Issues Magazine

The History of Pain Relief and Anaesthesia

By Steven Semiatin

History abounds with attempts to achieve pain relief, and they will continue into the future.

Pain is the way our body lets us know there is something wrong. It is the defence mechanism the body developed to ensure we seek help and treatment for the pain’s root cause, or to make sure we journey through life as safely as possible.

Pain is not a disease or an injury; it is a symptom of a disease, illness or physical damage. The mind knows that the body experiencing pain cannot recover to the best of its ability on its own, and the body seems to know that as long as the mind is focusing on pain, recovery is just as difficult. Without overcoming pain, it’s doubtful that civilisation would have advanced much past the Stone Age.

Throughout history there have been countless attempts at controlling, reducing and eliminating pain, both ordinary and severe enough to require surgery. The Chinese developed acupuncture. The Greeks and Romans primarily used alcohol. Africans induced numbing trances and drank or smoke potent mind-altering substances which made pain bearable. American Indians relied on the bark of the willow tree, the original source of our modern-day aspirin. Inca shamans chewed coca leaves (which contain a mild natural version of cocaine) while drilling holes in the heads of their patients to release evil spirits, periodically spitting into the wounds they’d inflicted – the coca-resin spittle would keep the gash sufficiently numbed until the “operation” was concluded.

Some cultures believed bleeding a person to the point of faintness was an effective pain-killer, and there were some who practised infusing the rectum with a large amount of tobacco in order to conquer pain (this method certainly gave the sufferer something else to think about). Ice was naturally and universally used to kill pain (except, of course, in tropical regions).

Peoples of the ancient world found relief in numerous plant by-products, primarily from marijuana, mandrake, belladonna and jimsonweed, all of which could sedate, but not truly anaesthetise, in preparation for primitive surgery. The principal “narcotic” (from the Greek narke, meaning “stupor”) that could make surgery an option was opium, a derivative of the poppy plant. The poppy’s sap was obtained by cutting the unripe seed pod of the plant, collecting the milky juice in a shell or dish and drying it in the sun. The final product could be snuffed, smoked or boiled in tea or alcohol. Parents used drops of opium tea to stop ear aches or colic.

Warriors carried small sacks of opium into battle, much the same way modern troops may carry syringes of morphine (a derivative of opium) when in danger of being wounded. The writers of antiquity commonly used a word popularised by Virgil to refer to poppy-induced sleep: Letheon (2000 years later that name would surface again as the word ether).

The most popular method of inducing narcosis during the Middle Ages was the soporific sponge. Historians described its ingredients as opium, mulberry juice, lettuce seed, mandrake, ivy and a touch of hemlock (the poison that killed Socrates). A fresh sea sponge was soaked in the liquid and allowed to dry in the sun.

The sponge became a common item carried about by most adults, and when needed, could be reconstituted by dipping it in water and squeezing the medicine sponge’s contents into the mouth (or, for faster relief, into the nostrils). If the concoction proved to be too strong, its effects could be reversed by drinking vinegar or the juice of the fennel root.

An early form of such a sponge may have been what was offered to Jesus Christ while suffering on the cross. Still, throughout history, when all else failed or wasn’t available, patients in pain or who needed surgery were sometimes simply, and mercifully, knocked unconscious by a blow to the head.

Before the advent of anaesthesia, the best surgeons were the fastest surgeons. One physician, Baron Larrey, became a legend for amputating more than 200 limbs in less than 24 hours after the Battle of Borodino in 1812.

Speed, however, never made up for the fact that it was infections that usually killed so many early surgery patients. Doctors even labelled such infections as “blood poisoning”, but for centuries didn’t realise that it was their lack of sanitary practices that caused such poisonings.

When President James A. Garfield was shot in 1881, it wasn’t the bullet that killed him but doctors sticking unwashed, bacteria-laden fingers in his wound. The same could possibly have been a reason for President Lincoln’s death, although his wound was much more serious.

Even after the advent of more modern forms of anaesthesia, there was a significant rise in the number of surgical patients dying within days of their procedures. More and more people readily lined up for the new “painless surgery”, relieved to be alive during a time when such wonderful advances were being made in medicine, but sadly the mechanisms behind infections were still not yet clearly understood.

The invention of surgical anaesthesia in the early 1840s was the first major contribution that American medical science made to the world; to this day, many consider it the single greatest gift to the art of healing. Crawford W. Long, an American, became the first doctor to use a modern chemical anaesthetic – ether – during major surgery. For a year or so, Long and his fellow physicians had been experimenting with the newly developed gas known as diethyl ether; however, their experiments were not taking place in laboratories, but at their homes during “vapour parties”.

