A Brief History of Anaesthesia

A Brief History of Anaesthesia
Andrew Ronald Consultant Cardiac Anaesthetist Aberdeen Royal Infirmary

Why study the History of Anaesthesia?
An understanding of our past guides our future The history of surgery is inextricably linked to the development of appropriate anaesthetic techniques and so the history of surgery follows the history of anaesthesia We are all part of it

History of Anaesthesia
Pre the foundations of anaesthesia establishment of anaesthesia 20th Century - consolidation and growth 21st Century - the future

The Foundations of Anaesthesia
Pre-1846 The Foundations of Anaesthesia

Pre 1846 - The Foundations of Anaesthesia
……..so the Lord God caused him to fall into a deep sleep. While the man was sleeping, the Lord God took out one of his ribs. He closed up the opening that was in his side……... Genesis 2:21 NIrV

Drug methods Alcohol Opium (poppy) Hyoscine (Mandrake) Cannabis (Hemp) Cocaine (New World) Non-drug methods Cold Concussion Carotid compression Nerve compression Hypnosis Blood letting

Status of surgery Barber shop surgeons Types of surgery Amputations & dental extractions No antisepsis Appalling mortality Indications Unbearable pain Crippling deformity Imminent death

“…the case was an interesting one of a white swelling, for which the thigh was to be amputated. The patient was a youth of about fifteen, pale, thin but calm and firm. One professor felt for the femoral artery, had the leg held up for a few moments to ensure the saving of blood, the compress part of the tourniquet was placed upon the artery and the leg held up by an assistant. The white swelling was fearful, frightful. A little wine was given to the lad; he was pale but resolute; his Father supported his head and left hand. A second professor took the long, glittering knife, felt for the bone, thrust the knife carefully but rapidly. The boy screamed terribly; the tears went down the Father’s cheeks. The first cut from the inside was completed, and the bloody blade of the knife issued from the quivering wound, the blood flowed by the pint, the sight was sickening; the screams terrific; the operator calm….” Contemporary description of surgery, 1841

What changed?

Industrial and Scientific Revolution
1540: synthesis of ether 1628: circulation of blood 1744: ether inhalation suggested to treat pain 1770’s: research on CO2 1771: discovery of O2 1772: “Mesmerism” 1773: discovery of N2O 1794: gas therapy in illness 1709: iron formed from coke 1712: first steam engine 1733: flying shuttle (1745: Battle of Culloden) 1769: water frame 1769: Watt steam engine 1771: cotton mills 1779: first iron bridge (1789: French Revolution) 1801: first steam carriage

Industrial and Scientific Revolution
Late 1700’s lots of new gases identified attempts to apply gas knowledge to medicine directed at treatment of existing diseases rather than novel use Gases of importance nitrous oxide ether carbon dioxide oxygen

Gas Therapy in Illness Pneumatic Institute, Dowry Square, Clifton, Bristol founded by Thomas Beddoes ( ) in 1794 with equipment designed by James Watt ( ) attempted to use used gas therapy (incl. oxygen, nitrous oxide & ether) to treat diseases incl. asthma, dropsy, consumption, & venereal disease

Pneumatic Institute New medical institution. Upper end of Dowry-Square, Hotwells, corner house. Treating incurable diseases. Medical professors at Edinburgh. Many Physicians in England. Consumption, Asthma, Palsy, Dropsy, obstinate Venereal Complaints, Scrophula or King's Evil. Other incurable diseases. Patients treated gratis. Expectation: Considerable portion of cases will be permanently cured. Methods are not hazardous or painful. Attendance will be given from 11 till 1 o'clock by Thomas Beddoes or Humphrey Davy. Subscriptions for support of Institution received by John Savery, Esq., Narrow Wine Street, Bristol. Bristol Gazette March

Pneumatic Institute Humphrey Davy (1778-1829)
became Superintendant in 1798 continued Priestley’s and Beddoe’s Work Nitrous oxide & Ether

