Anesthesia and Its Amazing History
The word "anesthesia", was coined by Oliver Wendell Holmes in 1846 from the Greek “an” meaning without and “aesthesis” meaning “sensation.” In other words, the inhibition of sensation.
Surgery and Pain in Earlier Cultures
“Pain is inevitable, suffering is optional.”—Buddhist proverb
"Now a surgeon should be youthful or at any rate nearer youth than age; with a strong and steady hand which never trembles, and ready use the left hand as well as the right; with vision sharp and clear, spirit undaunted; filled with pity, so that he wishes to cure his patient, yet is not moved by his cries, to go too fast, or cut less than necessary; but he does everything just as if the cries of pain cause him no emotion." Roman physician Celsus - 100 AD.
"He's a clever operator, is Walplole, though he's only one of your chloroform surgeons." "In my early days, you made your man drunk; and the porters and students held him down; and you had to set your teeth and finish the job fast. Nowadays you work at your ease; and the pain doesn't come until afterwards, when you've taken your cheque and rolled up your bag and left the house. I tell you, Colly, chloroform has done a lot of mischief. It's enabled every fool to be a surgeon." George Bernard Shaw, The Doctors' Dilemma
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 analgesic effect, most recipients of surgery endured pain through fortitude and strong forcible restraints.
Opium was used in Western Asia as far back as 4,000 BC. Henbane, a member of the nightshade family of plants used for digestive track spasms, toothache and other ailments, 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. These were used as inhalants that would sedate and induce paralysis in his patients.
Paracelsus, in the early 1500s, a famous physician, botanist and alchemist is credited with discovering the narcotic effect of ether while experimenting with chickens. It is believed he was the first to synthesize it and of giving it the name “sweet oil of vitriol.” He did this by distilling sulphuric acid and ethanol. In 1729, August Sigmund Frogenius, a German born chemist renamed the compound “ether.”
However, although medicine was undergoing continual improvement prior to the mid-1800s, surgery remained a treatment of last resort. Many patients that could have been helped by surgical procedures chose death rather than undergo the pain that was associated with major operations.
This attitude changed when anesthesia was first used during a tooth extraction on September 30th, 1846, performed on Eben Frost, a music teacher from Boston. The procedure conducted by William Thomas Green Morton 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 distinction.
Any discussion regarding anesthesia, however, cannot be undertaken without an examination of pain. In the final analysis, it was the agony suffered by patients in the past as they underwent any surgical procedures that became the catalyst for its development. Non-the-less, pain should 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; handle sharp objects with care in order to avoid being cut. Even the anticipation of pain allows us to avoid the bite of a dog or from firmly holding on to a prickly cactus. These actions are motivated by memories of pain we have experienced in the past.
On the other hand, prior to the development of any form of anesthesia, pain prevented medical sciences from advancing. It did not allow for exploratory surgery; physicians from taking the necessary time to properly amputate a gangrenous limb or to dig deeply into the human body in order to do open heart surgery. Anesthesia, has however, allowed for an appendectomy to take place without a screaming and squirming patient; a tonsillectomy to be performed while the patient breathes freely without gagging or even the dreaded visit to a dentist in which a tooth extraction required for a patient to be strapped down to an armchair.
The first step that William T. G. Morton took with the usage of the very rudimentary diethyl ether, opened the human body to medical procedures never thought possible. For centuries the conquering of pain represented a barrier which the medical profession deemed of the utmost importance to overcome. Ultimately, conquering it has potentially affected every human being alive today.
The Theatrics of Surgery and Pain - London Drama in Medical Theaters
As medicine became more advanced and surgery became more frequently sought, the pain that was associated with these medical procedures became a source for drama and 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 entertainment provided the paid audience with an evening at an operating theater where they could see the amputation of a limb, the removal of an over-sized ovarian cyst or a cancerous breast; all without anesthesia. Robert Liston considered to be the fastest surgeon around was one of the main attractions London denizens paid to watch.
He was a pioneering Scottish surgeon noted for his skill in the era prior to 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 did not wash his hands before operating. Like all medical professionals of the time, he did not understand the importance of a clean environment in order to avoid germs and bacterial infections. He would even hold operating tools between his teeth when he needed to free his hands. He would amputate limbs, remove tumors and appendixes on fully awake patients and without any sort of anesthetic.
The reality was that Liston was not very interested in how much his patients suffered. He seemed to have been more interested in impressing his audience and testing himself to see how much faster he could perform operations. Of course, he needed to operate fast and finish an operation before his patients would bleed out or as stated before, die from shock.