Long observed that whenever one of his jolly intoxicated friends did something that normally would’ve caused much pain, such as falling down stairs, running into walls or getting into fights, none reported feeling the slightest pain (some didn’t even recall getting injured). In the spring of 1842, Long approached one of his patients, James Venable, with an appealing idea. Venable had been putting off the removal of two large cysts on the back of his neck due to his fear of pain. Long suggested that he be allowed to put an ether-soaked towel over the patient’s face and, once sound asleep, he would then quickly and painlessly remove the cysts. Venable reluctantly agreed, and before he could change his mind, the operation was conducted that very evening. As promised, Venable experienced no pain and no memory of the surgery.

A few months later, Long used ether to painlessly amputate the diseased toe of a slave, and over the next several years performed other ether-induced operations. However, not being the competitive type, he waited until 1849 to publish the results of his use of ether; in the meantime another American surgeon, William Morton, started to use ether in 1846 and that year wrote of his work and was recognised, wrongly, as the first to use ether to induce deep sleep. Morton’s patient, a man who had a jaw tumour removed, awoke as he was being carried from the operating theatre and announced, “Gentlemen, this is no humbug”, to the onlooking doctors, many of whom he knew still scoffed at the idea of painless surgery.

Also in 1846, the physician and poet Oliver Wendell Holmes proposed in a letter that the new painkiller be named anaesthesia, a Greek word meaning “no sensation of pain”.

The wonderful dream that pain has been taken away from us has become reality. Pain, the highest consciousness of our earthly existence, the most distinct sensation of our imperfection, must now bow before the power of the human mind ….
Johann Dieffenbach (surgeon), 1846, after the successful use of ether as a surgical anaesthetic

Long was also the first, in 1847, to use ether to provide a relatively pain-free childbirth, but even this historic step didn’t earn him the honour he deserved. This was primarily because it was up to doctors, all men, to bestow such honours, and not many were concerned about pain-free childbirths.

Even as he lay dying, Long’s thoughts were only of his patients. On 16 June 1878, the 62-year-old doctor had just completed the delivery of a child from an “etherised” mother when he experienced a terrible headache. Just after passing the baby into the arms of a nurse, he collapsed and whispered, “Care for the mother and child first”, and then died of a massive stroke.

Ether was about to face two new competitors when, in 1844, an American dentist named Horace Wells was the first to use nitrous oxide (also known as “laughing gas”) in a dental operation. Three years later another new chemical, chloroform, was used for the first time by another doctor, James Simpson, but because it was considered much stronger than ether he first used it on himself. It took an unusually long time to wake up after its use, but over the next few decades chloroform was used sparingly because it proved fatal in a number of surgical cases, and was finally banned in 1910. By then, it was determined that the chance of dying while under the influence of ether was about one out of 20,000; the chance of dying while anaesthetised with chloroform was about one out of 4000.

Like Dr Long, Horace Wells learned about the sedating effects of nitrous oxide while attending “laughing gas socials” with his peers. Instead of painlessly falling down stairs or running into walls, these party-goers simply laughed off any activity which normally would’ve been painful. He learned that nitrous oxide was usually effective enough for patients needing minor dental surgery, but because it tended to wear off quickly and didn’t put patients into deep sleeps it wasn’t going to be useful during more major operations. However, used in combination with ether, nitrous oxide was helpful in getting surgical patients relaxed just prior to being given ether. Dentists today sometimes still use nitrous oxide to calm patients before administering stronger anaesthesia for more extensive dental work.

By the mid-1880s, the science of surgical anaesthesia was becoming more complex. Procedural sedation, or “twilight sleep”, started to be used frequently to ease anxiety prior to the administration of stronger drugs.

The first use of local anaesthesia to numb only a particular spot on the body prior to surgery was introduced in 1880. Cocaine was the substance of choice, and was highly touted by Sigmund Freud – in 1884 several drops of liquid cocaine were dripped into his eyes a few minutes before he had successful (and painless) eye surgery.

A number of increasingly more effective local anaesthetics were introduced in the early to mid-20th century, all derivatives of cocaine, including eucaine (1900), procaine, also known as novocaine (1905) and lidocaine (1943).

Another family of anaesthetic drugs known as “regional drugs” or “nerve blocks” emerged for use in anaesthetising larger portions of the body. The most well-known nerve blocking procedure, which first became available in the 1950s, was called an epidural, which numbs a woman’s body from the waist down during childbirth.

