We resort to medical care, feeling that all is not well with your health. The most obvious and understandable sign of internal problems in the body is pain. And when we come to the doctor, we first of all wait to get rid of it. However, how often the doctor’s actions intended to help the patient, against his will, cause pain!
It’s painful to set a dislocation, it’s painful to stitch up a lacerated wound, it’s painful to treat a tooth... It happens that it is the fear of pain that prevents a person from seeing a doctor on time, and he stalls for time, triggering and aggravating the disease. Therefore, at all times, doctors have strived to conquer pain, learn to manage it and pacify it. But this goal was achieved relatively recently: just 200 years ago, almost any treatment was inseparable from suffering.
Achilles bandages Patroclus' wound inflicted by an arrow. Painting of a Greek kylix. V century BC e.
But even for a person unfamiliar with medical procedures, encountering pain is almost inevitable. Pain has accompanied humanity for as many millennia as it has inhabited the Earth. And probably already a dense healer from a primitive cave tribe tried to reduce or completely remove the painful sensations.
True, now the descriptions of the first " available funds"cause bewilderment and fear. For example, in Ancient Egypt, before performing a traditional circumcision surgery, the patient was rendered unconscious by squeezing his cervical blood vessels. Oxygen stopped flowing to the brain, the person fell into unconsciousness and felt virtually no pain, but such a barbaric method of pain relief could not be called safe. There is also information that sometimes patients were subjected to prolonged bloodletting so long that the bleeding person fell into a deep faint.
The first painkillers were prepared from plant materials. Decoctions and infusions of hemp, opium poppy, mandrake, henbane helped the patient relax and reduced pain. In those corners of the globe where the necessary plants did not grow, another painkiller was in use, and also of natural origin, ethyl alcohol, or ethanol. This fermentation product organic matter, obtained in the manufacture of all kinds of alcoholic beverages, affects the central nervous system, reducing the sensitivity of nerve endings and suppressing the transmission of nerve excitation.
The listed drugs were quite effective in emergency situations, but during serious surgical interventions they did not help; in this case, the pain was so severe that herbal decoctions and wine could not relieve it. In addition, long-term use of these painkillers led to a sad result: dependence on them. The father of medicine, the outstanding healer Hippocrates, when describing substances that cause temporary loss of sensitivity, used the term “drug” (Greek narkotikos “leading to numbness”).
Opium poppy flowers and heads.
Ebers Papyrus.
In the 1st century n. e. The ancient Roman physician and pharmacologist Dioscorides, describing the narcotic properties of an extract from mandrake root, first used the term “anesthesia” (Greek anaesthesia “without feeling”). Habituation, dependence side property consumption of modern painkillers, and this problem still remains relevant and acute for medicine.
Alchemists of the Middle Ages and the Renaissance presented humanity with many new chemical compounds and found various practical options for their use. So, in the 13th century. Raymond Lull discovered ether, a colorless volatile liquid, a derivative of ethyl alcohol. In the 16th century Paracelsus described the pain-relieving properties of ether.
It was with the help of ether that full-fledged general anesthesia, artificially induced complete loss of consciousness, was first carried out. But this happened only in the 19th century. Before that, the inability to effectively anesthetize the patient greatly hampered the development of surgery. After all, a serious operation cannot be performed if the patient is conscious. So necessary to save lives surgical interventions as amputation of a gangrenous limb or removal of a tumor abdominal cavity, may cause traumatic shock and lead to the death of the patient.
It turned out vicious circle: the doctor must help the patient, but his help is deadly... The surgeons were intensely looking for a way out. In the 17th century Italian surgeon and anatomist Marco Aurelio Severino proposed performing local anesthesia by cooling, for example, shortly before surgery, rubbing the surface of the body with snow. Two centuries later, in 1807, Dominique Jean Larrey, a French military doctor and chief surgeon of Napoleon's army, would amputate soldiers' limbs on the battlefield in subzero temperatures.
In 1799, the English chemist Humphry Davy discovered and described the effect of nitrous oxide, or “laughing gas.” He tested the pain-relieving effect of this chemical compound at the moment when his wisdom teeth were cutting. Davy wrote: “The pain completely disappeared after the first four or five inhalations, and the unpleasant sensations were replaced for a few minutes by a feeling of pleasure...”
A. Brouwer. Touch. 1635
Marco Aurelio Severino. Engraving 1653
Davy's research later attracted the interest of his compatriot, surgeon Henry Hickman. He conducted many experiments on animals and became convinced that nitrous oxide, used in the right concentration, suppresses pain and can be used for surgical operations. But Hickman was not supported by either his compatriots or his French colleagues, and he was unable to obtain official permission to test the effects of nitrous oxide on humans either in England or France. The only one who supported him and was even ready to provide himself for experiments was the same surgeon Larrey.
