Christopher Langton Hewer, later to become the first Editor of the Association’s journal Anaesthesia, was born in 1896 and was on the staff of St. Bartholomew’s Hospital in London from 1924 until his retirement in 1961, so this book was published one year before his appointment to Bart’s. As was common at the time, he also worked at several other London hospitals, including the Queen’s Hospital for Children in Hackney Road, which was presumably where he gained much of his experience of paediatric anaesthesia. Queen’s was founded by two Quaker sisters following the cholera epidemic of 1866. Originally the Bethnal Green Dispensary for Women and Children, the hospital merged with the Princess Elizabeth of York Hospital, Shadwell in 1942, and was re-named the Queen Elizabeth Hospital for Children.

Hewer’s book clearly reflects his considerable experience in anaesthetising children and contains many practical tips for the beginner. It must be remembered that there was virtually no anaesthetic training at the time and all doctors, and even medical students, were expected to be able to administer anaesthetics. In the 1930s, the University of Oxford opposed Lord Nuffield’s proposal for a chair in anaesthetics on the grounds that ‘anyone can give an anaesthetic’, to which he replied that that was exactly the problem.

Hewer’s book, a decade before, had clearly demonstrated the skills required to perform safe anaesthesia, especially for children. In his preface, Hewer points out that anaesthesia in children was a subject to which not much importance was usually attached. He is to be commended for stating that children require just as much skill to anaesthetise as adults, if not more. He was ahead of his time in criticising prolonged fluid deprivation before surgery, but we might not approve of his suggestion of some weak tea with plenty of sugar half an hour before induction, or his insistence that parents should not be present during induction. He was ahead of the field in suggesting that children should be kept warm throughout the procedure, and that patients under general anaesthesia suffered less shock from operative trauma if nerveblocking methods were used as well. His statement that the anaesthetist must look after the airway, and the quantity of anaesthetic, and monitor the general condition and clinical signs of the patient, even advocating continuous measurement of pulse and blood pressure, indicates his role as the patient’s physician, not a mere technician.

Anaesthetists largely relied on nitrous oxide, ether, ethyl chloride and chloroform, and it is interesting that individual paragraphs in the book are devoted to nitrous oxide with and without oxygen! Anaesthetic apparatus was also primitive. Ethyl chloride by Schimmelbusch mask is recommended for guillotine tonsillectomy, and ether via the Junkers bottle and Davis gag for dissection tonsillectomy. When using ‘sight feed’ apparatus a ratio of four bubbles of nitrous oxide to one of oxygen is recommended, “just sufficient oxygen to keep the colour pink and no more.” Chloroform was administered by open mask, Vernon Harcourt’s inhaler or Shipway’s bottle. Unusual methods included rectal or intravenous ether. Local techniques with cocaine or novacaine were thought to be of limited value in children, but included local infiltration, regional and spinal block. Sacral block, widely practised nowadays, was thought to be exceedingly difficult in children.

Being convinced that the anaesthetic properties of ether were due to impurities in the commercial preparation, Hewer devotes a complete chapter to the use in children of a mixture of ketones treated with carbon dioxide and ethylene called Ethanesal. This agent was later found to have no benefits over commercial ether. His emphasis on portable apparatus reflects the anaesthetist’s reliance on itinerary private practice, though he does envisage a time when, “the gases are laid on to our operating theatres along with the water supply.”

It has to be remembered that this book was published before the use of Magill’s wide bore tracheal tubes and before toand-fro ventilation had been popularised, so when describing endotracheal anaesthesia for intracranial or intrathoracic surgery, hare lip or cleft palate repair, Hewer is referring to the technique of insufflation with gases being delivered to the trachea through a small catheter, and expiration occurring though the patient’s own airway. Endo-pharyngeal anaesthesia was delivered through two small rubber tubes passed through the nostrils. In the pre-relaxant era, there was a natural emphasis on seemingly barbarous instruments such as mouth gags, props and tongue forceps. Hewer recognised that children developed hypoxia rapidly and stated that, “A slight degree of cyanosis which might possibly be allowed in an adult is not permissible in a child.” In noting a child’s vulnerability to shock and haemorrhage we are reminded of some of the medical conditions and surgical procedures common at the time such as osteoclasis (fracture of bones) for Rickets.

Anaesthesia in Children, published exactly fifty years before the foundation of the Association of Paediatric Anaesthetists, gives a fascinating, sometimes horrific, reflection on anaesthetic practice just after the first World War. One of the most striking impressions is of the dangers of anaesthesia at that time, with an overall mortality for some techniques being as high as 1:500, and probably higher in children. Unexpected deaths in the early stages of chloroform anaesthesia or cardiac arrest following laryngeal spasm caused by ethyl chloride are described, with recourse to such desperate measures as laryngotomy, tracheotomy and internal cardiac massage. As was common at the time, these deaths are often attributed to ‘status lymphaticus’, no longer recognised as a pathological entity. Attempts at resuscitation were rudimentary, cardiac massage being performed through a laparotomy. Interestingly, Hewer dismisses a suggestion of a strong galvanic current given to the heart via a long needle. Little did he realise how close this was to defibrillation. Deaths occurring under anaesthesia in the dental surgery were not uncommon, and continued in the UK from time to time until the practice was banned on the last day of December 2001. Such deaths were not only disastrous for the family but must also have seriously affected the anaesthetists concerned. There was no formal counselling in those days, but on the other hand virtually no litigation either.

David J. Hatch
Emeritus Professor of Anaesthesia, University of London.

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