A Blessing in Disguise: The Misuse of Anaesthesia | Association of Anaesthetists
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A Blessing in Disguise: The Misuse of Anaesthesia

A Blessing in Disguise: The Misuse of Anaesthesia

Often any discussion on anaesthesia focuses its benefits, on the fact that it is undoubtedly one of the greatest discoveries in medical history, and on grisly stories of the time before, when surgeons could saw off a limb in mere seconds. But what of the dark side of anaesthesia? In the 19th century, doctors used morphine, opium and cocaine to induce anaesthesia and in the 20th and 21st, several public figures have died as a result of overdose on anaesthetic or analgesic drugs.

This exhibition, displayed in the Heritage Centre in 2011-2012, shows how various substances, such as cocaine or morphine, were used from the earliest times to modern day, sometimes with disastrous effects. It looks at the origins of these powerful drugs, how they have been developed through history for medical use, but how they have also been misused.

nitrous-oxide-party

A nitrous oxide party in the 19th century

Anaesthetic drugs have been used through the ages recreationally and often before their medical use was discovered, as in the case of ether frolics. In the wrong hands, they have been used as murder weapons. They have been used to execute criminals and as a torture method. The exhibition illustrates the risks of addiction and overdose with celebrities, including Michael Jackson and Heath Ledger, dying from prescription pills and drug overdoses.

Modern day anaesthetic medicine is controlled by strict safety standards. Anaesthetists undergo nine years of training to learn how to administer these drugs safely. They are medically trained doctors and form the largest specialty group in NHS hospitals.

Blessing and Misuse: The Discovery

Before the 19th century, surgery was severely limited by pain, only partially offset by drugs such as opium, hashish and alcohol. Ice and pressure on nerves was used to provide local anaesthesia. The discovery of potentially useful anaesthetic drugs was almost accidental however and arose as a by-product of recreational use of new substances.

Ether had long been known to alleviate pain in colic, and to induce excitement and insensibility when inhaled mixed with air. It became popular in America at parties called ‘ether frolics’. Crawford Long, noticing that these riotous party-goers appeared insensible to pain, used sulphuric ether to remove two neck tumours in 1842. Sadly he did not publicise this and it was Morton, a Massachusetts dentist, who reaped the glory for using ether in 1846.

laughing-gas-poster

An advert for a laughing gas exhibition from 1845

Nitrous oxide had been discovered by Priestley a century previously and became the British equivalent of ether frolics. Fashionable celebrity parties included the poet Coleridge and Roget of Thesaurus fame. Nitrous oxide induced euphoria leading to dancing and recitation but unfortunately proved to be a weak anaesthetic agent. Its first public demonstration by American dentist Horace Wells in 1844 was a flop.

James Young Simpson, Professor of Obstetrics in Edinburgh, found ether unsatisfactory for relieving the pain of childbirth. He tried out various agents with friends after dinner parties. After inhaling chloroform they all collapsed but woke up the next morning unharmed. Simpson was impressed and used it in obstetric practice despite opposition from other doctors and religious ministers. Its use in obstetrics was only accepted in 1853 when Queen Victoria had chloroform administered by John Snow for the birth of Prince Leopold.

The discovery of local anaesthetic drugs also involved self-administration. Peruvian Indians were known to achieve well-being from chewing coca leaves. Cocaine, the active ingredient isolated in 1859 numbed the tongue. Freud in Vienna used it on his patients– and himself, becoming addicted in the process. But it was his colleague Koller who instilled cocaine into his own eye in 1884, producing surface anaesthesia.

Vassily Anrep performed the first nerve blocks but his work went unrecognised in the West. Thereafter Halsted in the USA used cocaine for nerve blocks (also becoming addicted), Corning accidentally performed the first spinal injection on a dog and by 1889 Bier had established the use of spinals for surgery.

