|Year : 2015 | Volume
| Issue : 1 | Page : 148-151
Looking back at painless surgery
Vice Chancellor, Yenepoya University, Mangalore, Karnataka, India
|Date of Web Publication||13-Apr-2015|
Prof. Dr. P Chandramohan
Vice Chancellor, Yenepoya University, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandramohan P. Looking back at painless surgery. Arch Med Health Sci 2015;3:148-51
| Introduction|| |
Surgery was available from the dawn of human civilization itself as a mode of treatment for a spectrum of human diseases. But many challenges had to be overcome before reaching the present status of surgery as a viable and safe choice of treatment. One of the challenges that made surgery the last choice or no choice as the treatment of a disease was the pain associated with surgery. The portrait depicting surgery being carried out by the celebrated Indian Surgeon, Shushrutha,  shows how the patient was kept in position for surgery with the help of a few healthy assistants during those days. Before reaching the era of anesthesia, dedicated attempts toward painless surgery can be seen throughout the recorded history of human civilization.
| Indian Contribution toward Painless Surgery|| |
India is often considered the cradle of surgery and Shushrutha, the Father of Surgery. Sushurutha describes eight types of surgical procedures including Chedana or Excision, Vyadhana or drainage, Esane or probing,  etc. Under these eight categories, he had included Rhinoplasty, surgical treatment of fistula in Ano, surgery for hemorrhoids, visuco, lithotomy, closure of perforated intestine, correction of intestinal obstructions, etc., under the specific type of anesthesia using a concoction of canabis hemp etc., in wine or alcohol orally. ,, Opium was brought to India by Arab traders in 8 th century A.D. ,
| Kshara Suthra|| |
Is an alkaline thread devised by Shushrutha. The thread is treated with herbal medicines and is used for painless removal of piles, fistulas, fissure, and sinus around the anal sphincter. ,,
| Samohini and Sanjeevani|| |
In the beginning of the Christian era, there is evidence of Raja Bhoj (527 A.D.), an Indian surgeon operating on his patients using concoction of herbs called Samohini for induction of anesthesia and Sanjeevani for recovery from anesthesia.
| Sumerians Contributions toward Painlessness and Euphoria|| |
Sumerians seem to have cultivated opium poppy as early as 3000-4000 B.C. ,, Opium is inscribed on a Sumerian tablet using the cuneiform script as "Hulgil" or a plant of joy. Later, when Sumeria became part of Babylonia, Babylonians came to know the euphoric effect of opium poppy.  According to the British Archeologist, Reginald Campbell Thompson opium was known to assyrians in the 7 th century B.C. and was inscribed on the Assyrian tablets. 
| Egyptian Contribution|| |
Ancient Egyptians  seem to have used analgesics and sedations of herbal and plant origin including extract of Mendrake fruits.  Application of opium for painless surgery is also recorded in the Ebers Papyrus. 
| Chinese Contribution|| |
Bianque, a Chinese internist used Sushrutha style of anesthesia with herbal drink for doing surgery.  Luo and Chao did a Gastrostomy using Sushrutha concoction, but the patients were unconscious for 3 days before they recovered successfully. Huotuo is the Chinese Surgeon of 2 nd century A.D. Who also followed the Sushrutha's method of using the herbal mix dissolved in wine for inducing anesthesia. He gave a specific name "Mafisan."  He used mafisan to do surgery on his own wife and daughter. It is believed that Huotuo introduced surgical analgesia through acupuncture. ,
| Greek Contribution|| |
In the 1 st century, A.D. Greek Physician Discoredis (40-90 A.D) described the use of wine prepared from Mandragori (Mandrake) to induce sleep before surgery which he described in Greek as "Anaesthesia." The famous Greek poet Homer has also referred to the pain killing effect of Mandrake.
