Introduction

Once upon a time..

The History of Modern Anaesthesia

Modern anaesthesia celebrated it 150
th
anniversary in 1996. Prior to 1846, surgery was synonymous
with pain. At best the pain was alleviated with alcohol or opiates. The following report from the New
York Herald of 21
st
J uly, 1841 describes what surgery was like for many at that time.

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 moments to insure saving of blood, the compress part
of the tourniquet was placed upon the artery and the leg was held by an assistant.
The white swelling was fearful frightful. A little wine was given 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 the knife carefully but
rapidly. The boy screamed terribly; the tears went down his fathers 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.
Again the knife was thrust under the bone, the terrific screaming was renewed; one or two picked up
their hats to leave; scream upon scream and again the bloody blade of the knife issued from the
wound and was laid aside. The flesh quivered and the boy cried agonizingly.
The flesh was thrust back with a small piece of wet linen; the divided ends of the quivering
muscles were stopped from blood with a sponge; the saw glistened in the hands of the operator, the
father turned pale as death; the boys eyes fastened on the instruments with glazed agony; grate
crush once, twice, and the useless limb from the toes to the centre of the thigh, was quickly dropped
into the tub under the table..

In the early 1840s Crawford Long and William Clark independently used Ether on patients but did not
publish their work at the time. Horace Wells a dentist had used Nitrous oxide for dental extractions but
his public demonstration of its use as an anaesthetic at the Massachusetts General Hospital in Boston
was a dismal failure. The credit for popularising modern anaesthesia goes to Dr. William TG Morton a
dentist, who on 16
th
October, 1846 publically demonstrated the efficacy of Ether as an anaesthetic for
a removal of a vascular tumour of the neck in a patient. The operation took place in the same theatre
used by Wells. Dr. J ohn Warren, the chief surgeon at the Harvard Medical School, in a reference to
Wells earlier failure declared Gentlemen, this is no humbug.

The term anaesthesia (Greek for an, without and aesthesia, perception) was suggested by
American author Oliver Wendell Holmes in a private letter written to Morton dated 21
st
November,
1846.

News of the successful use of Ether to produce unconsciousness and painless surgery spread rapidly
around the world. Within a week of the news arriving by ship in Liverpool, Ether was used for a dental
extraction in London, an operation in Scotland and for an amputation of a leg by Robert Liston in
London. Dr. William Guybone Atherstone in Grahamstown, became one of the first anaesthetists
outside America and Europe to use Ether as a general anaesthetic during an operation to amputate a
patients leg in Grahamstown. The anaesthetic lasted three minutes and an account thereof was
written up in the Grahamstown J ournal of 26
th
J une, 1847. In addition to being a respected physician,
Atherstone was also known as an eminent geologist and palaeontologist, and is remembered for being
the person who identified the Hope diamond as a diamond, triggering the Kimberly diamond rush.

Although Ether was a relatively safe anaesthetic, its flammable properties and propensity to cause
postoperative nausea and vomiting led to a search for a safer agent with fewer side effects. Although
a good analgesic, the low potency of Nitrous oxide mandated hypoxic concentrations to achieve
anaesthesia. Chloroform was introduced into anaesthetic practice by a Scottish obstetrician, J ames
Simpson in 1847. It achieved popularity particularly in the United Kingdom, where it was used by J ohn
Snow, a London physician and anaesthetist, to relieve the pain of childbirth to Queen Victoria during
the birth of her son Leopold. In her diary she wrote, Dr. Snow gave the blessed Chloroform and the
effect was soothing, quieting and delightful beyond measure. Dr. Snow rapidly became the leading
anaesthetist in the UK. His sharp mind led him to describe the 5 stages of anaesthesia and in 1847
he wrote the first textbook of anaesthesia On the Inhalation of Ether in Surgical Operations.

The history of modern anaesthesia
Intro - 2
The first recorded death under anaesthesia occurred on 28
th
J anuary, 1848, when a fifteen year old
girl, Hannah Greener, died during a Chloroform anaesthetic to remove an in-growing toenail. Further
Chloroform related anaesthesia deaths followed, causing its eventual abandonment in favour of Ether.
In 1954 Charles Suckling, a chemist at Imperial Chemical Industries in the UK synthesised Halothane.
This halogenated hydrocarbon was introduced into anaesthetic practice in 1956 and revolutionised
anaesthesia, rapidly replacing Ether as the agent of choice. It was potent, non-flammable, had a
pleasant odour and favourable kinetic characteristics. Halothane is an excellent anaesthetic but its
potential to cause severe hepatotoxicity in a small number of patients, particularly with repeat
anaesthetics resulted in it being replaced by Isoflurane in first world countries.

Local and regional anaesthesia
The first person to use local anaesthetic agents for operations was Karl Kller, an Austrian colleague
of Sigmund Freud, who demonstrated the efficacy of topical Cocaine for superficial eye operations.
His work was presented at an ophthalmology congress in Heidelberg, Germany in September, 1844,
receiving an enthusiastically favourable response. The credit for introducing injected local
anaesthetics into clinical practice to block sensory nerves went to two surgeons, Halstead and Hall,
who had worked in Vienna prior to emigrating to the USA. Both became addicted to Cocaine.

