Electroanaesthesia &#X2013

Anaesthesia 2014 doi:10.1111/anae.12887 Historical Article

Electroanaesthesia – from torpedo ﬁsh to TENS

J. Francis1 and J. Dingley2

1 Specialty Trainee 5, Department of Anaesthetics, University Hospital of Wales, Cardiff, UK 2 Reader and Consultant, Department of Anaesthetics, Swansea University College of Medicine, Swansea, UK

Summary In 153 AD, the Roman physician Scribonius Largus identiﬁed that electric current had analgesic properties, instruct- ing patients to stand on an electric ray for the treatment of gout. In 2014, transcranial magnetic stimulation was approved by the National Institute for Health and Care Excellence for the treatment of migraine. Although separated by nearly two millennia, these milestones represent the evolution of the utilisation of electric current in medical and anaesthetic practice. Signiﬁcant advances have been made over the last century in particular, and during the 1960s and 1970s, tens of thousands of patients were reportedly anaesthetised for surgical interventions using electric current as the anaesthetic agent. Many medical interventions, including transcutaneous electrical nerve stimulation and deep brain stimulation, have evolved in the aftermath of investigations into electroanaesthesia; the potential for electric current to be an anaesthetic agent of the future still exists...... Correspondence to: J. Francis Email: [email protected] Accepted: 3 September 2014

experimental. Many more might consider the concept of inducing and maintaining anaesthesia using electri- Every great advance in science has issued from a cal current passed directly into the brain as somewhat new audacity of imagination. What are now work- barbaric. However, less than 50 years ago, patients were ing conceptions, employed as a matter of course anaesthetised for surgical procedures using electrical because they have withstood the tests of experiment current as the general anaesthetic agent. The concept and have emerged triumphant, were once specula- originated long before that and many modern medical tive hypotheses. devices, including transcranial magnetic stimulators, —John Dewey, 1929 [1] transcutaneous electrical nerve stimulators and In January 2014 the National Institute for Health and implantable nerve stimulators, have indeed evolved Care Excellence (NICE) approved transcranial magnetic from similar ‘speculative hypotheses.’ stimulation for the treatment and prevention of migraines [2]. A portable device is held to the patient’s Early history scalp and delivers a magnetic pulse, creating a transient Ancient Greeks used the word ‘narke’ to describe the electric current within underlying tissues by magnetic electric ray after noticing the local anaesthesia pro- induction, to target migraine pain. The exact mecha- duced by its electrical discharge (Fig. 1). In 153 AD, nism of action of transcranial stimulation is not fully the Roman physician Scribonius Largus wrote “For understood and some may perceive it as somewhat any type of gout a live black torpedo should, when the

moderate contractions of the face muscles and even the muscles of the neck and forearm take place... The inhibition ﬁrst reaches the centres of speech and then the motor senses. The subject is unable to react even to painful stimulations... The subject has some stridor... The most unpleasant feeling is to be aware of the dissociation and progressive disappearance of the faculties. The sensation is identical to a nightmare during which, in the presence of great danger, one would feel unable to talk or to move.”

Another electroanaesthesia pioneer was Louise Ra- Figure 1 Electric ray (Torpedo torpedo) (with permis- binovitch and her work is perhaps more relevant to sion, Roberto Pillon; www.fishbase.org). modern medical techniques. Her interests included using electrical current for resuscitation after cardiac pain begins, be placed under the feet. The patient must arrest and also for inducing regional anaesthesia. She stand on a moist shore washed by the sea and he delivered electrical current through electrodes posi- should stay like this until his whole foot and leg up to tioned over peripheral nerves to induce regional anaes- the knee is numb. This takes away present pain and thesia for surgical procedures and some of her early prevents pain from coming on if it has not already work was reported in the New York Times on 26th arisen” [3]. Note the use of saline to keep the fish alive January 1910: and ensure good electrical conduction. During the 18th and 19th centuries many observa- “Electricity as an anaesthetic was used with suc- tions relating to electrical current and electroanaesthe- cess in an operation at St. Francis’s Hospital sia were made, including those of Benjamin Franklin, today. The electricity was applied by Dr Louise E. an eminent American politician and scientist [4]. In Rabinovitch of Paris... While a patient was being 1803 a Russian physicist, Petrov, reportedly noted subjected to the electrical current by Dr Rabinov- the ‘galvanarcosis’ of fish subjected to direct electric itch four toes were amputated by Dr Marcus M. current, with similar observations being made in 1875 Johnson, and the man felt no pain... He had not by Mach, an Austrian physicist. Subsequent investiga- felt the slightest sensation during the cutting and tion by d’Arsonval in 1890 and Hutchinson in 1892 had not known when the Surgeons were doing it. identified potential benefits of using interrupted direct During the operation he talked with the atten- current to narcotise larger animals [5]. dants and laughed at jokes.” Another Frenchman, who had collaborated with Rabinovitch reportedly oversaw numerous opera- Jacques d’Arsonval in Paris, is perhaps regarded as the tions similar to this, and experimented using different pioneer of electroanaesthesia. In 1902, following exper- current flows. In the case reported above, she used a imental work in animals, Stephen Leduc instructed his current of 4 mA and 54 V, but she subsequently used colleagues to subject him to electrical current (4 mA, up to 18 mA for a leg amputation. She observed that 35 V, 100 Hz interrupted DC), delivered through elec- anaesthesia was complete and reliable for each case; trodes on the forehead and spine [6]. A later transla- patients complained of tingling sensations with higher tion of his work describes the experience [7]: amperages, and interestingly the current induced vaso- “We have submitted ourselves to the action of elec- constriction of blood vessels providing relatively blood- trical cerebral inhibition... The sensation caused less operating conditions [5]. by excitation of peripheral nerves although Subsequent progress was slow, undoubtedly hin- unpleasant is easily bearable... The face is red, dered by two world wars. A significant event was the