| Islamic Contributions|| |
Ferdowsi, a Persian poet, described a cesarean section being done after giving a special wine prepared by a Zoroastrian priest as anesthesia. This shows that the Arabs in Persia knew about inducing anesthesia using alcohol during the 9 th and 10 th century A.D. , In 8 th century A.D. Sushrutha Samhitha was translated into Arabic and named it as Kithabi Sushruth.  Later, in 1000 A.D., Abu Al Qasim published a book of 30 volumes viz, Kithab Al Tasrif describing the use of anesthesia in surgery.
| Dawn of Inhalational Anesthesia|| |
In 1020 A.D., Ibn Sinha/"Avicenna" described the use of inhalational anesthesia in his famous treatise "Canons of Medicine." Ibn Sinha describes "Soporific sponge"  soaked with narcotics which could be kept under the patients' nose for induction of anesthesia before surgery and during surgery. In 12 th century A.D. Ibn Zutr in his book Al-Taisir describes surgery under general anesthesia using soporific sponge.
| Japanese Contributions|| |
Hanaoka Seisha of Osaka was aware of the Chinese medicine Mafesal and tried to recreate a similar one and named it as Mefuts-San which could also produce a state of anesthesia and skeletal muscle paralysis.  Hanoaka did surgery on 150 cases of breast cancer using Mefuts-San as an anesthetic agent. ,, He had also used the same for amputation of limb, removal of bladder stone, etc.
| European Contributions|| |
From 1200 A.D. to 1500 A.D., a concoction called Dwale  consisting of opium hemlock, lettuce, bryony, and bile was used for induction of anesthesia and recovery was achieved by rubbing the cheek bones with vinegar and salt. The name of Dwale is seen in Shakespeare's Hemlet and Keet's Ode to Nightingale. Europe knew about soporific sponge which was over heated, and vapor was used as inhalational anesthesia in Europe.
Diethyl ether was discovered in 1275, and para celsus discovered the analgesic properties of ether in 1525. Meanwhile, nitrous oxide was invented by an English man Joseph Pricestly and Davy  discovered the analgesic properties of nitrous oxide and called it "laughing gas." Morphin was isolated from opium in 1804 by Fredrick Sertumer.  Henry Hill Hickman experimented with carbon dioxide as an anesthetic agent, and Lancet described it as a surgical Humbug.
| Ether Frolics|| |
Even though diethyl ether was discovered in 1275 and the analgesic properties identified in 1525, it was only in the 1840s, the anesthetic effects of Ether were experimented and proved. Four notable figures viz, Crawford W Long, William Morton, Horice Wells, and William Edward Clark took an active role in demonstrating ether as an effective inhalational anesthetic agent to do surgery and these demonstrations are often described as wandering lectures on ether frolics.  In 1842, a medical student in Berkshair Medical College, William Edward Clark administered ether to Ms. Holikos for a dental extraction and became the first to use the inhalational anesthesia for a surgical procedure but he chose neither to publish nor to pursue further. ,
| First Documented Surgery under Ether Anesthesia and the Origin of Doctors Day|| |
it is widely known that the Doctors Day is celebrated in many countries on the 30 th of March to commemorate a historic event when for the first time in the history of surgery, a tumor from the back of the neck was removed under general anesthesia using ether by Crawford W Long, on 30 th March 1842 on a patient James Venable.  Physician and Pharmacist Practitioner from Jefferson and Georgia Crawford W Long was the heroic figure behind this venture. Subsequently, he used the same method for painless limb amputation. He also did not publish his achievement until 1849. On the 10 th of December, 1844 Gardner Quincy Colton demonstrated the analgesic effect of nitrous oxide  while Horace Wells did dental extraction under nitrous oxide analgesic administered by Gardner Quincy Colton.
William Morton  a new English dentist on the 30 th of December, 1846 administered diethyl ether for a dental extraction. Two weeks later, he made a public demonstration on the 16 th October 1846 by anesthetizing a patient Edward Gilbert Abat on whom reputed surgeon John Collins Warren removed a tumor from the neck. This was published immediately, and William Morton became the "Father of Modern Anesthesia," though this was contested by Dr. Jackson. ,
| Chloroform Mania|| |
In 1847, Scottish Obstetrician Young Simpson was the first to use chloroform as an inhalation anesthesia and subsequently chloroform replaced Ether. But soon this was reversed because of the cardiac and hepatic complications of chloroform.
