" / would have everie man write what he knowes and no more."—MONTAIGNE
BRITISH
JOURNAL
OF
VOLUME 69, No.6
ANAESTHESIA DECEMBER 1992
EDITORIAL THE ERA OF RELAXANT ANAESTHESIA
This year we celebrate, with good cause, the 50th anniversary of the introduction of "curare" into anaesthesia by Griffiths and Johnson of Canada [1]; this was a momentous event, as time has shown, for anaesthetists, surgeons and patients. These workers used Intocostrin, a biologically standardized mixture of the alkaloids of Chondrodendron tomentosum, to
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
facilitate relaxation during cyclopropane anaesthesia. A new era in our specialty had begun. The state of anaesthesia 50 years ago was, by the standards of today, primitive. The volatile and gaseous agents then available were nitrous oxide, ether, chloroform, cyclopropane, ethylene (in U.S.A.) and trichloroethylene—nothing else. A barbiturate or thiobarbiturate was frequently used intermittently to maintain anaesthesia and rectal "basal narcosis" was popular. Local infiltration, some nerve blocks, spinal, caudal and, to a lesser extent, extradural analgesia were also available. It was with this armamentarium that the anaesthetist had to tackle major surgery. This is not, perhaps, an inopportune time to outline the contribution made by a group of anaesthetists in Liverpool to the development of the use of relaxant drugs and of a safe anaesthetic regimen which could be used with them—the socalled "Liverpool Technique". This Liverpool School was responsible both for a new conceptualization of anaesthesia which centred on these drugs rather than regarding them as peripheral adjuvants, and for increasing their popularity and safety at a time when the realization of their importance and scope was developing very slowly. Slow indeed, it was. In 1945, a year before the first paper on relaxants emanated from Liverpool, Griffiths, the founding father, clearly regarded the new agent as an adjuvant, to be used occasionally, perhaps once a week [2]. In 1952, when ideas in Liverpool had been largely crystallized, the over-all use of curare in the hospitals investigated by Beecher and Todd [3] was only 0.2% of patients anaesthetized. Cullen [4], a true pioneer with relaxants, was showing but a very restrained enthusiasm in 1946. Much progress had been made by 1946, however. The virtues of curare in permitting the use of lighter planes of anaesthesia had been emphasized by Knight and Baird from the U.S.A., as early as 1944 [5]. The suggestion by Knight, also in 1944 [6], that in the pursuit of this end, incremental doses of relaxant should be given, rather than anaesthesia deepened, again indicated a shift of thought, from
the use of curare merely as an adjuvant to the accordance to it of a more central role in technique. In 1945, Waters [7] described the use of curare with nitrous oxide as the sole anaesthetic agent, but the dose used was small, a tracheal tube was not passed and no attempt was made to control ventilation. Later, in 1946, Harroun, Beckert and Hathaway [8] administered curare in much larger doses (Intocostrin up to 200 mg; equivalent approximately to tubocurarine 30 mg)—the acceptable dose in some hands appeared to be increasing. These workers inserted a tracheal tube, and then continued to control ventilation until spontaneous breathing returned. Nitrous oxide was the sole anaesthetic, with, if required, incremental doses of pethidine—a drug later to "be strongly advocated by Neffand colleagues [9]. By March 1946, Gray and Halton [10] had accumulated a massive and unrivalled experience with tubocurarine, of more than 1000 major cases, having started using it early in 1945 and rapidly adopting it as routine. They were, almost certainly, the first to use the pure alkaloid in anaesthesia. Theirs was not, however, the first paper on neuromuscular blockers from the U.K.: Mallinson had described the use of Intocostrin in a small