J Scull writes biographies and historical articles. Occasionally, he writes about common social issues impacting people in general.
Pain and Anesthesia
Prior to the advent of modern-day painkillers and anesthesia, many patients avoided surgery due to the fear of enduring excruciating pain. Nonetheless, there were times when surgery was unavoidable: legs and arms needed to be amputated; appendixes needed to be removed. How did humans deal with the pain?
The word ‘anesthesia’ was coined by Oliver Wendell Holmes in 1846, from the Greek an, meaning without, and aesthesis, meaning sensation. In other words, it means the inhibition of sensation. Anesthesia can come in many forms, but they are all used for the same purpose.
The Search for Pain-Free Surgery
There is ample historical proof pointing to the search by ancient civilizations for adequate remedies to minimize pain during surgical procedures. Unfortunately, other than alcoholic beverages and narcotics, which could bring some kind of analgesic effect, most patients went through the painful experience of a surgical operation with only their fortitude (and often coercive limitations of their movements) to help them.
Opium was used in Western Asia as far back as 4,000 BC. Henbane, a member of the nightshade family used for stomach spasms and toothache, has been used since Babylonian times—around 2,250 BC. The Assyrians and ancient Egyptians used carotid compression in order to cut off the blood supply to the brain and cause the patient to pass out. This technique was used for minor procedures, especially eye surgery and circumcision.
By the end of the 13th century, Theodoric Borgognoni of Lucca, Italy, soaked sponges with opium and a variety of nightshades, including hemlock, to sedate and induce paralysis in patients via inhalation.
The 16th-century physician, botanist and alchemist Paracelsus is credited with discovering the narcotic effect of ether while experimenting with chickens. It is believed he was the first to synthesize it by distilling sulphuric acid and ethanol. He gave it the name sweet oil of vitriol. In 1729, August Sigmund Frobenius, a German-born chemist, renamed the compound ether.
However, although medicine underwent continual improvement before the mid-1800s, surgery remained a last-resort treatment. Many patients that surgical procedures could have helped chose death rather than the pain associated with major operations.
The Theatrics of Surgery and Pain: London Drama in Medical Theaters
As medicine became more advanced and surgery became more frequently used, the pain associated with these medical procedures became an unlikely source of entertainment for the people of London. In the 1830s, it was customary for people to watch surgeries performed in a stage-like setting, where the patient and physicians were the main attraction.
This Roman-Colosseum-style exhibition of blood and gore provided the paid audience with an evening at an operating theater where they could see the amputation of a limb and the removal of an oversized ovarian cyst or a cancerous breast—all without anesthesia. Robert Liston, considered the fastest surgeon around, was one of the main attractions London denizens paid to watch.
Liston was a pioneering Scottish surgeon, noted for his skill in the era before anesthetics in which speed was necessary to minimize pain—but also to prevent the patient from dying from shock. Liston mostly operated in these types of small surgical theaters opened to the public.
In these archaic times, Liston was an anomaly— not just because of his incredible speed. Most medical professionals of his time did not understand the importance of a clean environment in order to avoid germs and bacterial infections. In fact, a bloody surgical apron was thought to be a symbol of expertise. Liston, however, was a maverick of cleanliness in the operating room: he washed his hands, changed into clean aprons, cleaned his surgical tools, and even shaved surgical sites. It is a relief that he did so, as he routinely amputated limbs and removed tumors and appendixes on fully awake patients without any sort of anesthetic.
Liston was also quite interested in how much his patients suffered. While he certainly impressed audiences and competed with himself to see how fast he could perform operations, he considered his patients thoroughly:
It is of utmost importance to attend to the state of the patient’s mind and feelings. He ought not to be kept in suspense, but encouraged and assured; and his apprehensions must be allayed. (Elements of Surgery, 1837)
Described by Richard Gordon, an author but also a surgeon and anesthetist during the mid-twentieth century, Liston was “the fastest knife in the West End. He could amputate a leg in 2 1⁄2 minutes.”
While somewhat of an exaggeration, some sources say that Liston was able to perform the amputation of a limb in 28 seconds.