2 © 2014 The Association of Anaesthetists of Great Britain and Ireland Francis and Dingley | Electroanaesthesia Anaesthesia 2014 advent of electroconvulsive therapy (ECT) in 1938, 200 mA for 12 s, and then reducing to 50 mA. He from which the concept and achievability of electroan- describes how the initial current must be high enough aesthesia undoubtedly gained momentum during the to stimulate clonic contractions before being reduced late 1940s and 1950s. to maintain these contractions. At this stage, an airway was inserted and patients were allowed to breathe ECT and electronarcosis ‘carbogen’ (95% oxygen with 5% carbon dioxide) to Electroconvulsive therapy was originally introduced by stimulate respiration. Italian neurologists Cerletti and Bini as a safer and less The second stage of treatment involved a steady unpleasant alternative to insulin coma (insulin-induced increase in current to 150–180 mA at 3 min: “By this hypoglycaemic coma repeated over several weeks) or time the patient is in the electronarcosis state – legs pentamethethylene tetrazol convulsion (during which extended, arms flexed, hands in carpo-pedal spasm and the patient was conscious) treatments for psychosis. mild stridor.” This current was maintained for The ECT technique used a current delivered to the 8–10 min and then gradually reduced to zero, ending patient via bi-temporal electrodes mounted on a for- the treatment. The author describes marked cardiac ceps [8]. In the literature, insulin coma therapy is irregularities including periods of asystole, bradycardia frequently referred to as insulin shock therapy and and tachycardia, with associated changes in blood ECT as electric shock therapy. pressure during the first stage, while during the second Following the introduction of ECT, some psychia- stage, all patients showed marked tachycardia with ele- trists perceived additional benefits in maintaining the vation of blood pressure. Monitoring was difficult convulsive state for more prolonged periods, and owing to electrical interference and muscular tension. numerous study groups investigated this in patients By 1950, with similar findings by other investigative during the 1940s [9, 10]. This resulted in the develop- groups [10–12], it became apparent that the prolonged ment of electronarcosis, essentially prolonged ECT. In application of current in electronarcosis exposed the literature, the term electronarcosis is often used patients to significant additional risks but no notable interchangeably with the term electroanaesthesia and benefits to ECT, and it was gradually abandoned. to avoid confusion, we refer to psychiatry-related treat- An important part of the story was contributed by ments as electronarcosis and anaesthesia-related ones Walter Freeman, an American psychiatrist and neurol- as electroanaesthesia. ogist, who was director of psychiatric research in In 1949, the American psychiatrist, Geoghegan, Washington in 1924. He collaborated with Egas published his findings in psychiatric patients [9]. He Moniz, a Portuguese physician who later won the premedicated patients with 100 lg atropine to reduce Nobel Prize in 1949 for developing the prefrontal salivation, positioned them with slight hyper-extension lobotomy for mental illness, and James Watts, an of the spine and administered 5 g sodium pentothal to American neurosurgeon. Lobotomies were originally induce sleep, before positioning electrodes 8 cm ante- performed under general anaesthesia with neurosur- rior to the mastoid process and 4 cm above the geons using a drill to penetrate the skull, but in 1937 zygoma. He describes liberal application of a conduc- Amarro Fiamberti developed a less invasive transorbit- tive gel to prevent the ‘multiple small electrical burns al approach to the frontal lobes that Freeman subse- that are common when uncovered electrodes are used’ quently developed into the so-called ‘ice-pick and how positioning of electrodes too posteriorly lobotomy’. As this simplified technique reduced surgi- caused ‘stridor and a superficial coma’. He also cal and anaesthetic requirements, he believed it more describes how the 60-Hz alternating current (AC) unit suited to psychiatric hospitals lacking these services they used produced a smooth rise to peak current and (i.e. the majority). Parting company with Watts, Free- how this ‘eliminates or almost eliminates compression man developed a portable electroshock machine that fractures of the vertebrae’. produced brief unconsciousness. He then hammered a Treatment was initiated with the current rapidly ‘leucotome’, early versions physically resembling an increased to 300 mA for 8 s, 250 mA for 10 s, ice-pick, through the superior orbital rim into the

© 2014 The Association of Anaesthetists of Great Britain and Ireland 3 Anaesthesia 2014 Francis and Dingley | Electroanaesthesia brain, to sever the connections of the frontal lobe. Freeman, however, also made an accidental contri- Bilateral lesions were performed in quick succession, bution to modern anaesthesia. In 1932, he was con- or even simultaneously before patients awoke (Fig. 2) sulted by Richard Gill, a patient suffering with painful [13]. muscle spasms following a horse riding accident. He Freeman popularised the technique, performing suggested that if Gill could collect arrow poison thousands of procedures until 1967, often in an ofﬁce (curare) from the South American jungle, it could be setting and initially at least, with the support of the puriﬁed and used to treat spastic conditions. Gill medical community. An insightful video documentary, returned with curare in 1938; he then collaborated with detailed footage of Freeman’s work, has been pro- with Abram Bennett, an American psychiatrist duced by the Public Broadcasting Service in America, researching its use to prevent bone fractures during with footage available through YouTube [14]. pentamethethylene tetrazol convulsive therapy, which led to the development of neuromuscular blocking

(a) drugs for clinical use during general anaesthesia [15, 16].

