Smile of the Day Tuesday, March 30, 2021

Tuesday March 30, 2021’s Smile of the Day: Anasesthetics

On this Day:

In 1842, Ether was used as an anaesthetic for the 1st time by Dr Crawford Long (Georgia).  But this was certainly not the first time doctors tried to use substances to dull pain during  surgery.

The first attempts at general anesthesia were probably herbal remedies administered in prehistory. Alcohol is one of the oldest known sedatives and it was used in ancient Mesopotamia thousands of years ago. The Sumerians are said to have cultivated and harvested the opium poppy (Papaver somniferum) in lower Mesopotamia as early as 3400 BCE.

The ancient Egyptians had some surgical instruments, as well as crude analgesics and sedatives, including possibly an extract prepared from the mandrake fruit. Bian Que (Chinese: 扁鹊, Wade–Giles: Pien Ch’iao, c. 300 BCE) was a legendary Chinese internist and surgeon who reportedly used general anesthesia for surgical procedures.

Throughout Europe, Asia, and the Americas, a variety of Solanum species containing potent tropane alkaloids was used for anesthesia. In 13th-century Italy, Theodoric Borgognoni used similar mixtures along with opiates to induce unconsciousness, and treatment with the combined alkaloids proved a mainstay of anesthesia until the 19th century. Local anesthetics were used in Inca civilization where shamans chewed coca leaves and performed operations on the skull while spitting into the wounds they had inflicted to anesthetize. Cocaine was later isolated and became the first effective local anesthetic. It was first used in 1859 by Karl Koller, at the suggestion of Sigmund Freud, in eye surgery in 1884. German surgeon August Bier (1861–1949) was the first to use cocaine for intrathecal anesthesia in 1898. Romanian surgeon Nicolae Racoviceanu-Piteşti (1860–1942) was the first to use opioids for intrathecal analgesia; he presented his experience in Paris in 1901.

Early medieval Arabic writings mention anaesthesia by inhalation. Inhalational anesthetics were first used by Arabic physicians, such as Abulcasis, Avicenna and Ibn Zuhr in the 11th century. They used a sponge soaked with narcotic drugs and placed it on a patient’s face. These Arabic physicians were the first to use an anaesthetic sponge. Arab/Persian physicians also introduced the use of preoperative anaesthetic compounds around the 9th century.

The “soporific sponge” (“sleep sponge”) used by Arabic physicians was introduced to Europe by the Salerno school of medicine in the late 12th century and by Ugo Borgognoni (1180–1258) in the 13th century. The sponge was promoted and described by Ugo’s son and fellow surgeon, Theodoric Borgognoni (1205–1298). In this anesthetic method, a sponge was soaked in a dissolved solution of opium, mandragora, hemlock juice, and other substances. The sponge was then dried and stored; just before surgery the sponge was moistened and then held under the patient’s nose. When all went well, the fumes rendered the patient unconscious.

The most famous anesthetic, ether, may have been synthesized as early as the 8th century, but it took many centuries for its anesthetic importance to be appreciated, even though the 16th century physician and polymath Paracelsus noted that chickens made to breathe it not only fell asleep but also felt no pain. By the early 19th century, ether was being used by humans, but only as a recreational drug.

Meanwhile, in 1772, English scientist Joseph Priestley discovered the gas nitrous oxide. Initially, people thought this gas to be lethal, even in small doses, like some other nitrogen oxides. However, in 1799, British chemist and inventor Humphry Davy decided to find out by experimenting on himself. To his astonishment he found that nitrous oxide made him laugh, so he nicknamed it “laughing gas”. In 1800 Davy wrote about the potential anesthetic properties of nitrous oxide in relieving pain during surgery, but nobody at that time pursued the matter any further.

On 14 November 1804, Hanaoka Seishū, a Japanese doctor, became the first person to successfully perform surgery using general anesthesia. Hanaoka learned traditional Japanese medicine as well as Dutch-imported European surgery and Chinese medicine. After years of research and experimentation, he finally developed a formula which he named tsūsensan (also known as mafutsu-san), which combined Korean morning glory and other herbs.

Hanaoka’s success in performing this painless operation soon became widely known, and patients began to arrive from all parts of Japan. Hanaoka went on to perform many operations using tsūsensan, including resection of malignant tumors, extraction of bladder stones, and extremity amputations. Before his death in 1835, Hanaoka performed more than 150 operations for breast cancer. However, this finding did not benefit the rest of the world until 1854 as the national isolation policy of the Tokugawa shogunate prevented Hanaoka’s achievements from being publicized until after the isolation ended. Nearly forty years would pass before Crawford Long, who is titled as the inventor of modern anesthetics in the West, used general anesthesia in Jefferson, Georgia.

Long noticed that his friends felt no pain when they injured themselves while staggering around under the influence of diethyl ether. He immediately thought of its potential in surgery. Conveniently, a participant in one of those “ether frolics”, a student named James Venable, had two small tumors he wanted excised. But fearing the pain of surgery, Venable kept putting the operation off. Hence, Long suggested that he have his operation while under the influence of ether. Venable agreed, and on 30 March 1842 he underwent a painless operation. However, Long did not announce his discovery until 1849.