But a start had been made: the very idea of using nitrous oxide in surgery was expressed. In 1844, the American dentist Horace Wells attended a circus-like performance that was popular at the time: a public demonstration of the effects of laughing gas. One of the voluntary test subjects severely injured his leg during the demonstration, but upon coming to his senses, he assured that he did not feel any pain. Wells suggested that nitrous oxide could be used in dentistry. New drug He first experienced it on himself, and radically: another dentist removed his tooth. Convinced that laughing gas was suitable for use in dental practice, Wells tried to attract general attention to the new remedy and staged a public operation using nitrous oxide. But the operation ended in failure: the volatile gas “leaked” into the audience, the patient experienced unpleasant sensations, but the audience who inhaled the gas had a lot of fun.
T. Phillips. Portrait of Sir Humphry Davy.
A. L. Girodet-Triozon. Portrait of Dominique Jean Larrey. 1804
On October 16, 1846, the first widespread known operation performed using ether anesthesia. Dr. William Thomas Green Morton euthanized the patient using diethyl ether, and surgeon John Warren then removed the patient's submandibular tumor.
Dr. Morton, the first anesthesiologist in official history medicine, practiced as a dentist until 1846. He often had to remove the roots of patients' teeth, which each time caused them severe pain Naturally, Morton wondered how to alleviate this pain or avoid it altogether. At the suggestion of the physician and scientist Charles Jackson, Morton decided to try ether as an anesthetic. He experimented on animals, on himself, and successfully; All that remained was to wait for the patient to agree to anesthesia. On September 30, 1846, such a patient appeared: E. Frost, suffering from severe toothache, was ready to do anything to get rid of the pain, and Morton, in the presence of several witnesses, performed an operation on him using ether anesthesia. Frost, having regained consciousness, stated that during the operation he did not experience any discomfort. This indisputable success of the doctor for the general public, alas, went unnoticed, and therefore Morton ventured into another demonstration of his discovery, which took place on October 16, 1846.
Dr. Morton's first anesthesia.
Morton and Jackson received a patent for their invention, and thus began the triumphant and life-saving march of anesthesia throughout the world. On the monument erected in Boston to Dr. William Thomas Greene Morton, the words are inscribed: “Inventor and discoverer of anesthesia, who averted and destroyed pain, before whom surgery was always a torture, after which science controls pain.”
Doctors around the world greeted Morton's discovery with joy and enthusiasm. In Russia, the first operation using ether anesthesia was performed just six months after the demonstration in Boston. It was performed by the outstanding surgeon Fyodor Ivanovich Inozemtsev. Immediately after him, the great Nikolai Ivanovich Pirogov began to widely use ether anesthesia. Summarizing the results of his surgical activities during the Crimean War, he wrote: “We hope that from now on the etheric device will be, just like a surgical knife, necessary accessory every doctor..." Pirogov was the first to use chloroform anesthesia, which was discovered back in 1831.
But the faster anesthesiology developed, the more clearly surgeons began to understand negative sides anesthesia with ether and chloroform. These substances were very toxic and often caused general poisoning body and complications. In addition, mask anesthesia, in which the patient inhales ether or chloroform through a mask, is not always possible (for example, in patients with impaired respiratory function). There were ahead long years searches, anesthesia with barbiturates, steroids, widespread introduction of intravenous anesthesia. However, everyone the new kind anesthesia, for all its apparent initial perfection, is not without its shortcomings and side effects and therefore requires constant monitoring by a specialist anesthesiologist. The anesthesiologist in any operating room is as important a character as the operating surgeon.
At the end of the 20th century. Russian scientists have developed a method for using xenon anesthesia. Xenon is a non-toxic gas, which makes it an extremely suitable means for general anesthesia. There are new developments and new discoveries ahead, new victories over man’s eternal companion, pain.
In the first year after the successful operations of Inozemtsev and Pirogov, 690 surgical interventions were performed under anesthesia in Russia. And three hundred of them are on the account of Nikolai Ivanovich Pirogov.
I. Repin. Portrait of N. I. Pirogov. 1881
Pain relief with natural intoxicants plant origin(mandrake, belladonna, opium, Indian hemp, some varieties of cacti, etc.) have long been used in ancient world(Egypt, India, China, Greece, Rome, among the natives of America).
With the development of iatrochemistry (XIV-XVI centuries), information began to accumulate about the analgesic effect of certain chemical substances obtained as a result of experiments. However for a long time Random observations by scientists of their soporific or analgesic effect are not related. .were aware of the possibility of using these substances in surgery. Thus, the discovery of the intoxicating effect of nitrous oxide (or “laughing gas”), which was made by the English chemist and physicist Humphry Davy (N. Davy) in 1800, as well as the first work on the soporific effect of sulfuric ether, published by him, remained without due attention. student Michael Faraday (M. Faraday) in 1818
The first doctor who drew attention to the analgesic effect of nitrous oxide was the American dentist Horace Wells (Wells, Horace, 1815-1848). In 1844, he asked his colleague John Riggs to remove his tooth under the influence of this gas. The operation was successful, but its repeated official demonstration in the clinic of the famous Boston surgeon John Warren (Warren, John Collins, 1778-1856) failed, and nitrous oxide was forgotten for a while.
