Historical significance of anesthesia

Anesthesia means temporary loss of sensation including pain. It is a Greek word, which literally means "to negate sensation." (Silver, 1957) the main significance of Anesthesia is its ability to provide painless procedures of surgery by causing analgesia, unconsciousness and amnesia in patients, subsequently it also results in undesirable suppression and relaxation of muscles. Combinations of drugs are required in order to achieve these effects quickly and effectively. Until the discovery of anesthesia, performing surgery and tooth extraction was an extremely painful procedure. Therefore, the significance of anesthesia is to relieve anxiety and stress in patients and making them comfortable for the surgery. Pain is an undesirable symptom which tells our body that something is wrong. Over time several efforts has been done to get rid of this symptom of pain. To overcome pain Chinese were known to use aqua puncture while Greeks and Roman promoted the use of Alcohol. Herbs were used in other parts of the world and finally these efforts led to the discovery of Anesthesia. Before the discovery of Anesthesia there was generally no respect for the medical professionals. Anesthesia played a significant role to provide medical practitioners their due place in the society. Previously the technique for Pain management was generally very crude and Brutal. Oliver Wendell Holmes an American physician and also a poet was the first one to give name "Anesthesia" in the year 1846. The respect and honor we see for physicians and surgeons today, giving them the title of Healers did not exist in Ancient time. Anesthesia is preferred over other drugs due to its property of being fat soluble. It allows drugs easy and quick passage through the cell membrane and producing its effect rapidly, making surgery a quick and safe procedure.

Attempting to administer pain-free surgery has been a dream as old as the ancient world itself

A. Pre-anesthesia, pain management techniques were crude attempts taken in order to fulfill the dream of surgery to be called as a painless procedure. According to Celsus who was a Roman Physician in 100 AD called the pain of surgery as torture "Now a surgeon should be youthful or at any rate nearer youth than age; with a strong and steady hand which never trembles, and ready use the left hand as well as the right; with vision sharp and clear, spirit undaunted; filled with pity, so that he wishes to cure his patient, yet is not moved by his cries, to go too fast, or cut less than necessary; but he does everything just as if the cries of pain cause him no emotion." The process of surgery and tooth extraction was considered to be brutal and therefore the surgeons were considered as heartless people who required to be strong enough to handle the patients in extreme pain. In older times several strong men were required to steadily hold the patient and the surgeon had to request the patient for cooperation and quickly conduct the process but due to pain the process became very difficult and often vomiting was aspired into lungs causing aspiration pneumonia. Even after inducing heavy doses of ether; process became very difficult and painful. Ether is a small molecule which was first discovered in year 1275 by a Spanish chemist who named it sweet vitriol, later in year 1730 the name was changed to Ether by a German scientist W.G. Frobenius and this name was kept until the early part 1800(Blatner,2009). "One elderly Boston physician could only compare it to Spanish inquisition." On the subject of surgery before Anesthetics. It was until 18th Century when some major advances in medicine took place. In ancient times surgery was an extremely painful procedure and was often hindered by the patients resulting into death due to disease which otherwise was curable by surgery. The surgeons in older times used herbs and plant derivatives such as marijuana, belladonna, jimsonweed and opium, some also preferred the use of alcohol and others used a blow on head to cause unconsciousness in an individual. These methods were not successful and did not cause a required aesthetic effect to carry out surgical procedure.

B. Before anesthesia the process of surgery was performed only rarely- According to annual report of Massachusetts General Hospital record from year 1821-1846, it showed total of 333 surgeries meaning one surgery in one month. (Sullivan, 1996). Surgery was simply considered as the last resort of treatment. An English scientist Joseph Priestley (1733-1804) carried out a discovery that by using Nitric Oxide pain might be relieved. Some used Carbon dioxide, while other injected cocaine into mouth, eyes and other parts of the body considering its effect to block the nerve impulses.

C. Before Anesthesia the medical profession did not have the respect it gets today:

During 19th century most of the medical practices took place privately at homes which increased the risk of infection resulting in sepsis. At this time doctors did not have much knowledge regarding the spread of disease and mode of infection therefore hospitals despite of being large were considered non-hygienic which affected the patients health during their stay in the hospital. Early anesthesia in the form of chloroform and ether contained the danger of Asphyxiation. There was also an increased risk of infection as antiseptic was not discovered in United States till the end of century (19th century Doctor within the U.S., 2009, Rose Melnick Medical Museum). Therefore, the patients and their family preferred to call doctors at home for treatment. In older times it was expected from a doctor to treat everything from tooth ache to a tumor. But with time the doctors focused on excelling themselves in specific fields of medicine and surgery.

When Anesthesia was discovered it was referred as the greatest gift ever made for the suffering humanity. The people who contributed to this Greatest Gift are as follows.

