History of Anesthesia

Since Grace is going into anesthesia, I’ve been doing a little bit of reading on the subject. The history is fairly interesting: the field has been happy accidents, virtuous cycles and technical change from the outside world.

The first departure point is a popular history book, Ether Day, about the men — a collection of physicians and swindlers — who discovered that there are substances that will make patients unconscious, allowing simple surgeries. Prior to the discovery of these substances — nitrous oxide and ether, both of whom were used as what we would call recreational drugs in the early 1800s — surgery was a ghastly affair, where the patient would have to be strapped down to a chair while the surgeon operated as quickly as possible. Some patient prefered death from their affliction or through suicide rather than go through surgery. Surgeons also didn’t have that much to do, since the pool of patients that had treatable afflictions and who would be willing to have surgery was not particularly large; the book notes that the operating arena (and there were always spectators, because surgeries were rare) at Mass General was only used once or twice a week.

The discovery and demonstration of nitrous oxide and ether by a pair of huckster dentists changed all that: surgery became more tolerable, even with the five or ten minutes of unconsciousness provided by the initial dose of ether. Once the first anesthesizing agents were discovered, doctors tried to find other ones (e.g., chloroform), and more effective means of delivery existing agents (chemical soaked rags gave way to pressurized gas canisters and closed circuit rebreathing systems). This was a process of decades, as surgeons figured out what they could and could not do, and how to make what was currently impossible into something routine. Surgeries became more complicated, with longer durations, as patients could be made unconscious for longer periods. (Beyond anesthesia, discoveries about antiseptics and blood typing were necessary for surgery to develop.)

Anesthesiology became its own speciality in the 1940s and 1950s when thoracic surgery became complicated enough to require the patient to be paralyzed and not simply made unconscious with a single simple agent like ether. This required a specialist to maintain the patients vital functions — breathing — under paralysis, and to mix the cocktail of drugs for the paralysis as well as unconsciousness and amnesia. Once delegated to an assistant of the surgeon, the tasks for anesthesia could no longer be performed by a non-specialist.

And, with increasing technical complexity, the advent of the information age played a role in the development of anesthesiology. The main points are the development of computer controlled or assisted anesthetic delivery and patient monitoring. Both delivery and monitoring go hand-in-hand, as modern systems have computers that run pharmacology models for the patients under anesthesia, introducing sufficient but not excessive quantities of drugs to do what the anesthesiologist wants. The monitoring technology developed for anesthesia has also spread throughout the hospital, in particular the pulse oximeter, which can monitor blood oxygenation non-invasively. Computers have also taken on the more general task of managing patient information (this applies to all aspects of health care, obviously) as well as providing simulation training for anesthesiologists (and simulation allows replayable scenarios, which allow best practices to be discovered and propagated). The field has improved patient safety over the decades as technical change works its way through the system.

Dr. Cottrell, the chair of the King’s County anesthesia department, has a useful book, Under the Mask, on anesthesia for the lay person about to undergo surgery.

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