Anaesthesia and the Practice of Medicine: Historical Perspectives

Keith Sykes, John P Bunker

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000515411
• Edition: 1
• Topic: Medicine
• Subtopic: Anesthesiology & Pain Management

Written by two anaesthetists, one British and one American, this unique book focuses on the transatlantic story of anaesthesia. The authors have both worked at the two hospitals where the first general anaesthetics for surgery were given in 1846, Massachusetts General Hospital in Boston, Massachusetts and University College Hospital, London. Each with more than fifty years' experience of working in anaesthesia, they combine their knowledge and expertise to offer a fresh outlook on the development of anaesthesia through the ages. This highly informative and intriguing text details the origins of anaesthesia, outlines the different techniques of anaesthesia and traces its progress with illuminating and enlightening commentaries. This is a fascinating book which considers the role key figures have played in developing anaesthesia including, Queen Victoria, William Morris, La Condamine, Bjorn Ibsen and Henry Beecher. Broken down into four sections, which are divided into easy-to-read chapters and filled withtop qualityphotographs, this book makes compelling reading. It is recommended toall those interested inthe history and development of medicine through the ages, and is of particular interest to anaesthetists. More than just the science of anaesthesia, this is the story about the people and personalities who have made anaesthesia what it is today.

Part 1

Anaesthesia: The first 100 years

In 1900, Sir Frederick Treves, the surgeon who later removed the appendix of King Edward VII two days before his planned Coronation, addressed the Annual Meeting of the British Medical Association in Ipswich and made these comments about the introduction of anaesthesia:

‘The changes that the discovery has wrought in the personality of the surgeon, in his bearing, in his methods, and in his capabilities are as wondrous as the discovery itself. The operator is undisturbed by the harass of alarms and the misery of giving pain. He can afford to be leisurely without fear of being regarded as timorous. To the older surgeon every tick of the clock upon the wall was a mandate for haste, every groan of the patient a call for hurried action, and he alone did best who had the quickest fingers and the hardest heart. Time now counts for little, and success is no longer to be measured by the beatings of a watch. The mask of the anaesthetist has blotted out the anguished face of the patient, and the horror of a vivisection on a fellow-man has passed away. Thus it happens that the surgeon has gained dignity, calmness, confidence, and, not least of all, the gentle hand.

Anaesthetics have, moreover, greatly extended the domain of surgery by rendering possible operations which before could only have been dreamt about, and by allowing elaborate measures to be carried out step by step.

The introduction of anaesthetics has not only developed surgery, but it has engendered surgeons. It has opened up the craft to many, for in the pre-anaesthetic days the qualities required for success in operating were qualities to be expected only in the few.’

(Treves F. Address in surgery: the surgeon in the nineteenth century. British Medical Journal 1900;ii:284–9)

1	In the beginning

Although the soporific effects of ether had been described in 1540, surgeons continued to operate on the conscious patient for a further 300 years. When anaesthesia finally arrived, it did so as an offshoot of the recreational drug culture of the time, and with the leading players hotly contesting their role in its discovery.

Surgery before anaesthesia

On the 30 September 1811, some 35 years before the demonstration that anaesthesia could abolish the pain of a surgical operation, Napoleon’s Surgeon-in-Chief, Dominique-Jean Larrey, removed the cancerous breast of the novelist Fanny Burney. She later wrote a long and harrowing account of the operation. After describing how she had lain on a mattress and had refused to be held down by the seven men and the nurse attending the procedure, she wrote:

‘Yet, when the dreadful steel was plunged into my breast – cutting through veins–arteries–flesh–nerves – I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision – & I almost marvel that it rings not in my ears still! so excruciating was the agony. When the wound was made & the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp and forked poinards, that were tearing the edges of the wound, – but when again I felt the instrument – describing a curve – cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose & tire the hand of the operator, who was forced to change from the right hand to the left – then, indeed, I thought I must have expired, I attempted no more to open my eyes, they felt as if hermetically shut, & so firmly closed, that the Eyelids seemed indented into the Cheeks’.¹

The excruciating pain felt by Fanny Burney was experienced by all the patients who were forced to have an operation at that time. And yet, 11 years previously, the young scientist Humphry Davy had described the pain-relieving properties of nitrous oxide (see below). Why, then, was the gas not used to relieve the pain of surgery until 1844? Was it the fear of the unconscious state, the fear of the outcome, or a reluctance to interfere with nature? Perhaps, it was all three. But we must remember that in those days there were no cures for disease, early death was common, working conditions were harsh, and most aspects of life were generally uncomfortable, so pain was accepted as a part of life. There were no pain-relieving drugs other than laudanum (an alcoholic extract of opium), and almost everyone suffered toothache or some other type of pain at some time in their life. There was also biblical support for the belief that pain was a necessary part of the human condition.

It is true that there had been some attempts to relieve the pain associated with surgery. The 1st century AD physician Dioscorides administered the root of the mandragora plant boiled in wine in an attempt to diminish the pain of surgery.² Later, some surgeons attempted to abolish pain by compressing the nerve or blood vessels supplying a limb, while military surgeons noted that extreme cold diminished the pain of an amputation on the battlefield. Although there are a number of reports of the administration of pain-relieving drugs such as hemp, hemlock or laudanum, the effects must have been variable because of the inability to standardize the dose: a drug powerful enough to produce unconsciousness could just as easily produce death. Other patients were given alcohol, but this was more commonly used to relieve pain after the operation, particularly in military surgery. Undoubtedly, the prospect of pain was a strong deterrent to the practice of surgery, so very few operations were performed, but, when the operation was potentially life-saving, the patient had to submit to the knife and hope that the surgeon would operate as quickly as possible.

