Celebrating 75 years of Anaesthesia: our past, present and future | Association of Anaesthetists
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Celebrating 75 years of Anaesthesia: our past, present and future

Celebrating 75 years of Anaesthesia: our past, present and future

Contemporary Classics 728X90 WOL

In 1946 the Association launched our new quarterly publication, Anaesthesia, with a foreword from the then president of the Royal College of Surgeons of England. The associated editorial from Henry Featherstone recounted the many challenges of the time, and set out why the inauguration of our own specialty journal was necessary. Its publication came 100 years following the first use of ether in the UK in 1846, and now, 75 years later, we celebrate our own anniversary.

‘Contemporary Classics’ is a new limited monthly series of articles which we have commissioned to celebrate our 75th anniversary. These will feature an important paper published from each decade of Anaesthesia, as selected by a member of the current editorial board. Our hope is to celebrate our history, but at the same time use our past to look forward to our future. We have selected a team of guest authors, some with an interest in the chosen paper or topic, and some with their own attachment to the history of the journal.

We will also feature monthly blog posts from the Heritage Centre, on topics related to these journal articles. The Heritage Centre will also run Heritage Lates, which will look back at some of the key developments within anaesthesia throughout the decades, since the journal's inception. You can find out more by following the Heritage Centre on Twitter.

The 1950s

Deaths associated with anaesthesia – 65 years on

In 1949, the Council of the Association of Anaesthetists announced the launch of an “investigation of deaths associated with administration of anaesthetic”. Two articles describing specific complications associated with death were published during the investigation but the complete report, 'Deaths associated with anaesthesia’ by Edwards et al., was published in Anaesthesia in 1956 and is this month’s ‘Contemporary Classics’ publication. 

The conclusion states: "The way in which the data have been collected precludes the formulation of inferences with respect to the relative safety of the different agents and techniques, and the relative frequency of the various forms of fatality in the country as a whole. But much information of clinical interest has been produced. From this it appears that some of the cases are inexplicable. It is to be hoped that light may be thrown on such by more frequent and accurate reporting, and by ad‐hoc investigations. In the great majority of the reports, however, there were departures from accepted practice. This fact, and its implications, should receive the attention of those responsible for the teaching of anaesthesia."

Read the full article in the journal

Safe in Sleep - a blog post from the Heritage Centre

The most cited Anaesthesia journal article in the 1950s was, Deaths Associated with Anaesthesia: A Report on 1,000 Cases, which was published in 1956, and authored by George Edwards, H.J.V. Morton, E.A. Pask and W.D. Wylie.

In 1949 the Council of the Association of Anaesthetists encouraged the voluntary reporting of deaths associated with anaesthesia. Questionnaires were distributed to all hospital groups, and the project was publicised in Anaesthesia. The authors noted above were appointed as a committee to review the returned questionnaires and the article, Deaths Associated with Anaesthesia, is an analysis of the causes of deaths associated with anaesthesia and the authors’ observations.

Given the motto of the Association, in somno securitas (‘Safe in Sleep’) it is hardly surprising that the Association commissioned this study. This study developed into the Confidential Enquiry into Perioperative Deaths (CEPOD) in the 1980s. This became the National Confidential Enquiry into Perioperative Deaths (NCEPOD) and fulfils a similar role today.

It was most likely that these deaths were caused by incorrect dosages, rather than the anaesthetic agent itself. The administration of anaesthetic by doctors who weren’t anaesthetic specialists was also a factor.

Anaesthetic death inquiries began during the 1840s in the earliest days of anaesthesia. John Snow and James Young Simpson investigated reported deaths from anaesthesia, hoping to improve patient safety. From March 1847, coroners held inquests into every “anaesthetic death.” It was most likely that these deaths were caused by incorrect dosages, rather than the anaesthetic agent itself. The administration of anaesthetic by doctors who weren’t anaesthetic specialists was also a factor.

