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The History Of Anaesthesia

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Attempts to alleviate the pain of disease, injury or simple surgical procedures by inducing unconsciousness are almost as old as civilization itself, although the techniques were crude. Most involved ingestion of ethanol and or herbal mixtures, but ‘knock-out’ blows to the head and carotid artery compression (carotid derives from the Greek for stupor) are also described. The methods were impossible to quantify and the best that can be said of many was that they were harmlessly ineffective, although that cannot always have been the case given what was involved. Most of the herbal mixtures were devised in southern Europe or the orient where plants with active alkaloids (e.g. opium) are indigenous, but one called ‘dwale’ appears in medieval English texts. However, such concoctions are irrelevant to the evolution of effective, drug induced Anaesthesia, which stems from discoveries made in Britain during the latter half of the 18th century, the time of the ‘enlightenment’. Di-ethyl ether, the first agent to be demonstrated successfully in public, was originally synthesized (by the action of Sulphuric Acid on ethanol) in the 13th century, and there are early reports of both analgesic and soporific effects. However, such observations were not applied clinically for centuries, this being the first example of a recurrent theme in the story: implementation often followed long after discovery.

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It was during the enlightenment that the gases carbon dioxide (Joseph black, 1754), oxygen (Joseph Priestley, 1771), and nitrous oxide (priestly again, 1772) were discovered. As with other scientific developments, the therapeutic possibilities were explored and pneumatic medicine was born, although many of its practitioners were charlatans happy to defraud a gullible public.

 

However, Thomas Beddoes (once black’s student) was different, establishing a pneumatic institute near Bristol in 1798 to allow objective studies and appointing the young Humphrey Davy to perform them. Davy’s ‘researches, chemical and philosophical: chiefly concerning nitrous oxide’, published in 1799, describes two major effects of its inhalation: euphoria (he coined the term laughing gas) and analgesia (it eased the pain of an erupting wisdom tooth). Davy suggested inhalation of nitrous oxide during surgical operations, but this was not acted upon (that recurring theme again) although a slightly earlier event may indicate possible explanations. In 1784, James more successfully used nerve compression before an amputation performed painlessly by john hunter, the ‘father’ of modern surgery, yet there is no record of a repeat. Was it fear of complications, inconsistency of effect, or simply that minds were not yet attuned to the concept of painless surgery?

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Davy went on to work at the royal institution in London, giving demonstrations of nitrous oxide and other discoveries of the age, Michael Faraday, another scientist famous in later life, joining him as assistant in 1813. Faraday studied the inhalation of ether and, in 1818, published his findings, including soporific and analgesic effects. However, one subject took over 24 hours to recover full consciousness, this providing another explanation for failure to implement important observations – the difficulty of quantifying and controlling their effects. A much less well-known figure interested in the inhalation of gases was Henry hill Hickman, a gp from Ludlow in Shropshire who developed the concept of ‘suspended animation’. This he induced by the inhalation of carbon dioxide, during which he performed operations painlessly on many animals, but why he chose carbon dioxide rather than nitrous oxide when he was familiar with Davy’s work is one of many unknowns.

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Hickman’s attempts to publicize his results were unsuccessful, both in England (even Davy was unimpressed) and France, and he died young, but he is the only person in this story to pro-actively conceive of ‘Anaesthesia’ and try to produce it. It is a sign of those times that, while the medical implications of inhaling nitrous oxide and ether were ignored, their potential for ‘recreational’ use was very much taken up: ‘laughing gas parties’ and ‘ether frolics’ were all the rage!

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The story moves to the USA, specifically to Hartford, Connecticut on 10 December 1844, when Gardner Quincy Colton, a travelling showman, gave a demonstration of the latest discoveries, including inhalation of nitrous oxide. In the audience was Horace wells, a local dentist who had mastered the art of using new materials to make dentures and had sought ways of easing the pain of first removing the patient’s own rotten teeth. Here was a prepared mind, and wells realized that he might have found a solution when a young man who had inhaled the gas cut his shin without any apparent discomfort. Discussions led to an experiment the following morning when wells had one of his own teeth removed by a colleague, John Riggs, after Colton had administered the gas.

 

Wells learned how to make nitrous oxide and used it in his practice until he felt confident enough to demonstrate the technique at the nearest major medical centre, Boston. He gave a talk to a class of the Harvard medical school and then administered the gas to one of them who, unfortunately for wells, cried out when a tooth was removed. Even though the student remembered nothing wells took being dismissed as a charlatan badly (he was probably a manic depressive) and, although he continued to use nitrous oxide, he faded from the scene.

