VIMS Journal: December 2017

Review Article

History of Anaesthesia

Dr. Tulsi Nag

History of anaesthesia which is young as compared to surgery & internal medicine, began only after public demonstration of ether anaesthesia by WTG Morton on 16th October, 1846 in Boston. But search for surgical anaesthesia goes back from days of ancient Greeks & Romans.
In first Century A. D. Pedanius Discordes, a Greek Physician observed the analgesic property of Mandragora which was used as late as seventh century. From ninth to thirteenth century Soporific sponge was in use for surgical pain relief.
In seventeenth century Marco Aurelio Severina used refrigeration anaesthesia to make surgical site insensible to pain.
In nineteenth century alcohol was thought to blunt impact of pain producing stupor but its ineffectiveness was evident from description of agonizing mastectomy undergone by Funny Bunney, a famous literal artist of nineteenth century after a wine cordial.
In 1820 surgical pain relief with hypnosis was undertaken by two French Physicians, Charles Dupotet & Jules Cloquet which was termed Mesmerism.
With progress of nineteenth century efforts to provide appropriate surgical pain relief were undertaken.
In 1800 Humphry Davy suggested use of N2O, prepared by Joseph Pristley, but was a missed opportunity to discover surgical anaesthesia. During 1823-1824 Henry Hill Hickman, an English surgeon used high dose CO2 to animals who became insensitive to pain. Though his concept was correct, the choice of agent was unfortunate.
In 1844, Horace Wells recognized analgesic property of N2O after Colton gave Wells N2O for tooth extraction which was painless. In January 1845 Wells attempted a public demonstration in Boston, which was judged a failure.
Diethyl ether was first synthesized in eighth century by Jibiron Havvan, an Arabian philosopher. Ramon Luly, an European chemist prepared ether in thirteenth century. In sixteenth century both Valerius Cordus and Paracelsus prepared diethyl ether as sweet oil of vitriol. Both of them could recognized the analgesic qualities of ether but none of them could make connection between pain relief and possible use in surgery.
For three centuries, ether remained for medical use or as recreation drug.
On January 1842 William E. Clark, a New York medical student administered painless anaesthesia for tooth extraction with ether but his professors believed the anaesthetic state to be due to hysteria & discouraged him.
On March 1842, Crawford William Long administered ether for surgical anaesthesia but did not mislead his professional colleagues with limited cases done.

At last public demonstration of ether anaesthesia took place on 16th October, 1846. WTG Morton, an English dentist became interested in anaesthesia, being instructed by Horace Wells.
Morton began experiment with inhaled ether & after being confident with animal experiment, administered ether anaesthesia in his dental clinic. Encouraged by his success Morton secured permission to demonstrate ether anaesthesia in Boston. On 16th October, 1846, he anaesthetized Edward Gilbert Abott with ether for excision of a vascular lesion. The surgeon John Collins Warren performed the procedure painlessly & at the end allegedly announced --- "Gentlemen this is no humbug".
Soon after Mortons demonstration, Oliver Wendel Hobnes termed anaesthesia for the state of temporary insensibility produced by ether. J. Y. Simpson, an Edinburgh obstetrician first used ether for labour analgesia but being dissatisfied with its slow onset, pungent smell and explosive characteristics, conducted search for a more pleasant, short acting anaesthetic by inhaling samples of volatile chemicals. David Waldie suggested Chloroform which was prepared in 1831. On 4th November, 1847, Simpson with friends inhaled chloroform in a dinner party, fell unconscious and when awakened were delighted with their success. Simpson encouraged use of chloroform for patient comfort during surgery. Chloroform became familiar after John Snow, an English obstetric anaesthetist used it to deliver the last two children of Queen Victoria. Victoria enjoyed relief of labour pain provided by chloroform & sanctioned obstetric anaesthesia.
Ethylchloride was formed in 18th century & was the inhaled anaesthetic in use after N2O, ether & chloroform, Cyclopropane was inadvertently discovered by George Lucas, a chemist, during identification of toxic product of stoned propylene. Encouraged by Velvien Henderson, a pharmacologist, Ralph Waters investigated the drag & reported its chemical success in 1934. All inhaled anaesthetics of this period were explosive except chloroform which had limited use due to hepatic & cardiac toxicity. To reduce explosion hazards, British anaesthesiologists turned to trichloroethylene during World War II, which founded limited use as it decomposed to phosgene with warm sodalime.
Ten years later florinated hydrocarbons revolutionized inhalation anaesthesia. The first attempt to prepare florinated anaesthetic by Harold Booth & E. May Bixby followed the appearance of Freon, in 1932.
In 1937, following the investigation with hydrocarbons by John C. Kranz, a pharmacologist, ethyl vinyl ether entered clinical use which was inflammable. In 1954 it was florinated by Julius Shukys to prepare floroxane, the first florinated anaesthetic.
In 1951, Charles Suckling, a British Chemist, created halothane having potency, safety, volatilily & non-inflammability. It simplified anaesthetic technique by sweet smell, smooth induction & potent action.
Halothane was followed by methoxyflurane in 1960. By 1970 nephrotoxicity of methoxyflurane & halothane hepatitis were recognized leading to search for newer inhaled anaesthetic focused on resistant to metabolic degradation. As a result of research, Ross Terrell created Enflurane & Isoflurane in 1963 & 1965. After 20 years Desflurane was released in 1992 & sevoflurane in 1994.