The era of anesthesia began with ether. The first experience with its use during operations was made by the American physician C. Long (Long, Crawford, 1815-1878), on March 30, 1842, but his work went unnoticed, since Long did not report his discovery in print, and it was repeated again.
In 1846, the American dentist William Morton (Morton, William, 1819-1868), who had experienced the soporific and analgesic effects of ether vapor, suggested that J. Warren test this time the effect of ether during surgery. Warren agreed and on October 16, 1846, for the first time successfully removed a tumor in the neck area under ether anesthesia, which was given by Morton. It should be noted here that W. Morton received information about the effect of ether on the body from his teacher, the chemist and physician Charles Jackson (Jackson, Charles, 1805-1880), who should rightfully share the priority of this discovery. Russia was one of the first countries where ether anesthesia found the widest use. The first operations in Russia under ether anesthesia were performed in Riga (B.F. Behrens, January 1847) and Moscow (F.I. Inozemtsev, February 7, 1847). An experimental test of the effect of ether on animals (in Moscow) was led by physiologist A. M. Filomafitsky.
Scientific background the use of ether anesthesia was given by N.I. Pirogov. He carried out extensive experiments on animals. experimental study properties of the ether using various methods of administration (inhalation, intravascular, rectalBom, etc.) with subsequent clinical testing of individual methods (including on yourself). On February 14, 1847, he performed his first operation under ether anesthesia, removing a breast tumor in 2.5 minutes.
In the summer of 1847, N.I. Pirogov was the first in the world to use ether anesthesia en masse at the theater of military operations in Dagestan (during the siege of the village of Salta). The results of this grandiose experiment amazed Pirogov: for the first time, operations took place without the groans and screams of the wounded. “The possibility of broadcasting on the battlefield has been indisputably proven,” he wrote in “Report on a trip to the Caucasus.” “...The most comforting result of the broadcast was that the operations we performed in the presence of other wounded did not frighten them at all, but, on the contrary, reassured them about their own fate.”
This is how anesthesiology arose (Latin anaesthesia from Greek anaisthesia - insensitivity), the rapid development of which was associated with the introduction of new painkillers and methods of their administration. Thus, in 1847, the Scottish obstetrician and surgeon James Simpson (Simpson, James Young sir, 1811-1870) first used chloroform “as an anesthetic in obstetrics and surgery. In 1904, S.P. Fedorov and N.P. Kravkov laid the foundation for the development of methods of non-inhalation (intravenous) anesthesia.
With the discovery of anesthesia and the development of its methods, a new era in surgery began.
N. I. Pirogov - the founder of Russian military field surgery
Russia is not the birthplace of military field surgery - just remember the ambulance volante of Dominique Larrey (see p. 289), the founder of French military field surgery, and his work “Memoirs of military field surgery and military campaigns” (1812-1817 ). However, no one has done as much for the development of this science as N.I. Pirogov, the founder of military field surgery in Russia.
In the scientific and practical activities of N. I. Pirogov, many things were accomplished for the first time: from the creation of entire sciences (topographic anatomy and military field surgery), the first operation under rectal anesthesia (1847) to the first plaster cast in field conditions(1854) and the first idea about bone grafting (1854).
In Sevastopol, during the Crimean War of 1853-1856, when the wounded arrived at the dressing station in the hundreds, he was the first to justify and put into practice the sorting of the wounded into four groups. The first category consisted of the hopelessly sick and mortally wounded. They were entrusted to the care of nurses and a priest. The second category included the seriously wounded, requiring urgent surgery, which was performed right at the dressing station in the House of the Noble Assembly. Sometimes they operated on three tables at the same time, 80-100 each patients per day. The third troupe included the wounded moderate severity who could be operated on the next day. The fourth group consisted of the lightly wounded. After rendering necessary assistance they were sent back to the unit.
Postoperative patients were first divided into two groups: clean and purulent. Patients of the second group were placed in special gangrenous departments - “memento mori” (Latin - remember “death”), as Pirogov called them.
Assessing the war as a “traumatic epidemic,” N. I. Pirogov was convinced that “it is not medicine, but the administration that plays the main role in helping the wounded and sick at the theater of war.” And he fought with all his passion against the “stupidity of the official medical staff”, “the insatiable predation of the hospital administration” and tried with all his might to establish a clear organization medical care wounded, which under tsarism could only be done through the enthusiasm of the possessed. These were the sisters of mercy.
The name of N.I. Pirogov is associated with the world’s first involvement of women in caring for the wounded at the theater of military operations. Especially for these purposes, in St. Petersburg in 1854, the “Establishment of the Cross-women’s community of sisters caring for wounded and sick soldiers” was founded.
