Historical lessons for modern medicine

When looking at the use of drugs in modern medicine, specifically anaesthesia and intensive care – it is important to realise that this is nothing new at all. The first attempts at general anaesthesia were most likely herbal remedies and opiates, evidence of which has been found as early as the third millennium BCE. Antiseptics, from the Greek words anti (against) and sepsis (decay) were also used in ancient times – with the Egyptians using resins, oils, and spices to preserve bodies, and the Greeks and Romans quickly realising the antiseptic properties of honey, vinegar, and wine.

Today, when looking at medicinal and anaesthetic drugs – it is important to consider those classed as ‘historical’. Take ether and halothane for example; ether (as a surgical anaesthetic) was first demonstrated by William T. G. Morton in Massachusetts in 1846, whilst halothane (an inhaled general anaesthetic) was first used clinically by M. Johnstone in Manchester, in 1956. Despite such agents no longer being in routine use in countries such as the United Kingdom, in other places they are still widely available. With this in mind, knowledge of discontinued drugs may prove extremely useful to a range of healthcare professionals.

Indeed, it could be argued that many more agents should still be used, as they have in the distant past, to treat commonly encountered conditions. For instance, take honey, white wine, flax, and flour. A useful medical tool kit? Many wouldn’t think so, but they were all used to successfully treat a severe facial injury, suffered by Henry V. These ‘antiseptic’ agents, together with the skill of a surgeon (no anaesthetists, intensivists, or microbiologists existed in 1403) led to the prince’s survival.

On the 21^st July 1403, during the Battle of Shreswbury, Prince Henry was struck by an arrow that penetrated his cheek, possibly entering his maxilla (the jawbone). Despite the efforts of numerous royal physicians, the metal arrowhead remained lodged in Prince Henry’s face. A surgeon named John Bradmore was summoned to attend to the young prince.

Firstly, he used probes soaked in rose honey to clean the wound. This was a common practice (and indeed is still used today), as the medicinal importance of honey had long been documented – it maintains a moist wound condition, offers antibacterial activity, and serves as a barrier preventing further infection. Secondly, Bradmore made a device similar to a pair of tongs to remove the barbed arrowhead, before finally washing the wound with white wine. The use of wine in the dressing of wounds dates back to the Greek physician Hippocrates, and can be seen as a precursor to our modern pure-alcohol! The wound was cleaned daily with a paste-like mixture of honey, flour, and flax.

The concept employed by Bradmore, of ‘source control in sepsis’ is one still at the heart of modern sepsis management. It is also an example of how humans are perhaps more able to deal with localized sepsis more effectively compared with systemic sepsis (i.e. wider infection). Indeed, Henry himself is rumoured to have died of dysentery (an infection of the intestines) during the siege of Meaux in 1422.

Moving into more relatively recent times, sodium pentathol, which is still used for the induction of anaesthesia, has for many years been associated with the statement:

“More US servicemen were killed at Pearl Harbor by pentothal than by the Japanese.”

Whilst I was taught this as a young trainee anaesthetist, the reality, as always, is somewhat different. Rather than deaths being caused by the drug itself, it was more the doses of pentothal being administered to patients that caused cardiovascular collapse. Whilst doctors were acting with their patients’ best interest at hearts, it was a lack of understanding of drugs and their impact, which led to the demise of so many.

So what can we expect in future anaesthetic drug development? A number of agents are currently in development, and ‘duration of action’ is a key area that is being targeted. Agents based on ‘benzodiazepine receptor agonists’ (a group of prescription drugs that slow down the body’s central nervous system) are being studied – but with more rapid onset and a shorter duration of action. ‘Etomidate derivatives’ used for induction of anaesthesia are also being developed that do not have the problematic adrenocortical suppression (adrenal glands producing less hormones) that is associated with the former’s use.

Whatever the future may hold, drugs used in anaesthesia and intensive care will continue to develop and progress. Whether it is the newest technology or the most ancient of methods, it is as important as ever that health professionals have readily accessible and sound pharmacological information. This evidence-based approach not only improves patient safety, but also the efficacy and efficiency of treatment – lessons from history we can all benefit from!

Featured image credit: ‘Honey’ by maxknoxvill, CC0 Public Domain via Pixabay.