So it doesn’t hurt: 170 years of anesthesia

Imagine what it would be like to undergo any operation – from having a tooth pulled or a cesarean section to a limb amputation or heart transplant – without anesthesia. Yet ether and painless surgery have existed for only 170 years; before this, one could give only a shot of whiskey or bathe a limb in ice. There was no way known in the Western world to make a patient completely unconscious and prevent all pain during surgery. On September 30, 1846, a young dentist named William Morton extracted a booth after administering ether to a patient. Upon reading a newspaper story about this event, surgeon Henry Jacob Bigelow arranged a few days later on October 16, 1846 for a now-famous demonstration of ether in the surgical theater of Massachusetts General Hospital (MGH), enabling Dr. John Collins Warren to painlessly removed a tumor from carotid salivary gland on the neck of a man named Edward Gilbert Abbott. The Bible describes how God put Adam to sleep to produce Eve from one of his ribs. Hua Tou – an ancient Chinese physician from the second century CE – reputedly was the first person to use a kind of anesthesia: wine mixed with cannabis-like herbs. But it took a millennium and a half after that for ether to be discovered. At the end of 1847, Scottish pediatrician Dr. James Young Simpson was first to demonstrate the anesthetic properties of chloroform on humans and helped to popularize the drug for medical uses. Cocaine was first used as a local anesthetic by Austrian ophthalmologist Karl Koller. In 1965, leading British neuroscientist Dr. Patrick David Wall and Dr. Ronald Melzack of the Massachusetts Institute of Technology developed the “gate control theory of pain” that describes how a “gate” on the spinal cord filters out feelings of pain that come from pain receptors; this prevents pain sensations from traveling to the central nervous system of the patient. Elective surgery was rarely carried out before 1847, according to an anesthesiology resident at MGH, Dr. John T. Sullivan, writing in the newsletter of the American Society of Anesthesiologists in 1996. “Elective surgery was performed very infrequently prior to the advent of effective anesthesia. From 1821 to 1846, the annual reports of the MGH recorded 333 surgeries, representing barely more than one case per month. Surgery was a last and desperate resort. Reminiscing in 1897 about pre-anesthesia surgery, one elderly Boston physician could only compare it to the Spanish Inquisition. He recalled 'yells and screams, most horrible in my memory now, after an interval of so many years.'” Sullivan noted that “over the centuries, numerous techniques had been used to dull sensation for surgery. Soporifics [sleep-inducing and awareness-dulling agents] and narcotics were prepared from a wide range of plants, including marijuana, belladonna and jimsonweed. Healers attempted to induce a psychological state of anesthesia by mesmerism or hypnosis. Distraction could be provided by rubbing the patient with counter-irritants such as stinging nettles. A direct but crude way of inducing a state of insensitivity was to knock the patient unconscious with a blow to the jaw. But by 1846, opium and alcohol were the only agents which continued to be regarded as of practical value in diminishing the pain of operations.” Giving the patient a large enough amount of alcohol to induce sleep and reduce pain during surgery can cause nausea, vomiting and even death, Sullivan wrote. THE FIRST national Anesthesia Day was marked in the United Kingdom in 2000, and a few years later, it began to be marked around the world to note the use of ether for complete anesthesia. The Israel Anesthesiologists Society was founded in 1952 to promote the profession and introduce new technologies in the field. It now has 1,800 members. Prof. Benjamin Drenger, head of the orthopedic anesthetic d e p a r t - ment at Hadassah Unive r s i - ty Medical Center in Jer usalem's Ein Kerem and head of the society gave The Jerusalem Post an interview about the past and current uses of anesthesiology and the problems the specialty faces here and abroad. “The event in the Etherdome at MGH was a historic event, and to mark the 150th anniversary two decades ago, a special conference was held. I was there. The original 1847 operation was accompanied by a drawing that became famous. The patient who survived said it was painless and a miracle.” Drenger noted that as a young anesthesiologist, he was told by a senior specialist at Hadassah then, Prof. Terry Davidson, that during World War II, when no anesthesia was available for amputations, ice and plastic bags were used to eliminate sensation in the limb. They didn't feel anything, said Drenger, but ice is not possible for conventional surgery. After the breakthrough of ether and chloroform for general anesthesia – which suppresses the activity of the central nervous system and produces unconsciousness and total lack of sensation, there were major leaps in the field. Sedation, for example, suppresses the central nervous system to a lesser degree, inhibiting anxiety without creating unconsciousness. Regional anesthesia and local anesthesia, which leave the patient conscious, block the transmission of nerve impulses between a specific organ and the central nervous system, causing a loss of sensation in the targeted body part. For dental procedures, nitrous oxide (“laughing gas”) is conventionally used for dental surgery. Retired Hadassah anesthesiology Prof. Florella Magora wrote a Lancet medical journal article in 1979 in which she suggested administering morphine to the spine. It was the first article on epidural morphine,” said Drenger in admiration. “A big jump occurred at the end of the 1970s when the pulse oximeter was developed. Doctors used to check the amount of oxygen in the blood by examining a finger. Pulse oximetry,” said Drenger, “is a non-invasive method for monitoring a person's oxygen saturation. A sensor device is placed on a thin part of the patient's body, such as fingertip or earlobe, or in the case of an infant, across a foot. The device passes two wavelengths of light through the body part to a photodetector that