It is almost certain that, in the past, pain and infections were what gave such a bad reputation to surgery. Patients who had no real chance of survival would die randomly through pain and infections.
The most famous 18th century surgeon, John Hunter, would apparently go as white as a sheet before operating for he detested being the cause of so much unavoidable pain. Some practitioners even came to the conclusion that pain was “necessary” to the surgical act.
Though, it must be said that because of the religious context in Europe from the Middle Ages to the Renaissance, the population was persuaded that pain was completely part of the sanction that Man had to pay for the Original Sin. You have only to see the influence this philosophy had on Art, with its paintings of Martyred Saints, to understand how deeply ingrained this notion was.
And yet, during the Great Explorations, voyages and conquests, it seemed that there existed ways of softening and diminishing pain, even making it disappear whilst operating (analgesics) or through loss of feeling (anaesthesia). The opium stick was one of those. As was the discovery, made by the famous doctor Larrey of Napoleon’s Great Army during the Russian Campaign that cold considerably reduced the patient’s sense of feeling during surgery. For the most, these surgical acts were amputations.
In 1772, the Anglican pastor Priestly discovered a gas which has had, and still has, a long standing career in anaesthesia: Nitrous oxide also known as dinitrogen oxide or dinitrogen monoxide. This gas was more commonly known as “laughing gas” in the 19th Century Fairs due to the euphoric effects it has once inhaled. Yet both nitrous oxide and ether (which was liquefied in 1801) were not immediately put into medical use.
Once more, it was thanks to the spirit of enterprise of these pioneering doctors that steps were taken to overcome pain. An American dentist, Horace Wells, whilst taking part in a demonstration of ‘laughing gas’ in a travelling circus, noticed that one of the patients had not felt any pain when hit at the tibia. The next day he tried it on himself and feeling no pain, he successfully removed a wisdom tooth. In 1845 he then gave a similar demonstration in front of a group of medical students in Boston but the gas was improperly administered and the patient cried out in pain. Because of this embarrassment, Wells was discredited by the medical community and gave up his dentistry.
A year later, on 30th September 1846, Horace Wells’ friend and fellow dentist William Morton performed a painless tooth extraction after administering ether to a patient. This led to the famous demonstration of 16th October 1846, during which Dr. John Collins Warren painlessly removed a tumor from the neck of a patient. The operation went smoothly as the patient ‘slept’, knocked out after having breathed ether through a mask.
The following year chloroform was discovered and used to assist Queen Victoria during labour for a painless childbirth. At last, pain was no longer feared.
The 20th Century brought along its own contribution to anaesthesia with the appearance of barbiturates in 1932 (drugs that act as central nervous system depressants), the curares in 1936 (introduced into anesthesiology as a muscle relaxant for surgery), and neuroleptics or antipsychotic drugs in 1952.
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Anaesthesia in medicine can be carried out in three different forms: local, regional or general.
It can be administered through contact, infiltration, intravenously or through inhalation. The aim of these anaesthesias is to avoid pain during a surgical procedure whilst protecting the patient against any physiological and biological angst that result from the aggression that the body feels due to the operation.
Modern Pharmacology has lessened intoxication due to the anaesthesia products as it has reduced it dosages and has become more selective in its objectives such as in the use of narcotics, analgesics and sedatives. In synchronising its use with a paralysing product, the Anaesthetist obtains a complete muscular relaxant which eases the surgeon’s work.
Local anaesthesia is used during a surgical procedure which does not require the patient to be asleep. With this procedure, the product may be injected directly into the area which needs to be anaesthetised. It will act on the cutaneous area that rely on a specific nerve or branches of, and so effectively block the nerves influx. Increasingly, a local anaesthetising cream is used, 1 to 1:30 hours prior to the main local anaesthesia so as to render the injections painless, particularly on the face, as is the case in a lifting.
The most currently used products in local anaesthesias are marcaine, lidocaine, and scandicaine which are sometimes coupled with adrenaline whose vasoconstrictor properties (i.e. the retraction of blood vessels) lessen bleeding. The effects can last between 1 to 3 hours.
