A Brief History of Anaesthesia

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A Brief History of Anaesthesia

• Andrew Ronald
• Consultant Cardiac Anaesthetist
• Aberdeen Royal Infirmary

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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

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History of Anaesthesia

• Pre-1846 - the foundations of anaesthesia
• 1846 - 1900 - establishment of anaesthesia
• 20th Century - consolidation and growth
• 21st Century - the future

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Pre-1846

• The Foundations of Anaesthesia

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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 221 NIrV

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The Foundations of Anaesthesia

• Drug methods
• Alcohol
• Opium (poppy)
• Hyoscine (Mandrake)
• Cannabis (Hemp)
• Cocaine (New World)

• Non-drug methods
• Cold
• Concussion
• Carotid compression
• Nerve compression
• Hypnosis
• Blood letting

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The Foundations of Anaesthesia

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

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• 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 Fathers 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

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What changed?
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Industrial and Scientific Revolution

• 1540 synthesis of ether
• 1628 circulation of blood
• 1744 ether inhalation suggested to treat pain
• 1770s 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

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Industrial and Scientific Revolution

• Late 1700s
• 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

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Gas Therapy in Illness

• Pneumatic Institute, Dowry Square, Clifton,
  Bristol
• founded by Thomas Beddoes (1760-1808) in 1794
  with equipment designed by James Watt (1736-1819)
• attempted to use used gas therapy (incl. oxygen,
  nitrous oxide ether) to treat diseases incl.
  asthma, dropsy, consumption, venereal disease

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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 21 1799

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Pneumatic Institute

• Humphrey Davy (1778-1829)
• became Superintendant in 1798
• continued Priestleys and Beddoes Work
• Nitrous oxide Ether

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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
  

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Gas Therapy in Illness

• Nitrous oxide
• Ether

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Nitrous oxide

• 1800 Davys 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

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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 1790s research at Pneumatic Institute

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Ether

• 1818 Michael Faraday (1791-1867) described
  narcotic effects of ether

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Ether

• 1821 Benjamin Brodie (1783-1862) demonstrated to
  Royal College of Surgeons that ether inhalation
  could induce insensibility in a guinea pig -
  .ether acted like a narcotic poison

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Ether

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

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• 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.

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So why no anaesthesia until 1846?

• Why did Davy not pursue his work?
• no real concept of anaesthesia in late 1700s /
  early 1800s ? 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

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So why no anaesthesia until 1846?

• Or wasnt there?

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Henry Hill Hickman (1800-1830)
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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

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Henry Hill Hickman

• 1821-1824 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

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Henry Hill Hickman
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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 subjectI 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 ..

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Henry Hill Hickman

• 1824 moved to Shifnal
• 1824 A Letter on Suspended Animation (W Smith,
  Ironbridge, 1824) to TA Knight of Downton Castle

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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

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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

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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

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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

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Henry Hill Hickman

• 1830 died buried in Bromyard churchyard

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Henry Hill Hickman

• 1847 letters in Lancet by Thomas Dudley of
  Kingswinford identifying Hickmans work with
  reports of the Letheon
• 1912 first modern reference to Hickman Thompson
  CJS. Brit Med Jour 1912 i 843-845
• 1930 plaque erected by Section of Anaesthetists
  of RSM

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1846-1900

• The Establishment of Anaesthesia

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1846-1900

• General Anaesthesia
• Ether
• spread to Europe
• Nitrous oxide
• Chloroform
• James Young Simpson
• John Snow

• Local Anaesthesia
• anaesthesia without sleep
• New techniques
• early landmarks

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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

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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

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Ether - the news spreads

• 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 Bootts 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

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Ether - the Dumfries connection

• William Fraser
• Cunard Ships 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

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Ether - the news spreads

• 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 Listons own experiences

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Ether - the news spreads

• 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

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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

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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

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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

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James Young Simpson

• many objections to analgesia for childbirth
• religious and moral
• Genesis 316 - ..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..

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Chloroform

• 1847 John Snows regulating inhaler
• 1847/48 Chloroform eclipses ether
• 1848 Hannah Greener - first anaesthetic death
• 1858 John Snow On Chloroform and other
  anaesthetics

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John Snow (1813-1858)

• Born in York in 1813
• became interested in anaesthesia via work in
  toxicology
• apprenticed in Newcastle, then worked in London
  1836-1858 until his death
• acknowledged as first full-time anaesthetist
  developing ways to improve methods of ether and
  chloroform administration

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John Snow

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

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• .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

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John Snow

• Worlds first epidemiologist
• On the mode of communication of cholera self-
  published in 1849
• July 1854 - cholera outbreak in Broad street area
  of London
• September 1854 - Snow removed handle of Broad
  Street pump
• outbreak declared over 7 days later

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John Snow

• John Snow Society
• Pump handle lecture
• Blessed chloroform lecture
• John Snow Pub
• March 2003 - John Snow voted greatest doctor of
  all time

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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

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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

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The 20th Century

• Consolidation and Growth

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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

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

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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
• 1950s PVC tubes introduced
• 1980s PVC finally replaces Red Rubber tubes. Rae
  (Ring, Adair Elwyn) tubes LMAs introduced

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Anaesthetic Equipment

• 1908 Rotameters
• 1917 Boyles machine (Plenum flow)
• 1914-18 Flagg can

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Anaesthetic Equipment

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

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Anaesthetic Equipment

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

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Monitoring

• 1901 BPs 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

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Monitoring

• 1960s ECG monitoring and capnography
• 1960s CVP and arterial monitoring
• 1970 Swan-Ganz catheter
• 1980s/90s increasing use of microprocessor-cont
  rolled monitoring equipment

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Monitoring

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

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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

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Drug advances

• 1956 Halothane
• 1964 Introduction of Entonox
• 1980s New generation ethers - Enflurane
  Isoflurane
• Opioids - Fentanyl, Alfentanil, (Sufentanil)
• New methods of analgesia
• Relaxants - Atracurium / Vecuronium
• Propofol
• 1990s TCI anaesthesia
• Opioids - Remifentanil
• Volatile agents - Sevoflurane Desflurane
• Relaxants - CisAtracurium / Mivacurium /
  Rocuronium

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Local Anaesthesia

• 1904 Stovaine
• 1929 Cinchocaine
• 1931 Amethocaine
• 1943 Lignocaine

• 1952 Chlorprocaine
• 1959 Prilocaine
• 1963 Bupivacaine
• 1993 Ropivacaine
• late 1990s Levobupivacaine

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Local Anaesthesia

• 1907 use of heavy spinal solutions - Barker
• 1908 IVRA - Bier
• 1909 Sacral block - Stoekel
• 1921 barbotage and positioning in spinal
  anaesthesia - Labat

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Local Anaesthesia

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

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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

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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
• 1990s development of Acute Pain Teams and
  multimodal analgesic strategies incl PCA /
  Epidural / PC Epidural / combination Rx

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Pain Management

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

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Organization of the Speciality

• 1908 Section of Anaesthetists of RSM
• 1914 Scottish Society of Anaesthetists
• 1932 Association of Anaesthetists of GBI
• 1933 Worlds first Chair of Anaesthesia - Ralph
  Waters, University of Wisconsin
• 1935 Diploma of Anaesthetics
• 1937 1st European chair of Anaesthesia (Robert
  Macintosh, Nuffield Chair, Oxford)

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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

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21st Century

• The future

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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

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Anaesthesia in the 21st Century

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

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Anaesthesia in the 21st Century

• 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

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Anaesthesia in the 21st Century

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

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