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e-Feature Fun Fact December 2011 Anesthesia! “To escape pain in surgical operations is a chimera which we are not permitted to look for in our time.” (Velpeau, 1839) As long as there has been medicine, humans have sought ways to lessen the physical pain associated with treatment. The earliest reference to a substance being inhaled to subdue pain during surgery is found in the work of Herodotus. He describes an intoxication induced by inhaling the vapors of a certain kind of burning hemp. Another early reference to anesthesia is found in the work of Theodoric, an Italian surgeon who used a rag soaked in a concoction made of opium, hemlock, lettuce, and mandragora; a practice that, he said, had been passed down for generations. Of this mixture, mandragora is by far most interesting – in history and in myth. Mandragora is an infusion of mandrake in wine or liquor. Mandrake was used widely in the middle ages for inducing sleep during surgery, increasing fertility, and as a divinatory talisman. The mandrake plant is commonly know for its long bifid tap root that has for centuries been compared to the shape of a human body. According to folklore, when pulled from the ground the root would scream. Any human who heard this wretched sound would either drop dead or be driven mad. 1st century historian Josephus advised that any party interested in harvesting mandrake should do so only in the moonlight after appropriate rituals. The interested party should tie the plant to the collar of a black dog then run off. The dog will chase after the master, uprooting the plant, and inevitably die upon hearing the scream. Reference to mandragora’s sleep inducing effects can be found in several of Shakespeare’s plays. It was most likely the sleeping potion that Juliet took. It is referenced many times in the bible. During his crucifixion Jesus refused the mandragora a woman offered to ease his pain. The precursor to our modern pneumatic anesthetics is diethyl ether. Ether was first synthesized in 1540 by Valerius Cordus and was widely used as a recreational inhalant. Upper class gentlemen were able to enjoy intoxication by ether because it did not carry the social stigma associated with alcohol and drunkenness. Many of the doctors who went on to experiment with ether as an anesthesia looked back fondly on boyhood romps under etheric exaltation. STAGE ONE: PERIOD OF EXCITEMENT In 1844, Horace Wells - a dentist in Connecticut - began providing ether and nitrous oxide before pulling teeth. His ability to perform minor surgery with relief of pain, though successful, did not excite much attention. His assistant William T.G. Morton – who falsely claimed to have studied at the Baltimore School of Dentistry– became interested in ether and its further applications. He acted as the first surgical anesthesiologist on October 16, 1846. In a crowded medical amphitheater, twenty year old Gilbert Abbott was administered ether and had a vascular tumor removed without the experience of pain. The surgeon, John C. Warren, exclaimed “Gentlemen, this is no humbug!” Morton and his companion Charles T. Jackson quickly secured a patent for ether under the name “Letheon”. It was their hope to keep the ingredients secret and sold the mysterious vapor infused with aromatic oils. Unfortunately litigations arose concerning the uncertain composition and discovery of the anesthetic and Morton lost both health and wealth arguing for continued rights to the drug. Sir James Simpson introduced chloroform as an anesthetic in 1847 to the Scottish medical practice. The first public demonstration took place at the Royal Infirmary on November 13 of that year. Simpson failed to make the operation in time and the surgeon proceeded without the aid of an anesthetic. The patient died on the table. It is not certain what caused this death – pain or surgical complications – but had chloroform been administered and had the patient still died, there would be no reason to keep this anesthetic on the market. Two days later Simpson oversaw a successful demonstration and chloroform, known as ‘curious liquid’, began its season of European popularity. Simpson, who was also an obstetrician, used chloroform as a benevolent eliminator of suffering during childbirth. The Scottish clergy violently opposed this development on the grounds that pain was ordained by the scriptural command, “in sorrow thou shalt bring forth children.” This was not the only objection. It became clear that chloroform could not be used without accident. Many fatalities occurred, including death, and in 1858 an article was published linking chloroform inhalation to cardiac paralysis. As a result, a committee was appointed by the Royal Medical Society to investigate and recommend a new anesthetic. This committee substantiated all dangerous conclusions and then offered a mixture of ether, chloroform and alcohol as a reliable substitute. STAGE TWO: TOLERATION OF PAIN An early understanding of ether and chloroform held that the vapors, upon entering the body, would cause a ballooning affect on the brain resulting in unconsciousness. Clinical inspection provides a different explanation. Both ether and chloroform act as depressants, similarly to alcohol. Chloroform is 3 - 3.5 times as depressant to the central nervous system than ether; its action on the heart is 8 times as great. Ether, therefore, must be administered in higher concentrations. Ether is effective through localized paralysis, beginning with centers of the brain and the spine. A brief moment of stimulation is experienced by the body followed by a deepened state of consciousness as the brain and then spine are slowly paralyzed. Muscular reflexes diminish and soon disappear. Chloroform affects the body similarly. In addition, it causes blood to accumulate in the core of the body resulting in a drop in blood pressure and slowed reflexes of the heart. The four components of anesthesia, by modern definition, are: amnesia (loss of recall), analgesia (insensibility to pain), hypnosis (unconsciousness) and muscle relaxation. The anesthetized state is in essence sleep but with greater insensibility. STAGE THREE: INSENSIBILITY (PERVERSION OF CONCIOUSNESS) Ether and chloroform were successful at knocking patients out but unfortunately many did not wake from this sweet slumber. A great many sudden deaths during surgeries and childbirths were attributed to improper use of the elaborate machines that had been invented to administer ether and chloroform. It was hard to regulate how much of a gas was being pumped into the face mask. One doctor remarked that simply using a rag soaked in the liquid was safer and more effective. Dr. Henry Lyman described a patient having an adverse reaction to the inhalation of chloroform thusly: “He coughs convulsively; the veins of the head and neck become turgid with black blood. The skin is livid; perspiration covers the surface. There is a convulsive effort to escape from the vaporizing apparatus, and the after a few brief struggles the unfortunate victim is dead.” Perhaps more of these casualties had to do with the fact that when inhaled chloroform can cause dangers and discomforts including cardiac arrest. Many deaths took place several days after the chloroform had been administered, seemingly out of no where. Delayed chloroform poisoning occurs typically 1-6 days after administration and is usually fatal. It is characterized by: irritability, restlessness, fright, moaning, delirium, nausea, and vomiting. Ether in its pure state (that is unmixed with chloroform) will not cause any seriously detrimental physical damage. The first effect of ether is a feeling of intoxication and euphoria which was often accompanied by vivid hallucinations. A doctor described a patients recounting of his experience while under ether: “He fancied himself borne upon a roseate cloud rushing through space on his way to plunge into the sun.” There are many accounts of women accusing doctors of sexual assault while they were etherized. Most cases were attributed to “ethereal hallucinations” and not taken seriously in courts of law. In an 1854 case a Philadelphia doctor dismissed a woman’s accusation of assault because she had “entered the office in a condition of more than ordinary amatory exhalation” after being escorted there by someone who was courting her. The doctor also claimed that when anesthetized it was common for patients to confuse bodily sensations and relocate them to other body parts. In the early 20th century more effective anesthetics replaced chloroform and ether. Chloroform was often a major ingredient in toothpastes, cough syrups, and nerve tonics and was not banned in consumer products until 1976. Small amounts of chloroform are used as a solvent in the pharmaceutical industry today. Ether is still used as an anesthesia in countries were medical practices are developing.
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