Electroanaesthesia During the 1950s and 1960s, the concept of electronarcosis progressed towards electroanaesthesia. Despite the adverse events noted in psychiatric practice, it must be considered that this was the era of ‘halothane hepatitis’ and ‘methoxyflurane renal failure’, and so there was real interest in exploring new anaesthetic techniques. In 1956, Knutson et al. reported electroanaesthesia in dogs [17]. Twenty-five dogs were anaesthetised for 3 h using electrodes positioned on the – (b) head, using 50 120 mA AC at 700 Hz. Although rhythm irregularities and hypertension were noted, the authors were satisfied with the haemodynamic profiles; other than marked hyperglycaemia, they found no changes in blood biochemistry during the passage of current. Twenty-four brains and spinal cords were assessed microscopically, with 17 reported as being entirely free from morphological changes. Using 120 mA current, the measured potential across the head was 18 V and the highest potential measured on the body was 11 V; the authors concluded that these low potentials would not put an operator in danger. Knutson et al. went on to experiment in five con- Figure 2 Electroshock anaesthesia used for lobotomy senting psychiatric patients, all of whom had previ- procedure. (a) electroshock anaesthesia delivered via ously received courses of ECT [17]. Each was given two electrodes in forceps style arrangement (b) the atropine premedication and subsequently anaesthetised ‘ ’ ice-pick procedure is started (permission obtained with 105–150 mA AC at 700 Hz for 12–32 min. Galla- from Basic Books Inc. Publishers, New York. Image mine (a non-depolarising neuromuscular blocker) appears in; Valenstein, Elliot S. Great and Desperate Cures, The rise and decline of psychosurgery and other facilitated tracheal intubation. They commented on the radical treatments for mental illness. Basic Books, Inc., severe tonic contractions and breath-holding following À New York, 1986). current application, heart rates of 140 beats.min 1 and

4 © 2014 The Association of Anaesthetists of Great Britain and Ireland Francis and Dingley | Electroanaesthesia Anaesthesia 2014 systolic blood pressures of 280 mmHg. The second mass movements. These findings were supported by patient who was initially anaesthetised with 135 mA Smith et al. in the USA, who duplicated the circuit ‘seemed to be awake’ when the current was reduced to and apparatus described by the Russian group and 105 mA and even nodded his head to command; he anaesthetised 11 mongrel dogs [20]. subsequently described his experience as ‘burning in In February 1961, a group from Mississippi pub- Hell, no pain, just the idea’. For the fifth patient, the lished reports on patients who had undergone electro- group used hexamethonium (an anti-cholinergic gan- anaesthesia for surgery. Following five years of animal glion blocker) to control the surge in blood pressure experiments, in January 1961, they induced electrical with application of current. The patient was reportedly anaesthesia in two patients; these are considered to be inarticulate on waking, smiling faintly to questions but the first reliable published case reports [21]. The first otherwise giving no response and he remained in patient was a 67-year-old woman with metastatic rectal an ‘unresponsive and suspicious state’ for several carcinoma requiring diagnostic laparotomy. Mild tran- months. Due to the seriousness of the cardiovascular quillity was achieved with thiamylal, a barbiturate, complications they had observed, the group before intubation using suxamethonium and topical discontinued investigations. They did, however, con- tetracaine. Bi-temporal electrodes were applied and the clude that safe electrical anaesthesia was a possibility current increased to 30 mA over 15 s, by which time and that further experimentation with varying cur- the patient had ‘ceased straining on the endotracheal rents, potentials and frequencies might produce ‘a sat- tube and was asleep’. The lungs were initially venti- isfactory narcosis without the frightening side-effects’. lated manually before the resumption of spontaneous Much electroanaesthesia research was performed respiration, although small suxamethonium doses were in the former Soviet Union with active groups in required to maintain relaxation for the operation, Moscow and Kiev. Much remains unpublished or inac- which lasted 30 min. No cardiac arrhythmias devel- cessible, but in 1959, a Russian paper was re-printed oped and the highest blood pressure reading was 190/ in the journal Anesthesiology [18]. It reported that in 120 mmHg. Within 60 s of current cessation, the 1948, Gilyarovskiy et al. had successfully performed an patient reportedly opened her eyes and shortly after- appendicectomy in a patient under electroanaesthesia wards she was able to nod her head appropriately. She lasting 25 min, although details of the technique were subsequently had no recollection of the operation, feel- not reported [19]. After reviewing the Russian litera- ing no pain and no symptoms of nausea, and was ture, Anan’ev et al. identified that a common problem apparently discharged three days later. was that the electrical resistance of the tissues The second case was a woman having a left-sided increased, thus reducing the current flow; perhaps, this mastectomy, and the procedure was again remarkably may have been as a result of vasoconstriction [18]. uneventful. Her recovery was rapid and straightfor- They describe an apparatus that delivered pulsatile ward, and the team commented on the absence of current overlaid upon a background of direct current residual somnolence seen with other forms of general through electrodes positioned over the eyes and the anaesthesia. occiput; the electrodes were placed thus so that the Hardy et al. continued work throughout 1961, pri- current passed better through the brain via the foram- marily investigating the possibility of inducing person- ina, minimally impeded by the skull which is a poor ality changes or brain damage in patients undergoing conductor of current. They reported their findings in electroanaesthesia. They describe exhaustive pre- and dogs, concluding that electronarcosis was produced postanaesthetic psychological evaluation and electroen- more effectively with the application of small currents cephalographic studies. Their techniques had evolved initially, inducing ‘electrosleep’, before gradually to include premedication with secobarbital 100 mg (a increasing the current flow to induce electroanaesthe- barbiturate) for sedation and atropine 800 lgto sia. They reported limb amputations and laparotomies reduce secretions. Tracheal intubation was performed in animals without any observed pain reactions, yet using thiamylal and suxamethonium before application avoiding the side-effects of apnoea, convulsions and of electrodes to each temple. They used currents

