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A Brief History of Anaesthesia. Andrew Ronald Consultant Cardiac Anaesthetist Aberdeen Royal Infirmary. Why study the History of Anaesthesia?. An understanding of our past guides our future

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a brief history of anaesthesia
A Brief History of Anaesthesia

Andrew Ronald

Consultant Cardiac Anaesthetist

Aberdeen Royal Infirmary

alronald@tiscali.co.uk

why study the history of anaesthesia
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
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

Pre-1846

The Foundations of Anaesthesia

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pre 1846 the foundations of anaesthesia
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

Alcohol

Opium (poppy)

Hyoscine (Mandrake)

Cannabis (Hemp)

Cocaine (New World)

Non-drug methods

Cold

Concussion

Carotid compression

Nerve compression

Hypnosis

Blood letting

The Foundations of Anaesthesia

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the foundations of anaesthesia9
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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slide10
“…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

What changed?

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industrial and scientific revolution
1540: synthesis of ether

1628: circulation of blood

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

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

Industrial and Scientific Revolution

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industrial and scientific revolution14
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
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
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 institute17
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
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 illness19
Gas Therapy in Illness

Nitrous oxide

Ether

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nitrous oxide
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
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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ether22
Ether
  • 1818: Michael Faraday (1791-1867) described “narcotic effects” of ether

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ether23
Ether
  • 1821: Benjamin Brodie (1783-1862) 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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ether24
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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slide25
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
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 184627

So why no anaesthesia until 1846?

Or wasn’t there?

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henry hill hickman 1800 1830
Henry Hill Hickman (1800-1830)

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henry hill hickman and carbon dioxide
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
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 hickman31
Henry Hill Hickman

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henry hill hickman32
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 hickman33
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 hickman34
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 hickman35
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 hickman36
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 hickman37
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 hickman38
Henry Hill Hickman
  • 1830: died; buried in Bromyard churchyard

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henry hill hickman39
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: 843-845
  • 1930: plaque erected by Section of Anaesthetists of RSM

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1846 1900

1846-1900

The Establishment of Anaesthesia

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1846 190041
General Anaesthesia

Ether

spread to Europe

Nitrous oxide

Chloroform

James Young Simpson

John Snow

Local Anaesthesia

anaesthesia without sleep

New techniques

early landmarks

1846-1900

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ether42
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
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 spreads44
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
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 spreads46
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 spreads47
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 oxide48
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
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
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
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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chloroform52
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
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 full-time” anaesthetist developing ways to improve methods of ether and chloroform administration

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john snow
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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slide55
“….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 snow56
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 snow57
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
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
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

The 20th Century

Consolidation and Growth

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the 20th century61
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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slide62
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
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
Anaesthetic Equipment
  • 1908: Rotameters
  • 1917: Boyles machine (Plenum flow)
  • 1914-18: “Flagg can”

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anaesthetic equipment65
Anaesthetic Equipment
  • 1926: McKesson demand machine (intermittent flow)
  • 1938: Artificial respiration via ventilator
  • 1940: Oxford vaporiser

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anaesthetic equipment66
Anaesthetic Equipment
  • 1954: classification of breathing circuits
  • 1961: Manley ventilator
  • 1972: Bain circuit
  • 1976: Lack circuit

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monitoring
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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monitoring68
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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monitoring69
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
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 advances71
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

1929: Cinchocaine

1931: Amethocaine

1943: Lignocaine

1952: Chlorprocaine

1959: Prilocaine

1963: Bupivacaine

1993: Ropivacaine

late 1990’s: Levobupivacaine

Local Anaesthesia

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local anaesthesia73
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 anaesthesia74
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
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
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 management77
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
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 speciality79
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

21st Century

The future

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anaesthesia in the 21st century
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 century82
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 century83
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

alronald@tiscali.co.uk

anaesthesia in the 21st century84
Anaesthesia in the 21st Century

The future of Anaesthesia is assured - but we may see our roles and how we practice it change

alronald@tiscali.co.uk