N.I. Pirogov with a detachment of doctors left for Crimea" in October 1854. Following him, the first detachment "of 28 nurses was sent. In Sevastopol, N.I. Pirogov immediately divided them into three groups: dressing nurses, who helped doctors during operations and with dressings; sisters-pharmacists, who prepared, stored, distributed and distributed medicines, and sisters-housewives, who monitored the cleanliness and change of linen, maintenance of the sick and housekeeping services. Later, a fourth, special transport detachment of sisters appeared, who accompanied the wounded during long-distance transport Many sisters died from typhoid fever, some were wounded or shell-shocked, but all of them, “enduring without complaint all the labors and dangers and unselfishly sacrificing themselves to achieve the goal undertaken... served for the benefit of the wounded and sick.”
N.I. Pirogov especially highly valued Ekaterina Mikhailovna Bakunina (1812-1894) - “the ideal type of nurse,” who worked in the operating room along with surgeons and was the last to leave the hospital when evacuating the wounded, being on duty day and night.
“I am proud to have led their blessed one. activities,” wrote N. I. Pirogov in 1855.
The history of the Russian Red Cross Society, which was created in St. Petersburg in 1867 (the original name was “Russian Society for the Care of Wounded and Sick Warriors”), dates back to the sisters of mercy of the Holy Cross community. Nowadays, the Union of Red Cross and Red Crescent Societies plays an important role in the development of domestic healthcare and the activities of the International Red Cross, founded by A. Dunant (Dunant, Henry, 1828-1910) (Switzerland) in 1864 (see p. 341) .
A year after the Crimean War, N.I. Pirogov was forced to leave his service at the academy and retired from teaching surgery and anatomy (he was then 46 years old).
A. A. Herzen called the resignation of N. I. Pirogov “one of the most vile deeds of Alexander... dismissing a person of whom Russia is proud” (“Bell”, 1862, No. 188).
“I have some right to gratitude to Russia, if not now, then perhaps someday later, when my bones are rotting in the ground, there will be impartial people who, having looked at my labors, will understand that I worked not without a purpose and not without inner dignity,” Nikolai Ivanovich wrote then.
Having high hopes for improvement public education, he accepted the post of trustee of the Odessa, and from 1858, the Kyiv educational district, but a few years later he was again forced to resign. In 1866, he finally settled in the village of Vishnya near the city of Vinnitsa (now the Museum-Estate of N.I. Pirogov, Fig. 147).
Nikolai Ivanovich constantly provided medical assistance to the local population and numerous people. patients who came to him in the village of Vishnya from different cities and villages of Russia. To receive visitors, he set up a small hospital, where he operated and bandaged almost every day.
To prepare medicines, a small one-story house - a pharmacy - was built on the estate. He himself was engaged in growing plants necessary for the preparation of medicines. Many medicines were dispensed free of charge: pro pauper (Latin - for the poor) was listed on the prescription.
As always, N.I. Pirogov attached great importance hygienic measures and dissemination of hygienic knowledge among the population. “I believe in hygiene,” he asserted. “This is where the true progress of our science lies. The future belongs to preventive medicine. This science, going hand in hand with state science, will bring undoubted benefit to humanity.” He saw a close connection between the eradication of disease and the fight against hunger, poverty and ignorance.
N.I. Pirogov lived on his estate in the village of Vishnya for almost 15 years. He worked a lot and rarely traveled (in 1870 to the theater of the Franco-Prussian War and in 1877-1878 to the Balkan Front). The result of these trips was his work “Report on a visit to military medical institutions in Germany, Lorraine, etc. Alsace in 1870" and a work on military field surgery "Military medicine and private assistance at the theater of war in Bulgaria and in the rear of the army in 1877-1878." In these works, as well as in his major work “The Beginnings of General Military Field Surgery, Taken from Observations of Military Hospital Practice and Memoirs of Crimean War and the Caucasian Expedition" (1865-1866) N. I. Pirogov laid the foundations of organizational tactical and methodological principles military medicine.
N. I. Pirogov’s last work was the unfinished “Diary of an Old Doctor.”
Information about the use of anesthesia during operations goes back to ancient times. There is written evidence of the use of painkillers as early as the 15th century BC. Tinctures of mandrake, belladonna, and opium were used. To achieve an analgesic effect, they resorted to mechanical compression of the nerve trunks and local cooling with ice and snow. In order to turn off consciousness, the vessels of the neck were compressed. However, the listed methods did not allow achieving the proper analgesic effect and were very dangerous for the patient’s life. Real prerequisites for the development of effective methods of pain relief began to take shape at the end of the 18th century, especially after the production of pure oxygen (Priestley and Scheele, 1771) and nitrous oxide (Priestley, 1772), as well as a thorough study of the physicochemical properties of diethyl ether (Faraday, 1818).
It is rightly believed that scientifically based pain relief came to us in the middle of the 19th century. May 30, 1842 Long first used ether anesthesia during an operation to remove a tumor from the back of the head. However, this became known only in 1852. The first public demonstration of ether anesthesia was made October 16, 1846. On this day in Boston, Harvard University professor John Warren removed a tumor in the submandibular region of the sick Gilbert Abbott under ether sedation. The patient was narcotized by dentist William Morton. The date October 16, 1846 is considered the birthday of modern anesthesiology.
