Don’t get me wrong, anaesthesia and lectures on the subject usually send me to sleep (haha), but a lecture this week (1) gave me a whole new perspective on my career. Was it a dynamic ‘change your life’ title? No. Essentially the history of anaesthesia – I certainly learned some history too: The first ‘Anaesthesia’ Journal was published in October 1946, 75 years ago. It was delayed due to the paper shortage during WW 2 – I didn’t know about that!
We heard how the filth and horrors of the barber surgeon’s operation was transformed to the oblivious patient in the clinical cleanliness of a modern ‘chamber of sleep’. Anaesthetists now are highly skilled in providing cocktails of drugs to make us sleep, forget the experience and keep us pain free during surgical procedures. But back then the introduction of ether and chloroform revolutionised the patient experience. Previously Mesmerism – the attempt to induce a trance-like state through processes similar to hypnosis, alcohol and something to bite down on, combined with ropes and strong bystanders were the only options. Actually there did need to be some patient collaboration, usually in the context of highly persuasive factors such as severe pain or disabilities (eg vision loss or bladder dysfunction), or the threat of imminent death.
There was not a straight forward transition to modern anaesthetics, I feel incredibly grateful to those early pioneering patients who enabled me to have practically painless key hole surgery for my gallbladder whilst blissfully unaware, far better even than my training days when cholecystectomy was a major operation routinely requiring morphine in hospital for some time.
My experience of surgery is only as a medical student, 6 months 1984-5 as a surgical house officer, and more recently as patient and relative. The first operation I witnessed was insertion of gold wires into someone’s brain, with the patient awake to state the effects of the insertion. Rather a surreal experience for me let alone the patient – perhaps akin to the heady effects of morphine!
As a junior doctor, the consultant turned to me one day and insisted that I must do an above knee amputation, so that in an emergency situation, if I saw someone trapped under a tram, I could do it. One of the nurses did point out to him there were no trams left in the area, but whilst that surprised him, it did not deflect him from his intent. Fortunately I have never needed to invoke that skill since!
One of the first operations under anaesthesia is said to be the amputation of Frederick Churchill’s leg by Robert Liston 21 Dec 1846 (2). Ahead of his time, Liston removed his frock coat, washed his hands and donned a clean apron before each operation. Study of 66 of his amputations 1835-1840 showed only 10 patients died, <1 in 6, whereas other eminent London hospitals boasted only losing 1 in 4 amputees to the mortuary.
That first anaesthetic experience, Frederick Churchill’s silence and stillness initially dumbfounded Liston. So dramatic. A sleeping patient not only allows quiet for the surgeon to concentrate, but the stillness makes the technical process easier, allowing much more precision and finer work. General anaesthesia allowed surgeons to start abdominal and even chest operations that could not have been contemplated before. Surgical mortality therefore increased initially, until techniques developed, hygiene and infection prevention methods were understood, and the era of antibiotics dawned.
Before anaesthesia, speed was Liston’s main weapon. He aimed to complete the amputation (from first cut to last stitch) in 30 seconds. Hardly surprising that occasionally things got in the way – one poor patient’s testicles and an assistant’s fingers!
I witnessed rapid female sterilisations in 1984 during my student elective in India. Picture simple operating tables set up as the sides of a square amidst power cuts in very basic village surroundings. The surgeon in the centre. Four women, one on each table. The tables were then positioned at 45 degrees, with heads down, so that the women’s bent knees dangling over the higher end held them in place. Gravity kept bowels out of the surgeon’s target area. It was a quick in and out job. 2 minutes per person. As he finished each one, the table was lowered, the patient went home, and another took her turn. How would you compare 2 minutes of terror and agony with the months of rising angst and concerns about infections patients face here today?
John Bonica’s visionary book on multidisciplinary pain control was published 1953. He apparently paid his way through medical school by wrestling professionally – perhaps inflicting and experiencing pain led to him recognise the multifaceted causes and treatments for pain?
Some developments catch on quickly – perhaps microwave ovens in the 1970 are an example. Mobile phones have had more of a gradual development from the ‘original ‘bricks’ of the wealthy to the near universal coverage, hands free watches and ear pieces of today. Good pain management has certainly had a slow trajectory. Clearly people have always suffered pain. Herbal approaches with willow bark and poppies have been around for centuries, yet we are far from the ideal solution still. Expert pain control requires delicately nuanced care. (From a medicines perspective we have not moved far, using aspirin and morphine – derivatives of the herbal remedies along with old fashioned nerve calming agents originally used for depression).
I realised pain control was an issue through an interest in cancer and palliative care. I approached Macmillan to set up some GP posts (one day per week) and took up one of the posts in 2000 for 9 years, telling anyone that would listen about the WHO pain ladder, the patient centred approach, good communication, considering social psychological and spiritual aspects in addition to physical, promoting ‘Gold Standards’ of palliative care and active care of the dying. I helped write a local booklet with a CD on pain management. There was a very real need for education but I didn’t have a sense of history and our place in the learning curve, until this lecture.
I was much more aware of surfing at the forefront of the wave of change during my two years in Malawi 2010-12, treating Kaposi’s sarcoma patients and those with various other untreatable cancers. Liquid morphine had only just been approved for use in the country. I was lucky to be involved in an education program promoting safe and effective use of liquid morphine, as part of pain control using the WHO ladder. Dispensing it largely in drinking bottles, we added green or red colouring to stop the clear liquid being mistaken for water.
As genealogists we are encouraged to write our own life story. Many of us know where we were when the twin towers were hit or when Princess Diana died. The Covid crisis and death of Prince Philip are perhaps noteworthy moments in our history. But my question is more about changes that have happened in your lifetime. Things that you are or have been part of or that affect your daily life. I am no pioneer, following on behind, but still seeing and making changes. What changes have you been part of that mark your place in history?
References
(1) Constructing the Chamber of Sleep: Emotions and Early Anaesthesia The Evolution of Pain Management Lecture given 16 April 2021 by Drs Michael Brown and Douglas Justins for the Association of Anaesthetists.
(2) Royal College of Surgeons of England Bulletin. https://publishing.rcseng.ac.uk/doi/pdf/10.1308/147363512X13189526439197
(3) https://www.healthrising.org/blog/2015/07/05/the-pain-pioneer-the-visionary-approach-of-john-bonica/
Sticklepath a Village and its People 