Before the invention of anaesthesia surgery was horrific. Patients would have to be strapped down or held by several men as they screamed and writhed in agony. Operating theatres resembled torture chambers with hooks and pulleys set into the walls to hold the patients’ restraints. And torture chambers is what they were. Many would opt for a premature death rather than endure the blinding pain of the scalpel or worse, the bone saw, while fully conscious. Fanny Burney, who underwent a mastectomy in 1811, survived to describe the experience.
‘When the dreadful steel was plunged into the breast … I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittently during the whole time of the incision … so excruciating was the agony … I then felt the Knife [rack]ling against the breast bone – scraping it.’
It wasn’t only harrowing for the patients but also the doctors themselves. John Abernathy, a 19th-century surgeon at London’s St Bartholomew’s Hospital, likened entering the operating room to ‘Going to a hanging.’ and would often cry or vomit after a gruesome operation. For this reason, surgeons were prized for their speed rather than cleanliness or attention to detail. Pus mixed with blood in their haste and post-surgery infections killed most.
British surgeon, Robert Liston became famous for his speed during the 1800s and was dubbed the ‘Fastest knife in the West End.’ He’d stride into theatre instructing his students to ‘Time me, gentlemen, time me.’ and they’d observe, with ticking pocket watches, as he cut and amputated. To save time he’d often hold his bloodied scalpel in his teeth as he sawed at bone. His most famous achievements included a 4-minute removal of a 45-pound scrotal tumour that was so enormous the patient had been transporting it in a wheelbarrow. He’d also managed a leg amputation in 2 and a half minutes. Unfortunately, in his hurry, he also removed the patient’s testicles.
Legend tells that one of his operations led to the death of 3 people. It was another 2 and a half minute leg amputation during which he cut off two of his assistants fingers. Both the patient and the assistant later died of gangrene. The third death was of a spectator. Liston had slashed through his coattails with his scalpel. The man was so terrified that he’d been fatally wounded he fainted and was later found to have died of shock.
Although clearly an exaggeration, it demonstrated that something had to change in the world of surgery. Speed could no longer be given priority over patient survival or the extremities of assistants. The only way to slow things down was to stop the patients feeling pain.
Early Anaesthesia
Of course, it’s not as though humans hadn’t tried. There are records of anaesthetic techniques dating back thousands of years.
As early as 3400 BCE, Sumerians are thought to have grown and harvested the first opium poppies. They named them the ‘plant of joy’ and used them both medicinally and to calm nerves. Records also tell of their use in Ancient Egypt and Rome. A famous user was Emperor Marcus Aurelius, who’d take a honey and opium mixture most nights to sleep.
While a sweet nightcap with a morphine kick might not sound too bad, not all early anaesthetics were so civilized. In 400 BCE, Assyrians and Egyptians practiced compression of the carotid artery to knock patients out before circumcision or cataract surgeries. Essentially placing people in a chokehold until they’d lose consciousness, hopefully for long enough to perform the procedure. This wasn’t the only drug-free technique employed. In ancient Italy, they’d place a wooden bowl on a patient’s head and beat it until they fell unconscious. Failing brute force, alcohol was often used. But, the painkilling effects were limited and the vomiting was undesirable.
In the 11th century, things progressed slightly and Arabic physicians started using the first inhalation anaesthetics in the form of soporific sponges. They’d soak sponges in mixtures of opium, hemlock and mandragora and hold them under a patient’s nose until they fell unconscious. Unfortunately, they’d take a long time to work and were unreliable at keeping the patient under.
And so the West continued to suffer agonizing operations with only 3 choices. Opium, alcohol or a smack round the head with a fist or wooden mallet.
Anaesthesia in Asia
Meanwhile, in Asia, vast strides were being made. In 200AD, Chinese surgeon Hua Tuo developed an anaesthetic formula of wine and herbs. He called it mafeisan and used it to perform incredibly invasive operations such as a resection of gangrenous intestines, something that couldn’t be attempted with opium or alcohol. Unfortunately, Confucian teachings considered surgery a form of mutilation of the sacred body and it was strongly discouraged in ancient China. So, he burned all of his work before his death and his recipes were lost.
Fortunately, Japanese doctor Hanaoka Seishu heard of Hua Tuo’s success and decided to attempt to recreate it. Beginning in 1785 he experimented with numerous herbs and formulas to try and replicate the anaesthetic results of mafeisan. His wife volunteered to test his potions and was tragically blinded by a bad batch. But her loss wasn’t in vain as Seishu succeeded and named his compound tsusensan. After drinking, a patient would fall unconscious within 2 to 4 hours and stay that way for up to 24 hours. More than long enough to conduct a careful and hygienic surgery.
In 1804, he operated on his first patient using the formula. A 60-year-old woman, Kan Aiya, with breast cancer who needed a partial mastectomy. It worked. She made it through the operation without waking and news of the success spread across Japan. Seishu continued to use tsusensan and performed over 150 breast cancer operations before he died in 1835.