With extraordinary speed, news of the discovery of pain relief spread throughout the world. In England December 19, 1846 under ether anesthesia Liston operated, soon Simpson and Snow began to use anesthesia. With the advent of ether, all other means of pain relief, used for centuries, were abandoned.
In 1847 as narcotic substance Englishman James Simpson first used chloroform, etc. When using chloroform, anesthesia occurs much faster than when using ether; it quickly gained popularity among surgeons and replaced ether for a long time. John Snow first used chloroform to anesthetize labor for Queen Victoria of England when she gave birth to her eighth child. The church opposed chloroform and ether anesthesia in obstetrics. In search of arguments, Simpson declared God to be the first drug addict, pointing out that during the creation of Eve from the rib of Adam, God put the latter to sleep. Subsequently, however, the significant incidence of complications due to toxicity gradually led to the abandonment of chloroform anesthesia.
In the mid-40s of the 19th century widespread clinical experimenting with nitrous oxide, whose analgesic effect was discovered Davy in 1798year. In January 1845, Wells publicly demonstrated nitrous oxide anesthesia. during tooth extraction, but unsuccessfully: adequate anesthesia was not achieved. In retrospect, the reason for the failure can be recognized as the very property of nitrous oxide: for a sufficient depth of anesthesia, it requires extremely high concentrations in the inhaled mixture, which lead to asphyxia. The solution was found in 1868 Andrews:he began to combine nitrous oxide with oxygen.
The experience of using narcotic substances through the respiratory tract had a number of disadvantages such as suffocation and agitation. This forced us to look for other routes of administration. In June 1847 Pirogov applied rectal anesthesia with ether during childbirth.He tried to administer ether intravenously, but it turned out to be a very dangerous type of anesthesia.In 1902pharmacologist N.P. Kravkov suggested for intravenous anesthesia hedonol,first applied in clinic in 1909 S.P. Fedorov (Russian anesthesia).In 1913, barbiturates were used for anesthesia for the first time., and barbituric anesthesia has been widely used since 1932 with the inclusion of hexenal in the clinical arsenal.
During the Great Patriotic War, intravenous alcohol anesthesia became widespread, but in post-war years it was abandoned due to the complex administration technique and frequent complications.
A new era in anesthesiology was opened by the use of natural drugs curare and their synthetic analogues, which relax skeletal muscles. In 1942, Canadian anesthesiologist Griffith and his assistant Johnson first used muscle relaxants in the clinic. New drugs have made anesthesia more advanced, manageable and safe. The emerging problem of artificial lung ventilation (ALV) was successfully solved, and this in turn expanded the horizons operative surgery: led to the creation, in essence, of pulmonary and cardiac surgery and transplantology.
The next stage in the development of pain management was the creation of a heart-lung machine, which made it possible to operate on a “dry” open heart.
Elimination of pain during major operations turned out to be insufficient to preserve the vital functions of the body. Anesthesiology was tasked with creating conditions for normalizing impaired respiratory functions, the cardiovascular system, and metabolism. In 1949, the French Laborie and Utepar introduced the concept of hibernation and hypothermia.
Although not widely used, they played a big role in the development concepts of potentiated anesthesia(term introduced by Laborie in 1951). Potentiation is a combination of various non-narcotic drugs (neuroleptics, tranquilizers) with general anesthetics to achieve adequate pain relief at small doses of the latter, and served as the basis for the use of a new promising method of general anesthesia - neuroleptanalgesia(combination of a neuroleptic and a narcotic analgesic), proposed by de Castries and Mundeler in 1959.
As can be seen from the historical background, although anesthesiology has been carried out since ancient times, real recognition as a scientifically based medical discipline came only in the 30s. XX century. In the USA, the Council of Anesthesiologists was created in 1937. In 1935, an exam in anesthesiology was introduced in England.
In the 50s For most surgeons in the USSR, it became obvious that the safety of surgical interventions largely depended on their anesthetic support. This was a very important factor that stimulated the formation and development of domestic anesthesiology. The question arose about the official recognition of anesthesiology as a clinical discipline, and an anesthesiologist as a specialist in a special profile.
In the USSR, this issue was specifically discussed for the first time in 1952 at the V Plenum of the Board of the All-Union Scientific Society of Surgeons. As was said in the closing remarks: “We are present at the birth of a new science, and it is time to recognize that there is another branch that has developed from surgery.”
Since 1957, the training of anesthesiologists began in clinics in Moscow, Leningrad, Kyiv, and Minsk. Departments of anesthesiology are being opened at the Military Medical Academy and institutes for advanced training of doctors. Scientists such as Kupriyanov, Bakulev, Zhorov, Meshalkin, Petrovsky, Grigoriev, Anichkov, Darbinyan, Bunyatyan and many others made a great contribution to the development of Soviet anesthesiology. The rapid progress of anesthesiology at the early stage of its development, in addition to the increasing demands on it from surgery, was facilitated by the achievements of physiology, pathological physiology, pharmacology and biochemistry. The knowledge accumulated in these areas has proven to be very important in solving problems of ensuring patient safety during operations. The expansion of capabilities in the field of anesthesiological support for operations was largely facilitated by the rapid growth of the arsenal of pharmacological agents. In particular, new for that time were: fluorotane (1956), Viadril (1955), drugs for NLA (1959), methoxyflurane (1959), sodium hydroxybutyrate (1960), propanidide (1964 g.), ketamine (1965), etomidate (1970).
