Imagine a surgical scene of today. Sterile room, harsh bright lights. The monitors beep telling everyone you’re alive. The fact is that today a surgical procedure will be virtually pain free, and your chances of coming out of surgery alive have never been higher. The anaesthetised operations of today are a world away from surgery throughout much of human history, which was unbelievably painful, extremely dangerous, and usually fatal. For these reasons’ surgery was usually performed as a last resort.

For surgery to be transformed into what we know today, our forebears had to use their ingenuity, skills, and their ability to experiment to overcome three huge hurdles to enable surgery to develop into the reliable and safe treatment option we have today.

Preventing surgery from hurting like heck

Even with the aid of alcohol and herbs, surgery remained horrifically barbaric. Surgery before anaesthetics was simply brutal. Patients had to be restrained during operations. Pain was so great they sometimes passed out. Most surgeons believed it was necessary to keep patients alert and awake, so alcohol and opiates were used sparingly. The best that a patient could hope for was an intoxicant or sedative that would dull their senses while the surgeon operated as fast as he could.

From the 15th century, a mixture of opium, mandragora and henbane was the sedative of choice for surgical procedures such as amputation. Herbs and plants continued to be used into the 19th century. They were either swallowed or soaked into a sponge or cloth and inhaled. In 1804, the Japanese doctor Seishu Hanaoka is credited with performing the first operation using a general anaesthetic. He used a herbal mixture that was drunk.

In 1798 the famous British chemist Sir Humphry Davy inhaled the gas Nitrous Oxide to test its effects. He observed that it relieved his toothache and had a euphoric effect on him. He named it laughing gas. Parties involving laughing gas became all the rage.

Davy suggested it could be used as a surgical anaesthetic but was ignored by the medical profession for many years. However, it has now been used as an anaesthetic for 150 years. Henry Hill Hickman, experimented with carbon dioxide as an anaesthetic in the 1820’s and coined the phrase “suspended animation.” His work was also ignored by the medical profession and yet today carbon dioxide has its place in anaesthesia.

Ether was Discovered in 1275 by Spanish chemist Raymundus Lullius and called sweet vitriol.  In 1540, German scientist Valerius Cordus described the synthesis of ether, and the Swiss physician and alchemist Paracelsus discovered its hypnotic effects.  In 1730, German scientist Augustus Sigmund Frobenius changed its name to ether. In a similar way to Nitrous oxide, ether became known for intoxicating effects than its anaesthetic properties. People attended ‘ether frolics’ to experience the effects of inhaling the vapour, public demonstrations were also given. These socially acceptable frolics were attended by physicians who noted that under the influence of ether, they would stumble and fall but felt no pain. In 1846 a Boston dentist William Morton participated in the first public demonstration to use ether as a general anaesthetic in surgery at Massachusetts General Hospital. The operation was judged a success and surgeons across Europe and America were quick to see the potential benefits of a general anaesthesia.

Chloroform was discovered in the 1830s. Its anaesthetic properties were not realised at first. James Young Simpson, a Scottish obstetrician, was searching for a safer alternative to ether and tested chloroform on himself and two colleagues in 1847. He only regained consciousness the following morning. He soon began to use it on obstetric patients.

So, by the end of the 19th century, general anaesthesia was being used across Europe and America and surgery no longer hurt like heck.

You survived the barbaric operation, but the infection killed you

Almost 80% of surgical patients contacted gangrene from operations performed in rooms with poor ventilation and crowded by observers. Surgeons wore street clothes, sometimes with aprons, seldom changing either between patients. At best, instrument preparation consisted only of washing with soap and water. Sawdust from mill floors was used both as wound dressing and as an absorbent material for the surgical floor.

The development of antiseptics and aseptic techniques had a dramatic impact on the health and life of those living in the late-nineteenth century. Essentially, these techniques combat the growth and transmission of harmful organisms. Antisepsis, meaning the topical destruction of bacteria, was developed as an offshoot of French bacteriologist Louis Pasteur's germ theory. Asepsis, meaning the absence of harmful organisms, was a later refinement of antisepsis and led to the development of modern surgery.

The English surgeon Joseph Lister pioneered antisepsis. Lister reasoned that tissue breakdown from infection was caused by minute organisms. Lister developed an antibacterial solution containing carbolic acid, first spraying it in the air and then on his surgical instruments as well as bandages. When Lister first applied his antibacterial solution directly to compound fracture wounds in 1865, he observed that its use resulted in dramatically lower rates of infection. Lister subsequently championed cleanliness in the surgical operative area.