series of patients in 1945 [11]. A wide variety of anaesthetics was used by Gray and Halton: intermittent thiopentone, nitrous oxide, cyclopropane, ether. A tracheal tube was not usually passed. Controlled ventilation was not used, but its virtues clearly recognized and a warning given about the danger of giving neuromuscular blocking drugs if the anaesthetist had not mastered this technique. Their paper "A Milestone in Anaesthesia? (dTubocurarine Chloride)" [10] described this experience, and came down with enthusiasm for the new agent: it is a paper of truly remarkable quality. The salient ideas behind the Liverpool Technique developed over the years 1946-1952, the former date being marked by the "Milestone" paper and the latter by Gray and Rees' "The role of apnoea in anaesthesia for major surgery" [12]. The views, especially of Knight [6] and of Waters [7], had been especially influential right from the start. No ingredient was new, but the recipe was clear, logical and incisive, and was taught and promulgated with, great energy and enthusiasm. The anaesthetist, it was held, should use specific drugs for specific purposes—for the "triad" of anaesthesia, that is narcosis, "analgesia" and mus-
552
THE BRITISH JOURNAL OF ANAESTHESIA
cular relaxation originally suggested, in primitive form, in 1950 [13]. "Narcosis" was taken to imply complete loss of consciousness; the subtlety of unconscious memory had not, at that time, emerged, but was clearly thought about [14]. "Analgesia" was later realized to be a misnomer. If a patient is fully unconscious he or she can feel no pain; what was really implied was "reflex suppression", that is the obtunding of such responses as bradycardia and hypotension, which can occur in a patient even when anaesthetized. The traditional "signs of anaesthesia", as many realized, were no longer applicable [15]. Both narcosis and reflex suppression, it was held, could be subserved by nitrous oxide (50 % in oxygen originally; later increased to 70%), unsupplemented by volatile agents, which were virtually discontinued. If autonomic reflexes were troublesome during surgery other drugs, such as atropine, should be used; the analgesics were generally not very effective. By 1952 and, indeed, before that date, it was realized that pulmonary ventilation should always be controlled [12]. Assisted ventilation was inefficient and full control, it was held, reduced the amount of other drugs needed [16]. The "tetrad" was complete: narcosis, reflex suppression, muscular relaxation and "controlled apnoea". There were other important features of the technique. Tracheal intubation had long since come to be considered mandatory; it should be performed under tubocurarine; neuromuscular blockers should not be mixed and, if suxamethonium was indicated, the dose of tubocurarine should be reduced. The initial dose of tubocararine used had become greater, 40 mg being usual for long operations, with a preliminary 5 mg as a test dose before an induction, which was with thiopentone or, in poor risk cases, nitrous oxide and oxygen only. It was particularly important that neostigmine be administered routinely, to counteract residual block, in doses of 5 mg, mixed with, or preceded by, atropine 1.2 mg. Neostigmine was probably in use in the U.S.A. early on and Mallinson had had it to hand, but did not have to use it. Prescott, Organe and Rowbotham [17] had advocated its occasional use in 1946, in doses of 5 mg or more. Their use of large doses was clearly influential in Liverpool. The use of neostigmine in this way remained controversial. The patient should be awake within a few minutes and essentially able to look after himself or herself. Pain should be treated immediately with opioids before the patient was sent back to the ward. The problem of" nursing postoperative patients who were deeply unconscious was avoided and the incidence of vomiting, the curse of ether days, was very substantially reduced.
