Anaesthesia- a great advancement in Surgery

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Anaesthesia- a great
advancement in Surgery

Prof Altaf Husain Rathore, FRCS, DA (London), M.F.A, R.C.S (Hon)
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Anaesthesia is a great blessing of God for the ailing human being. It is the condition in which a person is made unconscious or senseless or painless by the drugs for the surgical operation. Modern anaesthesia not only guarantees complete depression of higher centers, painful stimuli and complete relaxation of skeletal muscles but also ensures an absolute safety of the patient.


Prof Altaf Husain Rathore

The history of surgery is as long as 12000 years but of anaesthesia is not very long. The earliest drugs used for pain were alcohol in the west opium in China Cannabis and its products in India, Mandragora from mandrake by Romans and mixture of Opium and Hyoscyamine was used by Egyptians. But it was difficult to tell the lethal dose from the therapeutic dose for the surgery. Only simple operations like trauma, setting of factures, amputation, letting out of pus, bladder stone surgery and trepination of the skull were performed. Joseph Priesly discovered nitrous oxide gas in 1772 and it was known as laughing gas. Hamphary Davy used it for narcosis in 1800, so was called father of anaesthesia. But in pure form it could cause the death that is why it was used after mixing with 20% of Oxygen by Edmund Andrews. Horace Wells a dentist in 1844 used it first time in human being to extract the tooth. Nitrous Oxide is still being used in the whole world for anaesthesia. CO2 was also used by Henry Hill Hickman in 1824 for anaesthesia but this narcosis was due to partial suffocation which was never popular. Other gas Xenon was also used to replace Nitrous Oxide but it is much more expensive and has no special benefit over later gas. Cyclopropane gas stored in Orange colored small cylinders was introduced in 1934 for the anaesthesia. It was a strong narcotic agent but could never get popular because it was not only high by combustible but also explosive.

The next break through was the discovery of a volatile anesthetic agent by a Botanist Valesus Cardus in 1540 by the name ether. It was first used for human by W.T.G Mortan in 1846. Its use continued for more than a century. It was used alone by open drop or by simple apparatus mixed with only air or Oxygen or Nitrous Oxide and O2 by simple anesthetic machines. It was a cheap, potent anesthetic agent and good muscle relaxant. The main disadvantage was that it was irritant, combustible, decomposed by air, light and heat. Its induction and recovery was slow, increased salivary gland secretion, nausea, vomiting and increased blood sugar.

Chloroform was synthesized in 1831 by Leibig, Guthrie and Soubeiran but it was used in clinical practical by a Scottish doctor Sir James Simpson in 1847. It was sweet smelling, potent anaesthesia agent, gave good muscle relaxation and could be given by any method. It was so popular at one time that chloroform was known as to be synonym with the general anaesthesia by general public. But it gave cardiac arrhythmias, respiratory depression and heptotoxicity. But main cause of its sudden disfavor was the series of deaths caused by sudden cardiac arrest.

Other volatiles anaesthetic agents like ethyl chloride, trichloroethylene (Trilene) were discovered upto 1860. Ethyl chloride was a potent anaesthesia agent, sweet smelling and was used vastly for induction for open drop anaesthesia. But was inflammable caused cardiac arrhythmias and sudden cardiac arrest. It caused local freezing so used as local anaesthesia for drainage abscess. Trilene was also sweet smelling and was a good analgesic agent but high doses had to be given for narcosis. Besides it was not a muscle relaxant and was incompatible with soda lime. It was more used for obstetrics analgesia.

In 1951 a new chemical fluorinated hydrocarbon was synthesized for narcosis. First of them was Halothane. It was a potent, sweet smelling, non irritant, volatile anesthetic agent. It is stored away from the light and corroded metals. Induction is quick but recovery is slow. It depresses myocardium, lowers the heart rate and blood pressure and causes arrhythmia. It is not a skeletal muscle relaxant but relaxes the uterine muscle so causes more postpartum bleedings after caesarian section and normal delivery.