Asepsis refers to any procedure that is performed under sterile conditions and being free from disease-causing micro-organisms. The concept of asepsis evolved in the 19th century through multiple individuals. In 1846 Austrian physician Ignaz Semmelweis suggested that physician hand-washing between attending patients lowered infection rates, while working in obstetrics at the Vienna General Hospital.  German physician Ernst von Bergmann made a major breakthrough in asepsis when he introduced steam sterilisation of surgical instruments in 1885. The British Physician Lawson Tait  instilled practices such as a strict no-talking policy within his operating room and drastically limiting the number of people to come in contact with a patient's wound. Everything from operating room uniforms to gloves was pioneered by American Surgeon William Halsted.

Halsted implemented a no street clothes policy in his operating room, opting to wear a completely white, sterile gown. Halsted would sterilise the operation site with alcohol, iodine and other disinfectants and use drapes to cover all areas except for the site. He enforced a hand washing ritual consisting of soaking in harmfully strong chemicals like permanganate and mercury bichloride solution as well as scrubbing with stiff brushes. The damage to a surgical nurse's hands compelled him to create the earliest form of the surgical gloves with the Goodyear Rubber Company.

The patient died because they lost so much blood

Losing more than 20% of your blood causes your heart rate to increase, together with your breathing rate. As you continue to lose blood, the heart rate continues to increase as your body tries in vain to maintain blood pressure. This is a lost cause if the blood loss is not stopped or replaced. Eventually, haemorrhagic or hypovolemic shock occurs. The heart cannot maintain pressure or adequate circulation and vital organs begin to fail. You will die. it’s easy to see why solving this problem is so important. Many of the techniques used today were developed a long time ago to treat battlefield wounds.

The tourniquet was developed in the 16th century to control blood loss, particularly after an amputation or loss of a limb during battle. Harvey Cushing created a pneumatic tourniquet, in 1904, which compressed the underlying blood vessels by inflating a cylindrical bladder. It could be applied and removed quickly decreasing the risk of nerve paralysis caused by depriving the blood vessels of blood for too long.

A ligature is a thread or wire that is tied around a blood vessel to seal it. There is evidence that it was used by the ancient Greeks.  The French surgeon Paré observed that bleeding after amputation could be stopped by ligating blood vessels. He developed a procedure for tying off veins and arteries that made thigh amputations possible. He published his technique in 1564. Cauterisation has been used for many centuries. To cauterise a wound, a metal tool was heated over a fire and applied to the wound, causing the blood to coagulate and seal off the damaged blood vessels. The 16th century method for sealing limbs after amputation was to use a combination of boiling oil and cauterisation. It was very painful, and the resulting burns caused a lot of tissue damage to an already injured body. But it could be done readily on the battlefield, and it was said to reduce the risk infection as well as blood loss.

However, none of the above were any use to you if you were unable to replace the lost blood with a transfusion. If you survived the operation you had to rely on your own body to replace the lost blood. In 1665 the first successful blood transfusion was carried out in England by Dr Richard Lower between two dogs. Subsequent experiments in transferring blood from animals to humans and between humans resulted in many deaths. In 1818 British obstetrician James Blundell performs the first successful transfusion of human blood to a patient for the treatment of postpartum haemorrhage. In 1901 Karl Landsteiner discovered that blood types had to be compatible in order for two people to share blood. Safe blood transfusion became a possibility. It took a number of years in which blood transfusion techniques were refined. Finally, during the second world war blood transfusions became routinely used.

Through imagination, experimentation thoughtfulness, ingenuity, and foresight the human race overcame the three huge barriers to ensuring patients could be safely operated on, enabling them to live longer. Pain was controlled, infection minimised, and blood loss prevented. This opened the way for surgery to be transformed into what we know today.

Well, this blog has been a bit of a history lesson for us all but the quest for safer surgery has not stopped. Innovgas was established by Dr. Andrew Wallis, a practising Australian anaesthetist who is driven by the desire to improve patient safety in the operating theatre. That is why patient safety is at the heart of everything we do at Innovgas. Why not view our Innovgas range and see for yourself how our products help keep patients safe during surgery in the 21st century.

Author: Niall Shannon, European Business Manager, Innovgas

This article is based on research and opinion available in the public domain.

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