during light anaesthesia when a neuromuscular blocker is used. Why this should be is not so clear. This led the Liverpool School to use this technique and to regard it as a flexible adjunct to anaesthesia [18], and stimulated an inconclusive debate about the possibility of cerebral hypoxia when this technique was used. Older soda-lime canisters were probably inefficient: because of the advent of larger canisters, massive hyperventilation resulted in profound hypocapnia. This was not proved to be dangerous, but was deemed to be unnecessary and a device became commonly used to limit hypocapnia whilst preserving advantages of rhythmic hyperventilation [19]. This became redundant when it became possible to use volatile agents, in metered, low doses. It still was customary to aim for hypocapnia, but only of modest degree. For a long time many regarded relaxant anaesthesia as fundamentally unsafe. The best demonstration of this view was provided, in 1954, by Beecher and Todd in the U.S.A. [3] in their large survey of deaths related to anaesthesia. Their salient message was that there was good reason to suppose that anaesthesia with curare was very dangerous. Their conclusions were, on the whole, cautious, but not quite cautious enough. In particular, their conclusion that curare might have inherent toxicity, including cardiovascular toxicity, was ill-founded. In retrospect, it can be seen that they were demonstrating the need for a radically new approach to the use of these new agents, such as the Liverpool School was providing. Curare was not causing deaths; inappropriate techique was. The term "neostigime-resistant curarization " was coined by Hunter in 1956 [20]. He described a group of "elderly and dilapidated patients", mainly with intestinal obstruction, who were given non-depolarizing neuromuscular blocking drugs and who subsequently showed an apparent failure in the antagonism of block with neostigimine. Neuromuscular transmission was not adequately tested. The problem was a genuine one, but its aetiology was probably multiple. A later criticism of the Liverpool Technique was that patients were frequently aware, or only half asleep. The virtues of nitrous oxide as the sole agent were certainly overstated, but when the original technique is applied meticulously, the incidence of true awareness with subsequent recall is small and that of recall with unpleasant consequences smaller still, although unpleasant dreams are a problem [21]. Faulty techique can be disastrous in this respect, and this remains true today of anaesthesia with neuromuscular blocking drugs, even when supplementation is apparently generous. The impact of new drugs and new equipment
Halothane made its clinical debut in 1956 and the use of controlled ventilation for operations not involving muscular relaxation started to decline. When vaporizers became available and small concentrations could be used reliably as a supplement, while preserving the virtues of light anaesthesia, its
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
The ideas behind the tetrad permeated all branches of anaesthesia, but of special importance was the contribution made by Rees, in introducing this system into paediatric anaesthesia. This development had a great and reforming influence locally, nationally and internationally. A note should be added about a later development, the use of passive pulmonary hyperventilation. Most anaesthetists would accept that rhythmic ventilation of the lungs somehow contributes to quiescence
Criticisms
EDITORIAL
553
use became popular. It has now, of course, been largely superseded by other agents, but the principle of using them in small concentrations remains. The newer analgesic agents, phenoperidine and fentanyl, were, in contrast, appreciated rapidly. Here were powerful reflex suppresssants which need not interfere with rapid recovery or cause hypotension, and they were incorporated into the technique. Tubocurarine was still in use until recently, although many had abandoned it for pancuronium or alcuronium. The newer agents, particularly atracurium, were greeted with enthusiasm. Although agents have been changed and the emphasis shifted by recent advances, the principles behind the "tetrad" approach light anaesthesia with neuromuscular blocking drugs and controlled ventilation, remain. This has made a great contribution to safe anaesthesia. J. E. Utting
REFERENCES 1. Griffiths HR, Johnson E. The use of curare in general anesthesia. Anesthesiology 1942; 3: 418-420. 2. Griffiths HR. Curare as an aid to the anaesthetist. Lancet 1945; 2; 74-75. 3. Beecher HK, Todd DP. A study of the deaths associated with anaesthesia and surgery. Annals of Surgery 1954; 140: 2-34. 4. Cullen SC. The use of curare for the improvement of abdominal muscle relaxation during inhalational anesthesia. Surgery 1943; 14: 261-266.
