Discovery Of Anaesthesia

Suffering is Relieved, and Surgery as we Know it Begins

“The morning of the operation arrived. There were no anaesthetics in those days, and I took no preparative stimulant or anodyne of any kind, unless two cups of tea, which with a fragment of toast formed my breakfast, be considered such.

“The operation was a more tedious one than some which involve much greater mutilation. It necessitated cutting through inflamed and morbidly sensitive parts, and could not be despatched by a few swift strokes of the knife. I do not suppose that it was more painful than the majority of severe surgical operations, but I am not, I believe, mistaken in thinking that it was not less painful, and this is all that I wish to contend for.

“Of the agony it occasioned, I will say nothing. Suffering so great as I underwent cannot be expressed in words, and thus, fortunately, cannot be recalled. The particular pangs are now forgotten, but the black whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close upon despair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so. Only the wish to save others some of my sufferings makes me deliberately recall and confess the anguish and humiliation of such a personal experience; nor can I find language more sober and familiar than that I have used, to express feelings which, happily for us all, are too rare as matters of general experience to have been shaped into household words.

“From all this anguish I should of course have been saved had I been rendered insensible by ether or chloroform, or otherwise, before submitting to the operation. On that point, however, I do not dwell, because it needs no proof and the testimony of the thousands who have been spared such experiences by the employ­ment of chloroform is at hand to satisfy all who are not determined not to be satisfied.

“During the operation, in spite of the pain it occasioned, my senses were preternaturally acute, as I have been told they generally are in patients in such circumstances. I watched all that the surgeon did, with a fascinated intensity. I still recall with unwelcome vividness the spreading out of the instruments; the twisting of the tourniquet; the first incision; the fingering of the sawed bone; the sponge pressed on the flap; the tying of the blood vessels; the stitching of the skin; and the bloody dismembered limb lying on the floor.”

The letter, and this is but a small fraction, was addressed to James Young Simpson, discoverer of the anaesthetic power of chloroform. Apart from the poignant detail, every bit of which Simpson knew to be true, and its plea for a more widespread use of the drug, it contained a number of deliberately misleading clues to the writer’s identity (“I belong to that large class, including most women, to whom cutting, is a source of suffering”), and was signed, “An Old Patient”. Simpson had no difficulty in recog­nizing the hand. George Wilson was a man who might easily, such was his brilliance, have become either a great physician or a great chemist, but while still a young man he had suffered a leg injury which called for amputation. He survived the operation, but in fact never regained his health. When he was offered the coveted Chair of Chemistry at Edinburgh University, he knew he must refuse. He did so and died, shortly after writing this letter. His name as the writer of one of the world’s most famous “anonymous letters” lives on, and the letter is required reading for most students of anaesthesia.

Anaesthetics, for which Wilson pleaded so eloquently, have been in use for only a hundred years. From ancient times man had experimented with pain-killers, but none was remotely satisfactory for surgery; every sort of operation, whether for removal of tooth, gall-stone or limb, had to be performed with the patient fully sensible to pain. The search for a potion to deaden pain continued over the centuries; Homer mentions “nepenthe”, which was probably hemp; the Romans took “mandragora” in their wine to dull the pain of wounds; and in later years people took opium from the poppy. Here is Shakespeare’s Othello:

”Not poppy, nor mandragora,

Nor all the drowsy syrups of the world,

Shall ever medicine thee to that sweet sleep

Which thou ow’dst yesterday.”

In fact, neither poppy nor mandragora, nor wine, were found effective as anaesthetic agents. However drowsy the patient, the touch of a knife was sufficient to have him awake and screaming.

The first real anaesthetic, that is to say, a substance which actually made patients insensible to pain, whether or not it sent them to sleep, was discovered by Sir Humphry Davy in 1799. He is famous for discoveries in the fields of electricity and magnetism: forgotten for his service to anaesthesia. Nitrous oxide gas was reputed to be a deadly poison and Davy, in characteristic fashion, resolved to disprove this by inhaling it himself. He found that, far from killing him, it induced a wild, uncontrollable mirth, at the same time depriving him of sensation in his limbs. Immediately he dubbed it “Laughing Gas”, and as it seemed to him “capable of destroying physical pain”, he wrote that it could “probably be used with advantage during surgical operations”.

No one listened. It was half a century later, in 1844, when a young American dentist, Horace Wells, wandered into a demonstration being given in Hartford, Connecticut, by a “Professor” Colton. Colton was a failed medical student who made a living by touring the country giving demonstrations of popular science. This particular demonstration of “Effects Produced by Inhaling Exhilarating or Laughing Gas” was a firm favourite. The lecturer handed round bladders of the gas, inviting selected members of the audience, but only “Gentlemen of the First Respectability”, to sniff it. One of his Gentlemen ran so wildly round the auditorium, cannoning off wooden benches and the wall, that when Wells, fascinated, took him aside, asked if his bruises hurt, the man said, “What bruises?” He had now recovered from the “exhilarating” effect; he was shocked at being shown them.

It immediately struck Wells that this was something a dentist could use. He invited “Professor” Colston to his surgery the next day to provide his gas, while he, Wells, had an uncomfortable wisdom tooth removed by a colleague.
The operation was painless and a complete success, and Wells’s remark, when he opened his eyes after this first effective administration of anaesthetic, the discovery that was to revolutionize surgery and medicine, was a masterpiece of unwitting understatement.

“Ohhh”, he gasped. “A new era in tooth pulling!”