Unfortunately, the military government of Japan at the time, the Tokugawa shogunate, had a strict isolation policy and news of the development didn’t leave the country. Globally, excruciatingly painful surgeries continued for 4 decades beyond Seishu’s first successful anaethetisation.
Nitrous Oxide
The first gas discovered to be an effective anaesthetic was nitrous oxide, isolated by an English chemist, Joseph Priestly in 1772. He recognized the potential for use in medicine, observing ‘I cannot help flattering myself that, in time, very great medicinal use will be made of the application of these different kinds of airs…’
Of course, he was right. But its other properties attracted attention first. Chemist Humphrey Davy started experimenting with the gas and discovered that inhaling it was ‘inconceivably pleasurable’. He’d send himself on drug-induced trips and write philosophical notes like ‘Nothing exists but thoughts.’ It wasn’t long before he began to share nitrous oxide with his friends and they’d get together inhaling silk balloons full of the gas, giggle and make ridiculous statements like ‘I feel like the sound of a harp’. He nicknamed it laughing gas, preventing anyone in the medical community taking it seriously for another 40 years.
The trend took off and entrepreneurs started travelling the country charging people to sample the gas. Whilst under the influence users would stumble about and act inappropriately, which was often hilarious. So, the sellers put them on stage and would make even more money by charging an audience to come and watch their intoxicated clients embarrass themselves. Fortunately, they’d have no recollection of events the next day and the travelling shows became very popular.
In 1844, Gardner Quincy Colton’s show the ‘Grand Exhibition of the Effects Produced by Inhaling Nitrous Oxide’ reached Horace Wells. Horace and his friend Samuel Cooley got incredibly high and, according to his wife, made total fools of themselves. After they’d come down, Samuel noticed that his knee was bleeding and realised he’d felt no pain until the gas had worn off. This gave Wells an idea and the very next day he inhaled a bag of nitrous oxide before allowing his dental partner, John Riggs, to pull out a tooth that’d been bothering him. He felt nothing and declared it the greatest discovery he’d ever made.
Wells tried the gas out on a number of his patients before deciding to present it to the medical community. He booked a demonstration at the Massachusetts General Hospital in Boston in January 1845 and prepared for a public tooth extraction. Unfortunately, the gas bag was removed too soon and the patient woke up and cried out in pain. Wells was booed and jeered at. His discovery was declared ‘a humbug.’ And he was left humiliated.
Ether
A former apprentice of Wells, dental student William Morton, recognized the potential of nitrous oxide and wanted to continue the work. However, he didn’t want a repeat of the shameful, failed demonstration in Massachusetts so instead turned his attention to a stronger agent, Ether.
It was first synthesised by German alchemist Valerius Cordus in 1540, by distilling ethanol and sulphuric acid. He called it the ‘sweet oil of vitriol’ and noted it “…quiets all suffering without any harm and relieves all pain, and quenches all fevers, and prevents complications in all disease.” Despite these observations, its medicinal applications weren’t pursued and humanity endured hundreds more years of conscious tooth extractions thanks to the oversight.
Just as with nitrous oxide, ether was used recreationally and was famed for the ‘ether frolics’ of the upper classes. Morton noted that it had the same anesthetic effects as nitrous oxide but was more powerful. He decided to pursue it but took no chances and used it on his goldfish, spaniel, 2 assistants and himself before giving it to a real patient. In September 1846, Eben Frost was given Ether before his dental extraction and woke to declare that he’d felt no pain at all. The success attracted attention and Morton realised ether’s potential wasn’t limited to dentistry but could also revolutionise general surgery. It was ready for its public performance.
Moreton was a dentist, not a surgeon but he managed to find one who was happy to help. So, in October 1846 surgeon John Warren, completed what the world thought was the first successful surgical procedure using anaesthesia. A tumour excision under the jaw of 20-year-old George Abbott. The operation was watched by a crowd of doctors and medical students who’d witnessed Well’s failed demonstration and humiliation just 2 years before. Remarkably, Abbott didn’t wake as the scalpel was plunged into his neck and he survived the surgery untraumatized. On completion of the procedure Warren famously declared ‘Gentlemen, this is no humbug.’
News of the success spread quickly across the globe with hundreds of surgeons clamouring to try the method for themselves. The first in Europe to attempt it was none other than ‘Time me, gentlemen.’ Robert Liston. Who was finally able to painlessly amputate a patient’s leg without accidentally castrating anyone.
Morton himself was ambitious and eager to see his discovery make him rich. He couldn’t patent Ether as it had long been used for other things. So, he mixed it with orange oil and opium and named it ‘Letheon’. Of course, everyone knew what the active ingredient was and the patent was useless. He continued to seek fame and wealth for the rest of his life, entering into bitter disputes with rivals claiming to have been key to the discovery. One of these was Wells who’d been Morton’s tutor and the other was Charles Jackson a chemist who claimed to have been the one who’d suggested using ether on patients in the first place.