Twentieth century witnessed further advances in painless surgery. In 1902, Herman Emil Fischer and Joseph Von Mering invented diethyl barbituric acid as an effective hypnotic agent Tabem and Volwiler also came out with sulfur containing barbiturates as effective hypnotics  and started the Barbiturate Era in Anesthesiology. Now, we know Barbiturate is one of the most commonly used intravenous anesthetic agents in the day to day surgical practice for induction of anesthesia. Thiopentone sodium is widely used for the induction of anesthesia and endo tracheal intubation.
| Endo Tracheal Anesthesia|| |
German surgeon Fredric Trendelenberg published the first successful endotracheal anesthesia through tracheostomy. ,
| Oro Tracheal Anesthesia|| |
William Macwen  was the first to report the use of orotracheal intubation in 1880 in the place of trans tracheal intubation for induction and maintenance of anesthesia. Alfred Kirsher of Germany was the first to perform a direct laryngoscopy and called it an "Autoscope."
Access to the larynx and orotracheal intubation still remained as a challenge. Blind intubation led to a series of complications. Henry H Jainway published his experiences with direct laryngoscopy in 1913, and this opened a new era of direct laryngoscopy and endotracheal intubation. Further modifications to the direct laryngoscopy came up. Subsequent, to these modifications, one of the memorable contributions is the one made by Sir Ivan White Sibe Magil who devised his curved laryngoscope blade.  But Magil is better known for his curved laryngeal forceps called Magill's forceps which is even now used for Naso Tracheal intubation. Finally, in 1949 Macintosh came out with his unique laryngoscope known as Macintosh Laryngoscope that made endotracheal intubation much easier.  Even today, the most common laryngoscope used is the Macintosh laryngoscope.
The innovations that took place subsequently are well-known to the present generation and hence not included in this article.
| References|| |
Ragu UK. Sushruta of ancient India. India J Opthalmol 2003;51:119-22.
Saraf S, Parihar R. Sushruta: The first Plastic Surgeon in 600 B.C. The Internet Journal of Plastic Surgery. 2006:4.
Rao SK. Encyclopaedia of Indian Medicine: Historical perspective 2005;1:94-8.
Bhattacharya S. Sushrutha - our proud heritage. Indian J Plast Surg 2009;42:223-5.
Ghanekar BG. Sushruta Samhitha, Sutra sthana 11. New Delhi: ML Publication; 1998.
Dwarakanath SC. Use of opium and cannabis in the traditional systems of medicine in India. Bull Narc 1965;17:15-9.
Gordon BL: Medicine in Assyro-Babylonia;in Medicine throughout Antiquity. Philadelphia, Davies, 1949. p. 158-196.
Powell MA. 9 wine and the vine in ancient mesopotamia, the cuneiforn evidence. In: McGovern PE, Fleming SJ, Katz SH, editors. The Origins and Ancient History of Wine (Food and Nutrition in History and Anthropology). 1 st
ed., Vol. 11. Amsterdam: Gordon and Breech Publishers; 1966. p. 96-124.
Evans TC. The opium question with special ref to Persia. Trans R Soc Trop Med Hyg 1928;21:339.
Booth M. The discovery of dreams. In: Opium A History. London: Simon & Schuster Ltd.; 1996. p. 15.
Anslinger HJ, Tompkins WF. The pattern of man's use of narcotic drugs. In: The Traffic in Narcotics. New York: Funk and Wagnals; 1953. p. I.
Thompson RC. The Assyrian Herbal, a Monograph on the Assyrian Vegetable Drugs. London: Luzac and Company; 1924. p. 46, 251, 61, 9.
Ludwing Christian Stern. In: Ebers G, editor. Papyrus Ebers (in German) 2. 1 st
ed. Leipzig: Bei S. Hirzel 1889.
Sullivan R. The identity and work of the ancient Egyptian surgeon. J R Soc Med 1996;89:467-73.