That is why other fluorinated hydrocarbons appeared in the market for anaesthesia from 1973 to 2000. They are Enflurane, Isoflurane, Sevoflurane, Desflurane. All are expensive and each needs a special evaporator. They are non irritant except isoflurane and desflurane which are slightly pungent. All give quick induction and quick recovery and relax muscles. All depress respiration, myocardium, are hepatotoxic and reduce blood pressure but less than halothane. All increase the heart rate except halothane and sevoflurane. All increase the intraocular pressure and sevoflurane cannot be used with sodalime. 

Intravenous anesthetics came into the picture quite late because no intravenous needle and syringe was invented up to 1855. Sir Christopher Wren and Robert Boyle in 1665 used a sharpened goose quill to inject opium into an animal for narcosis. Alexander Wood invented the first needle and syringe in 1855. The first most effective, safe and reliable intravenous anesthetic agent was thiopentone sodium. It was a short acting barbiturate synthesized by Volwiler and Tobern in 1932. It was followed by nonbarbiturates like Ketamine in 1962, midzolam a phenothiazin in 1976 and propofol in 1986. Thiopentone sodium starts its action in 30 seconds, is more hypnotic and less analgesic and is anticonvulsive. It gives minor bronchospasm and hangover for 24 hrs. It is contraindicated in cardiovascular diseases serious hepatic and renal dysfunction, mysthenia gravis, neuro muscular diseases, myxoedema, adrenocortical insufficiency, extreme age and asthma.

Katamine hydrochloride is a potent analgesic and gives a slow induction. It is notorious for causing delirium, hallucination and nightmare even after 24 hours. It increases heart rate and blood pressure. It is more useful for war surgery, short cases, dressing, for children and more suitable for the underdeveloped countries as it does not need any special equipment. Midzolam starts its action in 90 seconds and its half life is 2 hours. Propofol is more expensive and its onset is slower than thiopentone sodium but recovery is quick. It does not cause hangover and relax skeletal muscles. It lower blood pressure and pulse rate and causes apnea and depresses cough. Other intravenous agents given for anaesthesia are opiates. But they are no good for induction and are given intravenously to potentiate the anaesthetic and analgesic effects of inhalation agent. Morphine was extracted from opium by Serteirner in 1805. Lately more potent and shot acting semi synthetic opiates like fentanyl, sufentanyl, alfentanyl and remifentanyl were introduced which are not available in Pakistan. Instead less potent tramadole and nalbuphan are used. All the drugs are used to supplement the inhalation anaesthesia but some time they are used for purely intravenous anaesthesia (I.V.A) by intermittened doses or continuous infusion or by computer called T.C.I (Target Controled Infusion).

Tracheal intubation started in late nineteenth century by Maceven Odevyer and Kuhn. Guedel introduced cuffed endotracheal tube at the turn of the nineteenth century for the artificial ventilation. Waters introduced Soda line to absorb the CO2 in the circuit J.S Lundy was the first person who explains the balance anaesthesia in 1926. He started inducing the patient with thiopenton sod, maintained it by N2O and O2 and I.V Morphea and relaxed by curare. The endotracheal intubation was also helped by relaxants. By relaxants less dose of narcotics was required.

There are two types of skeletal muscle relaxants:

  1. Depolarizing neuromuscular blocking agent: So many depolarizing neuromuscular blocking agents have been synthesized but only succinyl choline stood the test of time. It is effective within one minute lasts for 10-15 minutes. It is used normally for endotracheal intubation. It causes fasciculation, muscular pain, increased eye pressure and raised K level. It is contraindicated in neuromuscular disorders and malignant pyrexea and hyperkalaemia.
  2. Non-depolarizing neuromuscular blocking agents: The first agent was curare which was derived from the bark of South American tree. It was used by South American natives for hundred of years to poison their arrows head to paralyse their victims. Griffith and Johnson used in Canada first in 1942 for endotracheal intubation. Gray and Halton used it in U.K in 1946 for relaxation during anaesthesia. Its onset is slow and duration is long and lower the blood pressure.

