The Art and Science of Anaesthesia “he that sleeps feels not the toothache”

The desire to live free of pain is universal among all living creatures, and humans have tried to find ways to alleviate pain. The history of anaesthesia dates back to times immemorial; Even in Ramayana, Laxman was made unconscious (Murcha), by Meghnad. Though science about anaesthesia was unknown, the concept and need of anaesthesia was already placed on record. Anaesthesia means (in Greek) “An – without” and “Aesthesia – sensation” – referring to the inhibition of sensation. Even Shakespeare’s observation (from Cymbeline) explains why attempts to alleviate the pain of disease, injury or simple surgical procedures by producing unconsciousness are almost as old as civilization, although the techniques were crude.

The development and growth of anaesthesia over the years can be divided into following phases:
1. Past: Pre- 1846 -The foundation of anesthesia;
2. 1846-1900: Establishment of anesthesia;
3. Present: 20th century: Consolidation and growth;
4. Future: 21st century

Pre – 1846 – The foundation of anesthesia

Various herbal and chemical cocktails were used in ancient days for the purpose of producing anaesthesia. Most involved ingestion of ethanol, opium, hyoscine, cannabis and herbal mixtures, but ‘knock-out’ blows to the head and bilateral carotid artery compression (carotid derives from the Greek for stupor) are also described. These methods were impossible to quantify, and the best that can be said of many is that they were harmlessly ineffective.

Hypnotism, introduced as ‘animal magnetism’ or ‘Mesmerism’ in the latter part of the eighteenth century, can be effective in susceptible individuals, but such people are relatively rare in developed societies.

1846 – 1900: Establishment of anesthesia

The branch of Anaesthesiology made its first footprint on 16 October 1846 (Ether Day) with the public demonstration of ether in Boston by “WTG Morton”, for removing tumour under jaw. The ether days in Anaesthesia practice dominated over a century. In 1847, James Young Simpson used chloroform for obstetric anesthesia. John Snow was the first who used chloroform during childbirth of Queen Victoria (1853) and also described the stages of ether anaesthesia. Introduction of ether also started the era of anaesthesia, oxygen and nitrous oxide. Oxygen and Nitous Oxide have stood the test of time and are still widely used and almost irreplaceable.

India also kept pace with the developments in anaesthesia. The first administration of ether anaesthesia was done on 22nd March, 1847, in the Medical College Hospital, Calcutta, under the supervision of Dr. O’ Saughnessy, the surgeon while the first chloroform anaesthesia in India was administered on January 12th 1848.

20th century: Consolidation and growth

20th century laid the foundation of modern anaesthesia, the notable ones being endotracheal intubation and airway instruments. A significant change in practice of anaesthesia occurred with discovery of muscle relaxants (1942) and the use of halogenated hydrocarbons (Halothane – 1951). Advent of curare produced rapid advance in the development of operative surgery. In early 1925 Mahatma Gandhi was operated upon for an emergency appendicectomy in Sassoon Hospital, Pune, using chloroform. Surgeon Col. Maddock completed the operation in the light of a kerosene lamp as electricity failed during the procedure. To mark the stay of Mahatma Gandhi in the hospital, a Gandhi Memorial was created in the old, stone building of the hospital.

Modern Anaesthesia developed in the last sixty years and the journey of ‘MORTON’ to MODERN’ Anaesthesia is amazing. Classical general anaesthesia consisted of Oxygen + Gas + Relaxant + IPPV + Morphine. As Sydenham wrote in 1680, “Among the remedies which has pleased almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.” Narcotics were the mainstay of analgesia and of common use was Morphine and Pethidine.

However, over years addiction to opiodes became an issue of concern, and shift towards opiodes free anaesthesia gradually set in. Regional techniques as adjunct are now very much in use, mostly subarachnoid block, and epidural and local plexus blocks. While lignocaine was most often used, newer agents like bupivacaine, levo-bupivacaine and ropivacaine which have lesser toxicity and better effect are now more often used.

Elective ventilation was another major advancement. Now, newer ventilatory modes are available. Electronic circuits are put in place of electrical circuits of earlier days and we can witness better controlled and precise ventilation during different phases of respiratory cycle. Even weaning becomes fairly easy and mathematical.

Even Today, techniques of anaesthesia remain as GA, RA, Local and sedative anaesthesia. Airway control saw decreasing use of mask ventilation and the new device laryngeal mask airway (LMA) occupies central stage of airway management.

The introduction of Ultrasound has revolutiozed regional anaesthesia practice. Advancements in monitoring devices, newer drugs which were more redicatable and safe, and introduction to pain management and intensive care saw a rapid growth of the speciality, with newer sub specialities getting recognised. This includes Cardiac Anaesthesia, Neuro- anaesthesia, obstetric anaesthesia, intensive acre, pain and palliative care and most recently onco-anaesthesia. Further advancements continue to exist.

The Future

Many developments have occurred in the last 15 years in therapeutics, monitors and automation. Analgesic pharmaco-kinetics are integrated to computerized drug delivery and PCA has advanced to remifentanil PCA. Monitors also have advanced. EEG assisted Bispectral Index has become the standard of care. MAC has now come to mean ‘Madam, are you comfortable? We see robotics in anaesthesia in future especially with the upcoming artificial intelligence and machine learning. More and more software and devices are in research phases where they give real time accurate results by predicting the events happening during surgery. In another 10 years anaesthesia will be administered and monitored by computers. Robots will perform airway intubation. Anaesthesia machines will be speaking machines and they may tell if you are going wrong.

Guest Editors

Dr. Rajiv Chawla
Director – Department of Anaesthesiology, RGCIRC

Dr. Nitesh Goel
Consultant – Anaesthesiology, RGCIRC