HISTORICAL ANESTHETICS

Dr. Kevin Joseph Ambadan

FIRST, SOME HISTORY…

• 16 October 1846, at Massachusetts General Hospital in Boston, the first public demonstration of ether anesthesia took place. Anesthetist: William MortonSurgeon: John WarrenPatient: Gilbert AbbottOperation: Removal of a lump under the jaw

• Difficult to understand today how major this advance was.Before this, surgery was a terrifying last resort.Few operations were possible.The inside of the abdomen, chest and skull were essentially ‘no go’ areas.Speed was the only determinant of a successful surgeon.Most patients were held or strapped down - many died either on the table or immediately post-surgery.

• A grim tale is told in the New York Herald, 21 July 1841, of an amputation:

• ‘The case was an interesting one of a white swelling, for which the thigh was to be amputated. The patient was a youth of about fifteen, pale, thin but calm and firm. One Professor felt for the femoral artery, had the leg held up for a few moment to ensure the saving of blood, the compress part of the tourniquet was placed upon the artery and the leg held up by an assistant. The white swelling was fearful, frightful. A little wine was given to the lad; he was pale but resolute; his Father supported his head and left hand. A second Professor took the long, glittering knife, felt for the bone, thrust in the knife carefully but rapidly. The boy screamed terribly; the tears went down the Father’s cheeks. The first cut from the inside was completed, and the bloody blade of the knife issued from the quivering wound, the blood flowed by the pint, the sight was sickening; the screams terrific; the operator calm’.

• The introduction of anesthesia changed all of this.Surgery could slow down - become more accurate and could move into 'forbidden areas’ of abdomen, chest and brain.

• Once ether was used then further inhalational agents were introduced. Chloroform was introduced by the Professor of Obstetrics in Edinburgh, James Simpson, in November 1847.

• The next major advance was the introduction of local anaesthesia - cocaine - in 1877

• Then came local infiltration, nerve blocks and then spinal and epidural anesthesia, which in the 1900s allowed surgery in a relaxed abdomen without the huge ‘depth’ of anesthesia required by ether and chloroform

PROPERTIES OF AN IDEAL ANESTHETIC

• ample potency

• low solubility in blood and tissues

• resistance to physical and metabolic degradation

• protective effect of and lack of injury to vital tissues

• lack of a propensity to cause seizures, respiratory irritation, and circulatory stimulation

• little or no effect on the ozone layer

• low acquisition cost

ETHER

• Diethyl ether (“sulfuric ether” – produced by a simple chemical reaction between ethyl alcohol and sulfuric acid)

• Originally prepared in 1540 by Valerius Cordus.

• “Ether frolics”

• Crawford W. Long and William E. Clark

• William T.G. Morton

ANESTHETIC PROPERTIES OF ETHER 

• Induction is very slow (blood gas coefficient 12) and very unpleasant (pungent smell)

• Potency is moderate (MAC 1.92)

• Very good analgesic.

• Usually required concentration is 5 - 15%.

• Very good muscle relaxant.

• Delivery method: By open drop; EMO inhaler, copper kettle vaporizer, Oxford miniature vaporizers.

ADVANTAGES OF ETHER 

• Very cheap

• Can be used as sole agent for anesthesia as it has all properties of anesthesia viz. narcosis, analgesia, muscle relaxation or in other words it is the only complete anesthetic agent.

• Very safe: Does not produce any cardiac or respiratory depression, so can be used at remote places (like wars and disasters) and with less experienced hands.

• Requires very less instrumentation for delivery (even can be given by open drop method).

• Does not produce any toxic metabolite.

• It can be given by using air as carrier gas by air ether apparatus i.e., even oxygen cylinders may not be required.

DISADVANTAGES OF ETHER

• Highly inflammable and explosive(Problem for doctors who often worked by candlelight in rooms heated by fireplace)

• Induction is very irritating and unpleasant and can induce severe laryngospasm.

• Tracheobronchial secretions are increased.

• Recovery is delayed.

• Very high incidence of nausea and vomiting, therefore recovery and postoperative period is unpleasant.

CHLOROFORM

• Chloroform was independently prepared by von Leibig, Guthrie, and Soubeiran in 1831.

• First used by Holmes Coote in 1847,

• Introduced into clinical practice by Sir James Simpson, Professor of Obstetrics in Edinburgh, who administered it to his patients to relieve the pain of labor ( Nov 1847)

• Ironically, Simpson had almost abandoned his medical practice after witnessing the terrible despair and agony of patients undergoing operations without anesthesia.

• Chloroform superseded ether in popularity in many areas (particularly in the United Kingdom), but reports of chloroform-related cardiac arrhythmias (sudden sniffer’s death), respiratory depression, and hepatotoxicity eventually caused practitioners to abandon it in favor of ether, particularly in North America

• The first baby born to a mother who received chloroform for pain was named Anaesthesia.

• Scottish clergymen quickly objected to this use of anesthesia, insisting the pain of childbirth was ordained by God. Simpson countered by citing the biblical account of the deep sleep cast on Adam when God took the first man's rib and used it to make Eve. The argument continued until 1853, when Queen Victoria chose to be chloroformed for the birth of her son. This event quieted the clergy and made chloroform the most fashionable anesthetic—especially in England—for the next 50 years.

• Queen Victoria's anesthetist, Dr. John Snow, developed an inhaler to regulate the amount of chloroform administered to a patient so that he or she felt no pain but remained conscious.

• More recently, it has been listed as a carcinogen by the U.S. Environmental Protection Agency and been banned for use in drug, cosmetic, and food products since 1976

NTROUS OXIDE

• Joseph Priestley produced nitrous oxide in 1772

• Humphry Davy noted its analgesic properties in 1800.

• Gardner Colton and Horace Wells are credited with having first used nitrous oxide as an anesthetic for dental extractions in humans in 1844.

• Nitrous oxide’s lack of potency (an 80% nitrous oxide concentration results in analgesia but not surgical anesthesia) led to clinical demonstrations that were less convincing than those with ether.

• Nitrous oxide was the least popular of the three early inhalation anesthetics because of its low potency and its tendency to cause asphyxia when used alone.

• Interest in nitrous oxide was revived in 1868 when Edmund Andrews administered it in 20% oxygen;

• Ironically, nitrous oxide is the only one of these three agents still in widespread use today.

LAUGHING GAS• Nitrous oxide (N2O; laughing gas) is colorless and essentially odorless.

• A gas at room temperature and ambient pressure. Can be kept as a liquid under pressure because its critical temperature lies above room temperature.

• Relatively inexpensive

• After confirming the anesthetic effect of nitrous oxide on other patients, Wells arranged through his former dental partner, William T. G. Morton (1819-1868), to demonstrate his discovery to a group of Morton's Harvard Medical School classmates in January 1845. Unfortunately, the nitrous oxide was applied incorrectly, and the patient yelped with pain when his tooth was pulled, embarrassing Wells before the group.

THANK

YOU