Humphrey Davy & the Pneumatic Institute
Recognised analgesic properties of N2O and christened it “laughing gas” first tentatively suggested a use during surgery “…as nitrous oxide in its extensive operation appear capable of destroying physical pain it may be used with advantage during surgical operations in which no great effusion of blood takes place …”

Gas Therapy in Illness Nitrous oxide Ether

Nitrous oxide 1800: Davy’s thesis
1834: Colton “anaesthetised” 6 Red Indians by mistake 1844: Horace Wells had his own tooth pulled under N2O - “a new era in tooth pulling” 1845: Wells “failed” to demonstrate N2O at MGH

Ether 1540: synthesised and named “sweet oil of vitriol” by Valerius Cordus renamed “ether” by Frobenius 1744: Matthew Turner published essay suggesting its inhalation in certain types of pain late 1790’s: research at Pneumatic Institute

Ether 1818: Michael Faraday ( ) described “narcotic effects” of ether

Ether 1821: Benjamin Brodie ( ) demonstrated to Royal College of Surgeons that ether inhalation could induce insensibility in a guinea pig - “….ether acted like a narcotic poison……”

Ether 1842: first use as clinical anaesthetic in USA
16th October 1846: first public demonstration of ether anaesthesia in Boston, Mass.

William T G Morton “Inventor and Revealer of Inhalational Anaesthesia: Before Whom, in All Time, Surgery was Agony; By Whom, Pain in Surgery was Averted and Annulled; Since Whom, Science has Control of Pain.”

So why no anaesthesia until 1846?
Why did Davy not pursue his work? no real concept of “anaesthesia” in late 1700’s / early 1800’s  how can you achieve a state which you assume impossible or cannot envisage achieving Pneumatic Institute concerned with treatment of disease by “Physicians” - surgery did not have same standing and therefore influence State of surgery - almost inevitably fatal - why encourage them? General moral / religious beliefs and fear / concerns about animal experimentation

So why no anaesthesia until 1846?
Or wasn’t there?

Henry Hill Hickman ( )

Henry Hill Hickman and carbon dioxide
Born at Lady Halton, Bromfield, Shropshire matriculated at Edinburgh University 1819 attended lecture “On Asphyxia” by Henry Goldwyer - “a temporary suspension of the vital functions arising from a deficiency of atmospheric air..” and described reversal using artificial respiration & electrical restarting of heart admitted as member of RCS London 1820 set up practice in Ludlow, Shropshire But before leaving this era we have to consider the work of Henry Hill Hickman, the one man who came closest to creating what we would recognise as Anaesthesia in the early 1800’s

Henry Hill Hickman : series of experiments on small animals to induce “suspended animation” semi-asphyxiation due to air starvation or by breathing Carbonic Acid (CO2) gas after unconsciousness was induced Hickman operated on them - amputations, removal of ears, skin incisions - and observed responses to surgery, evidence of pain, amount of bleeding and time to recovery 1824: attempted to bring work to notice of Royal Society As a country doctor, Hickman was well aware from personal experience of the appalling suffering which inevitably accompanied surgery Attempted to bring his work to the attention of the Royal Society by writing a letter to T A Knight of Downtown Castle. This local Squire was a Fellow of the Royal Society of which Davy was now the President and it was well known that Davy often visited Knight to go fishing

Henry Hill Hickman

Henry Hill Hickman “……there is not an individual who does not shudder at the idea of an operation however skillful the Surgeon or urgent the case, knowing the great pain that the patient must endure, and I have frequently lamented, when performing my own duties as a Surgeon, that something has not been thought of whereby the may be tranquillised and suffering relieved …..I have been induced to make experiments on Animals, endeavouring to ascertain the practicability of such treatment on the human subject……I have witnessed results which show that it may be applied to the animal world , and ultimately I think will be used with perfect safety and success in Surgical operations…..I have never known of a case of a person dying after inhaling Carbonic Acid gas if proper means were taken to restore the animal powers …..” Hickman described 7 experiments in his letter. All animals recovered This was the first description of an attempt to prevent pain and induce insensibility during surgical operations.