© 2014 The Association of Anaesthetists of Great Britain and Ireland 5 Anaesthesia 2014 Francis and Dingley | Electroanaesthesia ranging from 50 mA to 110 mA with a frequency of from their investigations in a total of 20 surgical 700 Hz and a voltage range of 12–47 V in 12 surgical patients, the group concluded that only 50% of their patients. They described how it was necessary to patients had complete amnesia of their surgical proce- employ neuromuscular blocking drugs to control gen- dure, a figure out of proportion, even then, to other eralised muscle spasms, and consequently patients also general anaesthetic techniques [24]. required controlled ventilation. Observations included In 1963, James Price and William Dornette pub- significant increases in pulse rate and blood pressure lished their findings on electroanaesthesia in 50 immediately after current application, arrhythmias in patients aged 4–81 years using the Narcotron device three patients, significant respiratory depression and (Fig. 3) [25]. Premedication included meperidine varying degrees of muscle spasms. They comment on a (pethidine) with atropine or scopolamine (hyoscine), ‘particularly interesting but poorly understood finding’ and they used electrodes positioned bi-temporally. of raised catecholamine and steroid levels, as well as They described calculating the current required increased pilomotor activity and tear production dur- according to the patient’s age, size and transverse ing the procedures. Complications were observed in diameter of the skull, with children under 12 years four patients, with one sustaining first-degree burns to requiring 80–100 mA and adults requiring 120– the forehead. Post-procedure assessments identified 130 mA. They further described altering current flow two patients with definite recollection of the entire according to intra-operative observations, with pulse experience and four with recall of certain elements; rate, blood pressure and eye signs being the most reli- however, none manifested any change in personality. able and easily monitored patient responses. The first Surprisingly, the group concluded that electroanaesthe- 10 patients studied received electric current without sia ‘can be utilised safely in humans’, but acknowl- pre-administration of thiobarbiturate, but this was sub- edged concerns relating to the uniform production of sequently reviewed for both ‘convenience and... analgesia and amnesia. They discussed the advantages patient comfort’. The group noted that suxamethoni- of avoiding chemical anaesthetics, while summarising um following induction was useful for tracheal intuba- the disadvantages of muscle rigidity, excessive secre- tion, but also because it prevented the ‘transient bout tions, haemodynamic instability, neuro-endocrine of laryngospasm noted when electroanaesthesia is responses and of course the ‘unpleasantness of the ini- induced in the conscious patient’. After initial experi- tial electric shock’ [22, 23]. ments with a slow induction technique for the first six Hardy’s group remained unsatisfied that electroan- patients, increasing the current to the desired level aesthesia reliably produced analgesia at the time of over 30–60 s, the group then changed to and surgery, prompting their further investigation in a group of five volunteers using multiple stimuli. Pain perception was tested using hypodermic needles inserted through the abdomen, arms and legs, temper- ature perception by ether-soaked gauze applied to the skin of the abdomen, and proprioception by the pas- sive movement of all extremities. During current application, the first volunteer reportedly opened his eyes to command, recalled nothing of the sensory tests performed, but was aware of the tracheal tube. The other four volunteers had similar experiences with none of ‘ ’ them recalling the sensory tests performed, but all Figure 3 Narcotron electroanaesthesia machine used by Price and Dornette, 1963 (reproduced with permis- recalling the presence of the tracheal tube. Seemingly sion of Lippincott Williams & Wilkins, publisher, from reassured, the group continued investigations in a fur- Price JH, Dornette WHL. Clinical experiences with ther eight surgical patients, two of whom had definite electroanesthesia: A preliminary report of 50 adminis- recollections of part of the surgical procedures. Overall, trations. Anesthesia and Analgesia 1963; 42: 487–95).