Then other semi synthetic non depolarizing agents came in the market. Gallamine was the first but its onset was long and duration was short. It crosses placental barrier, tachycardia and is contraindicated in renal diseases; so it was gone into disfavors. So many other semi synthetic relaxants of this group came into market. Most of them are safer comparatively shorter period of onset and duration than curare. Their action including curare can be reversed by an anticholinestrase like neostagmine, pyridostagmine. They are  Alcuronium, Atracurium (atrilix, tracrium, acuran), cisatracurium, daxacurium, mivacurium, pancurium (pavilon), vecuronium (norcurium), pipecuronium, rocuronium (esmeron) and rapacuroniums. Some are cheaper others very expensive. Some have shorter time of onset and short duration, other take long period to start and fade away. Some have short period of onset and long duration others have longer period of onset and short duration. Those who have short period of onset are more suitable for intubation and those whose effect lasts for longer period is more suitable for long operations. Some are very safe for cardiovascular system but unsuitable for kidneys and liver diseases and even release histamine.

Story of local anaesthesia

Thousands of years ago in South America Inca priests used to open the skull. They used to chew coca plant leaves and went on spitting in the wound which gave the patient relief from local pain. In 1858 cocaine was synthesized from the leaves of coca plant by Albert Niemann. It was first used by an eye surgeon. Carl. Kohler (1857-1944). In 1892 Karl. Ludwig Schleich used its injection for local anaesthesia. W.S Halsted injected it around a nerve 1885 for nerve block. August Bier was first to give spinal analgesia and he used Cocaine. He was also first to used I/V local analgesia for regional anaesthesia in 1908.

            Cocaine gave C.N.S stimulation allergy and more than that addiction. So search for new local anesthetics carried outs to find out more potent, long acting and non toxic drugs. So many drugs were synthesized but procaine, cincochaine, lignocaine and bupivacaine became more popular. They were used for topical applications, local infiltration, nerves, intercostals, bracheal plexus blocks, intravenous local blocks (Bier), spinal and epidural anaesthesia. All have toxic effect when dose was increased or given directly in the vein or given in the vascular area like epidural space, bracheal plexus and intercostals area. Procaine was discovered in 1904 by Alfred Einhorn. But it was not so potent, had short duration and gave allergic reaction. It was mixed with adrenaline 1:200000 as advised by Heinrich Braun to prolong its action. One could increase the dose of the anaesthetics with adrenaline. It is contraindicated in cardiac cases, ring and regional blocks. Cathalin and Sicard introduced caudal block in 1901 and Fidal Pages epidural block in 1921.

Cincochaine was introduced two decade before Lidocaine and was very potent. It was used mainly for spinal anaesthesia for some time but was given up due to its toxic effects.

Lidocaine (lignocaine or xylocaine) was introduced in 1945 in Sweden. It is a safe drug moderately potent, used for topical application (2-4%), local infiltration, different blocks (05-1%), epidural block (1-2%) spinal anaesthesia 5% and local intravenous block. Its duration is 1-2 hours and dose is 2mg per kg.

Bupivacaine came in the market in 1963. It is more potent and duration of action is longer (4-6 hours) so less dose is needed. It is cardio toxic so it is given mainly for spinal anaesthesia in 0.5% and its dose 0.3mg per kg.

Beside drugs local anaesthesia can also be induced by freezing the area locally; the lesson we learnt in Neopolianic War in Russia when amputation of soldiers (almost frozen) was found painless. We used to freeze the skin by ethyl chloride spray for incision drainage of superficial abscesses. How ever its place in modern surgery is limited.

Local anaesthesia is cheap, does not need any special equipment, gives bloodless field, safe for heart, liver and kidney diseases. It is more useful in dental and eye surgery, for superficial minor operation but is not suitable for children and extensive injuries. As far as spinal and epidural anaesthesia is concerned I have my own reservations. Lot of volumes have been written in their favor, still I will say this anaesthesia is cruel and inhuman. It reminds me of pithing of the frogs which we used to do before dissection. It should only be used sparingly when there are absolute contra indication for general anaesthesia.

