Anaesthesia: symbol of humanitarianismBMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39034.661377.94 (Published 04 January 2007) Cite this as: BMJ 2007;334:s5
- Stephanie J Snow, research associate [email protected]
- 1Centre for the History of Science, Technology and Medicine, University of Manchester, Manchester M13 9PL
In the anaesthesia room I stroke my 6 year old daughter's hair and watch the liquid enter her veins through the cannula. A large yawn, closed eyelids, and a lolling head signal the shutdown of her conscious self. After her fractured elbow has been repaired, she wakes, remembering nothing except the prick of the needle. To contemplate this happening without anaesthesia is almost impossible. Today's medical interventions may produce discomfort, but rarely do they cause the intense pain that was once endured in operations before anaesthesia. The discovery of a method to alleviate pain during operations is rightly regarded as a landmark in the history of medicine. Yet anaesthesia was not, as has often been written, the outcome of a rational and scientific search for a solution to the problem of pain, nor was it established without controversy.
In many ways anaesthesia was a discovery at one with its time. By the early 1840s successive cultural and medical changes had resulted in a view of physical pain as purposeless. Doctors had become the masters of pain relief, and the rapid growth in consumption of opiates in Britain from the 1780s indicates that patients welcomed use of the drugs to palliate the pain of chronic disease, death, and childbirth. But the pain of operations remained, despite attempts to circumvent it. Alcohol and opiates were used during operations, but too much of these depressed the body's systems and exacerbated the dangers of surgery. At the same time surgeons began to approach surgery differently. Rather than amputations, they excised diseased or injured tissue and bone; new operations for cataract, stammering, squinting, and club foot were recorded in the Lancet. But more complex operations increased the duration of surgery and thus the duration of suffering. Few patients consented to operations unless absolutely necessary.
The Yankee dodge
Some pioneers carried out experiments with nitrous oxide and ether to suspend consciousness—for example, the physician Crawford Long and the dentist Horace Wells in the United States. But these experiments gained little recognition, because breathing gas carried the danger of asphyxia and, ultimately, death. That William Morton succeeded in establishing the use of ether by demonstrating its effects at the Massachusetts General Hospital in October 1846 is due partly to serendipity (the ether worked and did not cause asphyxia) and partly to Morton's great ambition to expand his dental business with a method of numbing the pain of teeth extraction. Within six months news of ether had spread worldwide.
Anaesthesia became integrated into the structures of 19th century science only when news of ether—the “Yankee dodge”—reached doctors in London. Here John Snow, a young general practitioner (who later achieved fame with his theory of cholera transmission), was among the first to witness the use of ether for a tooth extraction and was captivated by the gas's power to produce “quietude” in patients. But, unlike others, Snow did not rush to treat patients. Instead he began chemical and physiological experiments to establish the parameters of the new technique and developed an inhaler that took into account the relation between temperature and “strength” of ether vapour. In just six months Snow had described the different degrees of anaesthesia that marked ether's sequential suspension of consciousness and volition. Snow's continuing standing among 21st century anaesthetists shows how impressively he secured ether within scientific bodies of knowledge.
Snow mastered the intricacies of ether, but other doctors struggled. Ether's irritant qualities made it difficult to breathe, and ill designed inhalers that gave too little of the vapour stimulated rather than subdued patients. Victorian society prided itself on self control and fortitude, so the spectacle of wriggling and riotous bodies clashed with social mores. Anaesthesia might have remained on the margins of medicine had it not been for the introduction of chloroform by the Scottish obstetrician James Young Simpson in 1847. Simpson discovered chloroform by chance when testing a number of volatile fluids in the hope of finding one that was easier to breathe than ether. Chloroform was less irritating to the lungs and produced unconsciousness swiftly. It immediately replaced ether.
It is hard to overstate the extent to which anaesthesia revolutionised the experience of surgery for patients and surgeons, although it remained a selective practice until the 1860s. It also reconfigured surgical practice: patients were far more willing to be operated on for small injuries, and thus operations became more common. The risk of haemorrhage and infection continued to deter surgeons from operating in the cavities of the body; nevertheless, it is likely that anaesthesia was a strong stimulus for developing methods to diminish infection. Pain in childbirth too was alleviated by anaesthesia, and Snow's administration of chloroform to Queen Victoria for the births of Prince Leopold in 1853 and Princess Beatrice in 1857 effectively silenced the debate on its risks in labour.
A civilising factor
By the end of the 19th century anaesthesia had become a symbol for the wider humanitarian movement. It was proclaimed as one of the civilising factors of the Western world and remains the most vivid example of medicine's capacity to diminish human suffering. In different circumstances anaesthesia may well have emerged in a different form. Mesmeric anaesthesia, although rejected by the London medical elite as quackery in the early 1840s, was successful in India. But a world entirely without anaesthesia is unimaginable.
Anaesthesia continued to develop in the 20th century: muscle relaxants and techniques such as spinal anaesthesia brought new benefits; anaesthetists extended their practice to intensive care and the management of chronic pain; and new inhaled and intravenous anaesthetic agents facilitated the development of day case surgery. The detail of anaesthesia will surely continue to evolve. But nothing is likely to be as significant as the early demonstrations of ether's potential to alleviate the pain of surgery.
Publication of this online supplement is made possible by an educational grant from AstraZeneca
Competing interest: SJS is related by marriage to John Snow.