6 © 2014 The Association of Anaesthetists of Great Britain and Ireland Francis and Dingley | Electroanaesthesia Anaesthesia 2014 maintained a rapid induction technique. To confirm literature, the team investigated different generators, adequate anaesthesia, they identified that the pulse rate currents, electrode types and delivery methods. Initial should increase by 20–40% and blood pressure by investigations were performed on animals and human 30–70%. If this was not observed, the current was volunteers that reportedly included Rama Rao himself. increased rapidly to achieve the expected elevation. Volunteers were initially anaesthetised without the use Eye signs were also described as being ‘interesting and of sedative medication, but with recall of ‘severe pain significant’, and reliable in 80–85% patients. With around the head, similar to a rope being tightened’, inadequate anaesthesia, the pupils were described as this was reviewed. The group used electroanaesthesia moderately dilated and reactive to light; with adequate for surgery in 2501 patients aged 3-63 years; this anaesthesia, the pupils were central, constricted and extensive experience was published in journals and relatively non-reactive, while with excessive anaesthe- book chapters as well as presented at international sia, they became widely dilated with an exaggerated fora and societies [33, 34]. Their findings were very light reflex. One 12-year-old girl suffered post- similar to those already discussed, notably discomfort, anaesthetic convulsions and hallucinations lasting for muscle rigidity and haemodynamic changes. They 72 h, and it was felt that she had received excessive noted similar findings to Price and Dornette concern- current for anaesthesia due to her narrow bi-temporal ing pupil reactivity. They reported that of the 251 diameter. In each group, there were failures, with patients they anaesthetised for surgery, 217 were ‘suc- patients complaining of recall and pain, and it was felt cessful’,25‘partially successful’ and eight ‘unsuccess- that 50% of these failures were due to electrode move- ful’. In 1975, the group suggested that “standard ment. In 11 patients, there was neither satisfactory clinical means for determining the depth of electroanalgesia nor apparently any anaesthesia and in seven anaesthesia should not be used. Indeed, it is possible others, there was some memory of pain and discom- that patients under electroanaesthesia are never truly fort. Furthermore, ‘of the successful anaesthetics, 10% asleep”. They continue to conclude that “with such of the patients recalled some pain or discomfort’. The spectacular advances in the field of safe and satisfac- group concluded that children and the elderly tend to tory anaesthesia by chemical agents, the immediate tolerate electroanaesthesia the best, emphasising that prospect of electroanaesthesia becoming popular is one elderly patient preferred her electroanaesthesia to questionable”, but that with further development, it either of her two previous general anaesthetics [25]. “would be an ideal technique of anaesthesia for battle- Numerous other groups explored the concept of field mass disasters, surgery in nuclear war, space electroanaesthesia throughout the 1960s, with notable medicine, surgery of high risk cases and myasthenics, work coming from Japan [26, 27], South Africa [28, busy outpatient clinics, repeated burns, and other 29] and Britain [30]. Important work was also carried painful dressings” [34]. out by military services worldwide, who viewed Professor Aime Limoge, an electrophysiologist electroanaesthesia as a potentially simple method of from Paris, was one of the last advocates of electroan- anaesthesia that was suitable for difficult environments aesthesia. As well as writing a book on electro- and requiring minimal compact equipment. anaesthesia [35], he also developed his own Following the end of the ‘British Raj’ leadership electroanaesthesia machine that delivered his ‘Limoge in India in 1947, the 1950s and 1960s was an impor- current’, a current that was reportedly free from side- tant era of modernisation in an India striving for effects. Limoge used biphasic currents of 40 V at self-sufficiency. News of Hardy et al.’s success was 167 kHz to anaesthetise reportedly tens of thousands published in the Times of India in January 1961 and of patients in France during the 1970s. He suggested the Indian Defence Services supported similar investi- that the biphasic current meant that the mean current gations in India. Brigadier Rama Rao, a consultant in intensity was 0 mA, preventing burns or convulsions, anaesthesia and intensive care medicine, oversaw and the high frequency, significantly greater than those investigations that primarily took place at an army advocated by others, prevented muscle spasms. Limoge hospital in Bangalore [31, 32]. Reviewing the always used drugs for induction of anaesthesia and to