In 1898, a German surgeon, August Bier gave the first deliberate spinal anaesthetic and then showed
his faith in the technique by allowing his assistant, Dr. Hilderbrand, to perform a spinal anaesthetic on
him using 2 ml 1% Cocaine solution. Bier then used the technique in 6 patients for operations on the
lower part of the body. Following Biers description of the technique the use of spinal anaesthesia
spread rapidly. Bier is also credited for introducing the technique of intravenous regional anaesthesia
(Biers block) for limb surgery

Intravenous anaesthesia
The development of barbiturates with sedative properties, such as Hexobarbital in 1932 and
Thiopentone in 1934, enabled rapid intravenous induction of anaesthesia for the first time. J ohn
Lundy in the Mayo Clinic introduced the term balanced anaesthesia using a combination of multiple
agents to reduce the dose and side effects from single agents.
The dangers of Thiopentone causing cardiovascular collapse in shocked patients was highlighted
when it was implicated as a cause of increased mortality when used to induce anaesthesia in patients
after the bombing of Pearl Harbour in 1942.

Muscle relaxants
Modern muscle relaxants developed from studies of a South American arrow poison that worked by
paralysing skeletal muscle. In 1814 Brodie and Waterton in England injected an extract of the poison
into the shoulder of a donkey and then ventilated the paralysed donkey for 2 hours using a pair of
bellows via a tracheotomy. The donkey survived and lived for another 25 years.
In another classic laboratory experiment performed on frogs in 1857, Claude Bernard, the famous
French physiologist, demonstrated that the site of action of muscle relaxants was the neuro-muscular
junction and not the nerve or muscle.
In the early 1940s, Harold Griffith from Montreal, Canada, became the first anaesthetist to popularise
the use of Curare for surgery in which muscle relaxation was required by the surgeon.

Anaesthesia equipment
In 1917, Henry Boyle described his portable Nitrous oxide

/

Oxygen

/

Ether apparatus. Boyle was left-
handed and to this day, the Commonwealth countries still have the O
2
flowmeter on the left. (South
Africa being the exception, ours were changed to the right in the 1970s). Basic anaesthetic machines
are still commonly referred to as Boyles machines.

Intensive care units
The polio epidemic that swept across the world between 1952 and 1954 stimulated the development
of ventilators and the birth of Intensive Care Units. Thousands of patients were kept alive using the
cumbersome Drinker respirator, a negative pressure tank ventilator that surrounded the patient and
became known as the iron lung. In Copenhagen alone in 1952, there were only 7 ventilators
available for the 315 patients with poliomyelitis requiring ventilatory support over a 4 month period.
Teams of medical students took turns to manually ventilate these patients. Bjorn Ibsen, a Danish
anaesthetist, initiated the concept of intensive care units to care for polio patients.

The history of modern anaesthesia
Intro - 3
Contributions to anaesthesia from UCT and Groote Schuur Hospital
Professor Arthur Bull joined the UCT Department of Anaesthesia as a registrar in 1948 and in 1965
was appointed to the first Chair in the Department of Anaesthesia at UCT. He was involved with the
development of the Taurus radiofrequency blood warmer which is named after him (Taurus - Greek for
Bull) and still used in theatres in GSH today.

Prof. Gaisford Harrison succeeded Prof Bull as Head of Department in 1981. He was an excellent
researcher who made 3 major contributions to anaesthesia. Whilst anaesthetising pigs for early
research into liver transplantation he realised that several of the pigs developed a syndrome identical
to that of Malignant Hyperthermia (MH) when exposed to Halothane. This identification of an animal
model to study the disease led to numerous further publications in the field. He later achieved fame
for identifying Dantrolene as the drug that could be used to terminate this hitherto invariably fatal
pharmacogenetic condition.

Professor Harrisons other major field of interest was in the epidemiology of anaesthetic morbidity. He
has the worlds longest published longitudinal study of anaesthetic morbidity, carried out at Groote
Schuur Hospital over a period of 30 years from 1956

-

1987. During this period he documented a 6
fold reduction in anaesthetic related mortality from 1

:

1 000 in 1956 to 1

:

14 250 by 1987.

Dr. J oseph Ozinsky achieved his place in anaesthesia history in December 1967, when he
anaesthetised Louis Washkansky for the worlds first successful heart transplant operation. The
anaesthetic was performed using Nitrous oxide, Oxygen and Halothane and without many monitors
that today would be regarded as essential. Blood pressure was measured by a sphygmomanometer
rather than an arterial line and transducer and pulse oximeters had not been invented. In an editorial
commemorating the 40
th
anniversary of the transplant in the February 2008 J ournal of Cardiothoracic
and Vascular Anesthesia, tribute was paid to Dr. Ozinsky and the anaesthetic team when the editor
wrote - It is humbling and enlightening for the 21
st
century cardiac surgeon and anesthesiologist to
recognize what smart and dedicated clinicians can achieve without the equipment and drugs currently
considered essential to success.

Professor Michael J ames succeeded Prof. Harrison as Head of Department in 1987. His early interest
was in the study of haemodynamic effects of Magnesium sulphate in anaesthesia and intensive care.
He pioneered the use of Magnesium sulphate to attenuate the haemodynamic response to intubation
in patients with pre-eclampsia and in its use to control hypertension in patients being operated on for
phaeochromocytomas. His current research relates to the search for the ideal fluid for resuscitation
and in the use of the thromboelastogram to study various aspects of blood coagulation.