Henry Hill Hickman 1824: moved to Shifnal
1824: “A Letter on Suspended Animation” (W Smith, Ironbridge, 1824) to TA Knight of Downton Castle

Henry Hill Hickman 1825: having failed to attract attention of Knight, Davy and Royal Society wrote to Shrewsbury Chronicle (dated 3rd June) Anonymous writer (“Antiquack”) responded to “Letter on Suspended Animation” and Shrewsbury Chronicle article in The Lancet 1825

Henry Hill Hickman “…can he for a moment suppose that any medical man of sense and judgement will be so far led away by a proposal so utterly at variance with all he has ever heard, saw, or read, of the deleterious effects of respiring the fixed air to believe that that this letter was published with any intention of benefiting mankind... intended to serve as a decoy by which credulous may be induced to give up their senses as well their cash to men…” “…an open and downright quack is superior to a plausible quacking physician… “

Henry Hill Hickman “…I sincerely hope, and believe, for the credit of the profession, be utterly impossible to find any surgeon so great a fool, and so unwarrantably bold as to undertake that operation on such terms..” “…I do fervently hope that the letter itself may be a complete hoax, and not written by Dr Hickman; for, in this age of science and gentlemanly acquirement, I feel assured, that no man who has any claim to the honourable appellation of a Doctor of Physic would so far disgrace both his profession and himself by writing such a tissue of quackery, which he himself, and every medical man must know is (to say the least) humbug” signed Antiquack, The Lancet 1825

Henry Hill Hickman 1828: appeal to Charles X of France - referral to Royal Academy of Medicine in Paris 1829: returned to practice in Tenbury Wells, Shropshire

Henry Hill Hickman 1830: died; buried in Bromyard churchyard

Henry Hill Hickman 1847: letters in Lancet by Thomas Dudley of Kingswinford identifying Hickman’s work with reports of “the Letheon” 1912: first modern reference to Hickman Thompson CJS. Brit Med Jour 1912 ; i: 1930: plaque erected by Section of Anaesthetists of RSM

The Establishment of Anaesthesia
The Establishment of Anaesthesia

1846-1900 General Anaesthesia Local Anaesthesia New techniques Ether
spread to Europe Nitrous oxide Chloroform James Young Simpson John Snow Local Anaesthesia anaesthesia without sleep New techniques early landmarks

Ether 16th October 1846: first public demonstration of ether anaesthesia in Boston, Mass. “Gentlemen this is no humbug. We have seen something today that will go round the world” Morton gained the support of many of Boston’s most influential medical men including Warren himself, Henry Jacob Bigelow (became a very famous surgeon) and Oliver Wendell Holmes, Professor of Anatomy and Physiology at Harvard and who later coined the word “Anaesthesia”. Henry Bigelow went on to lecture widely on ether anaesthesia and it was his father Jacob Bigelow (Professor of Materia Medica at Harvard), who sent news of ether to Francis Boott in England (Bigelow Snr and Boott knew each other well as they were both keen botanists). Bigelow Snr sent his letter on 28th November enclosing a letter detailing Morton’s discovery, and described a dental extraction performed on his daughter while under the influence of ether. He also enclosed a copy of the Boston Daly Advertiser of 19th November 1846 containing an article written by his son, Henry.

Ether - the news spreads
Letter and other papers from Jacob Bigelow (description of his daughters surgery under ether and relevant copy of Boston Daily Adveriser) sent to Francis Boott in London News carried by Cunard paddle steamer “Acadia” leaving Boston 3rd Dec 1846 and arriving Liverpool 16th Dec 1846

17th Dec 1846: Boott received letter and arranged with dentist James Robinson to experiment with ether inhalation 19th Dec 1846: ether administered by James Robinson to a Miss Lonsdale for molar extraction at Boott’s home 21st Dec 1846: Robert Liston, Professor of Surgery at University of London publicly amputated the leg of Frederick Churchill at UCH - “This Yankee dodge beats mesmerism hollow” There is evidence that news of ether anaesthesia had already reached the UK via other means beore Boott received his letter but no-one had chosen to follow it up. Anaesthesia appeared in the UK over a few days at the end of However it took much longer for it to become fully established within clinical practice. It’s flammable properties were well known and it must have been a challenge using it by candle-light in the short Winter days of 1846/47. Indeed such was the learning curve for those tried to administer it that many surgeons faced with inadequately anaesthetised patients preferred to continue to work without anaesthesia. Indeed many went back to working without anaesthesia. Robert Liston tirelessly continued to push the cause of anaesthesia, using it for his surgery and lectured extensively on it.