In our modern world of ‘big pharma’ and research ethics we might consider these early pioneers somewhat ‘gung ho’ in their approach – but would anaesthesia have evolved without the bravado of self-experimentation?

Recreational Use & Unplanned Effects

When used by trained anaesthetists, anaesthetic drugs are safe and provide the means to allow people to undergo life saving treatment. However, when used by unqualified people, the effects can be very far from beneficial.

Anaesthetic drugs have been used as murder weapons, to execute criminals, during torture and they can be used recreationally. Exploitation of these drugs for non-anaesthetic use is sometimes justified as being for the greater good. However, anaesthetic drugs are powerful and dangerous in untrained hands.

An example of this is the Moscow theatre siege of October 2002. A group of forty to fifty armed Chechens took 850 people hostage and demanded that Russia withdraw from Chechnya. After two and a half days, a chemical agent was pumped into the theatre to break the siege. The chemical agent had been derived from Fentanyl, a drug used as an anaesthetic. As a result of this, thirty-nine of the hostage takers were killed. Sadly 129 hostages also died, all but one of them from the effects of inhaling the gas.

The misuse of anaesthetic drugs and painkillers is often brought to our attention when it involves someone famous. Michael Jackson is probably the most famous celebrity to die as a result of misusing anaesthetic drugs and painkillers. A list of some notable people who used drugs is given below:

  • Benjamin Franklin died 1 December 1788, cause of death unknown, used opium 
  • Edgar Allan Poe died 7 October 1849, cause of death unknown, used opium 
  • Robert Louis Stevenson died 3 December 1894 of cerebral haemorrhage aged 44, used opium 
  • Charlie Parker died 12 March 1955 of lobar pneumonia and a bleeding ulcer aged 34, used heroin 
  • Billie Holiday died 17 July 1959 of liver and heart disease aged 44 used heroin and was arrested for drug possession as she lay dying 
  • River Phoenix died 31 October 1993 of an overdose of cocaine, morphine, diazepam, ephedrine and marijuana aged 23 
  • Kurt Cobain died 5 April 1994, committed suicide by shooting himself in the head, used heroin 
  • Jerry Garcia did 9 August 1995 of a heart attack aged 53, used heroin 
  • Heath Ledger died 22 January 2008 of an accidental toxic combination of prescription drugs (oxycodone, hydrocodone, diazepam, temazepam, alprazolam and doxylamine) 
  • Michael Jackson died 25 June 2009 of acute propofol intoxication, the benzodiazepine effect contributed to his death. The autopsy found propofol, benzodiazepmines, nordiazepam, diazepam, lorazepam, lidocaine, midazolam and ephedrine present in his body.

Safety and Training

Following deaths from anaesthesia as early as 1847, Dr John Snow realised the importance of training those administering these dangerous drugs, and published the first textbooks on the subject. Fredric Hewitt supported the General Anaesthetics Bill which sought to ensure that anaesthetics would only be given by qualified doctors but the onset of World War 1 prevented it from becoming law. Later, others persuaded the General Medical Council and the government that patients would not be safe unless only properly trained doctors were allowed to give anaesthetics. Dentists, however, continued administering anaesthesia in surgeries until 2002.

diploma-proposal

A proposal for a diploma in anaesthetics from 1932 in the AAGBI's minutes

In 1935 the Conjoint Board of the Royal College of Surgeons and Royal College of Physicians, held the first examination for the Diploma in Anaesthetics, and in 1948 responsibility for training passed to the Faculty of Anaesthetists of the Royal College of Surgeons (now the Royal College of Anaesthetists).

Today’s anaesthetists are fully trained medical doctors.

