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The art of anaesthesia

Published: 26 October 2018

Before we had modern anaesthesia, surgery was horrifically painful. The search for pain relief goes back a long way, and it’s a tale of mind-altering states, poisonous plants and recreational drugs.

What is anaesthesia?

Anaesthesia is the method of using substances, called anaesthetics, to reduce or block pain during surgery and other medical procedures. Different combinations of drugs and gases are used to create different levels of insensibility, from numbing one part of the body to making someone completely unconscious.

Many attempts have been made to reduce the excruciating pain of surgery. Until the arrival of general anaesthetics, the best that a patient could hope for was an intoxicant or sedative that would dull their senses while the surgeon operated as fast as he could.

Types of anaesthetic

  • Sedation ranges from feeling very relaxed to being very sleepy, but not unconscious. It is typically used for minor surgical procedures or to relax patients experiencing discomfort or distress. It is also used in intensive care.
  • General anaesthesia is a controlled state of total unconsciousness, used for major operations and surgical procedures where the patient needs to remain still for a long time.
  • Local anaesthetics are drugs used to numb parts of the body. They are injected directly around the operation site for minor surgical procedures. Regional anaesthesia is used in  major surgery, where the patient remains conscious. In this case local anaesthetics are injected near large nerves or the spinal cord. Epidurals given in childbirth are another example of regional anaesthesia.
  • Analgesia is pain relief rather than a form of anaesthesia, but the two often involve the same drugs and are used in combination. The mildest analgesics are sold on the high street as pain killers and the most potent are opioids such as morphine, used for extreme pain.

The herbal origins of sedatives

Throughout the world, healers and mystics have used plants with mind-altering properties to alleviate pain and suffering. 

Alcohol was commonly used to make patients insensible (or intoxicated) before treatment, but it was also used as a solvent in sedative potions. Another common ingredient in sedative potions was opium, extracted from the opium poppy.  

One of the earliest examples of a sedative potion was mafeisan, a mix of herbal extracts created by the 2nd century Chinese surgeon Hua Tuo. The exact recipe is lost, but it may have contained cannabis or monkshood.

In the Middle Ages, sedative potions began to standardise around a particular group of plants, usually mixed with opium and alcohol. The English sedative dwale was an alcohol-based mixture containing bile, opium, henbane, hemlock, lettuce and vinegar.

By the 15th century, a mixture of opium, mandragora and henbane was the sedative of choice for surgical procedures such as amputation. Sedatives changed very little until the 19th century.

Many of the plants used for sedation are highly toxic and it didn't take much to turn a sedative into a poison.

Inhaled vapours

Title page of The Canon of Medicine by Ibn Sinna. 1595 Wellcome Collection, CC-BY
Title page of 'Canon of Medicine' by Ibn Sinna, published in Italy, 1595.

Vapour inhalation is an established method for ingesting medicines, especially for chest and respiratory complaints.

And sedatives act far more quickly when inhaled than when drunk as a potion. 

The Islamic physician, Ibn Sīnā (980–1037), described sedative inhalation for surgery in The Canon of Medicine, probably the most influential Medieval text in European and the Islamic medicine.

The Canon describes a 'soporific sponge', soaked in an herbal potion that is placed under the patient's nose during an operation to keep them sedated. The soporific sponge or cloth continued to be used in surgery into the 19th century.

Anaesthetic gases

While working at the Pneumatic Institute in 1798, a young Humphrey Davy tested on himself, the effects of inhaling nitrous oxide gas.

He noticed two things: the euphoric effect, which led him to call it laughing gas, and the fact that it alleviated the pain of his toothache.

He suggested that nitrous oxide could be used as an anaesthetic during surgery. His suggestion was not taken up by the medical profession, but laughing gas caught the public imagination, and demonstrations and gas inhaling ‘parties’ became all the rage.

A group of 19th century people dancing from the effects of laughing gas Wellcome Collection, CC-BY
'Doctor and Mrs Syntax making an experiment in pneumatics'. Coloured aquatint by T. Rowlandson

Henry Hill Hickman (1800–1830) introduced the term ‘suspended animation’ to the world. He experimented with the use of carbon dioxide as an anaesthetic in the 1820s. 

