A Brief History
of Anaesthesia
Andrew Ronald
Consultant Cardiac Anaesthetist
Aberdeen Royal Infirmary
alronald@tiscali.co.uk
Why study the History of
Anaesthesia?
• An understanding of our past guides our future
• The history of surgery is inextricably linked to
the development of appropriate anaesthetic
techniques and so the history of surgery follows
the history of anaesthesia
• We are all part of it
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History of Anaesthesia
• Pre-1846 - the foundations of anaesthesia
• 1846 - 1900 - establishment of anaesthesia
• 20th Century - consolidation and growth
• 21st Century - the future
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Pre-1846
The Foundations of Anaesthesia
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Pre 1846 - The Foundations of
Anaesthesia
……..so the Lord God caused him to fall
into a deep sleep. While the man was
sleeping, the Lord God took out one of
his ribs. He closed up the opening that
was in his side……...
Genesis 2:21 NIrV
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The Foundations of Anaesthesia
• Drug methods
• Non-drug methods
– Alcohol
– Cold
– Opium (poppy)
– Concussion
– Hyoscine (Mandrake)
– Carotid compression
– Cannabis (Hemp)
– Nerve compression
– Cocaine (New World)
– Hypnosis
– Blood letting
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The Foundations of Anaesthesia
• Status of surgery
– Barber shop surgeons
• Types of surgery
– Amputations & dental
extractions
– No antisepsis
– Appalling mortality
• Indications
– Unbearable pain
– Crippling deformity
– Imminent death
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“…the case was an interesting one of a white swelling, for
which the thigh was to be amputated. The patient was a
youth of about fifteen, pale, thin but calm and firm. One
professor felt for the femoral artery, had the leg held
up for a few moments to ensure the saving of blood, the
compress part of the tourniquet was placed upon the
artery and the leg held up by an assistant.
The white swelling was fearful, frightful. A little wine
was given to the lad; he was pale but resolute; his
Father supported his head and left hand. A second
professor took the long, glittering knife, felt for the
bone, thrust the knife carefully but rapidly. The boy
screamed terribly; the tears went down the Father’s
cheeks. The first cut from the inside was completed, and
the bloody blade of the knife issued from the quivering
wound, the blood flowed by the pint, the sight was
sickening; the screams terrific; the operator calm….”
Contemporary description of surgery, 1841
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What changed?
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Industrial and Scientific Revolution
• 1540: synthesis of ether
• 1628: circulation of blood
•
•
•
•
•
•
•
1709: iron formed from coke
1712: first steam engine
1733: flying shuttle
(1745: Battle of Culloden)
1769: water frame
1769: Watt steam engine
1771: cotton mills
• 1779: first iron bridge
• (1789: French Revolution)
• 1801: first steam carriage
• 1744: ether inhalation
suggested to treat pain
•
•
•
•
•
1770’s: research on CO2
1771: discovery of O2
1772: “Mesmerism”
1773: discovery of N2O
1794: gas therapy in illness
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Industrial and Scientific
Revolution
• Late 1700’s
– lots of new gases identified
– attempts to apply gas knowledge to medicine
– directed at treatment of existing diseases rather than
novel use
• Gases of importance
–
–
–
–
nitrous oxide
ether
carbon dioxide
oxygen
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Gas Therapy in Illness
• Pneumatic Institute, Dowry Square, Clifton, Bristol
• founded by Thomas Beddoes (1760-1808) in 1794 with
equipment designed by James Watt (1736-1819)
• attempted to use used gas therapy (incl. oxygen, nitrous
oxide & ether) to treat diseases incl. asthma, dropsy,
consumption, & venereal disease
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Pneumatic Institute
New medical institution.
Upper end of Dowry-Square, Hotwells, corner house.
Treating incurable diseases.
Medical professors at Edinburgh.
Many Physicians in England.
Consumption, Asthma, Palsy, Dropsy, obstinate Venereal Complaints,
Scrophula or King's Evil.