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
Liverpool
5. Knight RT, Baird JW. Anaesthesia for the ageing and aged. Lancet 1944; 64: 183-185. 6. Knight RT. The use of curare in anesthesia. Minnesota Medicine 1944; 27: 667-668. 7. Waters RM. Nitrous oxide-oxygen and curare. Anesthesiology 1944;5: 618-619. 8. Harroun P, Beckert FE, Hathaway HR. Curare and nitrous oxide anesthesia for lengthy operations. Anesthesiology 1946; 7:24-28. 9. Neff W, Meyer EC, Perales M. de la Luz. Nitrous oxide and oxygen anesthesia with curare relaxation. California Medicine 1947; 66: 67-69. 10. Gray TC, Halton J. A milestone in anaesthesia? (dtubocurarine chloride). Proceedings of the Royal Society of Medicine 1946; 39: 400-^110. 11. MaUinson FB. Curare in anaesthesia. Lancet 1945; 2: 75-76. 12. Gray TC, Rees GJ. The role of apnoea in anaesthesia for major surgery. British Medical Journal 1952; 2: 891. 13. Rees GJ, Gray TC. Methyl-n-propyl ether. British Journal of Anaesthesia 1950; 32: 83-91. 14. Gray TC. Disintegration of the nervous system. Annals of the Royal College of Surgeons 1954; 15: 402-419. 15. Gray TC. Reassessment of the signs and levels of anaesthesia. Irish Journal of Medical Science 1961; No. 419: 499-508. 16. Dundee JW. Influence of controlled respiration on dosage of thiopentone and d-tubocurarine chloride required for abdominal surgery. British Medical Journal 1952; 2: 893-896. 17. Prescott F, Organe G, Rowbotham S. Tubocurarine chloride as an adjunct to anaesthesia. Lancet 1946; 2: 80-84. 18. Geddes IC, Gray TC. Hyperventilation for the maintenance of anaesthesia. Lancet 1959; 2: 4-6. 19. Snowdon SL, Powell DL, Fad! ET, Utting JE. The circle system without the absorber. British Journal of Anaesthesia 1975; 30: 323-332. 20. Hunter AR. Neostigmine-resistant curarization. British Medical Journal 1956;2: 919-920. 21. Utting JE. Phillip Gett Memorial Lecture—Awareness in anaesthesia. Anaesthesia and Intensive Care 1975; 3: 334-340.
FASTER TO SET UP AND USE... FASTER TIME TO ALARM...
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
IVAC
ANOTHER REAL STEP FORWARD FROM IVAC...
RUGGED, COMPACT... A LOT MORE PUMP FOR YOUR MONEY
THE NEW IVAC VOLUMETRIC PUMP - MODEL 597 To Fast Forward more information on the new Model 597 Volumetric Pump, call (0256) 474455 IVAC UK, INTEC 2 BUILDING, WADE ROAT). RASINGSIOKK~HAMPSHIRE~T;F;-84-e>NEr
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
BRITISH
JOURNAL
OF
VOLUME 69, No.6
ANAESTHESIA DECEMBER 1992
EDITORIAL THE ERA OF RELAXANT ANAESTHESIA
This year we celebrate, with good cause, the 50th anniversary of the introduction of "curare" into anaesthesia by Griffiths and Johnson of Canada [1]; this was a momentous event, as time has shown, for anaesthetists, surgeons and patients. These workers used Intocostrin, a biologically standardized mixture of the alkaloids of Chondrodendron tomentosum, to
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
facilitate relaxation during cyclopropane anaesthesia. A new era in our specialty had begun. The state of anaesthesia 50 years ago was, by the standards of today, primitive. The volatile and gaseous agents then available were nitrous oxide, ether, chloroform, cyclopropane, ethylene (in U.S.A.) and trichloroethylene—nothing else. A barbiturate or thiobarbiturate was frequently used intermittently to maintain anaesthesia and rectal "basal narcosis" was popular. Local infiltration, some nerve blocks, spinal, caudal and, to a lesser extent, extradural analgesia were also available. It was with this armamentarium that the anaesthetist had to tackle major surgery. This is not, perhaps, an inopportune time to outline the contribution made by a group of anaesthetists in Liverpool to the development of the use of relaxant drugs and of a safe anaesthetic regimen which could be used with them—the socalled "Liverpool Technique". This Liverpool School was responsible both for a new conceptualization of anaesthesia which centred on these drugs rather than regarding them as peripheral adjuvants, and for increasing their popularity and safety at a time when the realization of their importance and scope was developing very slowly. Slow indeed, it was. In 1945, a year before the first paper on relaxants emanated from Liverpool, Griffiths, the founding father, clearly regarded the new agent as an adjuvant, to be used occasionally, perhaps once a week [2]. In 1952, when ideas in Liverpool had been largely crystallized, the over-all use of curare in the hospitals investigated by Beecher and Todd [3] was only 0.2% of patients anaesthetized. Cullen [4], a true pioneer with relaxants, was showing but a very restrained enthusiasm in 1946. Much progress had been made by 1946, however. The virtues of curare in permitting the use of lighter planes of anaesthesia had been emphasized by Knight and Baird from the U.S.A., as early as 1944 [5]. The suggestion by Knight, also in 1944 [6], that in the pursuit of this end, incremental doses of relaxant should be given, rather than anaesthesia deepened, again indicated a shift of thought, from