Ether - the Dumfries connection
William Fraser Cunard Ship’s surgeon 19th December 1946 ? 1st European use of Ether anaesthesia What case? probably an amputation of a leg in a patient run over by a cart - patient died Some authorities do not believe the Dumfries case actually happened - not even reported locally until some time later William Fraser - Cunard ship’s doctor - from Dumfries - father was apothecary there and so WF known to Messers Scott and McLaughlin, the surgeons at DRI WF on Arcadia got to hear news from America ? Boston Advertiser ? Bigelow’s letter and on disembarkation in Liverpool on 16th December headed for his home town. Obviously convinced the surgeons it was worth a try and when a suitable case came in ……...

1847: arrival of Ether Anaesthesia announced in first edition of “The Lancet” of 1847 Letter from Francis Boott Letter to Boott from Henry Bigelow Paper from Boston Medical and Surgical Journal Robert Liston’s own experiences following first report there were a number of letters / papers over the ensuing months detailing new uses / experiences of anaesthetic ether. This culminated in attempts by Morton to patent ether anaesthesia under the name “Letheon” - considerable discussion / debate amongst Morton, Jackson, Boott and Bigelow

1847: Liston became an increasingly important supporter of ether in the following months at a time when many surgeons tried, then abandoned its use returning to practice without anaesthesia Reasons for possible abandonment attempts to “patent” anaesthesia and so limit its use inadequate anaesthesia excessive secretions vomiting patients risk of explosion and fire (candlelight!) perceived “risks” of rendering patient unconscious for surgery

Nitrous oxide 1847: Horace Wells published paper “A History of the Discovery of the Application of Nitrous Oxide Gas, Ether and Other Vapours to Surgical Operations” 1863: Colton “reintroduced” N2O, primarily for dental surgery 1865: N2O cylinders available in London 1881 pain relief in labour 1887 Hewitt “gas and oxygen machine” Horace Wells gave up dentistry, became a chloroform addict and toured the world with a bunch of performing canaries. Imprisoned for pouring sulphuric acid over a prostitute while recovering from self-administered chloroform and killed himself aged 33 by cutting his femoral artery Paper of 1847 an attempt to identify himself as inventor of anaesthesia

Chloroform 1831: Chloroform synthesised
1833: Cynthia Guthrie accidentally anaesthetised herself! 1847: Anaesthetic properties recognised 1847: First clinical use, St Barts, London 1847: James Young Simpson used chloroform for obstetric anaesthesia First use of Chloroform as “Chloric Ether” was at St Barts in Spring 1847 JYS didn’t use it until 6/12 later. Experimented with his friends, then used it clinically

James Young Simpson (1811-1870)
Professor of Midwifery in Edinburgh from 1840 Tried chloroform on himself and friends at suggestion of David Waldie, a chemist Secured and popularised chloroform as clinical anaesthetic, esp. in Obstetrics

James Young Simpson many objections to analgesia for childbirth
religious and moral Genesis 3:16 - “…..The Lord God said to the woman, I will greatly increase your pain when you give birth. You will be in pain when you have children. You will long for your husband. And he will rule over you……..”