Continued high number of deaths attributed to chloroform led the Royal Medical and Chirurgical Society (now the Royal Society of Medicine) to appoint a Committee in 1863 to investigate why this was and how it could be avoided in the future. Joseph Clover led the enquiry, which recommended that the pulse be monitored throughout an anaesthetic.

Clover with his chloroform apparatus 1862

Clover with his chloroform apparatus 1862

The Royal Humane society was an early advocate of ‘training’ to reduce the number of unnecessary deaths. Concerned by the number of people mistakenly thought to be dead (and sometimes buried alive!), Doctors William Hawes (1736-1808) and Thomas Cogan (1736-1818) founded the Royal Humane Society in 1774. The doctors wanted to promote the new resuscitation technique, and even offered money to anyone who used it to try and save someone.

Their hope was to restore, ‘a father to the fatherless, a husband to the widow and a living child to the bosom of its mournful parents’.

The first meeting of the Society was held with fifteen of their friends on 18 April 1774 at the Chapter Coffee House, St Paul’s Churchyard. Their hope was to restore, ‘a father to the fatherless, a husband to the widow and a living child to the bosom of its mournful parents’.

The Royal Humane Society (then called the Society for the Recovery of Persons Apparently Drowned) set five aims: 

  • to publish information on how to save people from drowning
  • to pay two guineas to anyone attempting a rescue in the Westminster area of London
  • to pay four guineas to anyone successfully bringing someone back to life 
  • to pay one guinea to anyone – often a pub-owner – allowing a body to be treated in his house 
  • to provide volunteer medical assistants with some basic life-saving equipment

Reports reveal that mouth-to-mouth resuscitation was practiced as early as the fifteenth century, while Paracelsus was the first to experiment with bellows a century later. The bellows method was preferred by the Royal Humane Society. Their resuscitation set contained equipment that could inject fresh air or stimulants such as tobacco into the lungs, stomach, or rectum, and were located by the River Thames, London for anyone to access. The Society has kindly lent two of their kits to the Anaesthesia Museum, and one is currently on display.

The effects of putting pressure on the chest to restart the heart had been known in the nineteenth century, but although German surgeon Dr Friedrich Maass successfully used external compressions to restart the hearts of two patients in 1891, his method did not catch on at the time. Only when researchers rediscovered external compressions in 1933 did it become widely used.

Tobacco smoke enema

Tobacco smoke enema

The first defibrillator was described in 1774 by Charles Kite. In that year, a 3-year-old child, Catherine Greenhill, fell from an upstairs window onto flagstones and, despite being declared dead, was successfully treated with electricity by an apothecary, Dr Squires. Again, it wasn’t until the 1930s that Dr W. Kouwenhoven developed internal and external defibrillation.

During the late 1950s dramatic changes took place in attitudes towards and technology for resuscitation. The new technique was to directly introduce air under pressure to ventilate the lungs. An early method was ‘mouth-to-mouth’, reintroduced by Dr Peter Safar, in which the resuscitator blew directly into the patient’s lungs, or via a tube or airway such as the Safar or the Brook. Until the 1960s, resuscitation was generally performed in hospitals. When Dr Bullough resuscitated Sylvia Berwick at the scene of a roadside accident in 1963, it was headline news.

The invention of the Ambu bag in 1956 proved to be a milestone in resuscitation equipment. Following a shortage of oxygen in Danish hospitals, Dr Henning Ruben developed the first artificial manual breathing unit, a self-inflating resuscitator and ventilation valve. It allowed the manual ventilation of the patient with room air or oxygen. Automatic gas powered resuscitators followed, such as the Stephenson and the Pneu Pac. These work off a cylinder of pressurised oxygen with an adjustable proportion of air. If connected to an endotracheal tube they can ventilate automatically, leaving the resuscitator’s hands free. They are often carried by the emergency services.

