Anesthesia: the story on HearLore

Anesthesia

On the 14th of November 1804, a Japanese doctor named Hanaoka Seishu performed the first successful surgery using general anesthesia, yet the rest of the world remained unaware of his achievement for nearly forty years. Hanaoka, who studied both traditional Japanese medicine and Dutch-imported European surgery, developed a formula he called tsusensan, which combined Korean morning glory and other herbs to induce unconsciousness. He went on to perform more than 150 operations for breast cancer before his death in 1835, including resection of malignant tumors and extraction of bladder stones. However, the national isolation policy of the Tokugawa shogunate prevented his findings from being publicized until after the isolation ended. This historical silence meant that when Crawford Long, an American physician, used diethyl ether in Jefferson, Georgia, on the 30th of March 1842, he was unknowingly repeating a feat that had been accomplished in Japan decades earlier. Long noticed that his friends felt no pain when they injured themselves while staggering around under the influence of ether, and he immediately thought of its potential in surgery. He performed a painless operation on a student named James Venable, but Long did not announce his discovery until 1849, allowing others to claim the spotlight in the interim.

The Ether Dome and The Birth of Anesthesia

The public birth of modern anesthesia occurred on the 16th of October 1846, when Boston dentist William Thomas Green Morton gave a successful demonstration using diethyl ether to medical students at the Massachusetts General Hospital. Morton, who was unaware of Long's previous work, was invited to the hospital to demonstrate his new technique for painless surgery. After Morton had induced anesthesia, surgeon John Collins Warren removed a tumor from the neck of Edward Gilbert Abbott in the surgical amphitheater now called the Ether Dome. The previously skeptical Warren was impressed and stated, Gentlemen, this is no humbug. In a letter to Morton shortly thereafter, physician and writer Oliver Wendell Holmes Sr. proposed naming the state produced anesthesia, and the procedure an anesthetic. Morton at first attempted to hide the actual nature of his anesthetic substance, referring to it as Letheon, and he received a US patent for his substance. News of the successful anesthetic spread quickly by late 1846, and respected surgeons in Europe including Liston, Dieffenbach, Pirogov, and Syme quickly undertook numerous operations with ether. An American-born physician, Boott, encouraged London dentist James Robinson to perform a dental procedure on a Miss Lonsdale, which was the first case of an operator-anesthetist. On the same day, the 19th of December 1846, in Dumfries Royal Infirmary, Scotland, a Dr. Scott used ether for a surgical procedure. The first use of anesthesia in the Southern Hemisphere took place in Launceston, Tasmania, that same year.

Common questions

When did Hanaoka Seishu perform the first successful surgery using general anesthesia?

Hanaoka Seishu performed the first successful surgery using general anesthesia on the 14th of November 1804. He used a formula called tsusensan which combined Korean morning glory and other herbs to induce unconsciousness. This achievement remained unknown to the rest of the world for nearly forty years due to the national isolation policy of the Tokugawa shogunate.

Who performed the public demonstration of modern anesthesia on the 16th of October 1846?

Boston dentist William Thomas Green Morton performed the public demonstration of modern anesthesia on the 16th of October 1846. He used diethyl ether to remove a tumor from the neck of Edward Gilbert Abbott at the Massachusetts General Hospital. This event took place in the surgical amphitheater now called the Ether Dome.

When did John Snow administer chloroform to Queen Victoria during labor?

John Snow administered chloroform to Queen Victoria in 1853 when she was in labor with Prince Leopold. This event granted chloroform royal approval and demonstrated its effectiveness for childbirth. The Queen stated the experience was delightful beyond measure.

How many surgical anesthetics did Alice Magaw successfully provide without an anesthetic-related death?

Alice Magaw successfully provided more than 14,000 surgical anesthetics without an anesthetic-related death. Her records indicate she administered 1,092 cases including 674 ether cases and 245 chloroform cases without an accident. This outcome created a legacy defining that the delivery of anesthesia by nurses would serve the surgical community without increasing risks to patients.

What is the rate of deaths totally attributed to anesthesia alone compared to patient health factors?

The rate of deaths totally attributed to anesthesia alone is 1:185,056. This is significantly lower than the rate of deaths totally attributed to the patient's health which is 1:870. These statistics illustrate that the single greatest factor in anesthetic mortality is the health of the patient.

When did the Food and Drug Administration issue a warning about general anesthetic use in children?

The Food and Drug Administration issued a Public Safety Communication warning on the 14th of December 2016. The warning stated that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years may affect the development of children's brains.