Unfortunately the medical journal The Lancet described his method as 'surgical humbug' and his work was dismissed. But both carbon dioxide and nitrous oxide are still used in anaesthesia today. 

General anaesthetics

The first use of A general anaesthetic 

A page from 'Illustrations of Strange diseases and their Surgical Treatments'. Surgical casebook by Hanaoka Seishū (1760-1835).

The first reliably recorded use of a general anaesthetic was in Japan, in 1804. Physician Seishu Hanaoka performed a partial mastectomy on a 60-year-old woman with breast cancer. 

His patient survived the operation, but she died six months after surgery. Hanoaka continued to perform complex surgery, which was often successful. He also trained more than 2,000 students throughout his career.

Hanoaka used a herbal mixture that was drunk rather than inhaled. It contained two very potent plants: monkshood and thorn apple.

His anaesthetic did not spread beyond Japan, and the rest of the world had to wait nearly 50 years for general anaesthesia.

Ether or chloroform?

Ether (diethyl ether) was the first general anaesthetic to be used widely in surgery. Michael Faraday actually published a report on the sedative and analgesic properties of this volatile and flammable liquid in 1818.

But as with nitrous oxide, it was appreciated more for its intoxicating effects than its anaesthetic properties. People attended ‘ether frolics’ to experience the effects of inhaling the vapour, public demonstrations were given and it was sold as an alternative to alcohol in pubs and shops in Britain and Ireland.

In the 1840s, medical students and dentists who attended ether frolics began to notice that people under the influence seemed to feel no pain. Boston dentist William Morton experimented with ether on himself before using it as an anaesthetic on his patients.

One of the reasons why dentists took up both nitrous oxide and ether more readily than surgeons was that their patients didn’t need to be insensible for long, and both substances were safer to use and control in small doses.

A photograph of an operation using ether at Massachusetts General Hospital in 1847.

In 1846, Morton participated in the first public demonstration to use ether as a general anaesthetic in surgery at Massachusetts General Hospital. The operation was judged a success and surgeons across Europe and America were quick to see the potential benefits of a general anaesthesia. 

In Edinburgh, Professor of Midwifery James Young Simpson became an enthusiastic advocate of anaesthesia and pioneered its use for women during childbirth.

Simpson discovered an alternative anaesthetic to ether—chloroform, a sweet-smelling, dense liquid. Chloroform received the royal seal of approval when Dr John Snow administered it to Queen Victoria during the birth of two of her children.

The effects of liquid chloroform of James Young Simpson and his friends, 1840s
In the tradition of the ether frolic, Simpson and his friends tested chloroform on themselves first (c.1840s)

Surgeons in England shifted to chloroform because it was easier to use, while the Americans stuck to ether because it had fewer risks. But whether it was ether or chloroform, by the end of the 19th century general anaesthetics were widely accepted.

Early anaesthetic equipment followed the inhalation method of putting some drops of ether or chloroform on a cloth and placing it over the patient's nose and mouth. Later equipment was designed for gases and the method of administration switched to injections with pharmaceutical anaesthetics. Local anaesthetics and pain relief could also be applied as eye drops, creams and tablets.

Fast-acting pharmaceutical anaesthetics

Advances in chemistry and pharmacology led to the manufacture of effective pharmaceutical anaesthetics. At first these were extracted from the plants used in traditional sedatives, but later new drugs were synthesised, which were more effective and had fewer side-effects.

Pharmaceutical drugs were administered intravenously, by injection, which meant that they were even faster to take effect than inhaled vapours and gases. They also had some very dark uses.

The modern anaesthetist

By the 1950s, all the elements of modern anaesthesia were in place. Anaesthesia has become part of the fabric of modern medicine. And anaesthetists are often the largest group of doctors in a hospital.  

Dr Andrew Morely is a Consultant Anaesthetist at Guy's and St Thomas' NHS Trust in London. In this film he talks about modern anaesthesia and explain some of the complexities of being an anaesthetist.

Suggestions for further research

  • Blessed Days of Anaesthesia: How Anaesthetics Changed the World by S J Snow,  2008.
  • Chloroform: The Quest for Oblivion by L Stratman, 2003.
  • Notable names in anaesthesia by R J Maltby, 2002.

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