Intravenous Anaesthesia :
In 1657, Christopher Wren stupefied a dog by injecting opium through goosequill attached to pigis bladder, from which originated the idea that substance could be injected intravenously. Richard Lawer first performed transfusion of lambis blood to dogs.
In 1845, a Dublin surgeon Francis Rynd created hollow needle to inject morphine for treating neuralgia.
In 1853, Charles Gabriel Pravaz designed first functional syringe for perineural injection. Alexander Wood however credited with perfecting the hypodermic glass syringe.
Intravenous induction became practical only after the use of I.V. barbiturates by Berdet & Bumm in 1920.
First short acting barbiturate hexobarbital was clinically available in 1932, which was cordially accepted for its rapid induction & utility in minor surgery.
In 1932, Donabe Tabern & Ernest H. Volwier synthesized pentothal & surital which replaced hexobarbital.
Though Thiopentone was first administered to patients in 1934, its successful clinical practice follow the use of it by John Lundy in 1935, which opened a new frontier. Etomidale was first described by Paul Jansen in 1964 but was released for clinical use in 1974.
Propofol was first tested clinically in 1977.

Muscle Relaxants :
Curare was originally used in hunting & tribal warfare by natives of South Africa. Its earliest clinical use in human was to ameliorate muscle spasm in tetanus.
In 1938, Richard Gill & Ruth Gill brought crude curare from South America. American anaesthesilogists studied semirefined curare which produced total respiratory panalysis in patients & was abandoned. Effective clinical application of curare occurred after A. R. Intyre refined curare in 1939. Soon Abrum E. Bennett administered curare during convulsive therapy to prevent fracture. By 1941, other psychiatries followed the practice of Bannelt. Harold Griffith, an anaesthesiologist applied Bannettís practice in anaesthesia.
On January 23, 1942, Harold Griffith & Enid Jonson, could provide satisfactory abdominal relaxation during appendisectomy by injecting curare. Their repot of successful use of curare in 25 patients launched a revolution in anaesthetic care.
H. A. Holladay, credited for safe introduction of curare by standardizing its doses. Introduction of other muscle relaxants followed the successful clinical use of curare.
In 1948, gallamine & decamethonium were synthesized. In 1949, Daniel Bovet prepared succinylcholine.
Neuromuscular monitoring began in 1958. In 1968, Pancuronium was introduced. Receptor specific drugs like Pipacuronium, Vecuronium & rocuronium emerged as a result of research from 1970 to 1980.
Gradually steroid based products like atralurium, mivacurium, doxacurium & Cis-atracurium came into clinical use.
Curare antagonists developed well before the use of muscle relaxants in surgery. In 1900, Jacob Pal introduced phypostigmine & neostigmine was synthesized in 1931.

Tracheal Intubation :
Tracheal intubation was challenging before introduction of muscle relaxant. Intubation became easier after Robert Miller of Texas & Robert Macintosh of Oxford created lanjngoscoope blades. In 1920 Magill devised Magill forceps to manipulate cathetertip. He also developed endotracheal tube.
In 1926, Aurther Guedel introduced cuffed E. T. tube & recommended that cuff should be positioned below vocal cords.
After accidental endobronchial intubation Ralph Waters recognized that longer cuff ET tube could be used to isolate the lungs.
Gnedel proposed for a double cuffed single lumen tube for lung isolation.
In 1953, double lumen endobronclial tubes, both right & leff were designed by Frank Rawbertshaw of England.
As convention laryngoscopes proved inadequate for difficult airways, a rigid bronchoscope was specially designed in 1928.
In 1964 Shigatolkeda developed the flexible fibre optic bronchoscope for intubation in difficult airway cases.
Simultaneously Roger Bullard developed Bullard laryngoscope for management of difficult airways.
In 1981, A. I. J. Archie Brain developed LMA to manage difficult airways.