Gordon described a Liston operation as follows:
“He was six foot two and operated in a bottle-green coat with Wellington boots. He sprung across the blood-stained boards upon his swooning, sweating, strapped-down patient like a duelist, calling, ‘Time me gentlemen, time me!’ to students craning with pocket watches from the iron-railinged galleries. Everyone swore that the first flash of his knife was followed so swiftly by the rasp of saw on bone that sight and sound seemed simultaneous. To free both hands, he would clasp the bloody knife between his teeth.”
Interestingly, on December 21, 1846, he performed the first surgical operation in Europe using ether as an anesthetic.
The Invention of Anesthetic Inhalation
This attitude changed when anesthesia was first used during a tooth extraction on September 30th, 1846; the procedure was performed on Eben Frost, a music teacher from Boston, and conducted by William Thomas Green Morton: it took place as a public demonstration of the efficacy of inhaled diethyl ether as an anesthetic. Today, Morton is recognized as the inventor and revealer of anesthetic inhalation, although Dr. Charles Thomas Jackson also claimed the title.
Any discussion regarding anesthesia, however, cannot be undertaken without an examination of pain. In the final analysis, the agony suffered by patients in the past as they underwent surgical procedures became the catalyst for its development. Nonetheless, pain should also be considered a gift from nature, as it is a protective mechanism or alarm system allowing humans and animals alike to avoid serious injury.
Pain allows us to quickly remove our hands from a hot stove before we suffer a severe burn; to handle sharp objects with care in order to avoid being cut. Even the anticipation of pain allows us to avoid a dog's bite or think twice before squeezing a prickly cactus. These actions are motivated by memories of pain we have experienced in the past.
On the other hand, before any form of anesthesia was developed, pain prevented medical sciences from advancing. This sort of extreme pain did not allow for exploratory surgery, for physicians to take the necessary time to properly amputate a gangrenous limb or to dig deeply into the human body to do open heart surgery.
Anesthesia has, however, allowed for an appendectomy without a screaming and squirming patient on the table and a tonsillectomy to be performed while the patient breathes freely without gagging him. Even a simple tooth extraction required a patient to be strapped to an armchair.
The first step William T. G. Morton took with the very rudimentary diethyl ether opened the human body to medical procedures never before thought possible. For centuries, overcoming the barrier of pain was a goal the medical profession deemed of the utmost importance. Ultimately, conquering it has potentially affected every human being alive today.
A Better Option to Ether
Inhaled diethyl ether had its drawbacks. Used in small quantities and as a recreational drug, which was quite common, ether was relatively safe. Used in heavier dosages to render a patient unconscious, it had some undesirable side effects. Most notably, ether is extremely flammable and capable of emitting explosive vapors. Being heavier than air, its vapors can accumulate close to ground level and travel considerable distances, eventually encountering ignition sources such as a hot plate, steam pipe, or heater. Its vapors can even be ignited by static electricity alone.
The first recorded case of either igniting during surgery was in a London hospital in 1850. During a facial operation, ether caught fire from the cauterizing tool being used to stop the bleeding. Since then, many other instances of explosions and fires during its usage occurred, fortunately, with no human lives lost. However, the impracticality of working with a chemical that required a high degree of safety precautions made the usage of ether problematic.
In addition to its flammability, ether is known for causing post-anesthetic nausea and vomiting. Sometimes the vomiting can occur before the patient awakens, risking the patient’s life. Ether can also cause mild hypertension and tachycardia, although both are temporary and do not pose a substantial risk to patients.
These limitations gave way to chloroform, which became the anesthetic of choice after it was first introduced in 1847 by Scottish obstetrician Sir James Young Simpson. Chloroform was easily inhaled and acted more quickly than ether; therefore, it was seen as a more efficient choice. Shortly after, this anesthetic made its debut not only in clinical settings but in the makeshift hospital tents that treated wounded soldiers during the wars.
The Mexican-American War (1846–1847), the American Civil War (1861–1865), the Crimean War (1853–1856) and, to some extent, World War One all made extensive use of chloroform. However, with the embrace of this powerful anesthetic by Queen Victoria during childbirth, it gained immense popularity.
However, there were some negative aspects to this organic compound, as many sudden and inexplicable deaths occurred during surgery. It was later determined, using experiments performed on dogs by Alfred Goodman Levy in 1911, that the cause of death was cardiac arrhythmia, now called sudden sniffer’s death. Further disapproval of chloroform came when many people began to use it as a recreational drug or to commit suicide. It gained an even more sinister reputation when it was found to play a part in thefts, rapes, and murders.