Morton ultimately won the acknowledgement and the 16th of October is now known as Ether Day, the day of Morton’s successful public ether demonstration. However, he never found fortune even after trying and failing to petition congress to award him $100,000 for his achievement. He died penniless.
Jackson was never given recognition and couldn’t overcome the bitterness he felt. He spent the last 7 years of his life in an Asylum. Finally, Wells. He fell into a deep depression following his humiliation, which was exacerbated by Morton’s Ether success. He began experimenting with a range of anaesthetic drugs and became addicted. In one episode he got so high that he went out into the street and threw sulphuric acid at 2 prostitutes. He was sent to jail where he sliced his femoral artery with a razor and died.
Ironically, despite the bitter feuds and tragic endings, neither Morton, Jackson nor Wells were the first to discover ether’s incredible application. Crawford Long, a surgeon in Georgia had begun using ether in his surgeries in 1842 after noticing its effects during his own ether frolics. So in fact, the first anaesthetised operation wasn’t on George Abbot’s Jaw but James Venable’s neck cyst. He’d agreed to be a guinea pig for Long due to his intense dislike of pain. Long had delayed publishing and didn’t get around to it until 1849, missing out on the accolades and his own national day.
Chloroform
While ether was a massive leap forward it wasn’t perfect. About 1 in every 15,000 patients died, usually when the dose was too high. It also smelled awful, irritated patients’ airways and was flammable, which made cauterization dangerous. So, the frantic race was on to find new drugs without the unpleasant side effects. The search didn’t last long as in November 1847 Scottish Professor James Simpson began administering chloroform to women during childbirth and it quickly became popular in general surgery too.
Chloroform was discovered in 1831 by American physician Samuel Guthrie. As with ether, it took many years before anyone considered its use as an anaesthetic. Even after Guthries’ 8-year-old granddaughter accidentally anaesthetized herself as chloroform is sweet so she’d often sneak a taste.
As it wasn’t flammable and not as irritating to airways its popularity soared. Unfortunately, no one knew that it was a cardiovascular depressant and excessive doses would lead to cardiac arrest. The first victim died just a few months after its initial use, in January 1848. Her name was Hannah Greener and she was a 15-year-old girl who was being treated for an ingrown toenail. It turned out to be so deadly that one in every 2500 patients would die after taking it. Either through cardiac arrest or severe damage to the liver.
However, the surgeons were slow to blame chloroform, citing incompetent physicians as opposed to the cardiovascular effects of the drug. For many doctors, it became their anaesthetic of choice and was famously popularized by Dr John Snow, an English physician who was then an anaesthetist. He later became more widely known as a founder of epidemiology for his work during the cholera outbreak of 1854. He’d begun using it to anesthetise women during labour and in 1853 chloroformed Queen Victoria during the birth of Prince Leopold. This captured the attention of the masses and anyone who was anyone in those days would be chloroformed during childbirth.
By 1858, 50 deaths had been reported and many more had likely been concealed. Dr Snow began research into the correct dosage of chloroform, testing different amounts on dogs. He announced that using concentrations of less than 4% would be safe. Unfortunately, the deaths continued and by 1864, 124 people had been killed.
Modern Anesthetics
Unfortunately, surgeons were still lacking any other options. Nitrous oxide was reintroduced in 1856 by Professor Gardner Quincy Coulton, the host of the travelling show who’d first given it to Wells. It was far safer than both ether and chloroform and is still used in dentistry today. But, it was slow to act and couldn’t keep patients under long enough for more complex procedures. Antiseptic surgery methods were introduced in 1867 by Joseph Lister which meant surgeons could delve deeper into the abdomen without guaranteeing their patient’s death by sepsis. Also, muscle relaxants were now in use allowing more complicated abdominal surgeries to take place. None of this was any good under nitrous oxide as the patients couldn’t tolerate the pain of the procedure.
The surgeons were crying out for a solution. But, it wasn’t until the mid-1900s that anaesthesia started to resemble what we know today.
The medical community began to prioritise the research and in 1889 Henry I Dorr was named the world’s first professor of anaesthesia. In 1893 the first anaesthesia society was formed and in 1898 Dr August Bier performed the world’s first spinal block using cocaine.
The invention of the hypodermic needle in 1844 made way for new research into anaesthetics that could be delivered intravenously. This led to the development of Benzodiazepine in 1955, Etomidate in 1964 and Propofol in 1973. Developments in science and pharmaceuticals meant new inhalation drugs also became available such as isoflurane in 1972, desflurane in 1992 and sevoflurane in 1994. These are all still used today and happily deaths from anesthesia are now only 1 in 250,000. Not perfect, but at least we no longer have to experience the sensation of scalpels, pliers or bone saws.