Horace Wells conducted the first public demonstration of the inhalational anesthetic at the Massachusetts General Hospital in Boston in 1845. However, the nitrous oxide was improperly administered and the patient cried out in pain. On 16 October 1846, Boston dentist William Thomas Green Morton gave a successful demonstration using diethyl ether to medical students at the same venue. Morton, who was unaware of Long’s previous work, was invited to the Massachusetts General Hospital to demonstrate his new technique for painless surgery. After Morton had induced anesthesia, surgeon John Collins Warren removed a tumor from the neck of Edward Gilbert Abbott. This occurred in the surgical amphitheater now called the Ether Dome. The previously skeptical Warren was impressed and stated, “Gentlemen, this is no humbug.” In a letter to Morton shortly thereafter, physician and writer Oliver Wendell Holmes, Sr. proposed naming the state produced “anesthesia”, and the procedure an “anesthetic”.

Morton at first attempted to hide the actual nature of his anesthetic substance, referring to it as Letheon. He received a US patent for his substance, but news of the successful anesthetic spread quickly by late 1846. Respected surgeons in Europe including Liston, Dieffenbach, Pirogov, and Syme quickly undertook numerous operations with ether. An American-born physician, Boott, encouraged London dentist James Robinson to perform a dental procedure on a Miss Lonsdale. This was the first case of an operator-anesthetist. On the same day, 19 December 1846, in Dumfries Royal Infirmary, Scotland, a Dr. Scott used ether for a surgical procedure. The first use of anesthesia in the Southern Hemisphere took place in Launceston, Tasmania, that same year. Drawbacks with ether such as excessive vomiting and its explosive flammability led to its replacement in England with chloroform.

Discovered in 1831 by an American physician Samuel Guthrie (1782–1848), and independently a few months later by Frenchman Eugène Soubeiran (1797–1859) and Justus von Liebig (1803–73) in Germany, chloroform was named and chemically characterized in 1834 by Jean-Baptiste Dumas (1800–84). In 1842, Dr Robert Mortimer Glover in London discovered the anaesthetic qualities of chloroform on laboratory animals. In 1847, Scottish obstetrician James Young Simpson was the first to demonstrate the anesthetic properties of chloroform on humans and helped to popularize the drug for use in medicine. Its use spread quickly and gained royal approval in 1853 when John Snow gave it to Queen Victoria during the birth of Prince Leopold. During the birth itself, chloroform met all the Queen’s expectations; she stated it was “delightful beyond measure”. Chloroform was not without fault though. The first fatality directly attributed to chloroform administration was recorded on 28 January 1848 after the death of Hannah Greener. This was the first of many deaths to follow from the untrained handling of chloroform. Surgeons began to appreciate the need for a trained anesthetist. The need, as Thatcher writes, was for an anesthetist to “(1)Be satisfied with the subordinate role that the work would require, (2) Make anesthesia their one absorbing interest, (3) not look at the situation of anesthetist as one that put them in a position to watch and learn from the surgeons technique (4) accept the comparatively low pay and (5) have the natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation that the surgeon demanded” These qualities of an anesthetist were often found in submissive medical students and even members of the public. More often, surgeons sought out nurses to provide anesthesia. By the time of the Civil War, many nurses had been professionally trained with the support of surgeons.

John Snow of London published articles from May 1848 onwards “On Narcotism by the Inhalation of Vapours” in the London Medical Gazette. Snow also involved himself in the production of equipment needed for the administration of inhalational anesthetics, the forerunner of today’s anesthesia machines.

The first comprehensive medical textbook on the subject, Anesthesia, was authored in 1914 by anesthesiologist Dr. James Tayloe Gwathmey and the chemist Dr. Charles Baskerville. This book served as the standard reference for the specialty for decades and included details on the history of anesthesia as well as the physiology and techniques of inhalation, rectal, intravenous, and spinal anesthesia.

Of these first famous anesthetics, only nitrous oxide is still widely used today, with chloroform and ether having been replaced by safer but sometimes more expensive general anesthetics, and cocaine by more effective local anesthetics with less abuse potential (per Wikipedia).

First, a Story:

My doctor was really supportive when I told him that I was going to administer the anesthesia to myself before the surgery. He told me to knock myself out.

Second, a Song:

The Amateur Transplants (aka Adam Kay and Suman Biswas) are two junior doctors who practice medicine with varying degrees of success. Both were students together at Imperial College, and competed in the annual inter-medical school comedy competition.

Their debut album Fitness to Practice (featuring the ultra-sweary London Underground song) is “a cult hit” Sunday Times and “extremely funny” Daily Telegraph. In 2008 they released their second album “Unfit to Practice”.

Here is the Anaesthetist’s Hymn from The Amateur Transplant’s “Unfit to Practise” album. I hope you enjoy this!

(https://www.youtube.com/watch?v=oZuPei9udVE)

Thought for the Day:

“Alcohol is the anesthesia by which we endure the operation of life.” – George Bernard Shaw

Have a great day!

Dave & Colleen

© 2021 David J. Bilinsky and Colleen E. Bilinsky