© 2014 The Association of Anaesthetists of Great Britain and Ireland 7 Anaesthesia 2014 Francis and Dingley | Electroanaesthesia facilitate intubation, but reported that electroanaesthe- Cerebral electrotherapy sia for maintenance was safe and resulted in significant Cerebral electrotherapy (CET) describes the application reductions in postoperative pain, also reporting that of low-intensity electrical current to the cranium as a electroanaesthesia was useful in obstetrics, where doses recognised treatment for insomnia, anxiety, depression of epidural anaesthesia were reduced by up to 60% and chronic pain (Fig. 4). Multiple devices are available [36]. In 2004, aged 72 years, Limoge underwent an commercially [41]. The CET concept developed along- oesophagectomy utilising transcutaneous cranial elec- side that of electronarcosis and electroanaesthesia, with trical stimulation (TCES) peri-operatively. In corre- much early work done in Russia. Research during the spondence published in Anesthesia and Analgesia, 1960s and 1970s reported variable findings [42, 43], Limoge described how TCES resulted in a marked although in 1964, an American group found their ‘elec- reduction in his postoperative doses of epidural ropiva- trosom’ apparatus to be as effective as 100 mg pheno- caine and sufentanil, and encouraged its use for peri- barbital for treating insomnia [44]. CET has also been operative analgesia and anaesthesia [37]. suggested to facilitate opioid withdrawal, both through its sedative effects and potentially through increased Electroanaesthesia – the aftermath cerebral endorphin production [45, 46]. An interesting The prospects of electroanaesthesia resulted in world- correspondence in the American Journal of Psychiatry, wide interest with regular international meetings in 1990, reflects on a technique previously observed in including the International Symposium on Electrosleep Hong Kong, where CET was used with naloxone to and Electroanaesthesia in May 1970. However, with facilitate rapid (outpatient) opioid withdrawal. They significant advances in chemical anaesthetic agents reported that while CET “permits the patient to remain during the 1970s and 1980s, interest in electroanaes- in some subjective comfort during the withdrawal period, thesia waned. Nevertheless, electrical stimulation of the patient undergoes several hours of severe with- neural tissue continued to be investigated and is now drawal... The rapid detoxification carries a risk to life” utilised in numerous ways within modern medical [47]. This was another research interest of Limoge, who practice. (a) Regional anaesthesia/analgesia Despite reducing interest in electroanaesthesia, it was recognised in the early 1970s that low-intensity electrical current delivered to the spinal cord inhibited cord function and pain transmission [38, 39]. In 1974, Shimoji et al. inserted stainless steel wires into the epidural spaces of eight human volunteers and used a constant-current stimulator delivering a 3.5–11.5 mA current at 5 Hz. They were then submitted to periph- (b) eral electrical stimulation and pinprick challenges. Shimoji et al. reported that all developed a ‘pleasant massage-like feeling at the site of cord stimulation’ and that six out of the eight had experienced analgesia or hypalgesia; they described how this may be a similar mechanism to the spinal cord gate, postulated by Melzack and Wall in 1965 [40]. The first portable transcutaneous electrical nerve stimulation (TENS) Figure 4 Two electrosleep machines (a) from the USA device was developed and patented in 1974 by the (b) from the former Soviet Union (permission American firm Medtronic, founded by Earl Bakken obtained from The Bakken Library and Museum, Min- and Palmer Hermundslie in 1949. neapolis, US).

8 © 2014 The Association of Anaesthetists of Great Britain and Ireland Francis and Dingley | Electroanaesthesia Anaesthesia 2014 reported promising results in thousands of patients in animals; interestingly, electrical stunning of ani- during the 1990s [48]. Although not widely used in the mals continues to be a well-recognised technique UK, this technique is well recognised in the USA. used in slaughterhouses to induce instantaneous, painless unconsciousness before slaughter. Numerous Dentistry stunning probes exist, with two recognised tech- Electric current has been extensively investigated as a niques reported: head-only stunning (inducing means of producing local anaesthesia for dental proce- unconsciousness); and simultaneous head-to-body dures, with very early work done in Japan [49]. In 1970, stunning (inducing unconsciousness moments before Brooks et al. used an electrical current that flowed cardiac arrest) – when performed properly, the ani- through their dental burr directly into the tooth. Using mals reportedly feel nothing during their slaughter. currents of 5 lA and 0.06 V, promising results were Temple Grandin, a professor of animal science at reported with 50/76 (66%) adult male patients reporting Colorado State University, has performed extensive complete absence or only minimal pain [50]. With research regarding animal stunning and welfare, growing interest in TENS, during the 1980s, research reviewed in 2013 [55]. shifted towards the use of intra- and extra-oral electrodes. Reported success rates varied, with authors gen- Current/future considerations erally concluding that further advances in equipment The concept of electrical stimulation of tissues for were required [51]. Numerous devices were investigated analgesic or anaesthetic purposes continues to evolve, during the 1990s; interestingly, much of this research with multiple forms of electroanalgesia now being was in paediatric patient populations. In 1996, Jones developed, some that may target specific types of pain and Blinkhorn compared electronic anaesthesia with through variations in current delivery. As well as local anaesthetic injection in patients aged 10–17 years TENS, percutaneous neuromodulation therapy (PNS; having restorative dental procedures [52], concluding previously known as percutaneous electrical nerve that the electronic anaesthesia study group had signifi- stimulation (PENS)) is now used, in which ultra-fine cantly higher pain scores than the control group and acupuncture needles are positioned in target tissues thus electronic anaesthesia was not an appropriate sub- before the passage of electric current; this technique is stitute for injected local anaesthetic. Another study pub- widely used for chronic pain in cancer patients [56]. lished in the same year compared electronic anaesthesia Other related treatments include transcutaneous acu- with placebo electronic anaesthesia in paediatric patients point electrical stimulation, H-wave therapy, interfer- having restorative dental procedures [53]. Interestingly, ential current therapy and piezo-electric current the group concluded that electronic anaesthesia was no therapy. More invasive techniques include direct spinal more effective than placebo, suggesting that the effects cord stimulation and deep brain stimulation, via surgi- may be produced simply through distraction. This find- cally- or radiologically-guided electrode placement. ing was somewhat supported by Cho et al. [54]; they These treatments are often reserved for patients in reported in 1998 that despite higher reported pain scores whom all others have failed. Deep brain stimulation with electronic anaesthesia than injected local anaesthe- has proven benefits for atypical facial pain, phantom tic, 63% of the children they investigated in a crossover limb pain and anaesthesia dolorosa [57] and is also a study preferred electronic anaesthesia, suggesting an NICE-approved treatment option for Parkinson’s dis- element of playful distraction with the technique. ease [58]. Although research continues, significant developments Much has transpired since Scribonius Largus remain to be made; electric current is not routinely used advised his patients to stand on moist torpedo fish. for anaesthesia in dental practice. Competing interest Electrical stunning of animals No external funding and no competing interests Most study groups cited in this article performed declared. preliminary investigations with electrical anaesthesia