 

However, William Morton (Wells’s student and later partner) who had helped with the demonstration, was made of sterner stuff and recognized that a ‘better’ agent was required. He was also a medical student at Harvard and consulted, among others, his chemistry teacher, Dr. Charles Jackson. What part Jackson actually played in Morton’s decision to use ether by inhalation became the subject of great controversy, but there is no doubt that it was Morton who studied it, tested it in animals and then tried it in his patients. Having been successful with these trials he offered to demonstrate his method to Dr. John warren, surgeon at the Massachusetts general hospital, and was invited to do so on 16th October 1846. Before a large audience, Morton administered ether vapour to one Gilbert Abbot, warren removed a tumour from Abbott’s neck without any sign of distress, and a new era dawned. However, Morton, unlike wells, was lucky because Abbott was only semi-conscious and remembered events during the operation, but the effect was sufficient to obtund pain. At first, Morton tried to keep the nature of his agent secret so that he could patent it, but the ethics of the time prevented him from doing so, although scientific credit was hotly disputed. The controversy between Morton and Jackson (later joined by wells) over primacy raged for so long that the ‘ether monument’ commemorating these events in Boston, bears no man’s name, leading it to be nicknamed the ‘either’ monument!

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There are claims that ether inhalation was used for surgery elsewhere in the USA as early as 1842, but those practitioners did nothing to communicate the news to others, making the events in Boston definitive. The news spread as fast as the ships of the time could carry it, but that meant that it was December before practitioners in Britain were involved. The first anaesthetics in these islands were given on 19 December 1846, one ‘probable’ in Dumfries (there is no contemporary record) and the other ‘definite’ at 24 Gower street, London. Dr. Francis Boott, an expatriate American, learning of Morton’s success by letter from Boston, arranged for a Miss Lonsdale to have a tooth removed by James Robinson before a group which included Robert Liston. Liston, then the leading London surgeon, was so impressed that he arranged to perform an amputation under ether on December 21st at university college hospital, the first public demonstration in Britain. At the time, James ‘young’ Simpson, professor of midwifery in Edinburgh was on his annual visit to London to learn of the latest advances, and he became an enthusiastic advocate of Anaesthesia. He pioneered inhalational analgesia for women in labour, was a major force in countering objections (both religious and medical) regarding its safety and use and sought a better agent – discovering the anaesthetic properties of chloroform in 1847.

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Thus, Anaesthesia was introduced into practice, although objections were to continue for some time, especially after the occasional, perhaps inevitable, death was reported. There was no knowledge of the pharmacology of the drugs, no experience to draw on to guide safe practice, and little understanding of normal physiology, let alone the adverse effects of Anaesthesia. All of these problems were compounded by the progressive delegation of administration of the anaesthetic to the more junior members of the surgical team. A very few individuals developed a special interest, notably dr. John snow in London who quickly developed the skills, experience, knowledge and equipment to allow him to publish some of the earliest instructional literature. His reputation grew such that he administered chloroform to queen Victoria for the birth of prince Leopold in 1853 and princess Beatrice in 1857, this royal patronage silencing the last objections to Anaesthesia. After Snow’s death Joseph Clover became Britain’s leading specialist, continuing the work on control of the concentration of anaesthetic administered and the monitoring of the unconscious patient. Dr. (later sir) Benjamin Ward Richardson was more scientist than clinician, but he promoted snow’s work, sought better drugs and introduced the ether (later ethyl chloride) spray (see below).

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From these historic beginnings the science and practice of Anaesthesia grew progressively, the details being beyond the scope of this short account, but a few events require mention. In the USA, Colton continued with his demonstrations, adding mention of Wells’s experiments, such that in 1862 a patient asked him if he would administer nitrous oxide to her for a dental extraction. This he did with such success that Colton gave up his demonstrations and established a company with the specific aim of providing a service for tooth extraction under the effects of the gas. Nitrous Oxide, used as the sole agent without oxygen, is safe only for the briefest of procedures, but that made it acceptable for dental extractions, the technique reaching London in 1868. Clover also found it useful for speeding the induction of Anaesthesia with ether, thus starting the trend towards the modern approach of using combinations of several drugs rather than a much larger, and more toxic, dose of one. However, the practicality of nitrous oxide was limited by the need to manufacture it at the site of administration until technical advances allowed it to be stored and transported under pressure in metal cylinders. Here is another explanation for delay between observation and implementation: the necessary equipment had to be developed as well.

