were you I would do the same. You need to explain firmly to the patient that it is very important and that if they co-operate it won’t be too bad, but if they don’t then it will be pretty unpleasant.’
Later on that day, towards the end of the afternoon, there was a forceps delivery that needed an anaesthetic, but by this time there was a general practitioner from Bridgewater on second call, and they phoned him up. He came dashing over in his car, covering the eleven miles in as many minutes. He told me that he found that gas, oxygen and Trilene was best for putting on the forceps and that if you avoided both thiopentone and Scoline you did not get regurgitation as you did not relax the sphincter at the top of the stomach, so you did could use an ordinary facemask and you did not need to put a tube down. The patient could still vomit, of course, but that was relatively safe as if she was light enough to vomit she would also be light enough to close her larynx.
It worked really well. Once the baby was delivered, he turned off the nitrous oxide and the Trilene, turned up the oxygen, adjusted the harness which he had used to hold the mask on the patient, asked the nurse to hold the chin up and airily said to the obstetrician who Had started to sew up the episiotomy
‘I expect you have you have seven or eight minutes, old chap, before she wakes up. Cheerioh.’
And he was gone, off back to the patients he had left waiting in his surgery eleven miles away.
I soon got used to the problems of being first on call. The commonest operations were appendicectomy, oversewing a perforated duodenal ulcer and ‘D & C’ for incomplete abortion. It could surely not be just a coincidence that they would get three women admitted with heavy bleeding in one night from the area around Minehead, and then the next day two from the neighbourhood of Wellington. There were also lots of cases of intestinal obstruction, which were often a real problem as they would not always breathe well if you used too much curare, even though you used lots of Prostigmin. Prostatectomy, which was performed by first opening the bladder, was often done in the middle of the night because the patients did better if they got their operation within twelve hours of admission.
One day, when I had been at Taunton for six weeks, they wanted to put an extra case at the end of the operating list. It was an old lady with gangrene of her foot who was so ill that they had at first just given her morphine and left her to die. However she had rallied a bit and now it seemed best to amputate her leg in order to get rid of her terrible pain. I was asked to look at her to see if I would be prepared to give her an anaesthetic, but I thought she was still far too ill. I asked the consultant what I should do.
‘Well, I’m sorry but I have a case to do in the nursing home so I can’t help you. You had best pack her leg with ice and wait a couple of hours. That’s what Baron Larrey, who was Napoleon’s surgeon, used to do on the retreat from Moscow. If you then give her some more morphia and some oxygen with just a trace of Trilene, not an anaesthetic dose, but just enough to add to the analgesia, they will be able to take the leg off without any trouble. They can inject the big nerves with Xylocaine before they cut them if they want to but it probably won’t be necessary if you get them cold enough.’
So that’s what they did. It worked marvellously. I was careful to turn the Trilene lever on only until I could just detect the smell and I let her breathe this and the oxygen for five minutes before they started. I gave her a little extra morphia intravenously before they sawed the bone and she seemed to drift off to sleep at that moment, so I turned the Trilene off. She never complained once during the operation.
I went to see her the next day and she seemed much better though I heard later that she had died from pneumonia several days later.
A.D. 1964
Royal Infirmary, Bristol
‘Don’t you take the blood pressure at all?’ I asked, surprised that there was no sphygmomanometer cuff on the patient’s arm. After all removing a large thyroid was a big operation.
‘Well, we’ve never seen any sort of problem with the blood pressure when we use Trilene, so we don’t usually measure it. We would, of course, if there seemed to be a good reason, but we’ve managed without it for the last twenty five years, so I don’t think we’ll bother this afternoon.’
I had only arrived in Bristol that morning and I was feeling very much the new boy. I knew too that it was Brad’s very last list before he retired, so it seemed only polite not to argue with him. Anyway I was enjoying listening to the older man’s reminiscences.
‘Even though we don’t take her blood pressure we will be watching her very closely. If her breathing stays quite regular we’ll know that there is enough blood flowing to her brain, and that she is deep enough. That’s one of the advantages of old fashioned anaesthesia. If you let the patient breathe for themselves they will tell you everything you want to know; if you relax them with drugs you have to take over their breathing and you lose a lot of valuable information that way. You will certainly need to take the blood pressure then!’