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 21⁄2 minutes." While somewhat of an exaggeration, the truth was that Liston was able to perform the amputation of a limb in 28 seconds. Still, an incredible accomplishment.
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 operation in Europe using ether as an anesthetic.
A Better Option to Ether
Inhaled diethyl ether had its drawbacks. Used in small quantities and as a recreational drug, which was quite common since its creation by Spanish chemist Raymundus Lullius in 1275, ether was relatively safe. Used in heavier dosages as a way of rendering a patient unconscious had some undesirable side effects. Most notably, it is extremely flammable and capable of emitting explosive vapors. Being heavier than air its vapors can collect close to ground level and travel considerable distances, eventually encountering sources of ignition such as a hot plate, steam pipe or heater. Its vapors can even be ignited with static electricity.
The first recorded case of either igniting during surgery was in a London hospital in 1850. During a facial operation ether ignited from the cauterizing tool being used to stop the bleeding the patient was experiencing. Since then many other instances of explosions and fires during its usage occurred, fortunately with no human life being lost. However, the impracticality of working with a chemical that required a high degree of safety precautions, made the usage of ether less desirable.
In addition to its flammability ether is known for causing post-anesthetic nausea and vomiting. Sometimes the vomiting can occur prior to the patient awakening risking the patient’s life. Ether can also cause mild hypertension and tachycardia although both conditions are ephemeral and do not pose 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, therefore seen as more efficient than ether. Shortly after this anesthetic made its debut in mass scale not only in clinical settings but in the makeshift hospital tents that treated wounded soldiers during war.
The Mexican-American War (1846 - 1847), the American Civil War (1861 – 1865), Crimean War (1853 – 1856) and to some extend World War One all made extensive use of chloroform. However, it was with the embrace of this powerful anesthetic by Queen Victoria during childbirth that it gained immense popularity.
There were, however, some negative aspects to this organic compound as many sudden and inexplicable deaths during surgery occurred. Later it was determined in experiments performed on dogs by Alfred Goodman Levy in 1911, the cause of death to be due to cardiac arrhythmia, in what is now called “sudden sniffer’s death.” Further disfavor in chloroform came when many people began to use it as a recreational drug or to commit suicide. Perhaps even a more sinister usage came when it was found to play a part in thefts, rapes and murder.
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 more precise 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 for childbirth, trauma, in ambulances and acute coronary syndrome.
Recreational Use of Nitrous Oxide
“Laughing gas parties” became a trend among the British upper class in 1799, during which 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 use 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 there are more than half a million users 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 the process (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 qualities which causes a feeling of mind-body detachment or 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 (narcotic) 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 also 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 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 in a localized basis. A patient could either be rendered unconscious with ether or chloroform, else receive a strong analgesic in the form of nitrous oxide. There clearly existed a need for a drug that could be applied directly to teeth needing extraction or to a hand with frostbitten fingers requiring amputation.
Interestingly, some five hundred year 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 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 from an expedition he made to Peru. The leaves were used by chemist and PhD candidate Albert Niemann shortly after, subsequently isolating cocaine. In his now famous PhD 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 as it became possible to carry out certain operations without having to render the patient unconscious. At the same time avoiding the nausea and vomiting associated with the anesthetic gases available at the time; as well as the risk of cardiac arrythmia and sudden death while under the influence of ether or chloroform.
Procaine - Novocaine
However, the disadvantages of cocaine were plentiful. Toxicity, short lasting effect and the risk of addiction became a drawback 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” which means new and “caine”, the common ending for alkaloids used as anesthetics.
While originally created by Einhorn as an anesthetic in the use of amputations, most surgeons preferred general anesthesia for these types of major procedures. Subsequently, procaine became preferred by 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 depend on the type of surgery and the patient’s medical condition. In addition, sedatives are used to make the patient sleepy plus analgesics to ease the pain.
The different types of anesthesia used today include:
An anesthetic agent is used to temporarily stop the sense of pain in a specific part of the body. The patient remains 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.
Given to a portion of the body that will undergo surgery. 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.
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.
- The Procain Molecule - Novocaine
- History of Anesthesia
- History of Anesthesia - Wood Library
- Opium to the OR: A Visual History to Anesthesia
- Journal of Anesthesia and Clinical Research
- The Painful Story Behind Modern Anesthesia
- Local Anesthetic
- Cocaine: What is the Crack. The Brief History of Cocaine as a Local Anesthetic