History of general anesthesia

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Re-enactment of the first public demonstration of general anesthesiaby William T. G. Morton on October
16, 1846 in the Ether Dome at Massachusetts General Hospital, Boston. Surgeons John Collins
Warrenand Henry Jacob Bigelow are included in this daguerrotype by Southworth & Hawes.

The Bulfinch Building, home of the Ether Dome

Attempts at producing a state of general anesthesia can be traced throughout recorded history in
the writings of the
ancient Sumerians, Babylonians, Assyrians, Egyptians, Greeks, Romans, Indians, and Chinese.
During the Middle Ages, which correspond roughly to what is sometimes referred to as
the Islamic Golden Age, scientists and other scholars made significant advances
in science and medicine in the Muslim world and Eastern world.
The Renaissance saw significant advances in anatomy and surgical technique. However, despite
all this progress, surgery remained a treatment of last resort. Largely because of the
associated pain, many patients with surgical disorders chose certain death rather than undergo
surgery. Although there has been a great deal of debate as to who deserves the most credit for
the discovery of general anesthesia, it is generally agreed that certain scientific discoveries in the
late 18th and early 19th centuries were critical to the eventual introduction and development of
modern anesthetic techniques.
Two major advances occurred in the late 19th century, which together allowed the transition to
modern surgery. An appreciation of the germ theory of disease led rapidly to the development
and application of antiseptic techniques in surgery. Antisepsis, which soon gave way to asepsis,
reduced the overall morbidity and mortality of surgery to a far more acceptable rate than in
previous eras. Concurrent with these developments were the significant advances
in pharmacology and physiology which led to the development of general anesthesia and the
control of pain.
In the 20th century, the safety and efficacy of general anesthesia was improved by the routine
use of tracheal intubation and other advanced airway management techniques. Significant
advances in monitoring and new anesthetic agents with
improved pharmacokinetic and pharmacodynamic characteristics also contributed to this trend.
Standardized training programs for anesthesiologists and nurse anesthetists emerged during this
period. The increased application of economic and business administration principles to health
care in the late 20th and early 21st centuries led to the introduction of management practices
such as transfer pricing to improve the efficiency of anesthetists.[1]
Antiquity[edit]
The first attempts at general anesthesia were probably herbal remedies administered
in prehistory. Alcohol is the oldest known sedative; it was used in
ancient Mesopotamia thousands of years ago.[3]
Opium[edit]

Opium poppy, Papaver somniferum

The Sumerians are said to have cultivated and harvested the opium poppy (Papaver
somniferum) in lower Mesopotamia as early as 3400 BC,[4][5] though this has been disputed.[6] The
most ancient testimony concerning the opium poppy found to date was inscribed in cuneiform
script on a small white clay tablet at the end of the third millennium BC. This tablet was
discovered in 1954 during excavations at Nippur, and is currently kept at the University of
Pennsylvania Museum of Archaeology and Anthropology. Deciphered by Samuel Noah
Kramer and Martin Leve, it is considered to be the most ancient pharmacopoeia in existence.[7]
[8]
Some Sumerian tablets of this era have an ideogram inscribed upon them, "hul gil", which
translates to "plant of joy", believed by some authors to refer to opium. [9][10] The term gil is still
used for opium in certain parts of the world.[11] The Sumerian goddess Nidaba is often depicted
with poppies growing out of her shoulders. About 2225 BC, the Sumerian territory became a part
of the Babylonian empire. Knowledge and use of the opium poppy and its euphoric effects thus
passed to the Babylonians, who expanded their empire eastwards to Persia and westwards to
Egypt, thereby extending its range to these civilizations.[11] British archaeologist and
cuneiformist Reginald Campbell Thompson writes that opium was known to the Assyrians in the
7th century BC.[12] The term "Arat Pa Pa" occurs in the Assyrian Herbal, a collection of inscribed
Assyrian tablets dated to c. 650 BC. According to Thompson, this term is the Assyrian name for
the juice of the poppy and it may be the etymological origin of the Latin "papaver".[9]
The ancient Egyptians had some surgical instruments,[13][14] as well as crude analgesics and
sedatives, including possibly an extract prepared from the mandrake fruit.[15] The use of
preparations similar to opium in surgery is recorded in the Ebers Papyrus, an Egyptian medical
papyrus written in the Eighteenth dynasty.[11][13][16] However, it is questionable whether opium itself
was known in ancient Egypt.[17] The Greek gods Hypnos (Sleep), Nyx (Night),
and Thanatos (Death) were often depicted holding poppies.[18]
Prior to the introduction of opium to ancient India and China, these civilizations pioneered the use
of cannabis incense and aconitum. c. 400 BC, the Sushruta Samhita (a text from the Indian
subcontinent on ayurvedic medicine and surgery) advocates the use of wine with incense of
cannabis for anesthesia.[19] By the 8th century AD, Arab traders had brought opium to India[20] and
China.[21]
Classical antiquity[edit]
 This section needs expansion. You
can help by adding to it. (February
2015)