‘I see,’ I said, but I was only half convinced. Even in Taunton they would have taken the blood pressure during a thyroidectomy. Still when in Rome, I thought to myself.
I watched the reservoir bag as it moved in its steady rhythmic pattern: in, pause, out, pause. I tried to guess when the next breath would come and how deep it would be. Yes, I could do that; I was getting it exactly right. Stage three anaesthesia, and a satisfactory cerebral circulation. Certainly Trilene was a good drug, as long as you did not want any muscle relaxation. It was even better after a good Om and Scop premed which helped tremendously to smooth things along and prevented the rapid shallow breathing that sometimes occurred if you pushed the vapour too much. I remembered how in Taunton I had always worried about the possibility of getting a very slow pulse to deal with as Trilene was vagotonic, but how you never had any problems if you gave atropine before you started.
Brad was recalling the old days when you did not have any antithyroid drugs with which to treat thyrotoxic patients before they came to surgery.
‘We used to steal the thyroid; at least, that’s what we called it. We wouldn’t tell the patient which day he was going to have his operation and then we would give him a basal narcotic, usually rectal Avertin, or sometimes paraldehyde. He would wake up after the operation was over. That way we hoped we would not get a thyroid crisis when the gland was handled during the surgery before the vessels were clamped. It was very sporting.’
‘Did you ever see a thyrotoxic crisis?’
‘Yes, we certainly did, and very exciting it was too. We used to put them into an oxygen tent, and sedate them and digitalise them. But, of course, it is all so different these days, you would hardly believe it. We really did do cholecystectomies on the kitchen table, you know.’
Several months later I found myself down on the rota to give the anaesthetics for this same afternoon list and there yet another was a thyroidectomy to be done. I went to see the patient the day before. She still had a very rapid pulse rate and I thought that she had not been on her antithyroid drugs for long enough and that she was still rather toxic. Surely it would be better to wait till this was controlled before the operation went ahead. I contacted the house surgeon who agreed with me but told me that the surgeon himself had said it was perfectly all right to go ahead, and so that was what they were going to do.
When the time came everything bled horrendously and the surgeon kept on muttering and muttering something about the anaesthetic. Eventually I was so incensed that I could stay silent no longer.
‘That’s right always blame the anaesthetist,’ I said in a loud voice and as sarcastically as he was able, ‘even if the patient is still thyrotoxic when she comes to theatre.’
The surgeon looked up, clearly surprised that a young registrar should be talking to him in such a disrespectful manner; after all he was a vice-president of the Royal College Surgeons and a man of power within the land.
‘I am not complaining about the anaesthetist,’ he said glowering over his surgical mask, ‘merely the effects of anaesthetic agents on the bleeding. What anaesthetic are you using?’
‘I am using Trilene,’ I replied.
‘Huh.’
Nothing more was said by either of us, though I was still seething at the end of the case.
Afterwards Mike, the surgical registrar, told me to simmer down and forget the incident, but Alan, one of the anaesthetic senior registrars said that he thought that I should apologise.
‘Apologise? Certainly not. Why should I apologise?’
‘Well you don’t want to cross him or you will never get on. It really would be the best thing, I think.’
‘Like hell! I don’t care how important he is. If anyone should apologise it should be him. Grumpy old sod.’
I did wonder if it would have been any better with Fluothane. The blood pressure would probably have been lower and the bleeding might have been less because of that. Perhaps it would have been better, too, if I had let the patient breathe on his own like Brad had done, so that the mean intrathoracic pressure was lower and therefore the venous pressure as well. Who knows?
A.D. 1967
Denver, Colorado
My year in Denver had been a fascinating experience. I had learnt such a lot. It had been especially curious to find myself helping and advising young men who had done perhaps twenty spinals in the last six months when I myself had only done ten in the last six years. Still I had managed very well, never failing to succeed when the resident was having difficulty, but this particular day the lady was so amazingly fat that I could not resist asking the professor, who was passing by the door at the time, if he had any special tricks to cope with such a problem patient.
