Evolution of anaesthesia in India.VM Divekar, LD Naik
Department of Anaesthesiology, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, India., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 11832613
Source of Support: None, Conflict of Interest: None
Keywords: Anesthesia, history,Anesthesiology, education,history,instrumentation,History of Medicine, 19th Cent., History of Medicine, 20th Cent., History of Medicine, Ancient, Human, India,
The history of Anaesthesia in India can be written in three stages. The pre-ether era, of beginning from Susruta when in 500 B C. operations were performed using opium, wine, Indian Hemp and of course by tying up! There is a mention in 527 A. D. in Bhoj Prabandh of a cranial operation on Raja Bhoj himself using “Sammohini” for induction and Sanjivani” for recovery! Later alcohol was used for unconsciousness during the Muslim period (Muslim contribution to medicine 1962, Prof. H. Wasty, Lahore Pakistan). In 1843, James Esdaile started Mesmerism More Details at the Imambarah Hospital Hooghly, Calcutta and published 216 operations, however a government report says it was not universally nor uniformly successful (Englishman 1845, 22nd September)
The first administration of ether anaesthesia in India was on Monday 22nd March, 1847, in the Medical College Hospitals, Calcutta, under the supervision of Dr. O’Saughnessy, the surgeon. (First ether anaesthesia in the world was administered on October 16th 1846 in Boston, USA). Ether was used within one week of the news reaching Calcutta in the 2nd week of March, 1847. The first chloroform anaesthesia in India was administered on January 12th 1848 (Chloroform was first used by Simpson in Edinburgh UK, on 15th November, 1847). It is interesting to note that David Waldie, a chemist who has been credited for introducing chloroform in clinical anaesthesia came to Calcutta in 1853; started his chemical company and lived there till his death in 1889.
During the first 16 years of chloroform anaesthesia, there were 393 deaths and 48 were reported due to ether. There was a controversy between two medical schools, the Edinburgh (Simpson) claiming death due to respiratory failure and London (John Snow) claiming cardiac failure as the cause of death. The British Medical Association appointed the Glasgow committee in 1880 which concluded that “Chloroform was injurious to the heart and in comparison more dangerous than ether”. In 1888 Edward Lawrie in Hyderabad claimed that he had administered chloroform anaesthesia to 40,000 people without a single fatality and formed the “First Hyderabad Chloroform Commission”. 141 animal experiments were done and it was concluded “Chloroform may be given with perfect safety and without any fear of accidental death, if only respiration is carefully attended to”. This was not accepted in England and so the “Second Hyderabad Chloroform Commission” was formed to which a representative from Lancet was sent. The Nizam of Hyderabad offered £ 1000 for a commission consisting of Lauder Bruntor, F.R.S. U.K., Surgeons Lawrie and Rustomji. Experiments were carried out on 430 animals (dogs, monkeys, horses, goats, rats, rabbits and cats) and a clinical study on 54 humans. They concluded that the Edinburgh School was right. This study was undertaken at the Afzalganj Hospital in Hyderabad where the Osmania Hospital now stands. Incidentally the first woman anaesthetist in India and perhaps the world, Roopabai Ferdunji was working under Edward Lawrie in Hyderabad in 1889; she later went to Edinburgh for further studies.
In 1890 after 20 years of accidents due to chloroform, the world began to discard it in preference to ether, after strictures by coroners against the use of chloroform. However in India till 1928, chloroform was the only anaesthetic used. In fact, it became synonymous with anaesthesia. “Chloroformed” was the popular expression for anaesthesia. It was cheap, easy to induce and British. It was Dr. M. C. Ganguli from Calcutta who observed the leniency of coroners and Jyoti Prasad of Jodhpur (1928) produced a classical well documented paper on ether and observed that “Open ether is practical even in hot weather and at less cost”.
The first recorded case of endotracheal insufflation anaesthesia was in 1880 for an osteosarcoma of the hard palate with a catheter in the trachea by MacReddie for MacEwan’s procedure (Ind. Med. Gaz. – 1880, 16, 131).
Cayley in 1879 reported successful removal of a femoral artery aneurysm in a patient with extensive heart disease, with uneventful recovery (Ind. Med. Gaz. – 1897, 15, 71).