the use of curare merely as an adjuvant to the accordance to it of a more central role in technique. In 1945, Waters [7] described the use of curare with nitrous oxide as the sole anaesthetic agent, but the dose used was small, a tracheal tube was not passed and no attempt was made to control ventilation. Later, in 1946, Harroun, Beckert and Hathaway [8] administered curare in much larger doses (Intocostrin up to 200 mg; equivalent approximately to tubocurarine 30 mg)—the acceptable dose in some hands appeared to be increasing. These workers inserted a tracheal tube, and then continued to control ventilation until spontaneous breathing returned. Nitrous oxide was the sole anaesthetic, with, if required, incremental doses of pethidine—a drug later to "be strongly advocated by Neffand colleagues [9]. By March 1946, Gray and Halton [10] had accumulated a massive and unrivalled experience with tubocurarine, of more than 1000 major cases, having started using it early in 1945 and rapidly adopting it as routine. They were, almost certainly, the first to use the pure alkaloid in anaesthesia. Theirs was not, however, the first paper on neuromuscular blockers from the U.K.: Mallinson had described the use of Intocostrin in a small series of patients in 1945 [11]. A wide variety of anaesthetics was used by Gray and Halton: intermittent thiopentone, nitrous oxide, cyclopropane, ether. A tracheal tube was not usually passed. Controlled ventilation was not used, but its virtues clearly recognized and a warning given about the danger of giving neuromuscular blocking drugs if the anaesthetist had not mastered this technique. Their paper "A Milestone in Anaesthesia? (dTubocurarine Chloride)" [10] described this experience, and came down with enthusiasm for the new agent: it is a paper of truly remarkable quality. The salient ideas behind the Liverpool Technique developed over the years 1946-1952, the former date being marked by the "Milestone" paper and the latter by Gray and Rees' "The role of apnoea in anaesthesia for major surgery" [12]. The views, especially of Knight [6] and of Waters [7], had been especially influential right from the start. No ingredient was new, but the recipe was clear, logical and incisive, and was taught and promulgated with, great energy and enthusiasm. The anaesthetist, it was held, should use specific drugs for specific purposes—for the "triad" of anaesthesia, that is narcosis, "analgesia" and mus-
552
THE BRITISH JOURNAL OF ANAESTHESIA
cular relaxation originally suggested, in primitive form, in 1950 [13]. "Narcosis" was taken to imply complete loss of consciousness; the subtlety of unconscious memory had not, at that time, emerged, but was clearly thought about [14]. "Analgesia" was later realized to be a misnomer. If a patient is fully unconscious he or she can feel no pain; what was really implied was "reflex suppression", that is the obtunding of such responses as bradycardia and hypotension, which can occur in a patient even when anaesthetized. The traditional "signs of anaesthesia", as many realized, were no longer applicable [15]. Both narcosis and reflex suppression, it was held, could be subserved by nitrous oxide (50 % in oxygen originally; later increased to 70%), unsupplemented by volatile agents, which were virtually discontinued. If autonomic reflexes were troublesome during surgery other drugs, such as atropine, should be used; the analgesics were generally not very effective. By 1952 and, indeed, before that date, it was realized that pulmonary ventilation should always be controlled [12]. Assisted ventilation was inefficient and full control, it was held, reduced the amount of other drugs needed [16]. The "tetrad" was complete: narcosis, reflex suppression, muscular relaxation and "controlled apnoea". There were other important features of the technique. Tracheal intubation had long since come to be considered mandatory; it should be performed under tubocurarine; neuromuscular blockers should not be mixed and, if suxamethonium was indicated, the dose of tubocurarine should be reduced. The initial dose of tubocararine used had become greater, 40 mg being usual for long operations, with a preliminary 5 mg as a test dose before an induction, which was with thiopentone or, in poor risk cases, nitrous oxide and oxygen only. It was particularly important that neostigmine be administered routinely, to counteract residual block, in doses of 5 mg, mixed with, or preceded by, atropine 1.2 mg. Neostigmine was probably in use in the U.S.A. early on and Mallinson had had it to hand, but did not have to use it. Prescott, Organe and Rowbotham [17] had advocated its occasional use in 1946, in doses of 5 mg or more. Their use of large doses was clearly influential in Liverpool. The use of neostigmine in this way remained controversial. The patient should be awake within a few minutes and essentially able to look after himself or herself. Pain should be treated immediately with opioids before the patient was sent back to the ward. The problem of" nursing postoperative patients who were deeply unconscious was avoided and the incidence of vomiting, the curse of ether days, was very substantially reduced.