Preparing the patient for anesthesia
Preoperative period– this is the period from the moment the patient is admitted to the hospital until the start of the operation.
Particular attention should be paid to preparing patients for anesthesia. It begins with personal contact between the anesthesiologist and the patient. First, the anesthesiologist should familiarize himself with the medical history and clarify the indications for the operation, and he should find out all the questions that interest him personally.
During planned operations, the anesthesiologist begins examining and getting to know the patient several days before the operation. In cases of emergency interventions, the examination is carried out immediately before the operation.
The anesthesiologist is obliged to know the patient’s occupation and whether his work is related to hazardous production (nuclear energy, chemical industry, etc.). The patient’s life history is of great importance: previous diseases (diabetes mellitus, ischemic disease heart disease and previous myocardial infarction, hypertension), as well as regularly taken medications (glucocorticoid hormones, insulin, antihypertensive drugs). Particular attention should be paid to the tolerability of medications (allergy history).
The doctor performing anesthesia must be well aware of the state of the cardiovascular system, lungs, and liver. Mandatory methods of examining the patient before surgery include: general analysis blood and urine biochemical analysis blood, blood clotting (coagulogram). The blood type and Rh affiliation of the patient must be determined. Electrocardiography is also performed. The use of inhalation anesthesia requires attention Special attention study of the functional state of the respiratory system: spirography is performed, Stange tests are determined: the time for which the patient can hold his breath while inhaling and exhaling. In the preoperative period during planned operations, it is necessary, if possible, to correct existing disturbances of homeostasis. In emergency cases, preparation is carried out to a limited extent, which is dictated by the urgency of the surgical intervention.
A person who is about to have an operation is naturally worried, so a sympathetic attitude towards him and an explanation of the need for the operation is necessary. Such a conversation can be more effective than the effects of sedatives. However, not all anesthesiologists can communicate equally convincingly with patients. The state of anxiety in a patient before surgery is accompanied by the release of adrenaline from the adrenal medulla, an increase in metabolism, which makes it difficult to administer anesthesia and increases the risk of developing cardiac arrhythmias. Therefore, all patients are prescribed premedication before surgery. It is carried out taking into account the characteristics of the patient’s psycho-emotional state, his reaction to the disease and the upcoming operation, the characteristics of the operation itself, and its duration, as well as age, constitution and life history.
On the day of surgery, the patient is not fed. Before surgery, you should empty your stomach, intestines, and bladder. In emergency cases, this is done using gastric tube, urinary catheter. In emergency cases, the anesthesiologist must personally (or another person under his direct supervision) empty the patient's stomach using a thick tube. Failure to carry out this measure in the event of the development of such a severe complication as regurgitation of gastric contents with subsequent aspiration into the Airways, which has fatal consequences, is legally regarded as a manifestation of negligence in the performance of the doctor’s duties. A relative contraindication for tube insertion is recent surgery on the esophagus or stomach. If the patient has dentures, they must be removed.
All preoperative preparation activities are aimed mainly at
reduce the risk of surgery and anesthesia, facilitating adequate tolerance of surgical trauma;
reduce the likelihood of possible intra- and postoperative complications and thereby ensure a favorable outcome of the operation;
speed up the healing process.
2 years after the failure that befell Wells, his student dentist Morton, with the participation of the chemist Jackson, used diethyl ether for anesthesia. Soon the desired result was achieved.
In the same surgical clinic Boston, where Wells' discovery was not recognized. On October 16, 1846, ether anesthesia was successfully demonstrated. This date became the starting point in the history of general anesthesia.
Professor John Warren operated on the patient in a Boston surgical clinic, and medical student William Morton euthanized the patient using his own method.
When the patient was placed on the operating table, William Morton covered his face with a towel folded in several layers and began to sprinkle liquid from a bottle he had brought with him. The patient shuddered and began to mutter something, but soon calmed down and fell into a deep sleep.
John Warren began the operation. The first cut is made. The patient lies quietly. The second one was made, and then the third one. The patient is still fast asleep. The operation was quite complicated - a tumor in the patient’s neck was removed. A few minutes after it ended, the patient came to his senses.
They say it was at this moment that John Warren uttered his historic phrase: “Gentlemen, this is not a hoax!”
