Anesthesia From Ether Frolics to Modern Surgery

Surgery is as old as civilization. People from the Stone Age to the pre-Columbian civilizations of the Americas practiced trephination—cut-ting a hole in the skull to let out "evil spirits" that were thought to cause headaches. The ancient Hindus were expert surgeons for their time, and the Greeks and Romans pioneered military surgery. But until the nineteenth century, surgery was a miserable and dangerous business, done only as a last resort and with little hope of the patient's survival. Surgeons rarely attempted anything more complex than amputations or kidney stone removal. A surgeon had to be somewhat indifferent to the struggles and screams of his patient. Most operations

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628 Part Three Integration and Control

Uncrossed Crossed

(ipsilateral) (contralateral)

fiber fiber Optic radiation

Uncrossed Crossed

(ipsilateral) (contralateral)

fiber fiber Optic radiation

Hemidecussation

Figure 16.41 The Visual Projection Pathway. Diagram of hemidecussation and projection to the primary visual cortex. Blue and yellow indicate the receptive fields of the left and right eyes; green indicates the area of overlap and stereoscopic vision. Nerve fibers from the medial side of the right eye (red) descussate to the left side of the brain, while fibers from the lateral side remain on the right side of the brain. The converse is true of the left eye. The right occipital lobe thus monitors the left side of the visual field and the left occipital lobe monitors the right side. If a stroke destroyed the optic radiation of the right cerebral hemisphere, how would it affect a person's vision? Would it affect the person's visual reflexes?

Figure 16.41 The Visual Projection Pathway. Diagram of hemidecussation and projection to the primary visual cortex. Blue and yellow indicate the receptive fields of the left and right eyes; green indicates the area of overlap and stereoscopic vision. Nerve fibers from the medial side of the right eye (red) descussate to the left side of the brain, while fibers from the lateral side remain on the right side of the brain. The converse is true of the left eye. The right occipital lobe thus monitors the left side of the visual field and the left occipital lobe monitors the right side. If a stroke destroyed the optic radiation of the right cerebral hemisphere, how would it affect a person's vision? Would it affect the person's visual reflexes?

had to be completed in 3 minutes or less, and a strong arm and stomach were more important qualifications for a surgeon than extensive anatomical knowledge.

At least three things were needed for surgery to be more effective: better knowledge of anatomy, asepsis60 for the control of infection, and anesthesia61 for the control of pain. Early efforts to control surgical pain were crude and usually ineffective, such as choking a patient into unconsciousness and trying to complete the surgery before he or she awoke. Alcohol and opium were often used as anesthetics, but the dosage was poorly controlled; some patients were underanesthetized and suffered great pain anyway, and others died of overdoses. Often there was no alternative but for a few strong men to hold the struggling patient down as the surgeon worked. Charles Darwin originally intended to become a physician, but left medical school because he was sickened by observing "two very bad operations, one on a child," in the days before anesthesia.

In 1799, Sir Humphrey Davy suggested using nitrous oxide to relieve pain. His student, Michael Faraday, suggested ether. Neither of these ideas caught on for several decades, however. Nitrous oxide ("laughing gas") was a popular amusement in the 1800s, when traveling showmen went from town to town demonstrating its effects on volunteers from the audience. In 1841, at a medicine show in Georgia, some students were impressed with the volunteers' euphoric giggles and antics and asked a young local physician, Crawford W. Long, if he could make some nitrous oxide for them. Long lacked the equipment to synthesize it, but he recommended they try ether. Ether was commonly used in small oral doses for toothaches and "nervous ailments," but its main claim to popularity was its use as a party drug for so-called ether frolics. Long himself was a bit of a bon vivantwho put on demonstrations for some of the young ladies, with the disclaimer that he could not be held responsible for whatever he might do under the influence of ether (such as stealing a kiss).

At these parties, Long noted that people sometimes suffered considerable injuries without feeling pain. In 1842, he had a patient who was terrified of pain but needed a tumor removed from his neck. Long excised the tumor without difficulty as his patient sniffed ether from a towel. The operation created a sensation in town, but other physicians ridiculed Long and pronounced anesthesia dangerous. His medical practice declined as people grew afraid of him, but over the next 4 years he performed eight more minor surgeries on patients under ether. Struggling to overcome criticisms that the effects he saw were due merely to hypnotic suggestion or individual variation in sensitivity to pain, Long even compared surgeries done on the same person with and without ether.

Long failed to publish his results quickly enough, and in 1844 he was scooped by a Connecticut dentist, Horace Wells, who had tried nitrous oxide as a dental anesthetic. Another dentist, William Morton of Boston, had tried everything from champagne to opium to kill pain in his patients. He too became interested in ether and gave a public demonstration at Massachusetts General Hospital, where he etherized a patient and removed a tumor. Within a month of this successful and sensational demonstration, ether was being used in other cities of the

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United States and England. Morton patented a "secret formula" he called Morton's Letheon,62 which smelled suspiciously of ether, but eventually he went broke trying to monopolize ether anesthesia and he died a pauper. His grave near Boston bears the epitaph:

WILLIAM T. G. MORTON Inventor and Revealer of Anaesthetic Inhalation Before Whom, in All Time, Surgery was Agony.

By Whom Pain in Surgery Was Averted and Annulled.

Since Whom Science Has Control of Pain.

Wells, who had engaged in a bitter feud to establish himself as the inventor of ether anesthesia, committed suicide at the age of 33. Crawford Long went on to a successful career as an Atlanta pharmacist, but to his death he remained disappointed that he had not received credit as the first to perform surgery on etherized patients.

Ether and chloroform became obsolete when safer anesthetics such as cyclopropane, ethylene, and nitrous oxide were developed. These are general anesthetics that render a patient unconscious by crossing the

Chapter 16 Sense Organs 629

blood-brain barrier and blocking nervous transmission through the brainstem. Most general anesthetics apparently deaden pain by activating GABA receptors and causing an inflow of CF, which hyperpo-larizes neurons and makes them less likely to fire. Diazepam (Valium) also employs this mechanism. Local anesthetics such as procaine (Novocain) and tetracaine selectively deaden specific nerves. They decrease the permeability of membranes to Na+, thereby reducing their ability to produce action potentials.

A sound knowledge of anatomy, control of infection and pain, and development of better tools converged to allow surgeons time to operate more carefully. As a result, surgery became more intellectually challenging and interesting. It attracted a more educated class of practitioner, which put it on the road to becoming the remarkable lifesaving approach that it is today.

60a = without + sepsis = infection

61an = without + esthesia = feeling, sensation

62lethe = oblivion, forgetfulness

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