‘Well , John, what you do is this. You get a whole handful of long spinal needles and stick them in one by one till you hit oil. Look, I’ll show you.’
We sat the good lady up and turned her sideways so that her legs dangled over the side of the operating table. With her sitting at least we knew where the midline was. Bob picked up one of the fine silver needles and thrust it to the hilt into the wobbly fat. He removed the stilette from the middle and waited . No fluid appeared. Leaving the needle in place he picked up a second needle and repeated the manoeuvre. No oil! Another needle. No oil this time either. Now there were three needles sticking out of her back. She looked like a bull when the toreadors had been at work.
‘The important thing is not to take out the needles that have missed or you will have no idea where you have already tried and failed, as the fat wobbles around so much. We’ll just go on till we do find CSF.’
It was not till the eighth needle had been inserted that we saw clear fluid drip from the hub.
‘Why, there you are, John. Remember there are only three things that look like that: cerebrospinal fluid, distilled water, and gin!’
I laughed. I would never forget the lesson!
Later that day Dave said to me
‘John, you will be on your way home soon and you haven’t shown us how to use Trimar yet. How about it?’
Trimar was the local trade name for trichloroethylene, as marketed by the Ohio Chemical Co, and was therefore the American version of what I knew as Trilene. Though Trimar was readily available no-one in the department remembered seeing it used, except for the professor, Bob, and Vi, the nurse anaesthetist who had taught the professor when he was a medical student (after already having been a professor of Organic Chemistry). I had hardly used Trilene myself over the last two years as it was so much easier to use Fluothane, but I was sure that it was like riding a bicycle in that once you knew how to do it you never forgot.
‘Right oh, certainly I’ll show you. First find me a suitable case. Something not too short, and fairly peripheral, would be best. Although it can be used very nicely as an adjuvant to nitrous oxide relaxant anaesthesia you won’t see it in its true colours unless it is used as the main agent in a patient who is breathing spontaneously.’
‘What about a middle ear operation? There’s a tympanoplasty to-morrow.’
‘That will do splendidly. What have you got as a vaporiser?’
‘Why, John, there’s always the copper kettle. That way you would know exactly what you were giving.’
‘Good Heavens, that would never do. With Trilene, or Trimar, as you call it, you need art not science! I wouldn’t have any idea what concentration to give. I need a simple uncalibrated ether jar. There must be one around somewhere.’
‘Why, sure, we will find one for you, John.’
They looked in all the drawers and on the shelves and they found one, which they fitted onto the anaesthetic machine in OR 8 (operating room no.8) so that it was ready for the next day.
When the time came to give the demonstration I could not help being a little nervous. I had given the lady a good dose of morphine an hour beforehand together with some Vistaril which was the favourite premed locally. In the correct Denver style I tested the fit of the mask on her face and gave her oxygen to breathe for a couple of minutes before I injected the thiopentone and suxamethonium into a running drip. I sprayed her cords and upper trachea liberally with some 4% lidocaine (lignocaine), popped a tube through her vocal cords and gently inflated her lungs with a mixture of nitrous oxide and oxygen with a just little Trilene till she started to breath again.
Good, I thought, she seems deep enough not to cough on the tube if no-one jogs her. Let’s take her deeper though before they get going. I had some Demerol (pethidine) to hand in case her respiratory rate rose too high. In any case I planned to give her some near the end of the operation so that I would be able to keep her asleep when they asked me to turn the nitrous oxide off; this would be so that bubbles of nitrous oxide would not lift the skin graft after it had been put into place within the ear. It would take some real art to keep her just right with oxygen and Trimar alone and still to get her to wake up promptly at the end.
In the event the anaesthesia went splendidly. The very slowness of the surgery, which took just under four hours, helped enormously because I was able to watch how she responded to changes in the concentration that I gave her to breathe. I alternately turned the Trimar off till I thought she was getting too light and then turned it on again at the same time keeping the total dose low by judiciously employing some pethidine. I tried not to look too pleased with myself when at the end, just as they finished putting the head bandage on, she opened her eyes and, with a little encouragement, took the endotracheal tube out herself.