After the death of Hanna Greener, a 15-year-old girl who was having an infected toenail removed, it was determined that too much chloroform had been administered. This gave rise to the development of inhalers that would allow for the application of the anesthetic in a more controlled fashion. Physicians such as John Snow, Joseph Thomas Clover and Edward William Murphy created different models that allowed for a more accurate dosage.
Nitrous Oxide or Laughing Gas
First manufactured in 1772 by Joseph Priestly in England, nitrous oxide, commonly known as laughing gas, was discovered to have analgesic qualities by Humphrey Davy in 1799. It predates ether in its usage in dentistry, although it was not as effective since patients do not become unconscious. Today it is used in surgery as a carrier gas, mixed with oxygen and in combination with more powerful anesthetic gases. Its usage in dentistry continues, as the patient can be kept awake throughout the procedure. Other uses are in childbirth, in ambulances, and in acute coronary syndrome.
‘Laughing gas parties’ became a trend among the British upper class in 1799: revelers would inhale the gas as a way of reaching a state of euphoria and experiencing mild hallucinations. Its wide availability during the nineteenth century allowed for recreational usage to mushroom on a global scale. Two hundred years later it is still used by young people in nightclubs, festivals and parties. It is estimated more than half a million people use it worldwide.
Those who use nitrous oxide recreationally must be warned that prolonged exposure to this gas will steal oxygen from brain cells, killing them in a process called apoptosis. It can also damage the protective covering of neurons, which may lead to long-term learning impairment. Other serious side effects are broken bones and head trauma from falls while intoxicated. These could be attributed to its dissociative anesthetic quality, which causes a feeling of mind-body detachment or a sense of floating, distorted perception and mild visual hallucinations.
Named by its discoverer, Freidrich W. A. Sertürner, after Morpheus—the Greek god of dreams—due to its tendency to cause sleep, morphine became the strongest opiate analgesic the medical sciences have to offer. Unfortunately, the potential for addiction, both physically and psychologically, is extremely high.
Sertüner, a 21-year-old pharmacist assistant in Germany, published the results of the experiments he conducted on opium in 1806, in which he isolated an alkaloid compound from the resin secreted by the opium poppy. His seminal work in isolating the active ingredient associated with a medicinal plant gave birth to the branch of science we know today as alkaloid chemistry.
Morphine’s popularity grew, and by the mid-1920s, it was widely available in Western Europe. Shortly after, it made its way into the United States. Originally administered in pill form or suppositories, its use flourished after the invention of the hypodermic needle in 1844.
Although morphine was touted as a cure for alcohol abuse and opium addiction, by the 1870s, the medical community became aware of its destructive addictive properties. It was for this reason that in 1874, Charles Romley Alder Wright of Essex, England created heroin from morphine, hoping for a non-addictive alternative. Unfortunately, heroin was a much stronger opioid—and even more addictive.
Today, the opioid crisis continues to worsen, in great part due to new types of drugs that find their way onto the streets and are consumed for purposes other than prescribed.
Cocaine as an Anesthetic
None of the anesthetics available to the people of the civilized world of the 19th century offered a viable way to block pain on a localized basis. A patient could either be rendered unconscious with ether or chloroform or receive a strong analgesic in the form of nitrous oxide. There clearly existed a need for a drug that could be applied directly to a tooth needing extraction or a hand with frostbitten fingers requiring amputation.
Interestingly, some five hundred years earlier, Inca shamans were chewing coca leaves mixed with vegetable ash and placing the spittle into the wounds of their patients. Ancient Incas chewed coca leaves during religious ceremonies as well as to get their hearts racing and speed up their breathing in order to counter the effects of living in the thin mountain air in the Andes. In fact, coca leaves continue to be chewed by many indigenous communities of South America—a practice that goes back four thousand years before the arrival of the Spanish conquistadors in 1492.
The first time coca leaves made their way to Europe was in 1859, when Karl Ritter von Scherzer, an Austrian explorer, diplomat and natural scientist, brought back a large quantity of leaves from an expedition to Peru. The leaves were used by chemist and Ph.D. candidate Albert Niemann shortly after, subsequently isolating cocaine. In his now-famous Ph.D. dissertation, titled On a New Organic Base in the Coca Leaves, which now sits in the British Library, Niemann wrote of the alkaloid:
colourless transparent prisms…Its solutions have an alkaline reaction, a bitter taste, promote the flow of saliva and leave a peculiar numbness, followed by a sense of cold when applied to the tongue.
