Electroanaesthesia –

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 © 2014 The Association of Anaesthetists of Great Britain and Ireland 1 Anaesthesia 2014 Francis and Dingley | Electroanaesthesia 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

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