EVOLUTION THROUGH REVOLUTION, COMMEMORATING ETHER DAY!

So the LORD God caused a deep sleep to fall upon the man, and he slept; then He took one of his ribs and closed up the flesh at that place.( Genesis 2:21) Who is the first Anaesthesiologist then? its Lord,The God almighty. Adam was first formed, then Eve and she was made of the man, out of his bone, and for the man (1 Co. 11:8, 9), Thus the speciality of Anaesthesiology is divine and .... Anaesthesiologists  are followers of God.! According to the law of equations, following  Anaesthesiologist is as equivalent as following God!!   .... Of course what is of more glorified act than  giving pain relief to whom who suffer from severe physical and mental agony? Even Eve was  not lucky enough to have a painless labour, a luxury  and privilege enjoyed by her descendants, made possible by this blessed branch of medical sciences. The history of anaesthesia dates back and starts from here.

Mesmer practising animal magnetism

Before the advent of anaesthesia, surgery was a terrifying prospect. Many approached surgery as if they are facing execution  and many suffered  pain, hemorrage, shock, infection  and death, due to inappropriate assessment, lack of proper agents or equipments.The pre anaesthetic era witnessed  the application of physical means  and herbal remedies for pain relief  eg:  local application of cold water, ice or pressure. Plants and extracts,Coca leaves chewed and saliva dripped into injured areas or open wounds -Inca Shamans, Alcohol with opium or hemp –“soporific sponge" (mentioned around 1200 by Nicholas of Salerno ) , Hypnosis (Its eponymous originator was Anton Mesmer (1734-1815)). etc. Amputations were performed by giving alcohol  and patients were made intoxicated  (Apuleius, a 5th century compiler) or the legs were frozen by applying ice(Refrigeration anaesthesia  by Marco AvrelioSeverino).  Egyptian surgeons apparently half-asphyxiated children undergoing circumcision by first almost strangling them. This practice sounds almost as barbarous as the operation itself.

Opium

The discovery that plant extracts, like opium (papaver somniferum), mandragora from atropa,  belladona (morning glory) Marijuana (cannabis indica) can provide pain relief, helped the primitive physicians to conduct surgeries and threw light into the pharmacological and physiological principles of pain transmission and pain management.While the physicians across the atlantic enjoyed the benefits of coca (Viennese ophthalmologist Karl Koller  used cocaine locally for ophthalmic surgeries)(1857-1944),the chinese were focussing on acupuncture

Humphry Davy

The 19th century  stood as an important mile stone  in the history of anaesthesia with the synthesis and use of atmospheric gases  and nitrous oxide by early scientific luminaries such as Black, Priestley, and Lavoisier.Of which the first gas recognised to have anaesthetic powers was nitrous oxide (N2O) which is inert, colourless, odourless and tasteless. Nitrous oxide was first isolated and identified in 1772 by the English chemist, Joseph Priestley (1733-1804). The exhilarating effects of inhaling nitrous oxide were noted by English  chemist Sir Humphry Davy (1778-1829).The term laughing gas was given to it  and N2O  was used widely for recreational purposes.It was Davy who suggested N2O for pain relief during surgery." Nitrous Air, and Its Respiration (1800)"  Davy described the different planes of  anaesthesia as stage 1: analgesia;  stage 2: delirium;  stage 3: surgical anaesthesia; stage 4: respiratory paralysis, though without appreciating the significance of each stage.. In 1824, English country doctor Henry Hill Hickman (1800-30), performed painless operations by inhalation of CO2 but was not widely recognised.

Crawford Williamson Long

Ether was first discovered by Catalan philosopher chemist Raymundus Lullius (1232-1315). Lullius called it "sweet vitriol", it was produced by distilled sulfuric acid fortified with wine and sugar.Paracelsus observed that  chickens who were given vitriol fell asleep and awaken unharmed.The first use of general anaesthesia probably dates to early nineteenth century in Japan. On 13th October 1804, a japanese physician [1]Seishu Hanaoka (1760-1835) removed a breast tumour uneventfully for which he used "Tsusensan", a herbal preparation.The first successful use of ether anaesthesia is by Crawford Williamson Long (1815-78).who may be called as the "discoverer of anaesthesia".He removed a cyst from the neck of  Mr James Venable under ether anaesthesia but this was remained  unpublished.



 

Horace Wells

 The anaesthetic revolution set a pace,  Horace Wells (1815-1848) demonstrated that injuring leg under N2O inhalation is painless. He himself was subjected to N2O anaesthesia for dental extraction without pain.Later on he attempted a public demonstration with N2O in january 1845 which was a failue.There was laughter and cries of "humbug".

The era of surgical anaesthesia unveils, William Thomas Green Morton (1819-1868). discovered the quality of ether that it can produce surgical anaesthesia without profound respiratory or circulatory depression. He found that a slow rate of induction allowed high margin of safety for ether. He was received an invitation to give a public demonstration at Massachussets General Hospital on friday 16 oct 1846. The patient was Edward Gilbert Abbot  and the surgeon was John Collins Warren.