Other incurable diseases.
Patients treated gratis.
Expectation: Considerable portion of cases will be permanently cured.
Methods are not hazardous or painful.
Attendance will be given from 11 till 1 o'clock by Thomas Beddoes or
Humphrey Davy.
Subscriptions for support of Institution received by John Savery, Esq.,
Narrow Wine Street, Bristol.
Bristol Gazette March 21 1799
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Pneumatic Institute
Humphrey Davy (1778-1829)
• became Superintendant in
1798
• continued Priestley’s and
Beddoe’s Work
• Nitrous oxide & Ether
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Humphrey Davy &
the Pneumatic Institute
• Recognised analgesic properties of N2O and christened it
“laughing gas”
• first tentatively suggested a use during surgery
“…as nitrous oxide in its extensive operation appear
capable of destroying physical pain it may be used
with advantage during surgical operations in which no
great effusion of blood takes place …”
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Gas Therapy in Illness
Nitrous oxide
Ether
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Nitrous oxide
• 1800: Davy’s thesis
• 1834: Colton “anaesthetised”
6 Red Indians by mistake
• 1844: Horace Wells had his
own tooth pulled under N2O -
“a new era in tooth pulling”
• 1845: Wells “failed” to
demonstrate N2O at MGH
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Ether
• 1540: synthesised and named “sweet oil of vitriol” by
Valerius Cordus
• renamed “ether” by Frobenius
• 1744: Matthew Turner published essay suggesting its
inhalation in certain types of pain
• late 1790’s: research at Pneumatic Institute
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Ether
• 1818: Michael Faraday
(1791-1867) described
“narcotic effects” of
ether
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Ether
• 1821: Benjamin Brodie (17831862) demonstrated to Royal
College of Surgeons that
ether inhalation could induce
insensibility in a guinea pig -
“….ether acted like a narcotic
poison……”
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Ether
• 1842: first use as
clinical anaesthetic
in USA
• 16th October
1846: first public
demonstration of
ether anaesthesia
in Boston, Mass.
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• William T G Morton
“Inventor and Revealer
of Inhalational
Anaesthesia: Before
Whom, in All Time,
Surgery was Agony; By
Whom, Pain in Surgery
was Averted and
Annulled; Since Whom,
Science has Control of
Pain.”
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So why no anaesthesia until 1846?
• Why did Davy not pursue his work?
• no real concept of “anaesthesia” in late 1700’s / early 1800’s
 how can you achieve a state which you assume impossible or
cannot envisage achieving
• Pneumatic Institute concerned with treatment of disease by
“Physicians” - surgery did not have same standing and
therefore influence
• State of surgery - almost inevitably fatal - why encourage
them?
• General moral / religious beliefs and fear / concerns about
animal experimentation
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So why no anaesthesia until
1846?
Or wasn’t there?
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Henry Hill Hickman (1800-1830)
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Henry Hill Hickman and carbon dioxide
• Born at Lady Halton, Bromfield, Shropshire
• matriculated at Edinburgh University 1819
• attended lecture “On Asphyxia” by Henry Goldwyer - “a
temporary suspension of the vital functions arising from a
deficiency of atmospheric air..” and described reversal
using artificial respiration & electrical restarting of heart
• admitted as member of RCS London 1820
• set up practice in Ludlow, Shropshire
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Henry Hill Hickman
• 1821-1824: series of experiments on small animals to
induce “suspended animation”
• semi-asphyxiation due to air starvation or by breathing
Carbonic Acid (CO2) gas
• after unconsciousness was induced Hickman operated on
them - amputations, removal of ears, skin incisions - and
observed responses to surgery, evidence of pain, amount
of bleeding and time to recovery
• 1824: attempted to bring work to notice of Royal Society
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Henry Hill Hickman
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Henry Hill Hickman
“……there is not an individual who does not shudder at the idea of
an operation however skillful the Surgeon or urgent the case,
knowing the great pain that the patient must endure, and I
have frequently lamented, when performing my own duties as a
Surgeon, that something has not been thought of whereby the
may be tranquillised and suffering relieved …..I have been
induced to make experiments on Animals, endeavouring to
ascertain the practicability of such treatment on the human
subject……I have witnessed results which show that it may be
applied to the animal world , and ultimately I think will be used
with perfect safety and success in Surgical operations…..I have
never known of a case of a person dying after inhaling Carbonic
Acid gas if proper means were taken to restore the animal
powers …..”