‘Gee,’ said Ted, ‘That must be the cheapest anaesthetic given in Denver this year. Why don’t we use this stuff more often?’
‘Because it is slow, both in and out, and it makes some people horribly sick if you push it too hard, and it does not relax their muscles at all, and it is not compatible with sodalime. I think I was lucky today that it all went quite so well, and a good conjuror never does the same trick twice! But it is a jolly good adjuvant to nitrous oxide when you are using relaxants and so do not have to push it too much. Some people in the UK swear by it. Also it’s splendid for draw-over anaesthesia and Trimar-air-curare is highly portable and effective.’
I wonder if this was the very last time that Trilene was used in Denver.
A.D. 1987
Southmead Hospital, Bristol
The coffee room was a good place to wait while the next patient was fetched from the ward. I asked the room at large
‘Who was the very first anaesthetist?’
‘Wasn’t it someone in America in the middle of last century?’ said Rachel.
‘No. It was God! He put Adam into a deep sleep, didn’t he?’
I paused for a moment, for effect, and then asked
‘Who was the very surgeon?’
‘I suppose it must be God as well,’ said Lucy, whose grandfather had taught me obstetrics when I had been a student myself, a third of a century earlier.
‘Quite right. Of course, it was God. He took a rib out of Adam, didn’t he? And what was the very first and the most longlasting postoperative complication there has ever been?’
I waited for an instant, and then pounced
‘It was women, of course!’
There was a audible groan from the group of female medical students.
‘That’s sexist,’ Sue cried out, and Rachel added ‘God is a woman anyway, you know.’
‘Nonsense. Of course, he isn’t. But who was the very first person to be mentioned in the bible?’
The girls looked puzzled. Surely it was Adam?
‘It was ‘Chap 1’!’
Another groan.
‘That’s the worst joke I’ve heard this year,’ said Anne.
The phone rang.
‘Hello.’
‘The next patient for theatre two is here.’
‘O.K., thank you, we’re coming.’
I nodded at Anne. We got up and made our way to the anaesthetic room. The patient was a rather jolly man of thirty five. We had already drawn up and labelled the drugs we needed so Anne was able to get on with looking for a vein on the back of his hand, while I got the ‘Butterfly’ needle ready for her.
‘There’s a nice one here,’ she said.
I was still fumbling with the packet the needle came in.
‘You’ll have to hang on a moment,’ I said to her. ‘I can’t get the packet open.’
The patient looked up at me.
‘I know just what it’s like , doctor,’ he said. ‘It’s happened to me lots of times!’
We all laughed.
Soon the needle was in the vein, and in no time he was asleep and we moved into the theatre so that the operation could start. When it was over we lifted him back onto the trolley and took him round to the recovery ward where we handed him over to the care of one of the nurses. Back in the anaesthetic room we heard that there was going to be a ten minute delay in bringing the next patient.
‘Do you think what we were doing to that good man was physical or chemical?’ I asked Anne. ‘ With the nitrous oxide and halothane, I mean.’
‘Both, probably. Surely it depends on how you define physics and chemistry.’
‘Fair enough, but if you take a simplistic view you can make out a good case that’s anaesthesia is a physical phenomenon. Let me give you a demonstration. We’ll anaesthetise a piece of rubber.’
‘Anaesthetise a piece of rubber? What on earth do you mean?’
‘Well, obviously you can’t actually anaesthetise a piece of rubber but you can expose it to an anaesthetic agent and see what happens. Let me draw you a Venn diagram on this piece of paper. Of course, they hadn’t invented Venn diagrams when I was at school but I haven’t had three children doing modern maths not to have learnt about them.’
I drew a big circle.
‘That’s the effect of anaesthetic agents on things in general; all things, both animate and inanimate. Now we’ll draw another circle inside that one. This is the effect of anaesthetics on animate things. We still cannot call it anaesthesia as that means no feeling implying at least the loss of sensation. So you can only anaesthetise something by taking away sensation from it. So, for example, if you stop a cell in a hair follicle from dividing that may be the effect of an anaesthetic agent but it is not really anaesthesia.’
