A Gas & the Liver

When halothane was introduced as an anesthetic in 1956, it seemed nearly perfect. Unlike ether and cyclopropane, it is both nonflammable and nonexplosive--a valuable asset in the modern operating room crammed with electronic gadgetry. It causes patients a minimum of discomfort and, it seemed, could do them no harm at all. It rapidly became widely used. But last week doctors were disturbed by reports in the New England Journal of Medicine that halothane might have caused as many as ten deaths by damaging the patient's liver.

Halothane (C2HBrCIF3) is chemically kin to chloroform, which has long been accused of causing occasional liver damage. First synthesized in England in 1951, halothane was cautiously tested and carefully evaluated. By the time it was released for U.S. distribution by Ayerst Laboratories under the trade name Fluothane, it had been adjudged harmless in 10,000 human cases.

The New England Journal's warning covered reports from three topflight medical centers (Manhattan's Columbia-Presbyterian, Stanford University and the University of Michigan) of cases in which patients died after otherwise successful operations under halothane. Some autopsies showed the liver to have become a mass of dead tissue. Some patients who survived had liver disease for weeks or months.

Multiple Medicines. Since the swashbuckling practitioners of a century ago popularized ether, chloroform and nitrous oxide ("laughing gas") in surgery and dentistry, the anesthetic art has become vastly more complex and has developed into a new specialty. Only an M.D. can be an anesthesiologist. Except in emergencies, he studies the patient in advance of operations, to decide what anesthetics will be safest and most effective.

Long before the operation, often the night before, the patient gets a preanes-thetic, usually a barbiturate, to quiet him down. In the morning, he may get more of the same, or a morphine-type drug, or both. Next, atropine to help keep mucus from clogging his air passages. In the operating room at last, a clout of barbiturate (often thiopental sodium) to put him to sleep. Then the anesthesiologist rigs the patient with a mask--or, especially for chest operations, a tube inserted through the mouth and down the windpipe. Even that is not all in many cases: an intravenous drug resembling curare (arrow poison) relaxes his muscles. Only when the anesthesiologist nods assent can the surgeon make the first cut. Any time one of his monitoring gadgets flashes a danger signal, the anesthesiologist may tell the surgeon to stop his cutting.

Fast Recovery. Every anesthetic has such potential dangers that it must be used with caution. With halothane, the dosage is especially critical. But it won wide approval because it quickly gets the patient to a level of unconsciousness at which the operation can begin. Patients "come out" faster and feel better after operations, because they usually have less nausea and other discomforts. After years of experience with it, an eminent British anesthesiologist dubbed halothane "the universal anesthetic."

At least 6,000,000 Americans have had operations in the last five years under halothane. Even if all the deaths and illnesses now charged against the gas were proved, its safety record would still be impressive: in the previous five years, about as many patients were killed or severely injured in operating room explosions of anesthetics.

Alerted U.S. anesthesiologists are planning to go right on using it, but cautiously. It probably should not be given twice within two or three months to the same patient. Physicians will watch, both before and after an operation, for signs of liver disorder. Stanford's Dr. John Bunker, one of a team reporting two deaths, says that "on the basis of what seems to be an almost infinitesimal number of complications from halothane, I don't think a moratorium on the drug is justifiable now." The Food and Drug Administration, still studying the reports, was inclined to agree. Some claims for halothane may have been too good to be true, but the anesthetic is still too good to lose.

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