Mahatma Gandhi was operated upon on 12th January, 1925 for an eventful emergency appendicectomy in Sassoon Hospital, Pune. Dr. Date administered open drop Chloroform. A notable feature being that electricity failed; a torch was brought in which got fused; Surgeon Col. Maddock completed the operation in the light of a kerosene lamp !! (D. G. Tendulkar – Mahatma Gandhi – Vol. 2, Page 76).
J. Frayer, reported the first case of delayed chloroform poisoning in the world in 1869 in a 27 year old man who was treated for compound fracture of the leg. 24 hours later he started vomiting, developed jaundice, coma, anuria and died on fourth post operative day (Ind. Med. Gaz. – 1869, 4, 260). Guthrie’s report on a chloroform poisoning appeared in Lancet in England appeared in 1894!
Alexander Crombie of the Presidency General Hospital, Calcutta, started using hypodermic morphine in 1880 for smoother course of chloroform anaesthesia; this is the first documented report of premedication in the world, confirmed by Gwathmey and Rene. F. Miller of U.S.A. (Ind. Med. Gaz. 1888, 23, 34).
Chloroform and ether continued to be used till mid – fifties in many hospitals. Trilene was introduced in the late 1940’s and is still in use and Halothane appeared on the scene in 1960. We reported the first case of Halothane hepatitis in 1972. Enflurane trials were made in 1975 but it was not made available. Isoflurane is now used introduced in 1992.
Cocaine 4% was first reported as a local anaesthetic in 1894 for removal of a facial tumour. Spinal anaesthesia was first reported by Capt. A Chalmers of Trichinopoly with hyperbaric stovaine. The first death under spinal anaesthesia was reported by W. Gabbett of Madras, He gave 3 c.c. of distilled water containing 1 mgm strychnine and 1 dg of Novocaine at T11 and T12. The patient had dyspnoea and died (Ind. Med. Gaz. – 1910, 44, 54).
Spinal analgesia in children was reported by Rutter Williamson (1915) from Madras. He preferred stovaine from Saidapet Madras to that from London (Ind. Med. Gaz. – 1915, 50, 156). Stovaine was discarded in 1933. Later spinocaine and Percaine were used; a report on herniorrhaphies by J. C. Drummond was published.(Ind. Med. Gaz. – 1933, 68, 699).
Lumbar and caudal extadural analgesia were reported by Dr. G. R. Kokatnur (Belgaum, Karnataka). He had been doing that since 1925 with 40–60 c.c. of 1% Novocaine with no risk in over 400 cases (J. Ind. Med. Assoc. – 1946, 15, 342). Dr Hari Rao of Vizagpatnam published a study of a series of 970 cases of caudal extradural anaesthesia and 6 patients who were given lumbar epidurals (J. Ind. Med. Assoc. – 1941, 10, 448).
Total spinal for controlled hypotension was introduced in 1954 (Dr. G. S. Ambardekar). Nupercaine 1% heavy and 1:1500 hypobaric were commonly used in this decade. Though regional anaesthesia was discarded for several years in U.K., it was the most popular here, because of economics, simplicity and good operative conditions. Labour analgesia was also practised routinely in some centres.
Thiopentone was introduced in early 1940s by Dr. M. M. Desai and Dr. B. N. Sircar (Bombay) at the G. S. Medical College. Dr. Desai had the misfortune of being the first and perhaps the only anaesthetists to die in a dental chair following thiropentone, given by his own resident!
d-tubo curarine was introduced in 1949 and subsequently gallamine and scoline in the late fifties. Pancuronium was in use sine 1975, Norcuron in 1979 – 1990.
The first mitral commisurotomy was performed in 1952 (G. S. Medical College); hypothermia for atrial septal defect in 1953. At about the same time blind intubations were in practice.
Neurosurgery as a speciality started in 1941 and open heart surgery (1961) was started at B.Y.L. Nair Hospital, Bombay, using an indigenous reusable bubble oxyenator! We were not for behind in transplant surgery, the first kidney transplant was performed at Vellore in the early 70’s, heart transplant attempted at Bombay in late 1960’s. Recently cadaver transplants have been performed in Hyderabad, Madras, Bombay and Delhi. The stage is set for liver transplants.