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Henry Hill Hickman
• 1824: moved to Shifnal
• 1824: “A Letter on
Suspended Animation” (W
Smith, Ironbridge, 1824)
to TA Knight of Downton
Castle
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Henry Hill Hickman
• 1825: having failed to attract
attention of Knight, Davy and
Royal Society wrote to
Shrewsbury Chronicle (dated 3rd
June)
• Anonymous writer (“Antiquack”)
responded to “Letter on
Suspended Animation” and
Shrewsbury Chronicle article in
The Lancet 1825
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Henry Hill Hickman
•
“…can he for a moment suppose that any medical man of sense
and judgement will be so far led away by a proposal so utterly
at variance with all he has ever heard, saw, or read, of the
deleterious effects of respiring the fixed air to believe that
that this letter was published with any intention of benefiting
mankind... intended to serve as a decoy by which credulous
may be induced to give up their senses as well their cash to
men…”
•
“…an open and downright quack is superior to a plausible
quacking physician… “
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Henry Hill Hickman
•
“…I sincerely hope, and believe, for the credit of the
profession, be utterly impossible to find any surgeon so great a
fool, and so unwarrantably bold as to undertake that operation
on such terms..”
•
“…I do fervently hope that the letter itself may be a complete
hoax, and not written by Dr Hickman; for, in this age of
science and gentlemanly acquirement, I feel assured, that no
man who has any claim to the honourable appellation of a Doctor
of Physic would so far disgrace both his profession and himself
by writing such a tissue of quackery, which he himself, and
every medical man must know is (to say the least) humbug”
signed Antiquack, The Lancet 1825
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Henry Hill Hickman
• 1828: appeal to Charles X
of France - referral to
Royal Academy of
Medicine in Paris
• 1829: returned to
practice in Tenbury
Wells, Shropshire
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Henry Hill Hickman
• 1830: died; buried in
Bromyard churchyard
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Henry Hill Hickman
• 1847: letters in Lancet by
Thomas Dudley of
Kingswinford identifying
Hickman’s work with reports
of “the Letheon”
• 1912: first modern reference
to Hickman Thompson CJS.
Brit Med Jour 1912 ; i: 843845
• 1930: plaque erected by
Section of Anaesthetists of
RSM
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1846-1900
The Establishment of Anaesthesia
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1846-1900
• General Anaesthesia
– Ether
• spread to Europe
– Nitrous oxide
• Local Anaesthesia
– anaesthesia without
sleep
• New techniques
– early landmarks
– Chloroform
• James Young Simpson
• John Snow
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Ether
• 16th October
1846: first public
demonstration of
ether anaesthesia
in Boston, Mass.
• “Gentlemen this is
no humbug. We
have seen
something today
that will go round
the world”
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Ether - the news spreads
• Letter and other papers
from Jacob Bigelow
(description of his
daughters surgery under
ether and relevant copy
of Boston Daily Adveriser)
sent to Francis Boott in
London
• News carried by Cunard
paddle steamer “Acadia”
leaving Boston 3rd Dec
1846 and arriving
Liverpool 16th Dec 1846
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Ether - the news spreads
• 17th Dec 1846: Boott received letter and arranged with
dentist James Robinson to experiment with ether
inhalation
• 19th Dec 1846: ether administered by James Robinson to
a Miss Lonsdale for molar extraction at Boott’s home
• 21st Dec 1846: Robert Liston, Professor of Surgery at
University of London publicly amputated the leg of
Frederick Churchill at UCH - “This Yankee dodge beats
mesmerism hollow”
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Ether - the Dumfries connection
• William Fraser
– Cunard Ship’s surgeon
• 19th December 1946
– ? 1st European use of
Ether anaesthesia
• What case?