In Classical antiquity, anaesthetics were described by:

 Dioscorides (De Materia Medica)

 Galen
 Hippocrates
 Theophrastus (Historia Plantarum)

China[edit]

Hua Tuo, Chinese surgeon, c. AD 200

Bian Que (Chinese: 扁鵲, Wade–Giles: Pien Ch'iao, c. 300 BC) was a legendary
Chinese internist and surgeon who reportedly used general anesthesia for surgical procedures. It
is recorded in the Book of Master Han Fei (c. 250 BC), the Records of the Grand Historian (c.
100 BC), and the Book of Master Lie (c. AD 300) that Bian Que gave two men, named "Lu" and
"Chao", a toxic drink which rendered them unconscious for three days, during which time he
performed a gastrostomy upon them.[22][23][24]
Hua Tuo (Chinese:華佗， c. AD 145–220) was a Chinese surgeon of the 2nd century AD.
According to the Records of Three Kingdoms (c. AD 270) and the Book of the Later Han (c. AD
430), Hua Tuo performed surgery under general anesthesia using a formula he had developed
by mixing wine with a mixture of herbal extracts he called mafeisan (麻沸散).[25] Hua Tuo
reportedly used mafeisan to perform even major operations such
as resection of gangrenous intestines.[25][26][27] Before the surgery, he administered an oral
anesthetic potion, probably dissolved in wine, in order to induce a state of unconsciousness and
partial neuromuscular blockade.[25]
The exact composition of mafeisan, similar to all of Hua Tuo's clinical knowledge, was lost when
he burned his manuscripts, just before his death.[28] The composition of the anesthetic powder
was not mentioned in either the Records of Three Kingdoms or the Book of the Later Han.
Because Confucian teachings regarded the body as sacred and surgery was considered a form
of body mutilation, surgery was strongly discouraged in ancient China. Because of this, despite
Hua Tuo's reported success with general anesthesia, the practice of surgery in ancient China
ended with his death.[25]
The name mafeisan combines ma (麻, meaning "cannabis, hemp, numbed or tingling"), fei (沸,
meaning "boiling or bubbling"), and san (散, meaning "to break up or scatter", or "medicine in
powder form"). Therefore, the word mafeisan probably means something like "cannabis boil
powder". Many sinologists and scholars of traditional Chinese medicine have guessed at the
composition of Hua Tuo's mafeisan powder, but the exact components still remain unclear. His
formula is believed to have contained some combination of:[25][28][29][30]

 bai zhi (Chinese:白芷，Angelica dahurica),

 cao wu (Chinese:草烏, Aconitum kusnezoffii, Aconitum kusnezoffii, Kusnezoff's
monkshood, or wolfsbane root),
 chuān xiōng (Chinese:川芎，Ligusticum wallichii, or Szechuan lovage),

 dong quai (Chinese:当归, Angelica sinensis, or "female ginseng"),

 wu tou (烏頭, Aconitum carmichaelii, rhizome of Aconitum, or "Chinese monkshood"),
 yang jin hua (洋金花, Flos Daturae metelis, or Datura stramonium, jimson weed, devil's
trumpet, thorn apple, locoweed, moonflower),
 ya pu lu (押不芦,Mandragora officinarum)
 rhododendron flower, and
 jasmine root.

Others have suggested the potion may have also contained hashish,[26] bhang,[27] shang-luh,[22] or
opium.[31] Victor H. Mair wrote that mafei "appears to be a transcription of some Indo-
European word related to "morphine"."[32] Some authors believe that Hua Tuo may have
discovered surgical analgesia by acupuncture, and that mafeisan either had nothing to do with or
was simply an adjunct to his strategy for anesthesia.[33] Many physicians have attempted to re-
create the same formulation based on historical records but none have achieved the same
clinical efficacy as Hua Tuo's. In any event, Hua Tuo's formula did not appear to be effective for
major operations.[32][34]
Other substances used from antiquity for anesthetic purposes include extracts
of juniper and coca.[35][36][37]