measures the changing absorbency at each of the wavelengths, so it can measure the absorbances that are due to the pulsing arterial blood alone, and exclude blood in the veins, skin, bone, muscle, fat, and usually nail polish. Before pulse oximetry, the death rate during surgery due to anesthesia was one out of 200,000. Today, it is only a small fraction of that figure. One in 3,000 people who undergo an operation can die from the surgery itself, but only rarely from the anesthesia, he said. In Israel and the West, the small yellow box costs around $2,000. But the price tag makes it prohibitive for hospitals in the developing world to buy them, so the death rate in surgery there due to anesthesia problems is relatively high, Drenger said. “A few years ago, an Indian doctor launched a project called Lifebox in which the price has been reduced significantly by the manufacturer and Westerners donate pulse oximeters to the Third World. Every year for the last half-dozen years, I have been making out a check for our society to send 10 of the devices to developing countries. They have really changed things.” DRENGER NOTED noted that in recent months, at the initiative of the government, supplementary health insurance policies offered by the four public health funds have had their conditions changed to reduce the amount of private medicine and the fee paid by public and private insurers to surgeons. “There is also an intention to bring more operations to the public hospitals to increase their workload and efficiency and reduce the queue for surgery.” He urged that the patient be allowed to choose one's anesthesiologist in public hospitals and not only in private medical institutions. “I met recently with Health Minister Ya'acov Litzman about the issue, and he promised to help.” Choosing one's anesthesiologist “gives the patient more transparency, safety and medical quality. It's an automatic thing in private hospitals; our society believes it should be so in public hospitals as well. In addition, as supplementary health insurance policies allow you to get second opinions twice a year, you should take advantage of this and choose an anesthesiologist you prefer. He or she will carry out tests and examinations that will shorten the period that you have to wait for surgery.” Although patients almost always know the name of their surgeon, even in public hospitals, they almost never know – or care about – the name of their anesthesiologist. This is frustrating for Drenger, because he insists that this specialist keeps the patient alive during an operation and constantly monitors vital functions. “Your life depends on this medical professional. Don't accept the hospital's claim that 'all of our anesthesiologists are excellent.' Find out about them and demand the one you want. The anesthesiologist not only gives the suitable anesthesia but also monitors his condition during the procedure and makes sure that post-operational pain is minimal.” There are ministry-sanctioned quality measurements, and one involves anesthesia. “At Hadassah, we held a pilot on reducing pain already in the recovery room after surgery.” Although surgeons and pediatricians for many years thought infants do not feel pain because their nervous system is “underdeveloped,” they know now that they do feel pain and – sometimes – a lot of it. Every baby gets a painkiller before surgery begins, and they can also, with parental permission, get a nerve block by injection in the stomach to eliminate pain. ANESTHESIOLOGISTS ADMITTEDLY have an image problem, he admits. But there is also a problem of a severe shortage of them. Because anesthesiologists do not get SHARAP (private medical service) payments in public hospitals, they have earned less than others who do. This has led to the fact that at least half of them are women, who generally work fewer hours and shifts because of their family duties. So too few newly minted doctors become anesthesiology residents. “We have an annual shortage in Israel of 300 anesthesiologist residents,” Drenger said. It is unfortunate, as many more medical procedures, from brain catheterizations on down, require anesthesiologists. “We have tried to show how interesting the specialty is. There is also a possibility of getting bigger bonuses because of the shortage of manpower in the profession. There is also an arrangement that we get higher pensions that many other specialists, and our working hours are very reasonable, usually during the day except for residents and supervising specialists working night shifts.” To attract more residents to the field and to improve anesthesiologists' image in the public, the society did a publicity campaign with jingles on Facebook a few years ago, “but it wasn't successful. The shortage is getting more serious, because all of those who came in the wave of Russian aliya in the 1990s are reaching retirement age. And 10% to 20% of anesthesiologists have left the country or switched to another profession.” In many developed countries, the profession of non-doctor nurse anesthetists has skyrocketed. They are not permitted to carry out all responsibilities of an anesthesiologist, but they can do many of them. In the US, said Drenger, they can earn $100,000 a year. There they are supervised by nurses. In Israel, the society insisted that they be called anesthesia assistants and be supervised by anesthesiologists, who are physicians. As the field expands all the time and is much more varied, the society encourages its anesthesiologist members to undergo continuing education courses so they can be updated,” concluded the senior anesthesiologist. “There are not as many new advances in the technology as there are in computers. Unfortunately, the pharmaceutical companies don't invest enough in the development of new anesthesia drugs as in antibiotics. But we believe that the next generation will focus on anesthesia for specific parts of the body.”

So it doesn’t hurt: 170 years of anesthesia

Anesthesiologists around the world are marking the 170th anniversary of their profession while there are too few of them for the advanced medical procedures of today.

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