Subsequently, Morton himself told the story of his discovery as follows: “I purchased Barnett’s ether, took a bottle with a tube, locked myself in the room, sat down in the operating chair and began to inhale the vapors. The ether turned out to be so strong that I almost suffocated, but the desired effect was not came. Then I wet a handkerchief and brought it to my nose. I looked at my watch and soon lost consciousness. When I woke up, I felt as if I was in a fairy-tale world. All parts of my body seemed numb. I would have renounced the world if anyone had come to this minute and woke me up. next moment I believed that, apparently, I would die in this state, and the world would greet the news of this stupidity of mine only with ironic sympathy. Finally, I felt a slight tickling in the phalanx of the third finger, after which I tried to touch it thumb, But could not. On the second attempt I managed to do it, but the finger seemed completely numb. Little by little I was able to raise my hand and pinch my leg, and found that I hardly felt it. Trying to get up from the chair, I fell back on it. Only gradually did I gain control over parts of my body, and with it full consciousness. I immediately looked at my watch and found that I had been insensible for seven or eight minutes. After that, I rushed to my office shouting: “I found it! I found it!”
Anesthesiology, especially during its development, had many opponents. For example, the clergy were especially vehemently opposed to pain relief during childbirth. By biblical legend, expelling Eve from paradise, God commanded her to give birth to children in pain. When obstetrician J. Simpson in 1848 successfully used anesthesia to relieve labor pain in Queen of England Victoria, this caused a sensation and further intensified the attacks of the clergy. Even the famous French physiologist F. Magendie, Claude Bernard's teacher, considered anesthesia "immoral and takes away self-awareness and free will from patients and thereby subjugates the patient to the arbitrariness of doctors." In a dispute with the clergy, Simpson found a witty way out: he declared that the very idea of anesthesia belonged to God. After all, according to the same biblical tradition, God put Adam to sleep in order to cut out his rib from which he created Eve. The scientist's arguments somewhat calmed the fervor of the fanatics.
The discovery of anesthesia, which turned out to be very effective method surgical anesthesia has aroused widespread interest among surgeons around the world. Skepticism about the possibility of painless surgical interventions quickly disappeared. Soon anesthesia received universal recognition and was appreciated.
In our country, the first operation under ether anesthesia was performed on February 7, 1847 by Moscow University professor F.I. Inozemtsev. A week after this, the method was used equally successfully by N.I. Pirogov in St. Petersburg. Then a number of other major domestic surgeons began to use anesthesia.
Much work on study and propaganda in our country was carried out by the anesthesia committees created shortly after its opening. The most representative and influential among them was the Moscow one, which was headed by Prof. A.M. Philamothite. The result of the generalization of the first experience of using ether anesthesia in the clinic and in experiment were two monographs published in 1847. The author of one of them (“Practical and physiological studies on etherization”) was N.I. Pyrrgov. The book was published on French counting not only on domestic, but also Western European readers. The second monograph (“On the use of sulfuric ether vapor in surgical medicine”) was written by N.V. Maklakov.
Having perceived ether anesthesia as a great discovery in medicine, leading Russian surgeons not only did everything possible to widely use it in practice, but also sought to penetrate into the essence of this seemingly mysterious condition and to find out the possible adverse effects of ether vapor on the body.
The greatest contribution to the study of ether anesthesia at the stage of its development and later when chloroform anesthesia was introduced into practice was made by N.I. Pirogov. In this regard, V. Robinson, the author of one of the most informative books on the history of surgical anesthesia in 1945, wrote: “Many of the pioneers of pain management were mediocre. As a result of accidental circumstances, they had a hand in this discovery. Their quarrels and petty envy left an unpleasant mark on science. But there are figures of a larger scale who participated in this discovery, and among them the most important person and researcher should be considered, first of all, N.I. Pirogov."
About how purposefully and fruitfully N.I. worked. Pirogov in the area under consideration is evidenced by the fact that a year after the discovery of anesthesia, in addition to the mentioned monograph, he published: the articles “Observation of the effect of ether vapor as an analgesic in surgical operations” and “Practical and physiological observations of the effect of ether vapor on animals organism." In addition, in the “Report on a trip to the Caucasus”, also written in 1847, there is a large and interesting section"Anesthesia on the battlefield and in hospitals.
After the first use in patients with H.I. Pirogov gave the following assessment of ether anesthesia: “Ether steam is a truly great remedy, which in a certain respect can give a completely new direction to the development of all surgery.” Giving this description of the method, he was one of the first to attract the attention of surgeons to other complications that can arise during anesthesia. N.I. Pirogov undertook special study in order to find a more effective and safe method anesthesia In particular, he tested the effect of ether vapor when injected directly into the trachea, blood, gastrointestinal tract. The method of rectal anesthesia with ether that he proposed received wide recognition in subsequent years, and many surgeons successfully used it in practice.
In 1847 Simpson as narcotic drug successfully tested chloroform. The interest of surgeons in the latter quickly increased, and chloroform became the main anesthetic for many years, pushing diethyl ether to second place.
In the study of ether and chloroform anesthesia, the introduction of these drugs into widespread practice in the first decades after their development, in addition to N.I. Pirogov, many surgeons of our country made a significant contribution. A.M. was especially active in this area. Filamofitsky, F.I. Inozemtseva, A.I. Polya, T.L. Vanzetti, V.A. Karavaeva.
