Welcome to London.

Of course it's kind of raining.

Let's talk about surgery in the Victorian period.

So if you’ve had any kind of surgery, whether it's something relatively routine, like a colonoscopy or having your wisdom teeth removed, or maybe not quite so routine, like producer Steph wenthome to Suriname and got a botfly parasite infection on her chest, tried to remove it herself, and then it got infected, so she had to have a six- centimeter abscess operated on... then chances are, you’ve probably had anesthesia.

I think most of us take for granted that when we have a medical procedure today, we're probably going to be able to receive medication that makes the procedure not painful.

But not so long ago, surgery was very different.

The precursor to the modern anesthesia we know and love today wasn't even discovered until the 1800s, and then, it wasn't even discovered on purpose!

It was discovered by people who were having a little too much fun at parties.

Oh my God, this is so many stairs!

Oh!

The smell really hits you, doesn’t it?

Yeah, it smells like aged nail polish remover?

It still smells??

So Steph, let's say it's around 1770, and you are about to undergo a surgery.

Congratulations.

You get wheeled in to this room, which is full of people waiting to be an audience to your surgery.

So after you get wheeled in, about 2-4 very strong attendants are going to come in to hold you down.

Why?

Because you're about to undergo this surgery without any anesthesia.

I don't like that.

When I say general anesthesia, by the way, here's the modern definition: a controlled state of unconsciousness.

So anesthesia is the term used in the medical world to describe something that results in a total loss of sensation, either locally, regionally or generally.

And general anesthesia results in a total loss of sensation generally, and therefore in a state of unconsciousness.

But before that momentous occasion, when we finally realized we could use some gases to put us into that state of controlled unconsciousness, humans have used a cornucopia of natural remedies since ancient times, things like mandrake root, hemp, opium, alcohol, laudanum, bloodletting, pressure therapy, hot and cold therapy, acupuncture, and even hypnotism.

Hypnotism for an amputation?

Yeah, yeah, my guy.

Sarah, you said they have names?

Balthazar, Drusilla, and a few others, but I can’t remember what their names are.

They release like a natural sort of anesthetic.

So you can't really feel that they're chomping away, which is sneaky on their part, which means they can get more blood.

They’re cuddling!

Look at the wiggling on the bottom!

I wanna see their mouths!

I am really going to try not to fall down the stairs while I do this.

So we have all of those options, but we don't have any true anesthetic, something that can completely numb you to sensation and pain, and knock you unconscious for something as painful and intense as surgery.

The first ever anesthetic was created by a Japanese surgeon named Dr. Seishū Hanaoka.

He developed a mix of herbs that the patient would drink to result in unconsciousness, and he trialed it successfully in 1804 on a patient who needed a breast cancer mass removed.

She didn't wake up, didn't feel a thing during her surgery.

But Japan during this era was isolationist, meaning it didn't really let anyone or anything in or out of the country.

And so his discovery went unknown by the rest of the world for decades.

And in the meantime, the rest of the world moved in a different direction towards gases, because this was an era of gas discovery.

Episode two, scene two.

Is that right?

Shot one, take one.

Woo!

Basically at the end of the 18th century, during the, sort of, age of enlightenment, people were increasingly interested in how the world works.

Science had progressed, scientific equipment had progressed sufficiently that people were able to start isolating gases.

So there was a sort of appetite to learn a bit more about what all of this is around us.

It was a gassy era.

A gassy area.

Totally.

And one of those newly discovered gases is nitrous oxide.

People are interested in all sorts of its properties, thinking that it could maybe be useful as an inhaled substance for patients with asthma or tuberculosis.

But along the way, people are finding that it also has other properties.

There were nitrous oxide parties that were well-advertised.

There were big posters made up inviting people—only respectable people—to come to nitrous oxide party.

You could buy a ticket, and you could either inhale some nitrous oxide yourself and see what sort of buzz it gave you, or you could just sit back and watch everyone else make a bit of a fool of themselves.