In conclusion I would say that anaesthesia is one of the greatest advancement in human medical sciences. Anaesthesists are real angle of mercy. They take away pain during operation but also after the operation. I am saying these words not as a surgeon or anesthetist (once) but also as a human who has undergone 8 operations in his life time like fistula in ano, stone kidney, nasal tumor, bilateral arthoplasty of knees (one at a time), coronary bypass and laminectomy of four lumbosacral vertebrae. All were done under general anaesthesia. Last operation was done at the age of 78 years which lasted for 6 hours. I think it was a great and pleasant experience. I never felt unbearable pain during and after operation.

Its progress attributed not only to the doctors who gave anaesthesia but more than that those scientists who discovered and synthesized its medicines. It started by open drop method by Schimmelbusch mask. Then simpler apparatus came into existence where air or oxygen was passed over ether or chloroform like one developed by John Snow and other E.M.O (Epstein Mackintosh Oxford) apparatus.

Snow (1858) also wrote first book on anaesthesia and was claimed to be the first full time anesthetist of the world. However Hoarace wrote the first proper text book of anaesthesia. Then came proper anesthetic machines and one of them was Boyles apparatus which was simple fitted with the bottles containing ether or trilene through which gas and oxygen was passed before delivery to the patient. Later on more potent and safe anaesthetic agents for inhalation and intravenous injections were discovered. Endotracheal tube even double lumen tubes and laryngeal masks replaced face masks. Safe muscle relaxants came in the market which made intubation easier and but also decreased the requirement of anaesthetic agents. So modern machines like Draeger and Datex Ohmeda were introduced which were not only fitted by gas, O2 special bottles of volatile anesthetic agents, but also by ventilator, close circuit apparatus with soda lime , cardiac monitors, pulse oxymeters and what not. Anaesthetist in OT has all the ressuscitative equipment and drugs as suggest by Clover in 1853. He monitors the patient closely as suggested by Hewitt in 1893 who also also wrote the proper text book of anaesthesia. Anesthetist is not only a physician in OT but also examines and assesses the patient before operation and visit him after the operation to find out any anesthetic complications.

In U.S.A by the turn of the century there was no special doctor for anaesthesia. It was given either by nurses or medical students or the most junior doctors. Anaesthesia started in mid nineteen century but was really established after world war ll. The chair of anaesthesia were created in U.S.A in 1904 and in U.K in 1937. The first diploma in anaesthesia (DA) started from London in 1935, and F.F.A in 1947 which was later on converted into F.R.C.A . In the end of nineteen century Lundy started a course of M.S in anaesthesia in U.S.A. Now anaesthesia has more specialized branches like Pediatrics, Cardiovascular obstetric and neuro anaesthesia.

We have reached to a point where most safe and effective drugs and state of art anesthetic machines are available. Now no patient should be declared unfit for the anaesthesia and surgery, anesthetist has to just choose the type anaesthesia given to the patient. All depends if the anesthetist has a will, devotion and courage. 

Anaesthesia in Pakistan

Chloroform vanished in first few years of Pakistan’s history. The most commonly used drugs and method was ether and spinal anaesthesia for operations till late seventies. Trilene was also commonly used. Halothane was introduce in late fifties and was popular till now. Initially open drop ether anaesthesia was used after induction by ethyl chloride and this method was still popular in the peripheral area till late sixties. Boyle’s anesthetic apparatus was used in the teaching and big hospitals but in periphery an indigenous apparatus was evolved. It was a small tin canister containing ether in it. Air even Oxygen was passed over it then it was delivered to a face mask or even endotracheal tube by a rubber tube. The patient was induced either by open drop ethyl chloride and ether or thiopentone and succinyl choline if endotracheal tube was used. It was spontaneous breathing anaesthesia. Later on cheap portable machines were available. Lately there has been a flood of second hand refurbished anaesthesia machines imported from Europe and America. So, almost every private and public hospital has got their own machines.