From foreign doctors to study, improve and promote anesthesia methods in the second half of the 19th century. D. Snow did a lot. He was the first who, after the discovery of anesthesia, devoted his entire activity to surgical anesthesia. He consistently defended the need for specialization of this type of medical care. His works contributed to the further improvement of anesthesiological support for operations.
After the discovery of the narcotic properties of diethyl ether and chloroform, an active search began for other drugs that have an analgesic effect. In 1863, the attention of surgeons was again drawn to nitrous oxide. Colton, whose experiments at one time gave Wells the idea of using nitrous oxide for pain relief, organized an association of dentists in London who used this gas in dental practice.
Surgery and pain have always gone side by side since the first steps in the development of medicine. According to the famous surgeon A. Velpo, it was impossible to perform a surgical operation without pain; general anesthesia was considered impossible. In the Middle Ages, the Catholic Church completely rejected the very idea of eliminating pain, passing it off as a punishment sent by God to atone for sins. Until the mid-19th century, surgeons could not cope with pain during surgery, which significantly hampered the development of surgery. In the middle and end of the 19th century, a number of turning points occurred that contributed to the rapid development of anesthesiology - the science of pain management.
Emergence of anesthesiology
Discovery of the intoxicating effects of gases
In 1800, Devi discovered the peculiar effect of nitrous oxide, calling it “laughing gas.”
In 1818, Faraday discovered the intoxicating and desensitizing effects of diethyl ether. Devy and Faraday suggested the possibility of using these gases for pain relief during surgical operations.
First operation under anesthesia
In 1844, dentist G. Wells used nitrous oxide for pain relief, and he himself was the patient during tooth extraction (removal). Later, one of the pioneers of anesthesiology suffered a tragic fate. During public anesthesia with nitrous oxide, carried out in Boston by H. Wells, the patient almost died during the operation. Wells was ridiculed by his colleagues and soon committed suicide at the age of 33.
It should be noted that the very first operation under anesthesia (ether) was performed by the American surgeon Long back in 1842, but he did not report his work to the medical community.
Date of birth of anesthesiology
In 1846, the American chemist Jackson and dentist Morton showed that inhaling diethyl ether vapors turns off consciousness and leads to loss of pain sensitivity, and they proposed using diethyl ether for dental extraction.
On October 16, 1846, in a Boston hospital, 20-year-old Gilbert Abbott, a patient at Harvard University, had a tumor of the submandibular region removed under anesthesia (!) by Harvard University professor John Warren. Dentist William Morton narcotized a patient with diethyl ether. This day is considered the birth date of modern anesthesiology, and October 16 is celebrated annually as anesthesiologist's day.
The first anesthesia in Russia
On February 7, 1847, the first operation in Russia under ether anesthesia was performed by Moscow University professor F.I. Inozemtsev. A.M. also played a major role in the development of anesthesiology in Russia. Filomafitsky and N.I. Pirogov.
N.I. Pirogov used anesthesia on the battlefield, studied various ways injection of diethyl ether (into the trachea, blood, gastrointestinal tract), became the author of rectal anesthesia. He said: “Ethereal steam is a truly great remedy, which in a certain respect can give a completely new direction to the development of all surgery” (1847).
Development of anesthesia
Introduction of new substances for inhalation anesthesia
In 1847, Edinburgh University professor J. Simpson used chloroform anesthesia.
In 1895, chlorethyl anesthesia began to be used. In 1922, ethylene and acetylene appeared.
In 1934, cyclopropane was used for anesthesia, and Waters proposed including a carbon dioxide absorber (sodium lime) in the breathing circuit of the anesthesia machine.
In 1956, halothane entered anesthesiological practice, and in 1959, methoxyflurane.
Currently, halothane, isoflurane, and enflurane are widely used for inhalation anesthesia.
Discovery of drugs for intravenous anesthesia
In 1902 V.K. Kravkov was the first to use intravenous anesthesia with hedonal. In 1926, hedonal was replaced by avertin.
In 1927, pernoctone, the first barbituric drug, was used for intravenous anesthesia for the first time.
In 1934, sodium thiopental was discovered, a barbiturate that is still widely used in anesthesiology.
Sodium oxybate and ketamine were introduced in the 1960s and are still used today.
IN last years A large number of new drugs for intravenous anesthesia (methohexital, propofol) have appeared.
The occurrence of endotracheal anesthesia
An important achievement in anesthesiology was the use of artificial respiration, for which the main merit belongs to R. Mackintosh. He also became the organizer of the first department of anesthesiology at Oxford University in 1937. During operations, curare-like substances began to be used to relax muscles, which is associated with the name of G. Griffiths (1942).
The creation of devices for artificial lung ventilation (ALV) and the introduction of muscle relaxants into practice contributed to the widespread use of endotracheal anesthesia - the main modern method of pain relief during major traumatic operations.
Since 1946, endotracheal anesthesia began to be successfully used in Russia, and already in 1948 a monograph by M.S. Grigoriev and M.N. Anichkova “Intratracheal anesthesia in thoracic surgery.”