References 24. Fabian LW, Hardy JD, Turner MD, Moore FJ. A review of the 1. Capps JM, Capps D. James and Dewey on Belief and present status of electronarcosis. Anesthesia and Analgesia 43 – Experience. Urbana and Chicago: University of Illinois Press, 1964; :87 96. 2005. 25. Price JH, Dornette WHL. Clinical experiences with electroanes- 2. National Institute for Health and Care Excellence (NICE). Trans- thesia: a preliminary report of 50 administrations. Anesthesia 42 – cranial magnetic stimulation for treating and preventing and Analgesia 1963; : 487 95. migraine. NICE interventional procedures guidance [IPG477], 26. Shimoji K, Higashi H, Terasaki H, Morioka T. Clinical electroan- 2014. http://www.nice.org.uk/guidance/IPG477 (accessed esthesia with several methods of current application. Anes- 50 – 02/09/2014). thesia and Analgesia 1971; : 409 16. 3. Kuhfeld ER. Return with us now. http://washuu.net/ 27. Shimoji K, Higashi H, Terasaki H, Kano T, Morioka T. Physiolog- Med-Lec/Return.htm (accessed 27/08/2014). ical changes associated with clinical electroanesthesia. Anes- 50 – 4. Hill L. Electric methods of producing humane slaughter. Veteri- thesia and Analgesia 1971; : 490 7. nary Journal 1935; 91:51–7. 28. Wulfsohn NL, McBride W. Electronic anaesthesia. South African 36 – 5. Herin RA. Electroanesthesia: A review of the literature (1819– Medical Journal 1962; : 941 3. 1965). Activitas Nervosa Superior 1968; 10: 439–54. 29. Wulfsohn NL. Electrical anaesthesia in man. South African 41 – 6. Leduc S. Production du sommeil et de l’anesthesie gen erale Medical Journal 1967; : 238 42. et locale par les courants electriques. Comptes Rendus de 30. Clutton-Brock J. The present position of electrical anaesthesia. 21 – l’Academie des Sciences 1902; 135: 199–200. Anaesthesia 1966; : 101 2. 7. Van Poznak A. Electrical anesthesia. Anesthesiology 1963; 24: 31. Rama Rao KR. Two decades of anaesthesia in the armed – 101–8. forces in India, 1949 1969 (Progress and Prospect). Armed 26 – 8. Cerletti U, Bini L. L’Elettroshock. Archivio Generale di Neurolo- Forces Medical Journal (India) 1970; :76 83. gia, Psichiatria e Psicoanalisi 1938; 19: 266. 32. Rama Rao KR, Sita RB. Present spectrum of electroanaesthesia 18 – 9. Geoghegan JJ. Electronarcosis. Canadian Medical Association in India. Indian Journal of Anaesthesia 1970; : 111 4. Journal 1949; 60: 561–6. 33. Rama Rao KR, Bhat S, Rajagopalan MS. Clinical experiences of 10. Kalinowsky LB. Present status of electric shock therapy. Bulle- electro-anaesthesia. In: Wulfsohn NL, Sances A, eds. The Ner- tin of The New York Academy of Medicine 1949; 25: 542–53. vous System and Electric Currents. New York: Plenum publish- – 11. Garmany G, Early DF. Electronarcosis, its value and its dangers. ing, 1966: 165 72. Lancet 1948; 251: 444–6. 34. Rama Rao KR, Bhat S, Rajagopalan MS. Experimental and clin- 12. Bowman KM, Simon A. Studies in electronarcosis therapy. ical studies in India: a review. In: Sances A, Larson SL, eds. American Journal of Psychiatry 1948; 105:15–27. Electroanaesthesia: Biomedical and Biophysical Studies.New – 13. El-Hai J. The Lobotomist: A Maverick Medical Genius and his York: Academic Press, 1975: 294 323. Tragic Quest to Rid the World of Mental Illness. New Jersey: 35. Limoge A. Introduction to Electroanaesthesia. Baltimore: Uni- Wiley, 2005. versity Park Press, 1975. 14. YouTube. Lobotomy – Public Broadcasting Service documen- 36. Goldman B. Can Aime Limoge sell electroanesthesia to North 130 tary on Walter Freeman, 2008. www.youtube.com/watch? America? Canadian Medical Association Journal 1984; : – v=_0aNILW6ILk (accessed 02/09/14). 1191 200. 15. Larson M. Electrical anesthesia. California Society of Anesthe- 37. Limoge A, Dixmerias-Iskandar F. A personal experience using siologists Bulletin 2008; 57:56–60. Limoge’s current during a major surgery. Anesthesia and 99 16. Bennett AE. The history of the introduction of curare into Analgesia 2004; : 309. medicine. Anesthesia and Analgesia 1968; 47: 484–92. 38. Shealy CN, Mortimer JT, Hagfors NR. Dorsal column electroan- 32 – 17. Knutson RC, Tichy FY, Reitman JH. The use of electrical algesia. Journal of Neurosurgery 1970; : 560 4. current as an anesthetic agent. Anesthesiology 1956; 17: 39. Campbell JN, Taub A. Local analgesia from percutaneous elec- 815–25. trical stimulation. A peripheral mechanism. Archives of Neu- 28 – 18. Anan’ev MG, Golubeva IV, Gurova EV, Kaschevskaia LA, Levits- rology 1973; : 347 50. kaia LA, Khudyi YB. Preliminary data on experimental electro- 40. Shimoji K, Kitamura H, Ikezono E, Shimizu H, Okamoto K, narcosis induced with apparatus of the scientific research Iwakura Y. Spinal hypalgesia and analgesia by low-frequency institute of experimental surgical apparatus and instruments. electrical stimulation in the epidural space. Anesthesiology 41 – Anesthesiology 1960; 21: 215–9. 1974; :91 4. 19. Gilyarovskiy VA, Sluchevskiy NF, Liventsev MM, Kirillova ZA. 41. Fisher Wallace Laboratories. Fisher Wallace Stimulator, 2014. Klinicheskaia Meditsina 1948; 26:18–23. www.fisherwallace.com/ (accessed 02/09/2014). 20. Smith RH, Goodwin C, Fowler E, Smith GW. Volpitto PP. Electro- 42. Rosenthal SH. Electrosleep: a double-blind clinical study. 4 – narcosis produced by a combination of direct and alternating Biological Psychiatry 1972; : 179 85. current. A preliminary study: 1. Apparatus and electrodes. 43. Moore JA, Mellor CS, Standage KF, Strong H. A double-blind Anesthesiology 1961; 22: 163–8. study of electrosleep for anxiety and insomnia. Biological 10 – 21. Hardy JD, Fabian LW, Turner MD. Electrical anesthesia for major Psychiatry 1975; :59 63. surgery. IV. Report of two cases. Journal of the American Med- 44. Straus B, Elkind A, Bodian CA. Electrical induction of sleep. 248 ical Association 1961; 175: 599–600. American Journal of the Medical Sciences 1964; : – 22. Fabian LW, Hardy JD, Turner MD, Moore FJ. Electrical Anesthe- 514 20. sia: V. Survey of clinical progress with illustrative cases. Anes- 45. Gomez E, Mikhail AR. Treatment of methadone withdrawal thesia and Analgesia 1961; 40: 653–61. with cerebral electrotherapy (electrosleep). British Journal of 134 – 23. Fabian LW, Hardy JD, Turner MD, Moore FJ, McNeil C. Clinical Psychiatry 1979; : 111 3. experiences with electronarcosis for surgical patients. Anes- 46. Gabis L, Shklar B, Geva D. Immediate influence of transcranial b thesiology 1962; 23: 145–6. electrostimulation on pain and -endorphin blood levels: an