Initially open drop anaesthesia was given by the dispensers even by the ward boys, though spinal anaesthesia was given by the surgeon himself who usually had no qualifications in surgery. Teaching and big hospitals had the full time anesthetists.

King Edward Medical College Lahore started awarding two years D.A in 1960 which was more difficult than D.A from London, Copenhagen and Canada. Later on Nishtar Medical College Multan and other colleges also started awarding this diploma. College of physicians and surgeons of Pakistan started awarding F.C.P.S in anaesthesia in 1972. Some Pakistani universities include Punjab Univresity have also started awarding M.D and M.S in anaesthesia (to very few people). Credit goes to Prof Mehdi Hassan Mumtaz, a devoted anesthetist who started one year D.A course at Nishtar Medical College Multan who trained good number of anesthetists. The first qualified anesthetists and teachers in Pakistan, as I know of, were Dr Attar (my teacher) Dr Hussain Ahmed from Karachi and Dr Rustam Nabi from Lahore and Brig Saleem from army and first chair of anaesthesia was created at K.E.M.C Lahore in 1959.

As I said earlier no doctor wanted to become anesthetist due to inferiority complex that their job is surgeons dependant like nurses and paramedics. When I finished my one year house job in surgery in 1960, Civil Hospital Karachi administrator, during Ayub Martial Law, posted me as registrar anaesthesia as a punishment because I was too arrogant during my house job. It was my third year in anaesthesia in U.K and I was registrar with D.A from London. Still I had same complex so decided to switch over to surgery. I used to apply for the senior house officer in surgery but I was offered senior registrarship in anaesthesia. Eventually I manage to get a job in general surgery after serving in casualty and orthopedics. After 42 years my second son repeated the same scenario. He wasted 7 years in Philippines after his graduation. To compensate this delay I and my friend who was the principle of Punjab Medical College Faisalabad suggested him to take anaesthesia as a career. He got so much offended that he left for Australia and took a job in critical care medicine. But days have changed. There are so many qualified or unqualified surgeons, urologists, plastic pediatric, cardiovascular, thoracic, E.N.T, eye, neuro and gynecological surgeons in Pakistan. Each needs an anesthetist for the surgery. Now Pakistan public even in villages are well aware of their health. They demand for proper anaesthesia and anesthetist. So surgeons have become dependant on the anesthetists. Now anesthetist fixes the priority of the cases, chooses the time and anaesthesia for the patient and their fee. Modern anaesthesia machines like Draeger and Datex-Ohmeda (refurlished) are available in every hospital. All the potent new and safe drugs used for anaesthesia like Propofol, Ketamine, Isoflurane, Sevoflurane, Succinyl choline, Atracurium Vecuranium and Mivacurium are available. Oxygen and Nitrous oxide is available every where. Every anesthetist even unqualified one charges 1500 to 10,000 rupees ( ten thousand rupees) for each case even for spinal. Some of them earn more money and respect than the surgeons. It is high time that more doctors of Pakistan should take interest in this specialty. They have a great future not only in Pakistan but also abroad. In 1961 I got a job in U.K after only 9 months of experience in anaesthesia at Jinnah Hospital Karachi. These opportunities still exist in Europe, America and Australia for the anesthetist if they have proper qualifications and experience in this specialty.

Acknowledgement

I am grateful to our chief anaesthetist Dr. Waseem Channa and his wife Dr. Hina Fatima for their suggestions and help in writing this paper.

Further Reading

* Rathore A.H a short textbook of surgery, 2nd Ed, 1993, Ilmi Kitab khana Lahore
* Haeger, K, Illustrated History of Surgery, 1st Ed, 1990, Harold Starke, London.
* Bishop W.J, The early history of surgery 1st Ed, 1960, Hale, London
* Lee Alfred, A Synopses of anaesthesia 12 Ed, 1999, London
* Morgan G.E, Mikhail M.S, Murray M.J, Clinical anesthesiology. 5th Ed, 2013 Lange Medical Books London
* Aietkenhead A.R Rowbotham D.J Smith G. Text book of anaesthesia, 6th Ed, 2011 Churchill Livingston, London.

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