The most powerful family of painkilling drugs became known as “general anaesthesia”, which induces deep sleep and immobilisation during major surgery. Today, general anaesthesia is most commonly administered via gas, an intravenous line or a combination of both.

The most often used gases are isoflurane or desflurane. Occasionally muscle relaxants are added to the mix to make sure the body remains motionless during the operation.

We’ve learned that one of the newer sedating drugs, propofol, can be abused; it was responsible for the death of singer Michael Jackson.

Another new medication, Duzitol, is derived from the urine of sheep fed shiitake mushrooms. It has multiple uses.

Hyptiva is a drug that permits patients to awaken within minutes of stopping its flow into the body. It is safe for patients with kidney and blood diseases, and is well-tolerated by the elderly.

Not all anaesthetics are administered by an anaesthetist, a medical specialty whose need was first recognised in the late 1930s. Much depends on the situation and the type of anaesthesia to be used. An anaesthetist is a medical doctor who only gets involved if regional or general anaesthesia is to be used, and he/she is often supported by an anaesthesia care team during surgeries in case of emergencies.

Depending on the requirements of the particular operation, the anaesthetist may need to paralyse the body, help maintain circulation and oxygenation of the blood while the heart and lungs are stopped, determine the need to replenish blood components or chill the brain or spinal cord to avoid nerve damage. It takes careful training to know exactly how much anaesthetic to provide, as well as which ones to use. Larger people may need more, while people with certain health conditions, or very old or very young patients, might not tolerate particular drugs or dose levels as well as others.

It’s hard to imagine that something as benign as hair colour would be related to anaesthesia, but recent studies indicate that redheads may not only be more sensitive to pain but also have a higher tolerance for both local and general anaesthetics.

There’s even a situation called “anaesthesia awareness”, which occurs when the patient can recall aspects of their surgery after being put to sleep. They may feel pressure, pain or just be generally aware of what’s going on. In the most extreme cases, patients have reported being totally paralysed but aware of all the pain of being cut up and every detail of the procedure, which can naturally result in severe emotional trauma. While anaesthesia awareness is a frightful thing to consider, the phenomenon is exceedingly rare, occurring about once in every 100,000 operations.

Safer drugs and ever-improving equipment to monitor patient vital signs and control the flow of medication, including the invention of an anaesthesia simulator that allows anaesthesiologists to experience handling major crises in a computer-generated practice environment, are advancing rapidly.

Interestingly, much of the equipment and drugs utilised by veterinary anaesthetists is similar or identical to that used in anaesthesia for human patients (except, of course, when large or wild animals such as elephants or tigers need to be anaesthetised – in such cases, drugs must be delivered from a distance by devices such as dart guns).

Doctors and scientists predict a bright future for the field of anaesthetics. Over the next decade or two, specialised anaesthetics will be developed to allow most infants and senior citizens to undergo surgery with far fewer side-effects or dangers. We are discovering that ultrasound technology, already generations old, can be modified to send an ultrasound-guided nerve block into the body, thus providing a non-invasive form of regional anaesthesia. Safer drugs with fewer side-effects and drugs specially tailored for individuals, such as those who have diabetes or mental illnesses, will become available, along with new ways to administer them (for example, through non-invasive electrical stimulation of particular areas of the brain, or through patches applied to the skin).

Computers will become more involved in assisting anaesthetists, providing advice and options that are based on decades of research and knowledge that may not be immediately familiar or recalled by the doctor, and they will become more important in the monitoring of the patient’s vital signs while asleep. Medications that will return the sedated patient to full consciousness more quickly, meaning less time in a recovery room, will be available.

There is even ongoing research to see if the role of newer anaesthetics can be expanded to actually treat medical problems such as heart disease, infections, organ transplants and mental disorders, and not just put people to sleep.

Providing less expensive, more easily accessible anaesthesia to those living in poorer nations is another important, achievable goal over the next couple of decades, according to the American Society of Anesthesiologists.

Mankind had been waiting for effective surgical anaesthesia for so many centuries that its reception a century and a half ago was predictably enthusiastic. Today, for most of us, we take it for granted and can’t imagine a time when living with intense pain and in dire fear of the blood-stained surgeon with rusty knives was not without good reason.

A regular contributor to History Magazine, Steven Semiatin has served as a special education teacher for 30 years. Reprinted with permission from the June/July 2012 issue of History Magazine. © Steven Semiatin.