‘No, I suppose not.’
‘So we need a new word to describe what is going on in the biggest circle, which includes ‘anaesthesia’, of course, but a lot of other things as well. I’ve often meant to write to New Scientist to see if its readers could come up with something, but I’ve never got around to it. The best suggestion anyone has given me so far is reversible moleculopathy, but I don’t remember whose idea that was.’
‘I like that... reversible moleculopathy, eh? Sounds good, but what does it mean?’
‘Oh, nothing, but its a start. Anyway, inside this second circle there is a smaller circle that really is anaesthesia. That’s the reason the patient did not feel any pain during her operation. What we need now is a rubber glove. Not one of the sterile ones because that would be wasteful but I know where they keep a stock of unsterile ones for sigmoidoscopies and I’ve got one of those in the drawer here.’
I took the glove and with a pair of scissors I cut out four rough squares each about an inch across. I laid the squares out on the metal table top.
‘Is there any one of these that is clearly odd man out?’ I asked. ‘Or are they all about equal? I’m only interested in obvious differences, not minor aberrations.’
‘No, they are pretty much the same.’
‘Well, we are going to anaesthetise them and watch what happens. Let’s put some Trilene in this metal dish and we’ll pop these three into while we keep this one for a control.’
We watched the fluid run over the small pieces of rubber. Almost immediately we could see the squares begin to grow bigger and bigger till each of the sides seemed nearly to have doubled in length.
‘That’s amazing.’
‘You can see the effect in two dimensions easily enough but don’t forget there actually are three dimensions. There is no reason to suppose that the thickness has not doubled as well as the sides you can see. Two by two by two is eight. So the volume of the rubber has increased eight times! Of course we are giving it an awful lot of Trilene. It only takes 0.2% Trilene in air to produce anaesthesia so putting it into liquid Trilene must be at least five hundred times an anaesthetic dose. What we must do now is to see if the effect is reversible. We’ll take one of the pieces out of the dish and let the Trilene evaporate. It will take several minutes as Trilene isn’t very volatile and it has to get itself out of the middle of the rubber. Look, it’s already starting to curl at the edges where it’s drying out the quickest. While we are waiting we’ll take a second piece out and see if it is still elastic or not, and whether it is as strong as it was.’
I held it between my fingers and pulled gently and then let go again. Yes, it was still elastic, but when I pulled somewhat harder it snapped in two.
‘O.K. then, it is not as strong as it was even though it has not lost its elasticity. What has happened is that the molecules of Trilene have interfered with some of the cross linkages between the rubber chains. Moleculopathy was right but is it reversible?’
The rubber square was still shrinking before our eyes. After several minutes the only way we could tell which piece was the one that had been in the Trilene was by the blue colour that was left in it because the dye in the Trilene was not volatile like the Trilene itself. In all other respects it was the same as it had been before we had started.
‘Yes,’ said Anne. ‘I’m convinced. Anaesthesia is reversible moleculopathy!’
Almondsbury, Bristol
The post was late arriving but I managed to pick it up from the mat before I left for the hospital. There was the usual collection of bills and two adverts about where to invest my savings, as if I had any. Underneath these was the latest issue of Today’s Anaesthetist. Good, it would give us something to discuss in theatre. I chucked it in the back of the car.
Later that morning there was a lull as the recovery ward was full; we had to wait ten minutes before we could take the last patient out of the theatre.
‘Mike, go and have a cup of coffee, and read through Today’s Anaesthetist. Perhaps there is something in it we should discuss.’
When he came back we were still waiting for there to be a space in the recovery ward; he handed me the journal and said:
‘There’s lots in it to read, but the editorial was the thing that interested me most. Its about the economics of inhalational anaesthesia. I’ll watch the patient while you read it.’
I opened the journal. Whoever had written the Editorial (it was not signed, but I guessed it was Robin) had worked out the cost of a unit of inhalational anaesthesia, defining a minor case as one unit, an intermediate case as five units and a major case as ten units, and ignoring the cost of the nitrous oxide which would be the same whichever volatile agent was used. That seemed fair enough. The cost per unit worked out at 107p for halothane, 2p for Trilene and 146.3p for Isoflurane.