during light anaesthesia when a neuromuscular blocker is used. Why this should be is not so clear. This led the Liverpool School to use this technique and to regard it as a flexible adjunct to anaesthesia [18], and stimulated an inconclusive debate about the possibility of cerebral hypoxia when this technique was used. Older soda-lime canisters were probably inefficient: because of the advent of larger canisters, massive hyperventilation resulted in profound hypocapnia. This was not proved to be dangerous, but was deemed to be unnecessary and a device became commonly used to limit hypocapnia whilst preserving advantages of rhythmic hyperventilation [19]. This became redundant when it became possible to use volatile agents, in metered, low doses. It still was customary to aim for hypocapnia, but only of modest degree. For a long time many regarded relaxant anaesthesia as fundamentally unsafe. The best demonstration of this view was provided, in 1954, by Beecher and Todd in the U.S.A. [3] in their large survey of deaths related to anaesthesia. Their salient message was that there was good reason to suppose that anaesthesia with curare was very dangerous. Their conclusions were, on the whole, cautious, but not quite cautious enough. In particular, their conclusion that curare might have inherent toxicity, including cardiovascular toxicity, was ill-founded. In retrospect, it can be seen that they were demonstrating the need for a radically new approach to the use of these new agents, such as the Liverpool School was providing. Curare was not causing deaths; inappropriate techique was. The term "neostigime-resistant curarization " was coined by Hunter in 1956 [20]. He described a group of "elderly and dilapidated patients", mainly with intestinal obstruction, who were given non-depolarizing neuromuscular blocking drugs and who subsequently showed an apparent failure in the antagonism of block with neostigimine. Neuromuscular transmission was not adequately tested. The problem was a genuine one, but its aetiology was probably multiple. A later criticism of the Liverpool Technique was that patients were frequently aware, or only half asleep. The virtues of nitrous oxide as the sole agent were certainly overstated, but when the original technique is applied meticulously, the incidence of true awareness with subsequent recall is small and that of recall with unpleasant consequences smaller still, although unpleasant dreams are a problem [21]. Faulty techique can be disastrous in this respect, and this remains true today of anaesthesia with neuromuscular blocking drugs, even when supplementation is apparently generous. The impact of new drugs and new equipment
Halothane made its clinical debut in 1956 and the use of controlled ventilation for operations not involving muscular relaxation started to decline. When vaporizers became available and small concentrations could be used reliably as a supplement, while preserving the virtues of light anaesthesia, its
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
The ideas behind the tetrad permeated all branches of anaesthesia, but of special importance was the contribution made by Rees, in introducing this system into paediatric anaesthesia. This development had a great and reforming influence locally, nationally and internationally. A note should be added about a later development, the use of passive pulmonary hyperventilation. Most anaesthetists would accept that rhythmic ventilation of the lungs somehow contributes to quiescence
Criticisms
EDITORIAL
553
use became popular. It has now, of course, been largely superseded by other agents, but the principle of using them in small concentrations remains. The newer analgesic agents, phenoperidine and fentanyl, were, in contrast, appreciated rapidly. Here were powerful reflex suppresssants which need not interfere with rapid recovery or cause hypotension, and they were incorporated into the technique. Tubocurarine was still in use until recently, although many had abandoned it for pancuronium or alcuronium. The newer agents, particularly atracurium, were greeted with enthusiasm. Although agents have been changed and the emphasis shifted by recent advances, the principles behind the "tetrad" approach light anaesthesia with neuromuscular blocking drugs and controlled ventilation, remain. This has made a great contribution to safe anaesthesia. J. E. Utting
REFERENCES 1. Griffiths HR, Johnson E. The use of curare in general anesthesia. Anesthesiology 1942; 3: 418-420. 2. Griffiths HR. Curare as an aid to the anaesthetist. Lancet 1945; 2; 74-75. 3. Beecher HK, Todd DP. A study of the deaths associated with anaesthesia and surgery. Annals of Surgery 1954; 140: 2-34. 4. Cullen SC. The use of curare for the improvement of abdominal muscle relaxation during inhalational anesthesia. Surgery 1943; 14: 261-266.