active placebo-controlled study. American Journal of Physical anaesthesia in children. International Journal of Paediatric Medicine and Rehabilitation 2003; 82:81–5. Dentistry 1996; 6: 245–51. 47. Westermeyer J. Rapid opioid detoxiﬁcation with electrosleep and 54. Cho S-Y, Drummond BK, Anderson MH, Williams S. Effective- naloxone. American Journal of Psychiatry 1990; 147:952–3. ness of electronic dental anesthesia for restorative care in 48. Limoge A. Treating drug addicts by transcutaneous cerebral children. Pediatric Dentistry 1998; 20: 105–11. electric stimulation. International Criminal Police Review 55. Grandin T. Making slaughterhouses more humane for cattle, 1995; 452–3. pigs and sheep. Annual Review of Animal Biosciences 2013; 49. Suzuki K. New dentin de-sensitising technique by means of 1: 491–512. electroanaesthesia. Journal of the Japanese Stomatology Soci- 56. White PF, Li S, Chiu JW. Electroanalgesia: its role in acute and ety 1952; 19:56–69. chronic pain management. Anesthesia and Analgesia 2001; 50. Brooks B, Reiss R, Umans R. Local electroanaesthesia in den- 92: 505–13. tistry. Journal of Dental Research 1970; 49: 298–300. 57. Boccard SGJ, Pereira EAC, Moir L, Aziz TZ, Green AL. Long-term 51. Quarnstrom F. Electronic dental anesthesia. Anesthesia outcomes of deep brain stimulation for neuropathic pain. Progress 1992; 39: 162–77. Neurosurgery 2013; 72: 221–31. 52. Jones CM, Blinkhorn AS. Dental electro-anaesthesia in chil- 58. National Institute for Health and Care Excellence (NICE). Deep dren: a pilot study. International Journal of Paediatric Den- brain stimulation for Parkinson’s disease. NICE interventional tistry 1996; 6: 107–10. procedures guidance IPG19, 2003. http://www.nice.org.uk/ 53. Modaresi A, Lindsay SJE, Gould A, Smith P. A partial guidance/IPG19 (accessed 02/09/2014). double-blind, placebo-controlled study of electronic dental