And sort of fall and trip around, and have a good time?

Yes!

Totally, Totally.

And that's how nitrous oxide came to be used as an anesthetic, because a dentist called Horace Wells in Boston went to one of these things and saw a man jump into a bench, and he didn't really seem to hurt himself.

So Horace Wells sat there and thought, ‘maybe that would be a good a good use for nitrous oxide, to relieve the pain of all of the teeth that I'm pulling out for all of my dental patients.’ And Horace Wells thinks, ‘this is how I'm going to become rich and famous.’ He gets all these doctors together in Boston to watch him extract the tooth from a medical student who supposedly volunteered for the job.

And he proclaims that he's going to use a method by which nearly or quite all of the pain which is usually caused by the operation may be avoided.

The audience is assembled.

Horace Wells lets him breathe the gas, he breathes it in, and when he thinks he's had enough, Horace Wells opens his mouth, inserts his pliers, and as he goes to pull the tooth, the medical student screams.

And the whole thing is a total disaster, and he's laughed out of town.

So Horace Wells gives up.

But he has colleagues who say, okay, this was an absolute fail, but it still seems like a good idea.

What else could we use instead?

The answer is ether.

This was used to ease pain since around the 15th century, but in liquid form as a drink or in little drops.

Now these physicians look at ether and say, okay, what happens if we inhale this?

So it's time for a demonstration round two, and this time it works.

The guy is out cold the whole time he's having a mass removed from his neck.

He reports having no pain during the procedure.

And the era of general anesthesia is born!

Kind of.

Ether was a really complicated drug to give.

It was irritating to breathe.

It made patients cough.

It made patients vomit, gave them an awful headache.

Many patients refused to have any more because it was so horrible to take.

And lots of doctors got to the point where they thought, actually, this is just all a bit too much, and I'm just going to go back to doing what I know best, which was, well, a glass of brandy and maybe a bit of opium, if you're lucky.

So nitrous oxide is rejected as a failure.

Ether is sort of used, but it comes with a lot of headaches, literally, and some bright young minds are looking for other potential alternatives.

Young minds like Dr. James Young Simpson of Edinburgh, Scotland.

And for this part, I did actually go to Scotland.

This guy was pretty awesome.

The annals of history have him down like pretty universally is just like a really kind, charismatic guy.

And this is a time in history when most women are having babies at home with midwives.

And so obstetrics, or the field of medicine that has to do with birth, is considered pretty much exclusively the purview of women and therefore not like “real medicine.” So all the bros at the University of Edinburgh, when James is going into medicine and wants to do obstetrics, are like, ‘Are you sure, man?’ I don't know.

Maybe it has something to do with the fact that his mother had eight children.

But James is pretty passionately committed to ensuring the safe delivery of babies.

Our guy Simpson here actually establishes a very robust practice here in Edinburgh, and he's a huge force in making the field of obstetrics more well-respected, and having a more solid place within medicine.

And he makes a lot of progress in improving care in this field.

Like better, gentler, more effective forceps, and the development of something like this vacuum extractor literally sucks on to a baby's head to like schloop it out if it needs some help.

So he is well-used to seeing women in the pain of labor, but not just that, seeing women undergoing quite painful procedures without any pain relief.

So he looks at ether and thinks, well, surgery is one thing and childbirth is different to surgery.

Surgery will be over in a few minutes, but childbirth might go on for 12 hours, 24 hours.

James Young Simpson thinks, ‘well, okay, if ether has worked, surely there must be another solvent that we can try that has similar effects.’ So he and his colleagues gather at his house in Edinburgh on Queen Street every Friday evening.

Simpson collects and curates a collection of chemical solvents.

A tasting menu?

Exactly.

If you will.

A tasting menu, yes.

He's the solvent sommelier.

Simpson has this little bottle of something called chloroform, and he thinks it probably doesn't look actually very promising.

But they've sort of run out of things to try this evening.