Unfortunately, Wells’s own public demonstration of the gas failed miserably: the bladder was removed too soon, and the patient, waking up, roared that he was in agony. Wells was booed from the auditorium with shouts of “Humbug!” and died a few years later, in poverty. His partner, William Morton, was able to go on with the work and he now tried a new substance, sulphuric ether. This had been remarked as early as 1818, by Faraday, as having similar properties to nitrous oxide. Unlike “Laughing Gas”, ether was a volatile liquid and could therefore be administered by soaking a handkerchief in it, holding it against the nose. It had a stronger power of anaesthesia than its predecessor, from which patients were likely to recover consciousness during particularly painful surgery. It seemed possible that even amputations could be painless, under ether.

Morton arranged to anaesthetize a patient at the Massachusetts General Hospital, being operated on for removal of a tumour in the neck. Unfortunately, he was having difficulty with his new ether “dispenser”, and he arrived fifteen minutes late, to find surgeon, patient and audience distinctly hostile. Breathlessly, he set up the machine beside the operating table, while the surgeon hummed, tapped his foot. At last, with a reassuring word Morton held his mask over the patient’s face.

After five minutes he seemed in a deep sleep. Morton nodded: the surgeon made an incision.

There was a gasp from the audience. This was the point at which the air, in all surgery, was rent with screams. Instead, there had been silence, not a move.

The operation was entirely successful, completely painless. The date, 16 October, 1846.

It is interesting to note that both nitrous oxide and ether were noticed by Englishmen at the turn of the century, were rejected by surgeons and rediscovered, fifty years later, by American dentists.

In 1847, a year after the ether demonstration, James Young Simpson, Professor of Midwifery at Edinburgh University, first used chloroform. This, like ether, was a volatile liquid, but more powerful in its effect; only a few drops on a cloth were needed to produce deep anaesthesia, sufficient even for abdominal operations, where the patient, while still being unconscious, might contract powerful abdominal muscles at the first incision, making further surgery impossible. It had a pleasant smell; there was none of the irritant effect on lungs for which ether was becoming unpopular; and it was uninflammable. So great were its apparent advantages that it almost completely superseded the earlier two anaesthetics.

Then, quite suddenly, it was found to have severe disadvantages. As suddenly as it had risen to fame, it dropped to unimportance. It was too easy, surgeons found, to give an overdose, and this injured both heart and liver. Its most tragic property, not quite understood, even to-day, lay in its tendency to cause sudden death early in its administration. Young, healthy patients, anaesthetized for some trifling surgery, died suddenly within a minute of its commencement, of heart failure.

There remain conditions where chloroform is still the best anaesthetic, and in the hands of an expert it is safe.

In the year Simpson first used chloroform, the anaesthetic property of yet another substance was noted: ethyl chloride. It was 1896 before it was used in surgery. Rapid and safe, but like chloroform requiring an expert, ethyl chloride is used a great deal for children’s operations, the tonsils, adenoids of childhood.

In 1929 cyclopropane was developed. It is extremely powerful and so little of it is required that a patient, particularly one suffering from a lung ailment, can be given an anaesthetic mixture which is almost entirely oxygen. This gas is extremely expensive and, rather unnervingly, explosive, so that a special “closed-circuit” machine is required to deliver it to the patient, a machine which allows him to go on breathing a proportion of his exhaled air.

During the Second World War yet another inhalant anaesthetic was developed, trichlorethylene, and this has proved the ideal for a number of types of cases.

All these “inhalants” make use of the body’s capacity for absorbing substances through the lungs into the blood-stream, whence they travel to the brain. It soon became apparent that a more direct method would be to inject the substance straight into a vein. This, when a suitable drug was found, proved highly effective. The first to be used was hexobarbitone, in 1932, and since then many similar drugs have been developed. They are far less alarming to the patient; there is no sensation of breathlessness, no choking; a prick with a needle is all. Often, for prolonged surgery, the intravenous drug is followed by an inhalant. The disadvantage of intravenous anaesthetics, the chief reason they are seldom, in major surgery, used alone, is that an overdose, once given, is almost impossible to rectify: there is no mask that can be whipped away from the patient’s face; the drug is in and away.

A common intravenous anaesthetic is thiopentone, which has achieved some fame, or notoriety, when given in small doses, as a “truth drug”.

A different, local form of anaesthesia can be obtained with the injection under the skin of certain drugs with an action on nerve tissue. They deaden sensation in the part injected, and have no effect on consciousness. The first to be used, and now almost entirely supplanted, though the name is a popular one, was cocaine, brewed first in 1884 from the leaves of the Peruvian coca plant. Probably the most used at present is procaine. All local anaesthetics achieve a “nerve block”, preventing the nerves around the area sending back messages to the brain.

A specialized form is spinal anaesthesia, in which a number of nerves, all those supplying a part of the body, can be temporarily blocked by injecting the drug into a point along the spinal column. The body’s nerves are linked to the spinal column, joining it in clusters the whole way along its length, and an anaesthetic into the right cluster will immobilize anything up to half of the body— without affecting consciousness. It was discovered by accident in 1885 when the New York neurologist Leonard Corning punctured the surrounding wall of a dog’s spinal column, during an experiment on anaesthetizing a nerve in the back, and found that he had anaesthetized a large part of the dog.

New anaesthetics, new techniques, are constantly being developed. A recent addition to surgery, which though not technically an anaesthetic at all, deserves mention is curare. This, a poison used by South American Indians to tip their arrows, is now used extensively to relax muscles. Once a patient’s muscles are relaxed, guaranteed to stay that way through the operation, an anaesthetist requires only sufficient “gas” to keep him unconscious. This makes for greater safety.

But probably no modern development in anaesthesia is likely to equal the breakthrough that took place on the day in 1846 when Horace Wells woke without his wisdom tooth, gasped and said,”Ohhh, A new era in tooth pulling!”