It takes a minimum of 9 years from medical school graduation to complete this training. They cannot progress to the next stage of training until they have reached the required standards and passed the exacting two part examination of the Royal College. UK trainees who have successfully completed the whole training programme can have their names included in the General Medical Council’s Specialist Register, apply for consultant posts in the National Health Service and administer anaesthesia without supervision.

the examining board

The exam paper set for the Diploma in Anaesthetics, 1948

Exhibition

Opium 

Opium is perhaps the oldest example of a drug that has been used for medicine and recreation, and has been used in this way since antiquity, with its first recorded use believed to be in Mesopotamia over 5,000 years ago. Though laudanum, a solution opium in ethyl alcohol, was popular in the 19th century, opium itself was banned from many countries in the 20th century. However, its derivatives including codeine, morphine and heroin are still manufactured today.

Ticture-of-opium

Glass bottle for tincture of opium with metal casing. ‘Tincture of Opium’ is engraved on the side of the bottle

Morphine 

In 1804 Friedrich Stertürner isolated morphine from the opium poppy. He found that the product he had discovered induced euphoria and was a far stronger analgesic than opium. He named it morphine after Morpheus, the Greek god of dreams. In 1874 and 1897, it was discovered that morphine could be refined to produce heroin. This new drug was originally marketed as a cough suppressant (particularly for children!) and as a cure for morphine addiction. Once in the body, heroin metabolises into morphine- an extremely embarrassing discovery for the company concerned! It was more widely used after the introduction of the hypodermic needle. Bela Lugosi, who played Dracula in the 1931 film, is said to have become addicted to morphine in the 1940s after suffering a back injury, though he later managed to overcome his addiction.

mrs-winslows-syrup

A 19th century advert for Mrs Winslow’s Soothing Syrup, aimed at families. One of the major ingredients was morphine

Codeine 

This analgesic is also found in the opium poppy. Though it is synthesized from morphine, it is less potent and addictive. It may originally have been prepared in c.1715 by the chemist Lemart in the Netherlands, though it was first isolated in in 1832 in France by Pierre Robiquest.

Howard Hughes’ post mortem showed lethal levels of codeine following his death aged 70 in 1976. After his death, x-rays showed five needles in his arms which had broken off when he injected codeine.

Cocaine 

Obtained from the leaves of the coca plant, cocaine was first isolated in 1855 by Friedrich Gaedick and named erythroxyline. It was purified in 1860 by Albert Niemann and renamed cocaine. It first use as an anaesthetic was by Dr Carl Koller who applied a cocaine solution to his eye and then pricked it with pins. Its use as a spinal anaesthetic was discovered by Heinrich Quincke in 1898, who described a technique of lumbar puncture which was later used by August Bier in his experiments on spinal anaesthetic. Addiction to cocaine amongst doctors during the late 19th and early 20th centuries was surprisingly common, with one estimate at 30% of doctors and dentists.

Cocaine can still be used as a local anaesthetic, though rarely and often in combination with other synthesised drugs.

cocaine

Packaging for cocaine hydrochloride pills for ophthalmic use, manufactured by Burroughs, Wellcome & Co. Ltd, early 20th century

Nitrous Oxide or ‘Laughing Gas’

Though nitrous oxide was first synthesized by Joseph Priestly in 1772, it was then prepared and thoroughly tested by 19 year-old Humphry Davy in 1798. Davy recognised the analgesic properties of the gas and its potential to be used in surgeries, though it was almost fifty years until it was taken up.

Laughing gas parties or ‘ether frolics’ became popular amongst the upper classes from 1799, when nitrous oxide or diethyl ether was inhaled to induce feelings of euphoria.

Since Wells’ first public demonstration in 1844, nitrous oxide has been used as a light anaesthetic and analgesic and is still used as a self-administered analgesic in obstetrics and also in surgery, where it is used as a light anaesthetic before stronger drugs are added.

laughing-gas-advert

Poster for laughing gas demonstration at the Adelphi Theatre in 1824

Sodium Thiopental

This rapid onset, shorter-acting anaesthetic is administered by intravenous injection. Ernest H Volwiter and Donalee L Tabern at Abbott Laboratories in the early 1930s. It continued to be manufactured at Abbott until 2004.

