Throughout recorded history, attempts at producing a state of general anesthesia can be traced back to the writings of ancient Sumerians, Babylonians, Assyrians, Akkadians, Egyptians, Persians, Indians, and Chinese.
Despite significant advances in anatomy and surgical techniques during the Renaissance, surgery remained a last-resort treatment largely due to the pain associated with it. This limited surgical procedures to addressing only life-threatening conditions, with techniques focused on speed to limit blood loss. All of these interventions carried high risk of complications, especially death. Around 80% of surgeries led to severe infections, and 50% of patients died either during surgery or from complications thereafter. Many of the patients who were fortunate enough to survive remained psychologically traumatized for the rest of their lives. However, scientific discoveries in the late 18th and early 19th centuries paved the way for the development of modern anesthetic techniques.
The 19th century was filled with scientific advancements in pharmacology and physiology. During the 1840s, the introduction of diethyl ether (1842), nitrous oxide (1844), and chloroform (1847) as general anesthetics revolutionized modern medicine. The late 19th century also saw major advancements to modern surgery with the development and application of antiseptic techniques as a result of the germ theory of disease, which significantly reduced morbidity and mortality rates.
In the 20th century, the safety and efficacy of general anesthetics were further improved with the routine use of tracheal intubation and advanced airway management techniques, monitoring, and new anesthetic agents with improved characteristics. Standardized training programs for anesthesiologists and nurse anesthetists emerged during this period.
Moreover, the application of economic and business administration principles to healthcare 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.
Etymology of anesthesia
In ancient Greek texts, such as the Hippocratic Corpus and the dialogue Timaeus, the term ἀναισθησία (anaisthēsíā) is used, which translates to "without sensation". This term is derived from the prefix ἀν- (an-), meaning "without", and αἴσθησις (aisthēsis), which means "sensation". The concept of anaisthēsia is significant in understanding the historical foundations of anesthesia and its relevance in medical practices. In 1679, Steven Blankaart published Lexicon medicum graeco-latinum with the Latin term anaisthesia. In 1684, an English translation appeared titled A Physical Dictionary, with anesthesia defined as a "defect of sensation, as in paralytic and blasted persons". Subsequently, the term and variant spellings like anæsthesia are used in medical literature signifying "insensibility".
In 1846, in a letter, Oliver Wendell Holmes proposed the term anesthesia to be used for the state induced by an agent and anesthetic for the agent itself. Holmes motivates this with earlier uses of anesthesia in medical literature to mean "insensibility", particularly to "objects of touch".
Antiquity 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.
Ethanol The first historical achievement in anesthesia occurred around 4000 BC in ancient Mesopotamia. This was the advent of ethanol (commonly known as drinking alcohol), the first general anaesthetic agent. These accounts of the anesthetic uses of ethanol come from the oldest known historical civilization of Sumer and are documented in the oldest known writing system cuneiform.
Opium
The Sumerians are said to have cultivated and harvested the opium poppy (Papaver somniferum) in lower Mesopotamia as early as 3400 BC, though this has been disputed. 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. 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. The term gil is still used for opium in certain parts of the world. 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. British archaeologist and cuneiformist Reginald Campbell Thompson writes that opium was known to the Assyrians in the 7th century BC. 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".
The ancient Egyptians had some surgical instruments, as well as crude analgesics and sedatives, including possibly an extract prepared from the mandrake fruit. The use of preparations similar to opium in surgery is recorded in the Ebers Papyrus, an Egyptian medical papyrus written in the Eighteenth Dynasty. However, it is questionable whether opium itself was known in ancient Egypt. The Greek gods Hypnos (Sleep), Nyx (Night), and Thanatos (Death) were often depicted holding poppies.
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. By the 8th century AD, Arab traders had brought opium to India and China.
Classical antiquity
In Classical antiquity, anaesthetics were described by:
Pedanius Dioscorides (De Materia Medica), a Greek physician living in Rome during the first century A.D., who is recorded as the first person to make explicit reference to the administration of mandrake-induced anesthesia to facilitate a surgical intervention. Galen Hippocrates Theophrastus (Historia Plantarum)
China and Hua Tuo's ancient chemical mixture
Bian Que (Chinese: 扁鵲, Wade–Giles: Pien Ch'iao, ) 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 (), the Records of the Grand Historian (), and the Book of Master Lie () 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.
Hua Tuo (Chinese:華佗， ) was a Chinese surgeon of the 2nd century AD. According to the Records of Three Kingdoms () and the Book of the Later Han (), 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). Hua Tuo reportedly used mafeisan to perform even major operations such as resection of gangrenous intestines. 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.
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. 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.
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:
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, bhang, shang-luh, or opium. Victor H. Mair wrote that mafei "appears to be a transcription of some Indo-European word related to "morphine"." 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. 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.
Other substances used from antiquity for anesthetic purposes include extracts of juniper and coca.
Middle Ages and Renaissance Ferdowsi (940–1020) was a Persian poet who lived in the Abbasid Caliphate. In Shahnameh, his national epic poem, Ferdowsi described a caesarean section performed on Rudaba. A special wine prepared by a Zoroastrian priest was used as an anesthetic for this operation.
Circa 1020, Ibn Sīnā (980–1037) in The Canon of Medicine described the "soporific sponge", a sponge imbued with aromatics and narcotics, which was to be placed under a patient's nose during surgical operations. Opium made its way from Asia Minor to all parts of Europe between the 10th and 13th centuries.
Throughout 1200 to 1500 AD in England, a potion called dwale was used as an anesthetic. This alcohol-based mixture contained bile, opium, lettuce, bryony, henbane, hemlock, and vinegar. Surgeons roused their patients by rubbing vinegar and salt on their cheekbones. One can find records of dwale in numerous literary sources, including Shakespeare's Hamlet, and the John Keats poem "Ode to a Nightingale". In the 13th century, we have the first prescription of the "spongia soporifica"—a sponge soaked in the juices of unripe mulberry, flax, mandragora leaves, ivy, lettuce seeds, lapathum, and hemlock with hyoscyamus. After treatment and/or storage, the sponge could be heated and the vapors inhaled with anesthetic effect.