A two–bedded ICCU was started in K.E.M. Hospital, Bombay (1962). The first documentation of an Intensive Care Unit was in 1963, in the Army Hospital, Delhi by Col. Ramarao. At this time there were units at AIIMS (Dr. Tandon) and at Safdarjung Hospital (Dr. Bhattacharya). Now there are ICCUs in every town and ICUs in all major hospitals and specialities, where anaesthesiologists play an important role.
In 1929, the FLAGG’s can was modified into a bottle! (The K.E.M. Bottle). On 22nd January, 1935, the first Boyle’s Apparatus arrived in Calcutta by ship, it had “Fine adjustment valves (no pressure reducing valves!) and water sight feed bottle for ether, a 2–way stop cock, for re–breathing / non-rebreathing and shipways CO2 absorption apparatus, 4 cylinders of 100 gallons for O2 and N2O”. The cost of this including custom duty and delivery charges was Rs. 645/-
The first O2 plants were installed in Calcutta in 1935 and N2O plant in 1962. Now there are Regional Centres in most areas. The pipe–line supply was first installed in Vellore (1954) and by 1979 over 150 centre and now every major hospital has it. Liquid Oxyugen has now been introduced a decade ago (Mid 80’s).
The first indigenous “Boyle F” rolled out of IOL, Calcutta in 1950, with imported parts. By 1956 it was entirely manufactured in India except the cylinders. At present machines with all the latest safety guards have been incorporated. During the 1st Indo-Pak war the Porta-Boyle was developed, as well as an Air–Trilene apparatus for inaccessible areas. Currently there are several companies manufacturing anaesthesia apparatus (Bombay, Delhi and Calcutta).
In the early 40’s Lord Nuffield of Oxford, a car magnate and benefactor to anaesthetists, donated “iron lungs” (drinker’s apparatus) to the Armed Forces and Metro Cities in India. The 1950’s saw “Dog–Pumps” later the Beaver and Bird – MK 7. In the late Sixties electromechanical anaesthesia ventilators were indigenously manufactured but till today Triggered Ventilators are yet to be indigenously made. However a plethora of sophisticated multimod ventilators are being imported.
Monitoring has also come of age, cardioscopes were introduced in 1960 for cardiac surgery, now it is universally used and indigenously manufactured too. Pulse oximeters were first introduced by Omeda in the mid–eighties; now the market is flooded with oximeters. End tidal carbondioxide monitor is also used in major centres. Neuromuscular monitoring is also catching up, first introduced in 1968 by wellcome laboratories, now computerised versions are available with several modes. Temperature monitoring is not yet universal or mandatory.
On October 16th 1946, a centenary celebration of “Ether – Anaesthesia” was held at the G. S. Medical College in Bombay; Dr. S. K. Bakshi (Delhi) Dr. B. N. Sircar. Dr. G. S. Talwalkar, Dr. M. N. Desai (Bombay); Mukteshwar Prasad (Patna) and F. Saher conceived the Indian Society of Anaesthetists (ISA). Dr. Saher; in charge of the correspondence for opinions, died soon after following an operation! Dr. B. B. Sircar of Seth G. S. Medical College, Bombay took over and the society was established in 1947.
On 23rd and 24th December, 1949, during the Annual Surgeons Conference, the first meeting of the ISA was held at the Seth G. S. Medical College. Dr. M. N. Desai was the chairman of the Reception Committee and Dr. J. R. Jagase (Bombay) was the President. The following delegates were present Drs. G. S. Ambardekar, Awalegaokar, G. S. Talwalkar (Treasurer), B. N. Sircar, V. Bhargav, K. M. Bakshi, I. Iqbal, W. P. Thatte, R. B. Redkar, R. P. Parulkar, Jadhav V. V., Hari Rao (Vizag), Gwenda Lewis (Vellore), Satyendra Singh (Delhi), P. D. Dhameja (Delhi), Mukteshwar Prasad (Patna) and A. T. Gokhale (Pune). Thereafter the society continued to meet yearly under the umbrella of the Association of Surgeons of India (ASI).