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Simpson’s major contributions are noted above, but in 1847 he also suggested that ‘local’ Anaesthesia would be even more beneficial than general. Cooling was suggested as a method, and this led Richardson to devise the ether spray, the cooling being produced by rapid evaporation, hence the term still used: ‘freezing’. More definitive techniques required recognition of the utility of the ‘numbing’ effects (first noted in 1860) of the south American alkaloid, cocaine. In Vienna in 1884, Sigmund Freud started a study of its systemic effects, assisted by his friend, tyro ophthalmologist Carl Koller. ‘freezing’ is inappropriate to the eye and Koller, who had been taught that a suitable local anaesthetic would be a great advance, had tried the application of several substances without success. One day, demonstrating the effect of ‘tasting’ cocaine, he realized that it was what was needed, and trials progressed quickly to clinical use. A paper was read (by a friend, Koller could not afford the trip) at a conference in Heidelberg on 15th September 1884, and this news was around the world in days thanks to the electric telegraph. Within a few months most techniques of peripheral nerve block had been described, but greater anatomical knowledge was required before spinal Anaesthesia (1898) and epidural block (1921) were developed.

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Initially, the introduction of Anaesthesia had minimal impact on the scale of surgery and attempts to increase it ran into a problem: infection. Operations were brief, and mostly minor in extent, until antisepsis (and later asepsis) was developed and more advanced surgery began to challenge the skills of the anaesthetists and the quality of their techniques. More sophisticated surgery required more skillful anaesthetists with better equipment and improved drugs; then, once these were available the challenge increased again! This cycle has driven progress ever since, with the problems of managing servicemen injured in the two world wars making major contributions to the specialty’s advance. Another major challenge was surgery to the thorax and abdomen, access requiring relaxation of the muscles of the body wall and diaphragm, an effect needing high concentrations of general anaesthetics. The result is marked depression of circulation and respiration, usually with very delayed recovery of consciousness, the net result being significant morbidity. Once again, the solution was in an observation made years before, namely that the south American arrow poison ‘curare’ produces ‘muscle relaxation’ (strictly neuromuscular blockade). Introduced into anaesthetic practice in 1942 by Griffith and Johnson of Montreal, it means that the muscles are relaxed primarily so that the amount of anaesthetic need only be enough to maintain unconsciousness.

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Use of curare requires that the patient’s airway be secured by insertion of a tube into the trachea, and the lungs ventilated artificially to preserve gas exchange, this giving anaesthetists important skills for the ‘control’ of respiration. Then in 1948 Griffiths and gillies of Edinburgh described their technique of induced hypo-tension, the deliberate lowering of blood pressure to decrease bleeding during surgery. This technique has generated more controversy than any other, but the wider implication is that the circulation is as amenable to ‘control’ as respiration. As modern medicine advanced it became apparent that lives could be saved if a patient’s cardiovascular or respiratory failure were to be managed while primary treatment dealt with the underlying disease. Thus, the skills learned in the operating theatre were applied to seriously ill patients, and anaesthetists took the lead in the development of intensive care units. 1948 also saw the introduction of the first modern local anaesthetic, lidocaine. The postgraduate examination in Anaesthesia, then as now, required knowledge of local as well as general anaesthetic techniques so clinicians were well placed to take advantage of lidocaine’s effectiveness. Skill in nerve block also has application outside the operating theatre, and so began involvement in the management of acute and chronic pain conditions.

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One consequence of increasing sophistication in anaesthetic techniques is that their benefits will only be obtained if the clinician has the necessary training to implement them safely. As Morton’s example demonstrates, simple ether Anaesthesia can be used successfully for minor surgery with little in the way of knowledge, skill or experience. However, multi-drug general Anaesthesia involving curare type agents is required for much modern surgery and would be disastrous in any number of ways if it were not managed properly. The benefits of specialization were recognized exceedingly early on, but most early anaesthetists were GP’s ‘with an interest’, the general practice side of their work providing their main income. The consequences of this, in terms of morbidity and mortality, became apparent as techniques evolved during the 1920's and 30's. The introduction of the first rapidly acting intravenous anaesthetic (thiopental) in 1934 made induction much pleasanter for patients, but its management requires far greater skills than the slower onset of an inhalational agent. Such concerns were behind the major developments in the organizations of the specialty occurring in that period. Ensuring patient safety was also behind the establishment, courtesy of lord Nuffield, of the first academic department of Anaesthesia at oxford under Professor (later Sir) Robert Macintosh in 1937. The training of others was an important function.

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By 1950 all of the elements of modern Anaesthesia were in place: very few of the drugs of that time are still in use, but their modern successors are really only improvements on the same theme.