During the later part of 18th century an evident change and advancement in medical technology took place. Two major advancements took place during this era one was the identification of germ cell theory and second was promoting the use of anesthesia in surgery. Continuous research and development of new tools led to the major change and advancement in curing and investigating diseases. I was Horace Wells a dentist who introduced the nitric oxide in the field of dentistry (James, 2009). The combination of nitric oxide and Diethyl ether was being used by dentist to relieve pain but it became unsuccessful during a dental surgery on a patient at Massachusetts General Hospital. In the year 1846, using their idea Dr. William Thomas who was a Dentist at Boston, used a combination of nitric oxide and sulfuric ether to painlessly remove a vascular tumor from his patient's jaw (Medicine Greatest Gift, 2012, Massachusetts General Hospital) by using a specially designed glass container which contained a sponge soaked in ether. (Hoffman and Martin, 2012) This was the first public demonstration of ether anesthesia. Where students realized that surgical procedure can be painless which at first was not imaginable. He soon gained a lot of popularity among people. By the end of year 1847 pamphlets and books regarding this anesthesia were published in United States and in Europe and for the first time a safe and efficient anesthesia was made. Crawford Williamson Long (1815-1878) is said to be the "Pioneer of Surgical Anesthesia" due to his work and observation on using Diethyl ether as the anesthetic to carry out surgical procedure. He brought the turning point in the medical and surgical history when the doctors no more had to think about the pain of surgery neither getting scared from screams in the operation theater. The day of this discovery of a painless surgery is remembered as "Doctors Day." This was the day in the history, when an end to human pain was achieved by using anesthesia in surgical and diagnostic procedures. Crawford for the first time on 30th March 1842 used Diethyl ether to painlessly remove a tumor from patients neck subsequently he removed another tumor and used ether in childbirths and amputations. The observation and results of the following trails were published in Southern Medical and Surgical Journal. He died in Athens and his last words were "Care for mother and child first." For his work he is regarded as the "Father of Anesthesiology" (Hani, 2010). The use of ether became a cultural foundation for the anesthesiologist for its use in providing a painless surgical procedure; Thomas Lee of Boston in year 1868 established a monument in a public garden to deliver the message to people that inhalation of ether helps in causing loss of pain. (Conquering surgical pain: Four men stake their claims, 2012, Massachusetts General Hospital). It was declared publicly that "we have conquered pain." The next man who played a role in the discovery of anesthesia was Horace Wells (1815-1848); he used Nitric Oxide as anesthesia for his patients. But because of it being short acting it did not produce much favorable outcome. Nitric Oxide also known as Laughing Gas; this chemical was first discovered in year 1722 by Joseph Priestly in England. In year 1799 anesthetic properties of Nitric Oxide were discovered by Humphery Davy (1778-1829) he advised that the by using nitric oxide, pain and shock of the surgical procedure can be negated. Third person who continue with Morton and Wells philosophy was Charles T. Jackson. The Fourth man who contributed to anesthetics was Thomas Mortan (Blatner, 2009). In the year 1848 James Simpson used chloroform in obstetric surgery, he used diethyl ether to anesthetize a women with a pelvic deformity for delivery (kodali, 2009) and in year 1853 John Snow did a successful induction of chloroform to her Majesty Queen Victoria at the time of Prince Leopold's Birth and also on Fenny Longfellow who wrote to her poet brother that this use of ether is certainly the greatest blessing of this era (Longfellow, 1956). In the year 1885-William Halsted introduced the nerve block. In 1891 Heinrich Quincke demonstrated the process of lumbar puncture. Successful clinical use of Spinal Anesthesia was introduced by August Bier. In the year 1909 school of anesthesia was first established in year 1909 in USA. In year 1915 carbon dioxide was used as absorber for the general anesthesia by D.F.Jackson. (Bergman, 1991)

Use of Anesthesia and Criticism / Controversies

Before giving anesthesia Pre-anesthetic medication such as Anti-Cholinergic prevents bradycardia, Antihistamines preventing allergic reactions, Barbiturates causing sedation, Antiemetic prevents aspiration of the gastric contents and nausea and vomiting after surgical procedure, Benzodiazepines to relieve stress and anxiety, Opioids that serves as analgesic and Muscle Relaxants that help in muscle relaxation and intubation are used in order to calm down the patient, relieve pain and to prevent the undesirable effects of the anesthesia. There are mainly two types of anesthesia, the General Anesthesia and Local Anesthesia. General Anesthesia causes the loss of sensation throughout the body and causing unconsciousness. General Anesthesia has further been divided into two forms Inhaled (Desflurane, Enflurane, Halothane, Isoflurane, Sevoflurane and Nitric Oxide) and Intravenous includes (Barbiturates, Benzodiazepines, Opioids, Propofol, Ketamines and Etomidate). Local Anesthesia causes loss of sensation on a particular location of the body without causing loss of consciousness. Local Anesthesia includes Bupivacaine, Lidocaine, Tetracaine and Procaine. Out of this lidocaine are frequently used. They block the nerve carrying the sensory impulses from the periphery to the CNS. The Local Anesthesia which has made the procedures extremely simple, only the particular area which requires surgery is anesthetized without affecting patient's consciousness by injecting local anesthesia drugs into the cerebrospinal fluid in the spinal cord called Spinal Anesthesia and into the epidural space called Epidural Anesthesia. This type of anesthesia allow patient to walk home safely. Anesthesia are induced after a pre-assessment of patients pharmacological, pathological and psychological state and also upon the type of Diagnostic or surgical procedure that is being conducted. There are three stages of Anesthesia: Induction, Maintenance and Recovery.