In 1964 the silver jubilee year of the Association of Surgeons of India it was decided after a lot of deliberation to separate out ISA as an independent association. The first independent conference of ISA was held in Hyderabad under the Chairmanship of Prof. Venkatrao and Presidentship of DR. R. P. Parulkar of Baroda. Two illustrious anaesthetists, Prof. Macintosh and Prof. Cecil Gray were present on the occasion. Silver Jubilee of ISA was celebrated at Madras organised by Dr. T. Srinivasan. The membership of the society has grown from 19 members in 1947 to 100 in (1955), 2500 (1979) and to over 8000 at present. Life membership was introduced in 1985. Sub-specialities such as in pain, cardiac anaesthesia, neuroanaesthesia, clinical pharmacology, and Anaesthesia Practitioners Forum were proposed at Vishkhapatnam in 1986; all these sub-specialities are flourishing in their respective group meetings. At present most major cities, towns and states have a branch of ISA. The Armed Forces Anaesthetists Forum and the All India Railway Anaesthetists Forum have their annual conferences too.
The first official journal of the society was published in July 1953. Dr. M. C. Ganguli was the first editor.
In 1956 ISA joined the World Federation of the Societies of Anaesthesiologists (WFSA) as a founder member and hosted the V Asia-Australasian Regional Congress (AACA) at Delhi in September 1978 organised by Dr. G. R. Gode.
A South Asian Confederation of Anaesthesiologists (SACA) of SAARC countries was conceived in New Delhi in November 1991 and the first SACA congress was held in Dhaka (1993) with Dr. (Mrs.) V. M. Divekar as the Founder President.
In 1890 in Hyderabad Medical School, 2 students were deputed for all cases that were to be given chloroform anaesthesia, one person administering anaesthesia and the other taking detailed notes – the earliest anaesthesia records in the country! These trained anesthetists were called “ Chloroformists” (Ind. Med. Gaz. P. Heir – 1893; 27, 80).
The Indian Medical Gazette in 1941 advertised a post of “One Paid Anaesthetist” for the Mayo Hospital, Calcutta and Sassoon Hospital, Poona. Dr. Jyotindranath Mukherjee L.M.S. was appointed on September 1st, 1914 on a salary of Rs. 50/- per month!
Lectures on anaesthesia for undergraduates were first started officially in Calcutta University in 1906. Incidentally in Great Britain it started in 1918 (Scurr). In two medical schools before independence there were teachers in anaesthesia in Bombay (S. G. Talwalkar), Calcutta (M. C. Ganguli), Lucknow (R. Pramanik) Madras (P. V. Francis and T. G. Baganath) Delhi (E. Soundaravalli). Lahore and Patna did not have teachers. Now, there are over 150 Medical Colleges each with departments of anaesthesiology. Tutorials and 8- 10 didactic lectures, certain basic skills in anaesthesia and CPR are compulsory, as well as half to one month internship.
Postgraduate teaching and training: A post independence phenomenon started with the Diploma in Anaesthesia in Bombay in 1946 and D. A. of College of Physicians and Surgeons in 1948. The first degree course, M. S. in Anaesthesia was started in Muzaffarpur and Darbhanga. Currently most university and post graduate institutes have M.D./M. S. in Anaesthesia. The National Academy of Medical Sciences started the Diplomate of National Board of Examinations in the 70s. The students whoh took these exams have increased from 5 to approximately 70 students per year at present. The quality of education in anaesthesia is of a high order by the reports our students bring in during their foreign assignments and of course the reduction in mortality and morbidity. Ph.D. in anaesthesia is also offered at some centres, the first student was Dr. J. R. Mitra of Calcutta under Dr. Barat.
Dr. Bhojraj, Dr. Bhattacharya and Dr. Pramanik were the first to receive F.F.A.R.C.S. in 1953.
Armed forces had a spurt in anaesthesiologists during the World War II. After 28 days of training, the specialist was let loose! The Indian Specialist took over in 1947, this is also the Golden Jubilee year of the Indian Armed Forces Anaesthetists. There is at present intensive training at the AFMC (Pune) and after 5 years of training they are classified specialists including Super Specialities.
Therefore, the science of anaesthesia is just about 150 years young as compared to the thousand years old well-established surgical faculties. It is truly an applied medical science of all the medical faculties, and has proved to be one of the three “A”s – Anaesthesia, Asepsis and Antibiotics – a millennium contribution for the tremendous advances made by the medicine, surgery intensive care and pain management.