The Chloroform Era and Royal Approval

Chloroform, discovered in 1831 by an American physician Samuel Guthrie and independently by Frenchman Eugène Soubeiran and Justus von Liebig, was named and chemically characterized in 1834 by Jean-Baptiste Dumas. In 1847, Scottish obstetrician James Young Simpson was the first to demonstrate the anesthetic properties of chloroform on humans and helped to popularize the drug for use in medicine. This first supply came from local pharmacists, James Duncan and William Flockhart, and its use spread quickly, with 750,000 doses weekly in Britain by 1895. Simpson arranged for Flockhart to supply Florence Nightingale. Chloroform gained royal approval in 1853 when John Snow administered it to Queen Victoria when she was in labor with Prince Leopold. For the experience of child birth itself, chloroform met all the Queen's expectations; she stated it was delightful beyond measure. Chloroform was not without fault though. The first fatality directly attributed to chloroform administration was recorded on the 28th of January 1848 after the death of Hannah Greener. This was the first of many deaths to follow from the untrained handling of chloroform. Surgeons began to appreciate the need for a trained anesthetist. The need, as Thatcher writes, was for an anesthetist to be satisfied with the subordinate role that the work would require, make anesthesia their one absorbing interest, not look at the situation of anesthetist as one that put them in a position to watch and learn from the surgeons technique, accept the comparatively low pay, and have the natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation that the surgeon demanded. These qualities of an anesthetist were often found in submissive medical students and even members of the public. More often, surgeons sought out nurses to provide anesthesia. By the time of the Civil War, many nurses had been professionally trained with the support of surgeons.

The Hidden Dangers and Modern Safety

Risks and complications as they relate to anesthesia are classified as either morbidity or mortality, and quantifying how anesthesia contributes to these can be difficult because the patient's health prior to surgery and the complexity of the surgical procedure can also contribute to the risks. Prior to the introduction of anesthesia in the early 19th century, the physiologic stress from surgery caused significant complications and many deaths from shock. The faster the surgery was, the lower the rate of complications, leading to reports of very quick amputations. The advent of anesthesia allowed more complicated and life-saving surgery to be completed, decreased the physiologic stress of the surgery, but added an element of risk. It was two years after the introduction of ether anesthetics that the first death directly related to the use of anesthesia was reported. To understand the relative risk of each contributing factor, consider that the rate of deaths totally attributed to the patient's health is 1:870. Compare that to the rate of deaths totally attributed to surgical factors 1:2860 or anesthesia alone 1:185,056, illustrating that the single greatest factor in anesthetic mortality is the health of the patient. These statistics can also be compared to the first such study on mortality in anesthesia from 1954, which reported a rate of death from all causes at 1:75 and a rate attributed to anesthesia alone at 1:2680. Direct comparisons between mortality statistics cannot reliably be made over time and across countries because of differences in the stratification of risk factors, however, there is evidence that anesthetics have made a significant improvement in safety but to what degree is uncertain. On the 14th of December 2016, the Food and Drug Administration issued a Public Safety Communication warning that repeated or lengthy use of general anesthetic and sedation drugs during surgeries or procedures in children younger than 3 years or in pregnant women during their third trimester may affect the development of children's brains.

The Brain Reboots Itself

The immediate time after anesthesia is called emergence, and emergence from general anesthesia or sedation requires careful monitoring because there is still a risk of complication. Nausea and vomiting are reported at 9.8% but will vary with the type of anesthetic and procedure. There is a need for airway support in 6.8%, there can be urinary retention, more common in those over 50 years of age, and hypotension in 2.7%. Hypothermia, shivering and confusion are also common in the immediate post-operative period because of the lack of muscle movement and subsequent lack of heat production during the procedure. Postoperative cognitive dysfunction is a disturbance in cognition after surgery, and it may also be variably used to describe emergence delirium and early cognitive dysfunction. Although the three entities are separate, the presence of delirium post-operatively predicts the presence of early POCD. There does not appear to be an association between delirium or early POCD and long-term POCD. According to a recent study conducted at the David Geffen School of Medicine at UCLA, the brain navigates its way through a series of activity clusters, or hubs on its way back to consciousness. Andrew Hudson, an assistant professor in anesthesiology states, Recovery from anesthesia is not simply the result of the anesthetic wearing off, but also of the brain finding its way back through a maze of possible activity states to those that allow conscious experience. Put simply, the brain reboots itself. Long-term POCD is a subtle deterioration in cognitive function, that can last for weeks, months, or longer. Most commonly, relatives of the person report a lack of attention, memory and loss of interest in activities previously dear to the person. In a similar way, people in the workforce may report an inability to complete tasks at the same speed they could previously. There is good evidence that POCD occurs after cardiac surgery and the major reason for its occurrence is the formation of microemboli. POCD also appears to occur in non-cardiac surgery. Its causes in non-cardiac surgery are less clear but older age is a risk factor for its occurrence.