Though a more modern drug than those above, it has just a dark and controversial a history as drugs such as opium and morphine.

One alternative use for it is as a truth serum. Doctors using it as an anaesthetic noticed that patients became disinhibited and talkative just before they lost consciousness. As a barbiturate, it slows down the messages that are sent to the brain and slows down the thought process, making it difficult to think clearly and thus to maintain a convincing lie. However, this process also makes the patient more suggestible and not necessarily truthful.

It has also been used as an execution tool. In 34 US states it was used as part of the lethal injection. Ohio was the first state to use a large single dose rather than a three drug cocktail, which also includes Pancuronium and potassium chloride. In 2010, the sole American supplier of sodium thiopental announced that production would stop.

Watch the clip below to discover what happened to BBC presenter Michael Moseley when he tried to convince doctors he was a famous heart surgeon, after a dose of sodium thiopental.


Ketamine (Ketalar)

This anaesthetic was developed by Parke-Davis in 1962 and given to American soldiers in the Vietnam War, where it was known as the ‘buddy drug’ because it could be administered by another soldier. It was primarily used in veterinary medicine. More recently is has become known as a drug that may be used for date rape.

ketamine-hydrochl-ldboc

Packaging for ketamine hydrochloride, c1960s

Oblivon

Perhaps not as well-known as ketamine and sodium thiopental, but far more widespread in the mid-20th century, Oblivon or methylpentynol was a hypnotic sedative with anticonvulsant effects. Developed in the 1950s, it was marketed as ‘the confidence pill’ and supposed to help with visits to the dentist, public speaking, job interviews and other potentially nerve-wracking events. Up to 1 million pills were sold weekly until 1955, when it became limited to prescriptions.

oblivon

The sedative Oblivon, c1950

The reasons behind this restriction was the reports of a burglary earlier in 1955. Two young men, aged 18 and 20, took Oblivon capsules to give them the courage to break into a house. The 18 year old drove away on a stolen motorbike and crashed, killing the 20 year old who was riding pillion.

Fentanyl (Sublimaze)

First synthesized by Paul Janssen in 1960, fentanyl is used for both anaesthesia and analgesia.

It is believed that a derivative of this drug was used by the Russian authorities to end the Moscow theatre siege in 2002, the use of which killed 40 attackers and around 140 hostages.

Ephedrine

Isolated by the Japanese chemist Nagayoshi Nagai in 1885, ephedrine is a stimulant used by athletes when training as it can be used to relax the airways. It is banned in most drug tested sports.

Ephedrine is said to have been found in the bodies of Michael Jackson and River Phoenix in their post mortems.

Tuinal, Secobarbital (Seconal) and Amobarbital (Amytal)

This piece is a combined holder for three drugs: tuinal, secobarbital and amobarbital. All of these are barbiturates and are said to have been responsible for the deaths of well-known figures.

Tuinal is a mixture of barbiturate salts secobarbital sodium and amobarbital sodium and which was developed back in the late 1940s by Eli Lilly. It acts as a sedative and has many references in popular culture. It has been claimed that Sid Vicious of the Sex Pistols took Tuinal on the night that his girlfriend, Nancy Spungen, died of stab wound. He died the following year in 1979.

Amobarbital, an analgesic barbiturate, was first synthesized in Germany in 1923. It has been suggested that this drug contributed to the death of actor Robert Walker in 1951, and that he suffered a severe reaction to this drug in combination with alcohol.

Secobarbital is another anaesthetic and sedative that was developed in the 1920s in Germnay. It was widely misused in the 1960s and 1970s, with reports of overdoses from this drug. The alleged cause of Judy Garland’s death was an accidental overdose of barbiturates. Her blood is said to have contained the equivalent of 10 seconal capsules.

tuinal-amobarbital-secobarbital

A plastic container for the three drugs, date of manufacture unknown

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