Large area Anaesthesias
This particular form of Anaesthesia targets a large area of the body. The anaesthetic solution is injected into the nervous system of the area that the surgeon wishes anaesthetised. It can be either the lower half of the spine or at the end of the spinal cord (in the spinal nerves): this is called an Epidural. It can also be administered directly into the spinal nerve system (the Cerebrospinal fluid) which effectively blocks the nerve endings: this is called a Spinal Anaesthesia.
These Anaesthesias are mostly practiced for larger areas. In the case of Spinal Anaesthesias and Epidurals the lower half of the body is numbed, more or less from the belly button down. Motricity is impossible; insensitivity is total, and all voluntary movement of the lower body is impossible.
Each childbirth or caesarean birth that is painless and without sedation the Epidural Anaesthesia has its moment of glory. Plastic Surgery employs this type of Anaesthesia in liposuctions, small abdominal tummy tucks and in the lifting of the thigh’s inner side. Risks incurred by this form of Anaesthesia are extremely rare.
General Anaesthesia through inhalation is still made with Nitrous oxide, otherwise known as “the laughing gas”. There are times when other drugs are administered so as to suppress pain, muscular tone or post-operative shock. Since the discovery of chloroform, other new products have been used but then have disappeared once their side effects were overcome by other more reliable gases. From risks of explosions to risks of liver failure, the progress made has been continuous.
Nevertheless, in most cases, General Anaesthesia is done intravenously as inhaling is usually just to maintain an anaesthetised state.
According to the current procedure, the Anaesthetist first administers a narcotic, such as a barbiturate or a hypnotic to make the patient fall asleep. Then he administers an analgesic (for a long time these drugs were made from morphine) which relieves all pain. Neuroleptics are prescribed in order to protect the body system from shock due to the surgery. Then, the muscles are paralysed with the administration of curare which produces rapid and complete muscular relaxation. The inconvenience of this is that the respiratory function is reduced and paralysis of the respiratory muscles occurs. Therefore since 1959, so as to maintain an open airway and a regular breathing pace, either an artificial breathing tube is inserted (intubation) or the anaesthetist holds a mechanical ventilation (a bag valve mask) over the patient and the breathing is monitored. Intubation is always done through an endotracheal tube which is made of rubber and is introduced through the nose or the mouth down to the trachea.
Other forms of General Anaesthesia are sometimes used such as induced hypothermia, but they are not practiced during Plastic Surgery.
Today’s drugs are programmed to have a short life span in the body; therefore the patient can recover consciousness within a few minutes, though the Anaesthetist with an injection can at any moment prolong the anaesthesia. However, General Anaesthesia remains the heaviest of all as it requires a considerable amount of drugs. The risks are therefore more than those present during a local anaesthetic and the post operative is more delicate. The patient is to remain at least 24 hours under medical observation in order to supervise the adverse reactions that the drugs may have, and to ensure their total evacuation from the body.
Narcoleptic Analgesic Anaesthesia
Even though it forms part of General Anaesthesias, narcoleptic analgesic anaesthesia deserves a little of our attention. A great many Plastic Surgeries are made with this type of anaesthesia. This anaesthesia is obtained through an intravenous injection of sedatives with analgesics that stop the pain.
Due to the narcoleptic both anxiety and stress are diminished and there is also a tranquilising and analgesic effect. During the operation the patient is in a soft slumber whilst remaining conscious and is quite capable of responding to simple questions even as he or she is undergoing a major operation. Narcoleptic analgesics are also frequently used during Local Anaesthesia.
This method is less dangerous than a General Anaesthesia as the patient is much less “drugged” and the products that are administered are much less toxic. During the surgical procedure the patient breathes spontaneously therefore normally and hence the after-effects are practically without risk as the patient is usually allowed to leave approximately 2 hours after the surgical act. The speediness between the patient’s time of arrival and departure constitute a new surgical procedure that is just as controlled and as effective as any other surgery. It originally started in the United States mainly for financial reasons, and is known as ambulatory surgery.
Anaesthesia is practically a new science which has developed through the study of the complex biochemical and neurophysiological mechanisms of the human body. Its main reason remains the elimination of pain during surgery, though nowadays its function is also to protect the body against the reactions of the autonomic nervous system (ANS) (or visceral nervous system) against this aggression. It may also be useful to point out that there has been a certain amount of research done to stimulate the nervous system and so block the pain message directly in the brain, which subsequently liberates natural analgesic substances such Endorphins (or more correctly Endomorphines).
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