Pneumatic medicine

In 1772, Joseph Priestley, a dissenting clergyman, political theorist and experimental scientist, discovered the gas nitrous oxide (N₂O), but at that time no one conceived that it would be used to produce anaesthesia. Later, he and Carl Wilhelm Scheele, a Swedish chemist, identified another gas that the French chemist Antoine-Laurent Lavoisier subsequently named oxygen (O₂). It was soon realized that oxygen was taken up by the lungs and that carbon dioxide (CO₂) was given out, so it is not surprising that Priestley should have urged physicians to explore the possibility of inhaling other gases as a treatment for respiratory diseases such as tuberculosis, which was rampant at that time. The idea was taken up by Thomas Beddoes, an Oxford physician and chemist who, in 1794, set up the Medical Pneumatic Institution in Bristol to further these aims.^3,4 Beddoes was acquainted with members of the Birmingham Lunar Society (who held meetings at the time of the full moon to allow members to see their way home). Josiah Wedgwood, one of its prominent members, made a large donation in support of the Institution, while another member, James Watt, inventor of the steam engine, designed and constructed some of the apparatus used to manufacture and store the gases.

In 1798, Beddoes met the 19-year-old Humphry Davy, who had been carrying out experiments with nitrous oxide in the small town of Penzance, Cornwall. He was so impressed by Davy’s accomplishments that he appointed him Medical Superintendent of the Pneumatic Institution. While examining the properties of nitrous oxide in Bristol, Davy found that inhalation of a few breaths of the gas relieved the pain caused by an acute infection in his gums. He also noted that the inhalation of nitrous oxide produced strange but pleasurable sensations, excitement, and intoxicating behaviour, often accompanied by irrational peals of laughter. Two of Beddoes’ acquaintances, the poets Robert Southey and Samuel Taylor Coleridge, were among those who enjoyed the effects of Davy’s ‘laughing gas’. In his Researches, Chemical and Philosophical: Chiefly Concerning Nitrous Oxide, published in 1800, Davy wrote:

‘As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place’.⁵

Davy had been apprenticed to a surgeon in Penzance, so it is surprising that neither he nor those of his colleagues who also inhaled nitrous oxide followed up this suggestion. This may seem strange to us today, but Davy was primarily interested in chemical research. It must also be remembered that attitudes to pain were very different in the 18th century; patients expected pain and tolerated it because there was no known way of abolishing it. But, as the anaesthetist W Stanley Sykes commented in 1960:

‘What is surprising is that his suggestion was ignored by the very people whom it should have interested most: that surgeons should have continued for nearly fifty years longer to operate on screaming, struggling patients in full consciousness. Surely a lasting testimonial to their thickheadedness’.⁶

The first attempt to produce pain-free surgery: Henry Hill Hickman

In fact, it was carbon dioxide, and not nitrous oxide, that was the first gas to be used in an attempt to produce surgical anaesthesia. The investigator was Henry Hill Hickman, a general practitioner in Ludlow in Shropshire. He was born in 1800, the year that Davy first suggested that nitrous oxide might be used for the relief of pain during surgery, and when he started to practise medicine he became concerned about the pain felt by patients when he had to perform surgical procedures. Hickman knew that carbon dioxide was present in expired gas and that it was produced during the fermentation of beer. In February 1824, he wrote a letter to TA Knight, a Fellow of the Royal Society who lived nearby, and described seven experiments in which he claimed that he had carried out painless surgical procedures on animals while they inhaled the gas. In August of that year, he published a pamphlet in which he set out in more detail his proposal that the inhalation of carbon dioxide should be used to relieve the pain of surgical operations. In the pamphlet, he stated:

‘I feel perfectly satisfied that any surgical operation might be performed with quite as much safety upon a subject in an insensible state as in a sensible state, and that a patient might be kept with perfect safety long enough in an insensible state, for the performance of the most tedious operation. . . . I believe that there are few, if any Surgeons, who could not operate more skilfully when they were conscious they were not inflicting pain’.⁷

Unfortunately, Knight seems to have been more interested in the growth of trees than in Hickman’s proposals, and it is not clear whether Hickman’s ideas were ever communicated to other members of the scientific community. In 1828, Hickman decided to try and further his aims by travelling to Paris, then the recognized centre of scientific research. In desperation, Hickman wrote to Charles X of France, and, in 1829, a committee was set up to consider his claims. Only Napoleon’s surgeon, Baron Larrey, who had operated on Fanny Burney, showed any interest, and in the following year Hickman died at the age of 30. It is now known that an excess of carbon dioxide...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Biographical notes
• Preface
• Acknowledgements
• Introduction
• Part 1: Anaesthesia: the first 100 years
• Part 2: Professionalism in anaesthesia: the reluctant universities and the Second World War
• Part 3: New horizons: the scientific background of anaesthesia and the emergence of intensive care
• Part 4: The relief of pain in childbirth and the care of the newborn
• Part 5: Anaesthesia yesterday, today and tomorrow
• Index