The 1940s

The science of neuromuscular blockade, 75 years on

This month, we focus on the 1940s, and we have chosen the first original article published in the journal which looked at curarisation as compared with other methods of securing muscle relaxation in anaesthesia. Of course, we no longer refer to such agents as ‘muscle relaxants’, due to our detailed understanding of their mechanism of action at the neuromuscular junction, which is different from muscle relaxants used in musculoskeletal disorders that act on the spinal cord or brain. This point becomes important when thinking about some of the language used throughout the paper.

The author, Frank Barnett Mallinson (23/07/1905–14/ 06/1965), was born in Malta and was a full-time anaesthetist at Woolwich Memorial Hospital from 1938. Previously, he worked as a general practitioner (as did many anaesthetists of his time) but his real interest was in patient safety and he was also an early advocate for road safety. At the time, the balance between achieving optimal neuromuscular blockade to facilitate surgery and the need to avoid excessive depth of anaesthesia was a cause of much concern, and the use of intocostrin (curare) was postulated as a new and exciting solution. His paper came 4 years after Harold Griffith and Enid Johnson reported the first case series of 25 patients who received intocostrin in clinical practice, and at a time where the field of anaesthesia was undergoing enormous change at the end of the Second World War. There are several themes from his paper that are arguably as applicable to clinical practice now as they were then. 

Read the full article in the journal

Explorer and botanist: The story of Richard C. Gill and curare - a blog post from the Heritage Centre

Richard C. Gill could be described as an adventurer, certainly a researcher, and an amateur ethnographer and botanist. Gill was born in America in 1901. Following in the family tradition, at university he studied medicine, but only for two years before deciding it wasn’t for him. He went on to read English at Cornell University and subsequently worked as a teacher and a Ranger in Yellowstone National Park. In 1928 he moved to South America to work for a rubber company, but left when the business was hit by the Great Depression in 1929. Gill and his wife Ruth loved the country so much, they decided to stay and establish a ranch to grow coffee and plants, and from where Richard could study the culture of the local peoples, and explore the jungle. After eight months of searching, they bought land in Ecuador and built the Rio Negro ranch.

Whilst living on the ranch, Gill made many expeditions into the jungle where he studied the people and built relationships with the local tribes and their leaders. His studies included their social practices, music, and use of botanicals for medicine. He became fascinated by the herbal remedy preparations of the shamans and watched them prepare arrow poison (curare). The tribes used curare coated darts or arrows in blow pipes and bows to shoot and kill or stun animals for food and clothing. When injected into the bloodstream curare acted as a muscle relaxant, which paralysed and asphyxiated prey. The mixing of curare poison and creating weapons is a highly skilled process. Different strength of poison is needed depending on the size of the prey, and mixing these accurately can only be determined by taste, curare is not toxic through ingestion alone. Learning about this poison directly from those that prepared and used it was therefore very important.

Yahua_Blowgun_Amazon_Iquitos_Peru_Creative Commons_Attritbue photographer JialiangGao

Yahua Blowgun Amazon Iquitos Peru, Creative Commons Attritbue photographer JialiangGao

However, arrow poison was not a new discovery, it has been known to Europeans since Sir Water Raleigh’s expeditions to Guyana in 1595. It was first brought back to England in the 1760s by Edward Bancroft (1741-1821) who had encountered the poison during his time in Guyana writing, An Essay on the Natural History of Guiana in South America.

In the nineteenth century, Naturalist Charles Waterton (1782-1865) brought curare samples, or ‘wourali’ as he called it, back to England and conducted experiments on animals. In 1814 at the Royal Vetinanary College in London, along with Benjamin Collins Brodie, Waterton administered wourali to a donkey whilst ventilating it with bellows until the poison wore off.

After Waterton’s experiments, more scientific work was conducted by physicians of the nineteenth century. It was Claude Bernard’s (1813-78) experiments on frogs in 1844 which showed conclusively that curare was acting as a muscle relaxant. He noted that, “it is an anaesthetic agent only in appearance. The animal feels, but cannot show it”.