Chloroform 1847: John Snow’s regulating inhaler
1847/48: Chloroform eclipses ether 1848: Hannah Greener - first anaesthetic death 1858: John Snow “On Chloroform and other anaesthetics”

John Snow (1813-1858) Born in York in 1813
became interested in anaesthesia via work in toxicology apprenticed in Newcastle, then worked in London until his death acknowledged as “first full-time” anaesthetist developing ways to improve methods of ether and chloroform administration

John Snow “Chloroform a la Reine” Prince Leopold Princess Beatrice
born 7th April 1853 Princess Beatrice born 14th April 1857 helped to overcome religious and moral objections to analgesia for childbirth

“…. administered Chloroform to the Queen in her confinement…. Dr
“….administered Chloroform to the Queen in her confinement…. Dr. Locock was sent for about nine o'clock this morning, stronger pains having commenced, and he found the os uteri had commenced to dilate a very little. I received a note from Sir James Clark a little after ten asking me to go to the Palace. I remained in an apartment near that of the Queen……………. At a twenty minutes past twelve by a clock in the Queen's apartment I commenced to give a little chloroform with each pain, by pouring about 15 minims by measure on a folded handkerchief……. Her Majesty expressed great relief from the application, the pains being very trifling during the uterine contractions, and whilst between the periods of contraction there was complete ease. The effect of the chloroform was not at any time carried to the extent of quite removing consciousness. Dr. Locock thought that the chloroform prolonged the intervals between the pains, and retarded the labour somewhat. The infant was born at 13 minutes past one………..consequently the chloroform was inhaled for 53 minutes. The placenta was expelled in a very few minutes, and the Queen appeared very cheerful and well, expressing herself much gratified with the effect of the chloroform…” John Snow Thurs 7th April 1853 John Snow’s description of his part in the birth of Prince Leopold in 1853 Original diary entry handwriting far better than rest of diary - obviously took especial care

John Snow World’s first epidemiologist
“On the mode of communication of cholera” self- published in 1849 July cholera outbreak in Broad street area of London September Snow removed handle of Broad Street pump outbreak declared over 7 days later

John Snow John Snow Society Pump handle lecture
Blessed chloroform lecture John Snow Pub March John Snow voted “greatest doctor of all time”

Local Anaesthesia in the C19th
1884: Cocaine 1885: Spinal analgesia for pain relief - Corning 1890: Oil of cloves (Eugenol) 1891: Tropocaine 1892: Infiltration LA 1898: Spinal anaesthesia for surgery - Bier

Other C19th Landmarks 1865: Lister introduced “Carbolic spray” - antisepsis 1878: first oral ETT - flexible brass, 0.95cm diam 1891: first partial pneumonectomy; no ETT 1894: first anaesthetic charts

Consolidation and Growth
The 20th Century Consolidation and Growth

The 20th Century Whereas in the late 18th / early 19th centuries the Industrial Revolution and sociological change triggered the events which led to the development of Anaesthesia, in the 20th Century increasing prosperity, better medical treatment, increased expectations, transport and modern warfare culminating in two World Wars has driven both the science and speciality of anaesthesia to new heights

Intubation and airway advances Anaesthetic equipment Monitoring
Drug advances Local anaesthetic advances Speciality advances - ITU & pain General progression of speciality

Intubation and airway advances
1919: Endotracheal intubation (Magill & Rowbotham), Queens Hospital, Sidcup 1928: Blind nasal intubation 1931: first double-lumen tube (Gale & Waters) 1949: Carlens double-lumen tube 1950’s PVC tubes introduced 1980’s PVC finally replaces Red Rubber tubes. Rae (Ring, Adair & Elwyn) tubes & LMA’s introduced McEwan metallic tube described 1978

Anaesthetic Equipment
1908: Rotameters 1917: Boyles machine (Plenum flow) : “Flagg can”

1926: McKesson demand machine (intermittent flow) 1938: Artificial respiration via ventilator 1940: Oxford vaporiser

1954: classification of breathing circuits 1961: Manley ventilator 1972: Bain circuit 1976: Lack circuit

Monitoring 1901: BP’s recorded on Mass Gen Hosp Anaes chart
1911: McKesson added Resp rate & insp O2 concentration to charts (SpO2 described 1913) 1946: paramagnetic O2 analysers 1949: first nerve stimulator 1956: blood-gas monitoring

Monitoring 1960’s: ECG monitoring and capnography
1960’s: CVP and arterial monitoring 1970: “Swan-Ganz” catheter 1980’s/90’s: increasing use of microprocessor-controlled monitoring equipment