So they pour a bit on their hankies.

They hold it up to their face.

They breathe in the vapor that's given off and they wake up some minutes later.

Simpson's on the floor, his colleague’s under the dining table, and the third colleague’s hanging over the back of the chair.

And they realize this is an incredible success because actually it's been quite pleasant to, it's been quite pleasant to breathe.

It's worked really quickly, much quicker than ether has worked.

And so Simpson realizes this is really the answer to a lot of the problems that ether has come with.

So here they all are, James Simpson and his colleagues, waking up from their chloroform-induced stupor.

And pretty much right away, he knows he's got something amazing on his hands.

In 1847, he attends the birth of a friend's child, and this is the first time that he ever uses chloroform during labor.

So he's using chloroform during the labors he attends.

And it's working pretty well.

But after a while, there is some significant moral backlash from people who thought it was unnatural to ease pain during childbirth and were worried that it would make women less virtuous to be under the influence?

I don’t know.

And on the more logical side of things, there are a few key incidents that show the world that maybe chloroform isn't quite as safe as Simpson wants it to be.. There’s a young girl, 15 year old called Hannah Greener, living near Newcastle in 1848.

She'd had an ingrown toenail operated on the year before and she'd been given ether.

She didn't like it very much.

And the doctor said, ‘Well, that's great.

We've got a new drug called chloroform.’ As he incises the skin with the scalpel, she makes a bit of a squirm and a bit of a funny noise and he stops.

They look at her, she's gone totally pale, and then she stops breathing.

They feel for a pulse, and there isn't one there.

Simpson is adamant that chloroform... [laughs] Bahar’s face is just... terrified!

This is the first time you're hearing this story.

That's terrifying.

She died because of an ingrown toenail!

Imagine!

Oh, my toe hurts, oh, I’m dead now.

So what happened was, she wasn't quite properly anesthetized when the surgery started.

So when the surgeon's scalpel comes in, she still feels the pain.

And just like if you stubbed your toe or trapped your finger in a door, the response to that is that your kidneys and your little adrenal gland on top starts to chuck out adrenaline.

And adrenaline makes your blood pressure rise and it acts on your heart to make your heart beat very fast.

Chloroform, as an unwanted effect, sensitizes the heart to the action of adrenaline.

She goes from a rhythm like this, to a rhythm like this, and her heart stops beating.

Uh-oh.

Thank you Matt, for drawing all this for us.

Sorry Bahar, you had to listen to the chalk on the chalkboard!

So we have the very public failure of nitrous oxide, the dangers that chloroform poses, the backlash about using anesthesia during childbirth, the horrible side effects of ether.

I mean, it's kind of amazing that anesthesia even got to where it is today at all.

But it did.

Nitrous oxide eventually gets given a second chance and these three gases form the basis of modern anesthesia, and they're used well into the 20th century.

We don't even get a new anesthetic gas until the 1950s.

And while the kinds of anesthesia available to us have progressed, we're still facing a lot of issues and questions in this field, like Who has access to anesthesia, and under what circumstances?

And how does the anesthesia even work in the first place?

Because we are literally only just starting to figure that out, if you can believe it.

I guess the question my question is like, why does it alter consciousness?

We can try and explain it.

Should we have a go?

Let’s have a go.

Okay!

I love it.

Great transition.

Yeah.

So the way that I've read about it— and stop me if I'm wrong about this— is that it's like, say you touch a hot pan, right?

Ow!

Then a signal gets sent like via your nerves to your brain where you can perceive the pain.

Yeah.

And so where does anesthesia disrupt that whole process?

Feel free to draw your own beautiful stick figure.

Yeah?

So you perceive the pain.

Goes through all these different neurons, local neurons to the spinal cord, up to the brain.

And then the brain goes ouch!

I've hurt, something's not right, and then it sends another signal down, doesn’t it, and then you move your hand away.

So local anesthesia, you would put an injection or cream or something around there, which literally blocks the nerve impulses in that one specific area.