Local Anaesthetics :
Cocaine, the first local anaesthetic was isolated from Coca leaves by German Chemists, Albert Neumann & Wilhem Lessen in 1860. Kerl Collar, while in search of a topical ophthalmic anaesthetic, first observed the local anaesthetic property of cocaine &recognized its clinical utility, in September 1884.
By October 1884, American surgeons recognized the efficacy of cocaine in anaesthetizing mucous membrane. In next month first report of subcutaneous injection of cocaine was published. In December 1884, two surgeons William Halsted & Richard Hall described sensory nerve block of face & arms. Halsted also performed brachial plexus block.
After the report of CNS & CVS toxicity of cocaine search for alternative local anaesthetic began.
In 1898, Alfred Eihorn, synthesized Nirvaquine the first amino-amide local anaesthetic which had tissue irritant effect. Following that Eithorn synthesized aminoester local anaesthetics Benzocaine in 1900 & Procaine in 1905. Tetracaine was the last developed aminoester local anaesthetic.
In 1944, Nils Lofgren & Bengt Lundquist developed lignocaine, an aminoamide local anaesthetic with potency, rapid onset but shorter action.
So for prolonged surgical procedures long acting local anaesthetics were needed & as a result bupivacaine was introduced in 1965.
As accidental I.V. injection of bupivacaine produced seizures & C.V. collapse, search for new long acting alternative began leading to introduction of less potent ropivacaine.

Regional Anaesthesia :
The term spinal anaesthesia was coined by Leonard Corning, a neurologist in 1885, but he did not describe escape of CSF. August Bier & Theodar Tuffer credited for describing authentic spinal anaesthesia with mention of CSF escape. Theodor Tuffer also suggested that local anaesthetic solution should not be injected before free flow of CSF.
It took 14yrs to perform spinal anaesthesia for surgery.
In the interval Henrich Quincke, in Germany, recognized that spinal anaesthesia could be safely performed at 3rd or 4th lumbar interspace, well below termination of spinal cord.
In 1899, Bier used Quinckes technique but lost interest in spinal anaesthesia following complications due to spinal puncture by widebone needle. In the same year Duley Tait and Guidlo Cogliere encouraged use of fine needle to lessen CSF escape to prevent complications.
In 1900, Heinrich Braun used epinephrine to prolong the action of local anaesthetic. Braun also developed several nerve blocks, coined the term conduction anaesthesia & became known as father of conduction anaesthesia.
Before 1907, frequent incomplete spinal anaesthesia was a problem. Therefore, Aurther Baker, a surgeon of London used hyperbaric solution of stovaine. Lincoln sise introduced the use of tetracaine in 1935.
In 1940, William Lemmon, a Philadelphia surgeon invented continuous spinal anaesthesia to avoid inadequate duration of single spinal injection. In 1944, Edward Touhy of Mayo clinic developed the Touhy needle to insert cather for incremental doses of local anaesthetic.
In 1949, Martinez Carbelo of Cuba, performed first continuous epidural anaesthesia using Touhy needle & urethral catheter.
At the beginning of twentieth century, two French clinicians experimented independently with caudal anaesthesia. Fernando Cathelin used caudal anaesthesia as a less dangerous alternative to spinal anaesthesia for hernia repair.

Conclusion :
From days of ancient Greeks & Romans to computerized operating room of 21st century care of patients undergoing surgery remained challenging.
Only during last 170 yrs, there has been consistent & reliable pain relief for surgical procedures. Improved surgical anaesthesia has allowed complex surgeries to be performed increasingly in ill patients.
Though surgeries can now be performed safely & painlessly, anaesthesia was universally recommended after several years due to prevailing belief that pain as a part of healing process.
Discoveries of anaesthesiology have taken decades to build upon the observations & experiments of pioneering personalities.
Though historically anaesthesia is a young speciality, it is truely an applied medical science & has proved to be one of "3AS" --- Anaesthesia, Asepsis, Antibiotics.

  1. Douglas R etal; Great Moments in the History of Anaesthesiology : In Healy & Knight ed. Wytie & Churchill-Davidsonis A Practice of anesthesia, 7th edition, Arnold Publication, London, 2003; 1-16.

  2. Jacob AK et al; The History of Anesthesia : In Paul G. Barash ed. Clinical Anesthesia, 7th edition, William & Wilkins, Philadelphia, 2013; 3-27.

  3. Miller RD, History of Anesthetic Practice : In Millerís Anesthesia, 7th edition, Charchill- Livingstone, Philadelphia, 2010; 3-41.

  4. Morgan GE et al ; The History of anesthesia : In Morgan GE ed. Clinical Anesthesiology, 4th edition, MC Graw- Hill, Newyork, 2006; 1-5.


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