 

Other aspects have changed and changed hugely for the better with the result that modern Anaesthesia has an impressive safety record thanks to two developments. The first of these is in equipment: the anaesthetist of 1950 would gasp in wonder at what is now available and in daily use. The advances include everything from sterile, disposable syringes and needles to computer controlled anaesthetic machines and electronic monitors providing a battery of information on both patient physiology and the proper functioning of the equipment. The second development is even more important – it is in the people required to take advantage of such sophisticated methods.

 

Formal postgraduate training of medically qualified anaesthetists began in 1935 with the institution of the diploma in anaesthetics requiring one year’s supervised clinical experience. Today’s fellowship standard examinations are associated with a competency-based training programme of six years minimum duration. Further, the safe administration of an anaesthetic has long required more than one pair of hands, and now the training of those who assist anaesthetists, and the technicians who maintain the equipment, is equally well-defined.

 

The above outline barely touches the surface of the history of Anaesthesia, but there are many

sources of further information, some of the more important being listed below.

 

Museums, societies and websites

 

There are two major British sources of further information on the history of Anaesthesia, both readily accessible:

  • the Anaesthesia heritage centre of the association of anaesthetists of Great Britain and Ireland, 21 Portland place, London w1b 1py has an important collection of equipment and books. Educational material is available, and there are permanent and special displays.

  • the history of Anaesthesia society has organized one or two meetings a year since it was founded in 1986. The full proceedings, a timeline of Anaesthesia and other information are available on the website.

 

Many medical schools and hospitals have collections, but they are not always generally available.

 

An exception with a useful website is:

 

General medical and surgical museums often have relevant items as well. In Britain, the main ones are:

 

Some important overseas resources are:

 

Further reading

 

Many books have been written on the history of Anaesthesia, some of the best appearing during the third quarter of the 20th century, and thus no longer in print. However, copies can be found and are worth the effort:

  • Keys te. The history of surgical anesthesia. Arguably the best ‘short’ book on the subject; the first edition (1945) was published in the USA by Schuman and reprinted by the wood library-museum of park ridge, USA in 1996. A second, enlarged edition appeared in 1963 from dover publications, inc of New York.

  • Duncum bm. The development of inhalation Anaesthesia. Oxford: oxford university press, 1947. This was written for the centenary of Morton’s great demonstration, and was reprinted by the royal society of medicine; copies are available from the history of Anaesthesia society (www.histansoc.org.uk).

  • Smith wda. Under the influence: a history of nitrous oxide and oxygen Anaesthesia. London: Macmillan, 1982 [isbn 0 333 31681 9] a compilation of articles published in the British journal of Anaesthesia between 1960 and 1972.

  • Davison mha. The evolution of Anaesthesia. Altrincham: john Sherratt and son, 1965.

  • Sykes ws. Essays on the first hundred years of Anaesthesia. Volume 1 – Edinburgh: e & s Livingstone ltd, 1960; volume 2 – Edinburgh: e & s Livingstone ltd, 1961; volume 3 (ed Ellis rh) Edinburgh: Churchill Livingstone, 1982.

 

Some more recent publications offer, respectively, a more up to date overview, an indication of how the development of Anaesthesia has influenced medicine as a whole, biographies of British academic anaesthetists, and a delightful insight into the eponyms of Anaesthesia:

  • Rush man gb, davies njh, Atkinson rs. A short history of Anaesthesia: the first 150 years. Oxford: Butterworth Heinemann, 1996 [isbn 0 7506 3066 3].

  • Sykes mk, bunker j. Anaesthesia and the practice of medicine: historical perspectives. London: royal society of medicine press limited, 2007 [isbn 978-1-85315-674-8].

  • Harrison mj. British academic anaesthetists 1950-2000.wellington: Harrison, 2011 [volume 1, isbn 978-0-47320-049-7] & 2015 [volume 2, isbn 978-0-473-32137-6]. Also available on-line at http://www.docdr.co.uk/baa.html.

  • Maltby jr. Notable names in Anaesthesia. London: royal society of medicine press limited, 2002 [isbn 1-85315-512-8].

 

Finally, mention must be made of two major works, one a limited-edition publication providing a comprehensive listing of major source documents, and the other an extensive collection of essays, albeit with a north American focus:

  • Sim p. The heritage of anesthesia: an annotated bibliography of the rare book collection of the wood library-museum of anesthesiology. Park ridge: wood library-museum of anesthesiology 2012 [isbn 978-0-9614932-5-7].

  • Eger ei, saidman lj, westhorpe rn. The wondrous story of anesthesia. New York: springer, 2014 [isbn 978-1-4614-8440-0].

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Source: - https://www.rcoa.ac.uk/about-college/heritage/history-anaesthesia 

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