‘That’s a pretty major difference in cost, isn’t it?,’ I said. ‘Even so, I don’t think Trilene will make a comeback,’ and I launched off into the list of disadvantages that I had given the folk in Denver.
‘What about the final sentence?’ he asked.
Tomorrow’s anaesthetist will have to strive to maintain standards both clinical and academic against a managerial attitude of ignorance, indifference and parsimony.
I laughed. Yes, it was certainly Robin who had written the editorial! But I wondered if parsimony always meant niggardliness; couldn’t it sometimes mean commendable economy? I did not think that that was what he meant.
A.D. 1990
Southmead Hospital, Bristol
‘John, have you read the new Today’s Anaesthetist yet?’ Iain asked.
‘No, my copy hasn’t arrived yet. Is there something in it that I should read.’
‘Yes. There’s as splendid letter from an anaesthetist in York called Kinnell. It isn’t very long; I’ll read it to you:
In the last issue of Today’s Anaesthetist there were a number of letters lamenting the withdrawal of Trilene as ICI did not consider the cost of building a new plant feasible. I have used Trilene clinically all my working life and found it to be a most useful agent. Its use extended beyond the clinical field and into dry cleaning and the garden We are periodically troubled with visits by moles which burrow round the borders and enter the lawn causing much havoc. We have lost our lone licensed mole man as he is now in an old peoples’ home. I can not obtain strychnine (probably a good thing) so I have resorted to stuffing the runs with disposable blue theatre caps soaked in Trilene. This has proved most effective. I am now wondering what to do when my last bottles of Trilene are finished.
We both laughed.
‘When did you last use Trilene?’
‘It’s so long ago that I hardly remember now. But it was good stuff, really, wasn’t it?’
‘Oh, yes, it was, in its time! But the new drugs are better, aren’t they?’
‘Yes, they certainly are.’
So, Trilene, rest in peace!
NOTES
[2] In his splendid book Mode of Action of Anaesthetics (Edinburgh: E & S Livingstone, 1951), TAB Harris discusses the effect of chlorine substitution on the aliphatic hydrocarbons methane, ethane and ethylene. He writes:
In each of these three series of chlorine substitution products, the hydrocarbon nucleus retains its influence upon the narcotic potency of the compounds; di-chlor-ethylene (C2H2Cl2) is a more potent narcotic than the ethane substitution product, di-chlor-ethane (C2H4Cl2), and this compound in turn is more potent than the methane derivative, methylene di-chloride (CH2Cl2).
The presence of chlorine in these compounds is, however, responsible for an increase in narcotic potency relative to the to the parent hydrocarbon, for methyl chloride is a more potent narcotic than methane, and ethyl chloride is more potent than ethane. It is found, moreover, that in a homologous series of chlorine substitution products narcotic potency increases with each additional chlorine atom substituted or added. When, however, chlorine substitution is carried to the complete exclusion of the hydrogen atoms of the hydrocarbon, narcotic potency decreases slightly, and in the methane series, carbon tetrachloride (C.Cl4)is a less potent narcotic than chloroform (CHCl3). This same effect is seen in the chlorine substitution products of ethylene, for tri-chlor-ethylene (C2HCl3) is a more potent narcotic than tetra-chlor-ethylene (C2Cl4).
(The bold high-lights were not in the original, but indicate agents that appear as chapters in this book.)
[3] Texts on Trilene rarely mention headache as a complication, though one study of the minor sequelae of anaesthesia[a] does report that of 513 patients studied. headache was complained of by fourteen patients. In two of these it followed unintentional dural tap with a wide bore (Barker) needle and lasted 3 to 4 days, and in eight others, who had received Trilene, the headache lasted about 24 hours.
Unfortunately we are not told how many of the 513 patients were given Trilene, nor what was the surgery.
[a] Edmonds-Seal J, Eve NH. Minor sequelae of anaesthesia: a pilot study. Brit. J. Anaesth. 1962; 34: 44.
email john@johnpowell.net