However, it wasn’t until Gill’s discoveries in the 1930s that the scientific research of curare really got underway.

Gill’s determination is shown by the physiotherapy care plan he devised for himself, which in two years saw him able to drive, and by 1938, he was able to walk with the aid of a walking stick.

In 1932, Gill fell from a horse and suffered neurological symptoms, the symptoms were assumed to be a result of the fall, but he was later diagnosed with multiple sclerosis. A severe attack in 1934 left Gill with near total paralysis and severe muscle spasms. This led him and his neurologist Walter Freeman to explore the idea of using curare to alleviate the spasms. Gill’s determination is shown by the physiotherapy care plan he devised for himself, which in two years saw him able to drive, and by 1938, he was able to walk with the aid of a walking stick. Throughout his rehabilitation he taught himself botany, spoke with pharmacists, botanists and doctors and read relevant texts, he was also making plans for an expedition to collect curare and plants which might relieve his symptoms.

In May 1938, funded by Sayre Merrill, Gill set off into the jungle in search of curare and other plant specimens with a crew of around 95 people, 36 mules, 12 canoes and two tons of equipment. The trip to the jungle base camp took three weeks. The camp was fully equipped with thatched roofed buildings housing living and sleeping quarters, a kitchen, office and laboratory. Here Gill hoped, “to see curare being made, learning all I could about its making, and bringing back that knowledge for those who needed it.” After five months he had done just that. Gill and his crew returned with around 75 plants and 12kg of curare.

Gill sent his plant specimens and botanical specimens of curare, which he’d collected, dried, and pressed, to botanist B.A. Krukoff at the New York Botanical Garden to be identified. They became part of the Steere Herbarium’s collection, where they remain today.

Gill manufacturing curare, c.1938_Arthur Guedel Anaesthesia Collection, University of California San Francisco

Gill manufacturing curare, c.1938 Arthur Guedel Anaesthesia Collection, University of California San Francisco

On returning to America, Gill supplied some of the curare to A.E. Bennett, a psychiatrist from Nebraska and A.R. McIntyre, Chairman of the Department of Pharmacology of the University Of Nebraska College Of Medicine. McIntyre agreed to standardise it and Bennett used it in early trials with patients suffering compilations from shock therapy treatment. In 1939, E.R. Squibb and Son bought Gill’s supply of curare and began researching its properties. Two of Squibb’s scientists reported that they had been able to extract an alkaloid similar to d-tubocurarine from the bark of Chondrodendron Tomentosum and had developed a new method for preparing curare. It was also found to be in the bark of Strychnos Toxifera. This synthesised curare was marketed by E.R. Squibb and Son in 1939 as Intocostrin. It was first used in electroconvulsive therapy (ECT) to control spasms during convulsion therapy, in the treatment of tetanus, and finally in 1942 for anaesthesia.

Before the advent of curare in the 1940s, in order to achieve muscle relaxation anaesthetists would have had to administer a very deep ether or cyclopropane anaesthesia, which could cause a number of heart, liver or kidney complications.

The synthesised curare was successfully used in anaesthesia when Harold Griffith and Enid Johnson used the preparation of curare, Intocostrin, successfully in 25 patients who were lightly anaesthetised with cyclopropane. In Britain, Cecil Gray found Intocostrin unreliable and instead popularised the use of d-tubocurarine chloride, which was more consistent in its potency. D-tubocurarine would become the muscle relaxant of choice until curare-like synthetic agents replaced natural curare from the 1980s onwards.

Before the advent of curare in the 1940s, in order to achieve muscle relaxation anaesthetists would have had to administer a very deep ether or cyclopropane anaesthesia, which could cause a number of heart, liver or kidney complications. Additionally, with the total paralysis of a patient’s diaphragm, these surgeries were only possible with the invention of tracheal intubation and mechanical ventilation of the lungs.

Now, with muscle relaxants and manual ventilation, life saving heart, brain and thoracic surgeries can be performed.

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