Induction is the phase from the initiation of administration of anesthesia to formation of an efficient surgical anesthesia. During the process of induction of anesthesia it is important to avoid phases of excitation (deliriums), thus general anesthesia is induced along with thiopental which is an intravenous anesthesia, and it helps in producing loss of consciousness within twenty five seconds after its administration.

Second Stage is Maintenance responsible to provide a sustained surgical procedure. This is the phase during which a patient is in surgical anesthesia. After the anesthesia has been administered it is the responsibility of anesthesiologist to carefully monitor the patient's vitals and response to different stimuli through the surgery. A careful balance should be achieved between the amounts of drug induced with the degree of anesthesia.

Third stage is the stage of Recovery which is the phase from the time the anesthesia was discontinued till physiological reflexes (such as breathing on its own) and consciousness are regained by the patient. Therefore it is important for the anesthesiologist to monitor patient closely after surgery.

The Depth of Anesthesia has been divided into four stages, Stage I is Analgesia- that is loss sensation due to blockage of sensory transmission along spinothalamic tract. In this phase the patient is conscious and able to talk. With the onset of stage II is Excitement -- the patient undergoes Amnesia and decrease in pain awareness. The patient undergoes delirium, the blood pressure increases and become irregular, the rate of respiration increases and to avoid this patient is given thiopental prior to administration of anesthesia. Stage III is Surgical Anesthesia- in which there is a regular relaxation and respiration of skeletal muscles. The reflexes in eyes decreases, till the movement of eyes get restricted and pupils get steady. Surgery can proceed during this phase. Stage IV is Medullar Paralysis- this stage involves he depression of vasomotor and respiratory centers followed by death. (Howland and Mycek, 2006).

There has been some moral obligation on the use of Anesthesia to relief the pain and suffering. There has been some criticism that the pain and suffering inflicted on an individual should be tolerated, as was tolerated by the Christian who faced the physical torture and suffering believing by doing so they will remain faithful to their God and to their conscience as well. It is believed that the effect of anesthesia of protecting one from pain interferes the Power of God and His Will. The use of Anesthesia for child birth was also criticized by some group of people believing that it prevents one from going through pain and suffering during child birth.

Various failures and success in the field of anesthesia led to rapid research and scientific experiments. The nurses became the first group of health care providers who administered ether, in United States doing so under the surgeon's observation. In later part of 1800 nurse started to play a vital role in an operation theater which led to formation of certified registered nurse anesthetists. At this time ether was well tolerated both hemodynamic ally and by the respiratory system. Till late 1800 nurses started to play a vital role in the health care system. Almost hundred years after the Morten's public demonstration of the anesthetic effect of ether the commonly used Anesthetics continued to be in the form of inhaled gases. Initially which were ether and Nitric Oxide followed by chloroform, Cyclopropane and Halothane. The other agents beside ether compromised the respiratory and the circulatory system and, therefore, needed to be administered with care. The very first death was reported from the use of chloroform anesthesia, a small girl died due to cardiac arrest and this made the risk of anesthesia evident. These new risk that can occur in operation theater were, asphyxia, a decrease in blood pressure, aspiration of stomach contents and cardiac arrhythmias followed by death as well. In this era the health professionals were considered to be the key person involved in patient's safety. Therefore, it was advised in the research papers that the induction of anesthesia should be done by specialized doctors. With time the practitioners started to specialize in Anesthesiology. In year 1905, nine physicians who specialized in Anesthesiology were responsible to form the first physician anesthesia society called Long Island Society of Anesthesia. In 1911 there developed a New York state society of Anesthesia. In the year 1936 American Society Anesthesiologist was established. 1941 American Board of Medical Specialty identified Anesthesia as a new medical specialty. In the 1930-1940 the interest grew in order to provide a safer way to induce anesthesia. The duties of anesthesiologist became not only to induce anesthesia but also to monitor patients closely. Until 1950's this patients' monitoring included pulse, Blood Pressure, respiratory movements, eye movements, pupil and sweating. EKG monitoring started in 1950's, followed by electronic blood pressure measurement by 1970's and pulse Oximetry and carbon dioxide end tidal by year 1980's. The advancement with time in patients monitoring led to better practice of Anesthesia and enhance the safety of patients. This advancement allowed the surgeons to perform bigger procedures like open heart surgery and transplantation under the influence of anesthesia with more ease. With time it is been understood that the importance of an anesthetist to have a firm knowledge regarding medical sciences, so he can co relate the heath condition, pre-existing diseases and evaluate the outcome of patient. Then administer and manage the dose of anesthesia accordingly.