William Thomas Green Morton

Morton's inhaler

The surgeon excised a vascular swelling from the neck successfully. Morton used a draw over vapouriser designed by him. on Completion of surgery  Warren announced  "Gentlemen this is no humbug"  A great discovery ,a golden mile stone in the history of anaesthesiology,the day being celebrated worldwide as "ether day".Oliver wendel homes(1809-94). suggested the name  anaesthesia for this painless state.[2]

Ether Day

Ether dome

The amphitheatre at MGH, where this demonstration took place is honoured by giving the name "ether dome"This  is now a national shrine.the  Morton's grave in Mount Auburn Cemetery near Boston bears the inscription:
WILLIAM T. G. MORTON
Inventor and Revealer of Anaesthetic Inhalation
Before Whom, in All Time, Surgery Was Agony
By Whom Pain in Surgery was Averted and Annulled
SinceWhom Science Has Control of Pain




James young simpson

In Scotland, Sir James Young Simpson (1811-1870), used Ether for the first time for relieving labour pain(1846) He was experimenting on chloroform  and proved the efficacy of chloroform by giving it to those who attended a dinner party He also tried the drug himself and published his findings in Lancet. Later he himself defended the use of chloroform for pain relief in labour as it was against religion and belief. Chloroform use also had a short history. It is a colourless volatile liquid with a characteristic smell and a sweet taste.It was discovered in1831 by American physician Samuel Guthrie (1782-1848);

John snow

In England, at least, the practice of anaesthesia during childbirth won greater respectability following its widely-publicised use on Queen Victoria. The delivery in 1853 of Victoria's eighth child and youngest son, Prince Leopold, was successful: chloroform was administered by Dr John Snow (1813-1858) of Edinburgh, the world's first anaesthesiologist/anaesthetist. He used chloroform in a hand kerchief for inhalation and Queen victoria never had pain during child birth.The contributions of John snow include

• Description of stages of anaesthesia based on patient's responsiveness
• Developed ether inhalers,  and an ether vapouriser which is thermocompensated.
• Development of agent specific chloroform vapouriser
• Described the minimum anaesthetic concentration to prevent movement  which led to the future discovery of  MAC
• Published books  and journals on chloroform and ether



Joseph clover

• Conducted epidemiological surveys  and proved that cholera is transmitted by water.

 Dr Joseph Clover (1825-1882) developed  the first apparatus to provide chloroform in controlled concentrations; in 1862 and a "portable regulating ether-inhaler" in 1877. This was to minimise the complications  associated  with the use of chloroform

The other Inhalation Anaesthesia landmarks include

Boyles apparatus

• Introduction of first anaesthesia machine in 1917 by Henry Boyle
• CO2 absorption canister in 1924 by Rudolf Waters
• Endotracheal intubation in 1920 by  Ivan Magill.
• Introducton of halothane in 1950 

Epoch of Regional Anaesthesia[3]

• Karl Koller( 1857-1944)  an ophthalmologist from vienna introduced cocaine for topical ophthalmic anaesthesia
• William Halstead, described nerve blocks of face and arm 1886,
• Description of spinal anaesthesia by Leonard Corning. He coined the term spinal anaesthesia. He used cocaine into the spinal canal



Regional Anaesthesia

• August Bier, further research  on  spinal anesthesia in 1898.
• Virginia Apgar promotes Regional analgesia in childbirth 1930.
• Arthur Barker hyperbaric spinal anaesthesia by addition of glucose  1935
• August Bier, intravenous regional anaesthesia in 1908
• Martinez Curbelo from cuba  continuous epidural anaesthesia  1949

Intravenous Anaesthesia

• 1903 Barbitone synthesis by Fischer, Berlin, Nobel Prize.
• 1932 Evipan used IV by Weese Schraff, & Rheinoff.
• 1934 Lundy, Mayo Clinic, used Sodium Pentothal.
• 1942 Curare first used clinically by Griffith and Enid johnson in Montreal
• 1857 Claude Bernard published that curare blocked the NMJ.
• 1940 Bennett used curare to modify seizures induced by metrozol.

Modern anaesthesia

• Starts from 1980
• Standards for Basic Anesthetic Monitoring ASA, House of Delegates 10/21/1986.
• Anesthesia Patient Safety Foundation 1984.
• International anaesthesia research society 1922 by mcMechaan
• BJA 1923
• Association of anaesthetists of great britain and ireland 1932. 

The modern Anaesthesiologist is a physician  and primary care provider who is concerned with the total wellbeing of his patients. Other than the safety and  comfort of patient in operation theatre, the anaesthesiologist's services extend outside the operating room as well. They are routinely asked to monitor or sedate patients for lithotripsy, MRI, cardiac catheterisation, electroconvulsive therapy, fluroscopy etc. They are considered to be the pioneers in cardiopulmonary resuscitation.  The anaesthesiologist is actively involved in  Intensive care, Trauma care, Pain management and complex specialised surgical procedures

Reference:

1). Matsuki A: Seishu Hanaoka, Japanese pioneer in anesthesia. Anesthesiol1970; 32:446-50 Fenster J M: 
2). Sykes: Essays on the First Hundred Years of Anaesthesia. Robert E. Kreiger Publishing Co. 1972.
     Wolfe & Menczer: I Awaken to Glory. Boston Medical Library, 1994.
3)  An article on  Anesthesiology yesterday, today and tomorrow by Mr.Adolph H. Giesecke MD.UTX Southwestern Medical Center, Dallas T
4)  Wylie and Churchil Davidson  Practise of Anesthesia.   7th edition.; Pp 01-15
5)  Images :
     http://en.wikipedia.org/wiki/Ether_Dome
     www.general-anaesthesia.com/images/ether-inhaler.html
     http://www.bmj.com/content/2/4475/536.full.pdf+html