– probably an amputation of
a leg in a patient run over
by a cart - patient died
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Ether - the news spreads
• 1847: arrival of Ether
Anaesthesia announced in first
edition of “The Lancet” of 1847
• Letter from Francis Boott
• Letter to Boott from Henry
Bigelow
• Paper from Boston Medical and
Surgical Journal
• Robert Liston’s own experiences
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Ether - the news spreads
• 1847: Liston became an increasingly important supporter
of ether in the following months at a time when many
surgeons tried, then abandoned its use returning to
practice without anaesthesia
• Reasons for possible abandonment
–
–
–
–
–
–
attempts to “patent” anaesthesia and so limit its use
inadequate anaesthesia
excessive secretions
vomiting patients
risk of explosion and fire (candlelight!)
perceived “risks” of rendering patient unconscious for
surgery
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Nitrous oxide
• 1847: Horace Wells published paper “A History of the
Discovery of the Application of Nitrous Oxide Gas, Ether
and Other Vapours to Surgical Operations”
• 1863: Colton “reintroduced” N2O, primarily for
dental surgery
• 1865: N2O cylinders available in London
• 1881 pain relief in labour
• 1887 Hewitt “gas and oxygen machine”
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Chloroform
• 1831: Chloroform synthesised
• 1833: Cynthia Guthrie accidentally anaesthetised
herself!
• 1847: Anaesthetic properties recognised
• 1847: First clinical use, St Barts, London
• 1847: James Young Simpson used chloroform for
obstetric anaesthesia
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James Young Simpson (1811-1870)
• Professor of Midwifery in
Edinburgh from 1840
• Tried chloroform on
himself and friends at
suggestion of David
Waldie, a chemist
• Secured and popularised
chloroform as clinical
anaesthetic, esp. in
Obstetrics
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James Young Simpson
• many objections to analgesia for childbirth
• religious and moral
• Genesis 3:16 - “…..The Lord God said to the woman, I
will greatly increase your pain when you give birth. You
will be in pain when you have children. You will long for
your husband. And he will rule over you……..”
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Chloroform
• 1847: John Snow’s regulating inhaler
• 1847/48: Chloroform eclipses ether
• 1848: Hannah Greener - first anaesthetic death
• 1858: John Snow “On Chloroform and other
anaesthetics”
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John Snow (1813-1858)
• Born in York in 1813
• became interested in
anaesthesia via work in
toxicology
• apprenticed in Newcastle,
then worked in London
1836-1858 until his death
• acknowledged as “first fulltime” anaesthetist
developing ways to improve
methods of ether and
chloroform administration
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John Snow
• “Chloroform a la Reine”
• Prince Leopold
– born 7th April 1853
• Princess Beatrice
– born 14th April 1857
• helped to overcome
religious and moral
objections to analgesia
for childbirth
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“….administered Chloroform to the Queen in her confinement…. Dr. Locock
was sent for about nine o'clock this morning, stronger pains having
commenced, and he found the os uteri had commenced to dilate a very
little. I received a note from Sir James Clark a little after ten asking
me to go to the Palace. I remained in an apartment near that of the
Queen……………. At a twenty minutes past twelve by a clock in the
Queen's apartment I commenced to give a little chloroform with each
pain, by pouring about 15 minims by measure on a folded
handkerchief……. Her Majesty expressed great relief from the
application, the pains being very trifling during the uterine contractions,
and whilst between the periods of contraction there was complete ease.