Monitoring 1990’s: explosion of new monitoring modalities
CO monitoring - CardioQ / PICCO / LidCO SvO2 monitoring pHi monitoring Experimental depth of anaesthesia monitors Perioperative Transoesophageal echocardiography

Drug advances 1911: Self admin N2O in labour
1911: “Balanced anaesthesia” (Crile) 1934: Cyclopropane, Thiopentone 1934: Minnnitt “gas-air” mix in labour 1941: Trilene 1942: Curare 1951: Suxamethonium

Drug advances 1956: Halothane 1964: Introduction of Entonox
1980’s: “New generation” ethers - Enflurane & Isoflurane Opioids - Fentanyl, Alfentanil, (Sufentanil) New methods of analgesia Relaxants - Atracurium / Vecuronium Propofol 1990’s: TCI anaesthesia Opioids - Remifentanil Volatile agents - Sevoflurane & Desflurane Relaxants - CisAtracurium / Mivacurium / Rocuronium By the 1980’s ether was available n a named patient basis only

Local Anaesthesia 1904: Stovaine 1929: Cinchocaine 1931: Amethocaine
1943: Lignocaine 1952: Chlorprocaine 1959: Prilocaine 1963: Bupivacaine 1993: Ropivacaine late 1990’s: Levobupivacaine

Local Anaesthesia 1907: use of “heavy” spinal solutions - Barker
1908: IVRA - Bier 1909: Sacral block - Stoekel 1921: barbotage and positioning in spinal anaesthesia Labat

Local Anaesthesia 1921: lumbar epidural anaesthesia - Pages
1949: ureteric catheter inserted via Tuohy needle Curbelo 1979: opioids injected into epidural space 1980’s: eutetic LA mixtures - Lignocaine / Prilocaine (EMLA) for topical use

Anaesthesia and Intensive Care
1929: tank ventilator 1934: ventilation for tetanus 1938: development of Nuffield plywood “iron lung” 1953: IPPR for bulbar poliomyelitis in Denmark (Ibsen) - hand ventilation via tracheostomy

Pain Management C20th: LA techniques
1960: Rudimentary self-controlled analgesia systems in Obstetrics 1967: first Patient-controlled analgesia system 1991: RCA report on Post-op pain - changes course of post-op pain management 1990’s: development of Acute Pain Teams and multimodal analgesic strategies incl PCA / Epidural / PC Epidural / combination Rx

Pain Management 1953: Liverpool Centre for Pain relief - cordotomies
- acupuncture Anaesthetists involvement in multi-disciplinary chronic team units - Liverpool, Hope (Salford), Norwich, Oxford

Organization of the Speciality
1908: Section of Anaesthetists of RSM 1914: Scottish Society of Anaesthetists 1932: Association of Anaesthetists of GB&I 1933: World’s first Chair of Anaesthesia - Ralph Waters, University of Wisconsin 1935: Diploma of Anaesthetics 1937: 1st European chair of Anaesthesia (Robert Macintosh, Nuffield Chair, Oxford)

Organization of the Speciality
1945: end of WW II 1948: Faculty of Anaesthetists of RCS 1948: Institution of the NHS 1953: FFARCS examination (later FCAnaes, now FRCA) 1989: College of Anaesthetists 1991: Royal Charter for RCA

21st Century The future

Anaesthesia in the 21st Century
Crystal ball new and better drugs “anaesthesia” perhaps not priority it was NDMR version of Suxamethonium analgesia and PONV more TCI “closing the loop” techniques new airway management techniques new monitoring - anaesthetic depth

Staffing and workload issues increased demand for “anaesthetic services” questioning of roles outside theatre questioning of roles within theatre

Staffing and workload issues development of non-medical anaesthetist pilot sites up and running how best to integrate with “medical anaesthesia” who to recruit nurse-based postgraduate science-based other background already raising a number of other training & service issues

The future of Anaesthesia is assured - but we may see our roles and how we practice it change

A Brief History of Anaesthesia

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