Niemann named the alkaloid cocaine from the Quechuan language cuca. He added the suffix -ine, creating the word cocaine.
With the development of this potent new drug, Western medicine and other industries created various derivatives and iterations that would exploit its analgesic qualities. From Sigmund Freud’s personal use and promotion of cocaine as a tonic to cure depression and sexual impotence to the inclusion of coca leaves in John Pemberton’s formula for Coca-Cola, this strong stimulant was ubiquitous in the West. Elixirs and potions of all sorts containing cocaine (and, in some cases, opium) claimed miraculous effects.
Cocaine also became popular as a local anesthetic. The advantages of cocaine were obvious: it became possible to carry out certain operations without having to render the patient unconscious, and, at the same time, avoiding nausea and vomiting associated with the anesthetic gases available at the time, as well as the risk of cardiac arrhythmia and sudden death while under the influence of ether or chloroform.
Procaine and Novocaine
However, the disadvantages of cocaine were plentiful. Toxicity, short-lasting effect, and the risk of addiction were drawbacks in its usage. In 1905, an alternative by the name of procaine was created by German chemist Alfred Einhorn, who gave it the trade name Novocaine by combining the Latin nov- meaning new, and the suffix -caine, the common ending for alkaloids used as anesthetics.
While originally created by Einhorn as an anesthetic for amputations, most surgeons preferred general anesthesia for these types of major procedures. Subsequently, procaine became the drug of choice for dentists until the arrival of more effective and hypoallergenic alternatives such as lidocaine, mepivacaine and prilocaine.
While cocaine ushered a new era of possibilities in the quest for an effective local anesthetic, it had a darker side, of which we are aware today. The number of people that have become addicted and died from cocaine use are innumerable. Add to that the deaths and destruction caused by the many drug wars the world has experienced in the last fifty years, and it is appropriate to say cocaine has been a true double-edged sword since its development.
Modern-day anesthesia has evolved to the point in which it is among the safest of all major medical procedures. Today, in the United States the death rate associated with its usage is estimated to be 8.2 per million hospital discharges.
The improvements made to anesthesia in the last hundred and seventy years have been truly wondrous. Ether and chloroform have been replaced by volatile liquids administered via technologically advanced vaporizers and by intravenous drugs. The type of anesthesia administered today depends on the type of surgery and the patient’s medical condition. In addition, sedatives are used to make the patient sleepy, plus analgesics are administered to ease the pain.
The different types of anesthesia used today include
- Local anesthetics — Used to temporarily stop the sense of pain in a specific part of the body: this allows the patient to remain conscious during the entire medical procedure. Normally an anesthetic is delivered via an injection to the site of the operation. Local anesthesia is not used when the target area is too large, or the operation needs to be deep.
- Regional Anesthesia — Given to a portion of the body that will undergo surgery. A local anesthetic is given into the nerves that provide sensation to an area of the body. Regional anesthetics comprise of:
- Spinal anesthetic — Used for surgeries on lower abdominal, pelvic, rectal or lower extremity areas. A single dose of an anesthetic medicine is injected into the area that surrounds the spinal cord in the lower back, below the end of the spinal cord. This causes numbness in the lower part of the body. This type of anesthetic is most used in orthopedic procedures.
- Epidural anesthetic — Similarly to a spinal anesthetic it is used for surgery of the lower limbs but also in labor and childbirth. Epidurals involve continually infusing an anesthetic drug through a catheter which is placed in the space that surrounds the spinal cord in the lower back. Epidurals can also be used for chest or abdominal surgery by injecting at a higher location in the back.
- General anesthesia — It is used to induce unconsciousness during surgery. Medicines are either inhaled through a mask or tube or administered intravenously. A breathing tube may be inserted into the windpipe of the patient in order to maintain appropriate breathing.
Side effects with all types of anesthesia are relatively minor. Other than grogginess, upon waking it is common for patients to experience some nausea, a sore throat due to the breathing tube used in general anesthesia, and some minor soreness in the injection site. Quite an improvement from the many deaths caused by ether and chloroform!