The effect of the chloroform was not at any time carried to the extent
of quite removing consciousness. Dr. Locock thought that the chloroform
prolonged the intervals between the pains, and retarded the labour
somewhat. The infant was born at 13 minutes past one………..consequently
the chloroform was inhaled for 53 minutes. The placenta was expelled in
a very few minutes, and the Queen appeared very cheerful and well,
expressing herself much gratified with the effect of the chloroform…”
John Snow Thurs 7th April 1853
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John Snow
• World’s first epidemiologist
• “On the mode of
communication of cholera”
self- published in 1849
• July 1854 - cholera outbreak
in Broad street area of
London
• September 1854 - Snow
removed handle of Broad
Street pump
• outbreak declared over 7 days
later
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John Snow
• John Snow Society
• Pump handle lecture
• Blessed chloroform lecture
• John Snow Pub
• March 2003 - John Snow
voted “greatest doctor of
all time”
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Local Anaesthesia in the C19th
• 1884:
Cocaine
• 1885:
Spinal analgesia for pain relief - Corning
• 1890:
Oil of cloves (Eugenol)
• 1891:
Tropocaine
• 1892:
Infiltration LA
• 1898:
Spinal anaesthesia for surgery - Bier
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Other C19th Landmarks
• 1865:
Lister introduced “Carbolic spray” - antisepsis
• 1878:
first oral ETT - flexible brass, 0.95cm diam
• 1891:
first partial pneumonectomy; no ETT
• 1894:
first anaesthetic charts
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The 20th Century
Consolidation and Growth
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The 20th Century
Whereas in the late 18th / early 19th centuries
the Industrial Revolution and sociological
change triggered the events which led to the
development of Anaesthesia, in the 20th
Century increasing prosperity, better medical
treatment, increased expectations, transport
and modern warfare culminating in two World
Wars has driven both the science and speciality
of anaesthesia to new heights
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• Intubation and airway advances
• Anaesthetic equipment
• Monitoring
• Drug advances
• Local anaesthetic advances
• Speciality advances - ITU & pain
• General progression of speciality
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Intubation and airway advances
• 1919: Endotracheal intubation (Magill & Rowbotham),
Queens Hospital, Sidcup
• 1928: Blind nasal intubation
• 1931: first double-lumen tube (Gale & Waters)
• 1949: Carlens double-lumen tube
• 1950’s PVC tubes introduced
• 1980’s PVC finally replaces Red Rubber tubes. Rae (Ring,
Adair & Elwyn) tubes & LMA’s introduced
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Anaesthetic Equipment
• 1908: Rotameters
• 1917: Boyles machine (Plenum flow)
• 1914-18: “Flagg can”
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Anaesthetic Equipment
• 1926: McKesson demand machine (intermittent flow)
• 1938: Artificial respiration via ventilator
• 1940: Oxford vaporiser
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Anaesthetic Equipment
• 1954: classification of breathing circuits
• 1961: Manley ventilator
• 1972: Bain circuit
• 1976: Lack circuit
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Monitoring
• 1901: BP’s recorded on Mass Gen Hosp Anaes chart
• 1911: McKesson added Resp rate & insp O2
concentration to charts (SpO2 described 1913)
• 1946: paramagnetic O2 analysers
• 1949: first nerve stimulator
• 1956: blood-gas monitoring
•
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Monitoring
• 1960’s: ECG monitoring and capnography
• 1960’s: CVP and arterial monitoring
• 1970: “Swan-Ganz” catheter
• 1980’s/90’s: increasing use of microprocessor-controlled
monitoring equipment
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Monitoring
• 1990’s: explosion of new monitoring modalities
– CO monitoring - CardioQ / PICCO / LidCO
– SvO2 monitoring
– pHi monitoring
– Experimental depth of anaesthesia monitors
– Perioperative Transoesophageal echocardiography
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Drug advances
• 1911: Self admin N2O in labour
• 1911: “Balanced anaesthesia” (Crile)