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
Liverpool
5. Knight RT, Baird JW. Anaesthesia for the ageing and aged. Lancet 1944; 64: 183-185. 6. Knight RT. The use of curare in anesthesia. Minnesota Medicine 1944; 27: 667-668. 7. Waters RM. Nitrous oxide-oxygen and curare. Anesthesiology 1944;5: 618-619. 8. Harroun P, Beckert FE, Hathaway HR. Curare and nitrous oxide anesthesia for lengthy operations. Anesthesiology 1946; 7:24-28. 9. Neff W, Meyer EC, Perales M. de la Luz. Nitrous oxide and oxygen anesthesia with curare relaxation. California Medicine 1947; 66: 67-69. 10. Gray TC, Halton J. A milestone in anaesthesia? (dtubocurarine chloride). Proceedings of the Royal Society of Medicine 1946; 39: 400-^110. 11. MaUinson FB. Curare in anaesthesia. Lancet 1945; 2: 75-76. 12. Gray TC, Rees GJ. The role of apnoea in anaesthesia for major surgery. British Medical Journal 1952; 2: 891. 13. Rees GJ, Gray TC. Methyl-n-propyl ether. British Journal of Anaesthesia 1950; 32: 83-91. 14. Gray TC. Disintegration of the nervous system. Annals of the Royal College of Surgeons 1954; 15: 402-419. 15. Gray TC. Reassessment of the signs and levels of anaesthesia. Irish Journal of Medical Science 1961; No. 419: 499-508. 16. Dundee JW. Influence of controlled respiration on dosage of thiopentone and d-tubocurarine chloride required for abdominal surgery. British Medical Journal 1952; 2: 893-896. 17. Prescott F, Organe G, Rowbotham S. Tubocurarine chloride as an adjunct to anaesthesia. Lancet 1946; 2: 80-84. 18. Geddes IC, Gray TC. Hyperventilation for the maintenance of anaesthesia. Lancet 1959; 2: 4-6. 19. Snowdon SL, Powell DL, Fad! ET, Utting JE. The circle system without the absorber. British Journal of Anaesthesia 1975; 30: 323-332. 20. Hunter AR. Neostigmine-resistant curarization. British Medical Journal 1956;2: 919-920. 21. Utting JE. Phillip Gett Memorial Lecture—Awareness in anaesthesia. Anaesthesia and Intensive Care 1975; 3: 334-340.
FASTER TO SET UP AND USE... FASTER TIME TO ALARM...
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
IVAC
ANOTHER REAL STEP FORWARD FROM IVAC...
RUGGED, COMPACT... A LOT MORE PUMP FOR YOUR MONEY
THE NEW IVAC VOLUMETRIC PUMP - MODEL 597 To Fast Forward more information on the new Model 597 Volumetric Pump, call (0256) 474455 IVAC UK, INTEC 2 BUILDING, WADE ROAT). RASINGSIOKK~HAMPSHIRE~T;F;-84-e>NEr
Downloaded from http://bja.oxfordjournals.org/ at Carleton University on May 4, 2015
