History of anaesthesia

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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 Foundation 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 2:21 NIrV

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THE FOUNDATION OF ANAESTHESIA

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Drug methods Alcohol

Opium (poppy)

Hyoscine (Mandrake)

Cannabis (Hemp)

Cocaine (New World)

Non-drug methods Cold

Concussion

Carotid compression

Nerve compression

Hypnosis

Blood letting

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

World Anesthesia Day 16th Oct

WHAT CHANGED?

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INDUSTRIAL AND SCIENTIFIC REVOLUTION

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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

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

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

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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

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 …”

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GAS THERAPY IN ILLNESS

Nitrous oxide

Ether

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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

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ETHER 1818: Michael Faraday

(1791-1867) described “narcotic effects” of ether


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……”


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

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SO WHY NO ANAESTHESIA UNTIL 1846?

Or wasn’t 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 HICKMANW

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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


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… “

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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


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: 843-845

1930: plaque erected by Section of Anaesthetists of RSM


1846-1900

The Establishment of Anaesthesia

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1846-1900

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General Anaesthesia 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”


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


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 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”

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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


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 Liston’s own experiences


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


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……..”

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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”

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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


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


“….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 World’s 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


JOHN SNOW John Snow Society

Pump handle lecture Blessed chloroform lecture John Snow Pub

March 2003 - 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

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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

1950’s PVC tubes introduced

1980’s PVC finally replaces Red Rubber tubes. Rae (Ring, Adair & Elwyn) tubes & LMA’s 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: 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

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MONITORING 1960’s: ECG monitoring and capnography

1960’s: CVP and arterial monitoring

1970: “Swan-Ganz” catheter

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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

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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

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

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LOCAL ANAESTHESIAW

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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

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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

1980’s: 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


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

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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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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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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-basedpostgraduate science-basedother background

already raising a number of other training & service issues

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

practice it change

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History of anaesthesia

Health & Medicine

Transcript of History of anaesthesia