• 1934: Cyclopropane, Thiopentone
• 1934: Minnnitt “gas-air” mix in labour
• 1941: Trilene
• 1942: Curare
• 1951: Suxamethonium
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Drug advances
• 1956:
Halothane
• 1964:
Introduction of Entonox
• 1980’s: “New generation” ethers - Enflurane & Isoflurane
Opioids - Fentanyl, Alfentanil, (Sufentanil)
New methods of analgesia
Relaxants - Atracurium / Vecuronium
Propofol
• 1990’s: TCI anaesthesia
Opioids - Remifentanil
Volatile agents - Sevoflurane & Desflurane
Relaxants - CisAtracurium / Mivacurium / Rocuronium
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Local Anaesthesia
• 1904: Stovaine
• 1952: Chlorprocaine
• 1929: Cinchocaine
• 1959: Prilocaine
• 1931: Amethocaine
• 1963: Bupivacaine
• 1943: Lignocaine
• 1993: Ropivacaine
• late 1990’s: Levobupivacaine
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Local Anaesthesia
• 1907: use of “heavy” spinal solutions - Barker
• 1908: IVRA - Bier
• 1909: Sacral block - Stoekel
• 1921: barbotage and positioning in spinal anaesthesia Labat
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Local Anaesthesia
• 1921: lumbar epidural anaesthesia - Pages
• 1949: ureteric catheter inserted via Tuohy needle Curbelo
• 1979: opioids injected into epidural space
• 1980’s: eutetic LA mixtures - Lignocaine / Prilocaine
(EMLA) for topical use
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Anaesthesia and Intensive Care
• 1929: tank ventilator
• 1934: ventilation for
tetanus
• 1938: development of
Nuffield plywood “iron
lung”
• 1953: IPPR for bulbar
poliomyelitis in Denmark
(Ibsen) - hand ventilation
via tracheostomy
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Pain Management
• C20th:
LA techniques
• 1960:
Rudimentary self-controlled analgesia systems
in Obstetrics
• 1967:
first Patient-controlled analgesia system
• 1991:
RCA report on Post-op pain - changes course
of post-op pain management
• 1990’s:
development of Acute Pain Teams and
multimodal analgesic strategies incl PCA /
Epidural / PC Epidural / combination Rx
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Pain Management
• 1953: Liverpool Centre for Pain relief
- cordotomies
- acupuncture
• Anaesthetists involvement in multi-disciplinary chronic
team units - Liverpool, Hope (Salford), Norwich, Oxford
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Organization of the Speciality
• 1908: Section of Anaesthetists of RSM
• 1914: Scottish Society of Anaesthetists
• 1932: Association of Anaesthetists of GB&I
• 1933: World’s first Chair of Anaesthesia - Ralph Waters,
University of Wisconsin
• 1935: Diploma of Anaesthetics
• 1937: 1st European chair of Anaesthesia (Robert Macintosh,
Nuffield Chair, Oxford)
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Organization of the Speciality
• 1945: end of WW II
• 1948: Faculty of Anaesthetists of RCS
• 1948: Institution of the NHS
• 1953: FFARCS examination (later FCAnaes, now FRCA)
• 1989: College of Anaesthetists
• 1991: Royal Charter for RCA
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21st Century
The future
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Anaesthesia in the 21st Century
• Crystal ball
– new and better drugs
• “anaesthesia” perhaps not priority it was
• NDMR version of Suxamethonium
• analgesia and PONV
– more TCI
– “closing the loop” techniques
– new airway management techniques
– new monitoring - anaesthetic depth
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Anaesthesia in the 21st Century
• Staffing and workload issues
– increased demand for “anaesthetic services”
– questioning of roles outside theatre
– questioning of roles within theatre
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Anaesthesia in the 21st Century
• Staffing and workload issues
– development of non-medical anaesthetist
– pilot sites up and running
– how best to integrate with “medical anaesthesia”
– who to recruit
» nurse-based
» postgraduate science-based
» other background
– already raising a number of other training & service
issues
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Anaesthesia in the 21st Century
The future of Anaesthesia is assured but we may see our roles and how we
practice it change
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