Okay.

So general anesthesia works slightly differently.

So you can either inhale it, as we've talked about with gases or you can have it injected.

So what happens when you inject it, goes into your bloodstream where it— and let’s say you've got a drip in the back of your hand— goes into your bloodstream, goes up, and then you have this sort of brain circulation.

You shouldn't remember being under anesthetic as well as you shouldn't move.

Wow.

And we don't really know how that part works?

Not particularly.

So there's various theories that have been proposed, but it's—certainly there’s experiments that have been done.

It's an area of ongoing, I would say ongoing research, and that's important in terms of developing new anesthetic gases or new intravenous agents, which there will be some, I'm sure, in 10 years time or 20 years time.

We’ll be saying, can you believe they used to use whatever it was back then?

When we figure out how all of this works?

So more research is needed to help us understand fully how the anesthesia of yesterday, today, and the future actually work.

But anesthesia’s efficacy isn't just about the science of how it works.

It's also the reality of how it's administered.

There are some studies which show ethnic differences in the type of anesthesia that people have had, which again, is complicated.

So it could be patient factors, lack of information that's been given to them.

There might be systemic discrimination within the system against certain groups, as well as what I describe as provider factors.

In the US and the UK, women of color, particularly Black women, are more likely to receive a C-section during their birth than white women, and they are more likely to receive general anesthesia for that C-section than an epidural.

Now, an epidural is the commonly accepted best practice for C-sections.

That means that the person giving birth is still awake and is conscious for the procedure and for the delivery of their baby.

They just can't feel pain below the point of the epidural.

Every birth it will be different and your experience of pain at that time may be different to your previous experience.

I think it's important that individuals can be— they should have their own choice and they shouldn't feel judged and everyone should be offered the full range of pain relief if they choose to have it.

Sometimes people might say, okay, no epidural.

That's what I said, no epidural.

I gave my husband strict instructions if I was to ask for an epidural, that he must tell me that I said no epidural, which he did say.

And he got he got shouted out.

[laughing] And I had my epidural, which was literally the most amazing thing that's had amazing.

And that is actually why I became an anesthetist.

It's well research that epidurals and C-sections have better outcomes than general anesthesia for both the birthing person and for the baby.

Lower neonatal morbidity and complications, lower rates of infection and hemorrhage and other benefits.

So why do we see this disparity in treatment between ethnicities?

I think it's fair to say that bias can impact on what a patient may have experienced in terms of pain relief and things like that, because I think most clinicians believe that they're giving equitable care.

And I think by accepting that actually that might not be the case, changing your own personal practice, and making sure that you are giving information to someone in a way that they can understand.

And so you need to make sure everyone has the information in a way that they can understand so they can make the right choice for themselves.

And so we've got that aspect of it.

And then I think it's really important to increase diversity in many ways, not just in ethnicity, but in background, socioeconomic background, because you bring that rich life experience to the profession and hopefully eliminates some of the biases that we may have when we give that we may have when we give patient care, for example.

I was considering becoming a doctor when I was pregnant, but I thought ‘well, this is really inconvenient, because I'm pregnant, I'm going to be a mum.

How am I going to have time to become a doctor?

Anyway, when I had my epidural, I went from the worst pain of my life to no pain at all, and I couldn't understand how that was possible.

And so whatever that job is, that's the job I'm going to do.

That's so exciting!

Okay, so my camera died just in time to film the outro, but I hope this episode has helped you see that even if something seems like an embarrassing failure at the beginning, like nitrous oxide did at first, it might inspire something that does work, and revisiting it might show that it does actually have value.

And whether it's a major career change because of a failed birth plan, like for Dr. Sethina Watson, or learning how chloroform works with our bodies’ hormones because of tragic deaths in the early days of chloroform, there is always something valuable to be learned from the things that we think of as failures.

Like producer Steph, who I hope has learned not to extract her own botflies at home.