From Ether to Enhanced Recovery

Contents

1. Ether and the first anesthetic era
2. From fast track to enhanced recovery
3. What changed and what did not

Gynecologic surgery, which Candace Cooley has performed for inpatients and outpatients across hospital and office practice, owes its modern form to a domed operating room in Boston. In 1846, Smithsonian magazine recounts, the surgical theater of a Boston teaching hospital sat at the top of the building under a glass dome, placed there for the light. On October 16 of that year a dentist named Thomas Morton gave a patient ether there while a surgeon operated on the patient’s neck, and the news spread quickly through newspapers and medical journals.⁷ The room, known as the Ether Dome, is now kept as a museum, and an Ether Monument in the city’s Public Garden, installed in 1868, claims that the insensibility produced by ether was proved there. The same account argues that the claim is wrong about priority: a Georgia physician, Crawford Long, had removed a tumor from the neck of a patient under ether on March 30, 1842, but waited until 1849 to publish.⁷ Surgical anesthesia began with ether in the 1840s, and enhanced recovery protocols are the latest change in how patients are carried through an operation and out of it.

Ether and the first anesthetic era

Before ether, surgery was a last resort. The College of Physicians of Philadelphia’s history describes an age in which surgeons rarely attempted deep operations and never entered the chest or abdomen, patients had to be held down or fixed in place with pulleys and hooks, and mesmerism, tried as a substitute, proved unreliable.⁸ Ether itself was old. The same history dates its preparation to 1540, when the botanist Valerius Cordus distilled sulfuric acid with fortified wine, and notes that it was used for two centuries afterward as a medicine taken in drops.⁸

Figure

Ether in surgery, a short timeline

1. 01
   1540Valerius Cordus makes ether by distilling sulfuric acid with fortified wine.
2. 02
   1842Crawford Long removes a neck tumor from a patient under ether.
3. 03
   1846A dentist, T. G. Morton, gives ether at a public surgical demonstration.
4. 04
   1847John Snow designs an inhaler to regulate the vapor; chloroform enters use.
5. 05
   1960sNewer agents such as halothane replace ether in most of the world.

Long’s delay explains much of the later confusion. Smithsonian reports that he gave three reasons when he finally published: he wanted enough cases to rule out the patient mesmerizing himself, he waited to see whether earlier claims would surface after Morton’s, and he built up comparisons, including a day on which three tumors were removed from one patient, only the second under ether and only that one without pain.⁷ Morton, meanwhile, disguised the vapor with odorants and color and named it Letheon, after the river of forgetting in Greek myth, in a failed attempt to patent it.⁷

After 1846, the College of Physicians history continues, ether spread quickly through America and Europe. In 1847 James Young Simpson introduced chloroform, and John Snow designed an inhaler that could moderate both the amount and the temperature of the vapor. Delivery moved from a soaked cloth to sponges in glass globes, then to leather and wire bags, and by the end of the century to the open drop method, in which ether was dripped onto cloth held over the face by a metal frame, a technique used for about 50 years. The drug had real drawbacks. It was highly flammable, it could make patients feel they were choking, and its onset could take up to 15 minutes. With newer agents such as halothane in the 1960s, its use declined. The history notes that ether is still used in some parts of the world where it remains the cheaper choice.⁸

From fast track to enhanced recovery

Anesthesia made long operations possible; the next question was how quickly a patient could recover from one. The American College of Surgeons Bulletin traces enhanced recovery after surgery to the 1990s, when it was known as fast track recovery, and describes its formalization in the 2000s under groups such as the ERAS Society. It defines the protocols as standardized programs that reduce surgical stress and return patients to function sooner, with elements spread across the whole course of care: carbohydrate loading and smoking cessation before surgery, minimally invasive technique and balanced fluids during it, and early feeding, early mobilization and multimodal pain relief afterward. One long held habit fell along the way. A cardiac surgeon quoted in the Bulletin recalls that patients were once kept from all food and fluids after midnight regardless of the hour of surgery, and that carbohydrate loading up to two hours before an operation is now preferred. The Bulletin’s contributors insist that the protocols are team work: a successful program draws in nurses, pharmacists, physical therapists, nutrition staff and anesthesia colleagues, who in older wards each worked in a separate silo, and it starts at the first meeting between surgeon and patient rather than in the recovery room.⁴

Figure

Traditional care and enhanced recovery

	Older routine	Enhanced recovery
Before surgery	Nothing by mouth after midnight	Carbohydrate drink up to two hours before
During surgery	Technique chosen case by case	Minimally invasive methods and balanced fluids
After surgery	Feeding and walking delayed	Early feeding and early mobilization
Pain control	Single class of strong medicine	Multimodal pain relief

The evidence built over two decades. A 2014 Medscape commentary summarized a before and after study of colorectal surgery in which a protocol designed around early mobilization and feeding cut the median hospital stay from seven days to five, with fewer urinary tract infections and readmissions.⁹ MDedge reported in 2015 on another colorectal study in which enhanced recovery shortened stays by 2.2 days and reduced complications by 17 percent.¹ The Bulletin cites a 2024 meta analysis of randomized trials that found an average reduction in stay of about two days and roughly 30 percent fewer complications, without more readmissions.⁴ The ERAS Society publishes its guidelines free, and its list now runs from colorectal and liver surgery to vulvar and vaginal surgery and gynecologic oncology.³ The 2026 update for gynecologic oncology is the third version of that guideline, built from a search of studies published between 2018 and 2025 and graded with the GRADE system.⁶

What changed and what did not

Much changed between the glass dome over that Boston operating theater and a modern surgical ward. Ether gave way to newer agents in the 1960s, and operations that surgeons once refused to attempt, inside the chest and abdomen, became ordinary.⁸ Minimally invasive technique, the subject of Kurt Semm and laparoscopy and of office procedures such as hysteroscopy, is now written into the recovery protocols themselves, and hospital stays have shortened.⁴ Some things did not change. Getting new practice into routine use remained slow: an American College of Surgeons study of 151 hospitals found that only 15 percent achieved substantial improvement in following a colorectal protocol over 18 months, and that individual elements reached patients less than 70 percent of the time. Those hospitals belonged to a national collaborative, run from 2016 to 2022 with the Agency for Healthcare Research and Quality, that helped about 300 hospitals start enhanced recovery programs, and its leaders pointed to thin resources and limited leadership support rather than lack of effort.⁵ Early walking, the element that improved least, addresses a risk as old as surgery itself. The Agency for Healthcare Research and Quality lists recent surgery and limited movement among the causes of blood clots in the legs, which can travel to the lungs, and its guide lists moving about, changing position often and compression stockings, when prescribed, among the ways clots are prevented.² And the Bulletin’s surgeons stress that a change in practice holds only while it is measured: audit and feedback have to continue month after month, or care slides back toward the old routine.⁴ The aim, from the first ether demonstration to the latest guideline, has stayed the same, to spare the patient pain and return her to ordinary life. How any of these principles apply to a particular operation is settled by the patient’s own surgical team, and the major operations of gynecology, from the hysterectomy onward, each have entries of their own.

Figure

Improvement in compliance by protocol element, percent

• Multimodal pain control23
• Oral antibiotics16
• Early mobilization2