Ebbell B, Banov L. Papyrus Ebers. The Greatest Egyptian Medical Document. Copenhagen: Levin & Munksgaard; 1937.
Salguero CP. The Buddhist medicine king in literary context reconsidering an early medieval example of Indian influence on Chinese medicine and surgery. Hist Relig 2009;48:183-210.
Chu NS. Legendary Hwa Tuo's surgery under general anesthesia in the second century China. Acta Neurol Taiwan 2004;13:211-6.
Chen J. A brief biography of Hua Tuo. Acupunct Today 2008;9:1-4.
Fu LK. Hua Tuo, the Chinese god of surgery. J Med Biogr 2002;10:160-6.
Ajram K. Miracle of Islamic Science. Apendix B. 1 st
ed. Vernon Hills, IL: Knowledge House Publishers; 1992.
Hunke S. Allahs Sonne Uber dem Abendland Unser Arabisches Erbe. Stuttgart :Deutsche Verlags-Anstalt 1960:279-80.
Ogata T. Seeshu Hanaoka and his anaesthesiology an surgery. Anaesthesia 1973;28:645-52.
Malsaki A. New studies on the history of anaesthesiology - A surgical experience with breast cancer Masue. Jpn J Anaesthesiol 2000;49:1038-43.
Matsuki A. New studies on the history of anesthesiology - a new study on Seish¯u Hanaoka's "Nyugan Ckiken Roku" (a surgical experience with breast cancer)". Masui: the Japanese Journal of Anesthesiology 2000;49: 1038-43.
Carter AJ. Dwale: an anaesthetic from old England. BMJ 1999;319:1623-6.
Davy H. Researches, chemical and philosophical - Chiefly concerning nitrous oxide or and dephlogisticated nitrous air and its respiration. Bristol: Biggs & Cottle; 1800.
Meyer K: Dem Morphin auf der Spur (German nyelven). Pharmazeutischen Zeitung. GOVI-Verlag, 2004. (Hozzáférés: 2012. június 12.).
Desai SP, Desai MS, Pandav CS. The discovery of modern anaesthesia - Contributions of Davy, Clarkee, Long wells and Morton. Indian J Anaesthesiol 2007;51:472-8.
Lyman HM. History of Anaesthesia Artificial anaesthesia and anaesthetics. New York: William Wood and Company; 1881. p. 6.
Stone RF, editor. Biography of Eminent American Physicians and Surgeons. Indianapolis: CE Hollenbeck; 1898. p. 89.
Long CW. An account of the first use of Sulphuric Ether by inhalation as an anaesthetic surgical operations. South Med Surg J 1849;5:705-13.
Wells H. History of the Discovery of the Application of Nitrous Oxide Gas, Ether and other Vapors to Surgical Operations. Hartford: J Gaylord Wells; 1847.
Morton WT. Remarks on the Proper Mode of Administering Sulphuric Ether by Inhalation. Boston: Button and Went worth OCLC 14825070; 1849.
Jackson CT. A manual of etherisation containing directions for the employment of ether. Boston: J B Mansfield; 1861.
Jackson C. "l: Instrumentarium" A manual of peroval endoscopy and laryngeal surgery. Philadelphia: W.B. Saunders; 1922. p. 17-52.
Trendelenburg F. Beiträge zu den Operationen an den Luftwegen" (German nyelven). Archiv für Klinische Chirurgie 1871;12:112-33.
Bain JA, Spoerel WE. Observations on the use of cuffed tracheostomy tubes. Can J Anaesth 1964;11:598-608.
Macewen W. Clinical Observations on the Introduction of Tracheal Tubes by the Mouth, Instead of Performing Tracheotomy or Laryngotomy. Br Med J 1880;2:163-5.
Tabem DL, Volwiler EH. Sulfur containing barbiturate hypnotics. J Am Chem Soc 1935;57:1961-3.
Magill IW. Technique in endotracheal anaesthesia. Br Med J 1930;2:817-9.
Macintosh RR. A new laryngoscope. Lancet 1943;241:205.