Agonising surgery paved the way for anaesthetics | Hacker News Reader

Agonising surgery paved the way for anaesthetics

bbc.com

54 pointsTomte61 comments

The demonstration by Liston of anesthesia in many ways was the moment that modern surgery was born. Liston was the epitome of the old surgery which was an agonizing, hurried, dirty, last ditch effort to save a life. Anesthesia could get rid of the agony and hurry. However, surgery was still a very deadly enterprise due to infection. In the audience watching the demonstration, was a young man named Joseph Lister. Lister would pioneer the practice of antiseptic (which would evolve into aseptic) surgery. Anesthesia and asepsis are the foundations of modern surgery. The passing of the baton from Liston to Lister is the birth of modern surgery.

Well there's a fun fact, Listerine was named after Joseph Lister

And the companion fun fact: so is Listeria :)

Nothing says fun quite like listeria-induced gastroenteritis!

I recommend the book The Emperor of All Maladies that goes into detail of this discovery.

In literature, I recall physically squirming during the sequence in Neal Stephenson's Baroque Cycle when our protagonist had some bladder stones removed sans anaesthesia.

And more recently, reading a thoughtful review of the BBC comedy series 'Quacks' from 2017 - where they described breathtaking advances in medicine around 1840.

Things went from "Let's cut this off quickly enough that you don't die from shock" with a 20+% chance of dying from the truly agonising operation meant to save you -- to a few decades later when they'd mostly worked out how to safely knock you out, carefully operate, and were aware of germ theory & sterilisation procedures.

I am in my mid-thirties and I was still operated on without anaesthesia as a child, growing up in a Russian-occupied part of Europe.

I remember being tied to a sort of lazy-chair with heavy belts and getting a giant lollipop afterwards. Everything in-between seems like a blur.

While it sounds brutal, it was actually a better option, and I am thankful to the surgeon for not putting me under. The thinking was, as I understand now from speaking to my parents, that soviet anaesthesia options were rather primitive and dangerous, especially to a child, and the surgeon elected to omit it, making the operation that much more challenging. Thankfully, he was at the top of his game.

Was it a major operation?

A tonsillectomy.

I am not from UA, but this video seems to be about right: https://youtu.be/ihBGocSbC-I?t=124

Some things cannot be unseen: this video can be quite traumatic for certain people.

I understand this perspective, but I find it personally hard to relate. Our ancestors regularly got eaten by lions and died horrible, gruesome deaths.

The bubble world of modern society lets us compartmentalize and brush these disturbing thoughts away, because unlike our forebears, we typically don't encounter these ordeals in our daily lives. But anyone can still be dismembered due to traffic accidents. Death and pain are still very much real. It's just slower and lower probability.

My second reaction to this is that I don't want the censure desired by others to be applied universally. I can appreciate that HN might not the the appropriate channel for this type of information, but I don't want to live in a PG-13 world everywhere I go.

But I haven't personally dealt with any major traumas, so perhaps I don't have the proper context to weigh in.

Wow that is quite poignant and horrifying

I had the exact same experience myself. I'm from a former Eastern Bloc country.

I had to go have my adenoids removed, and it was done with just a local anesthetic - actually, if I remember correctly I was given an injection beforehand which made me sort of woozy, but not very. I didn't get belted down to a lazy-chair, but I did sit on the lap of a beefy nurse who kinda held me down and made sure I didn't squirm too much. My dad was a doctor and was present throughout.

I live in the UK now and when I say that this sort of operation was done with just a local or nothing at all, people don't believe me.

Roald Dahl recounts this in his book 'Boy'

> I have only one unpleasant memory of the summer holidays in Norway. We were in the grandparents’ house in Oslo and my mother said to me, “We are going to the doctor this afternoon. He wants to look at your nose and mouth.”

> I think I was eight at the time. “What’s wrong with my nose and mouth?” I asked. “Nothing much,” my mother said. “But I think you’ve got adenoids.” “Don’t worry about it,” she said. “It’s nothing.” I held my mother’s hand as we walked to the doctor’s house. It took us about half an hour. There was a kind of dentist’s chair in the surgery and I was lifted into it. The doctor had a round mirror strapped to his forehead and he peered up my nose and into my mouth. He then took my mother aside and they held a whispered conversation. I saw my mother looking rather grim, but she nodded.

> The doctor now put some water to boil in an aluminum mug over a gas flame, and into the boiling water he placed a long thin shiny steel instrument. I sat there watching the steam coming off the boiling water. I was not in the least apprehensive. I was too young to realize that something out of the ordinary was going to happen. Then a nurse dressed in white came in. She was carrying a red rubber apron and a curved white enamel bowl. She put the apron over the front of my body and tied it around my neck. It was far too big. Then she held the enamel bowl under my chin. The curve of the bowl fitted perfectly against the curve of my chest. The doctor was bending over me. In his hand he held that long shiny steel instrument. He held it right in front of my face, and to this day I can still describe it perfectly. It was about the thickness and length of a pencil, and like most pencils it had a lot of sides to it. Towards the end, the metal became much thinner, and at the very end of the thin bit of metal there was a tiny blade set at an angle. The blade wasn’t more than a centimeter long, very small, very sharp and very shiny.

> “Open your mouth,” the doctor said, speaking Norwegian. I refused. I thought he was going to do something to my teeth, and everything anyone had ever done to my teeth had been painful. “It won’t take two seconds,” the doctor said. He spoke gently, and I was seduced by his voice. Like an ass, I opened my mouth. The tiny blade flashed in the bright light and disappeared into my mouth. It went high up into the roof of my mouth. It went high up into the roof of my mouth, and the hand that held the blade gave four or five very quick little twists and the next moment, out of my mouth into the basin came tumbling a whole mass of flesh and blood. I was too shocked and outraged to do anything but yelp. I was horrified by the huge red lumps that had fallen out of my mouth into the white basin and my first thought was that the doctor had cut out the whole of the middle of my head.

>“Those were your adenoids,” I heard the doctor saying.

> ...

> That was in 1924, and taking out a child’s adenoids, and often the tonsils as well, without any anesthetic was common practice in those days.

My grandfather (russian) talks about getting his tonsils removed when he was a kid in the army. He said the doctor was digging around his throat with a hot spoon and periodically telling him to spit.

I remember the curved white kidney-shaped enamel bowl! After the operation, I joined an adjoining room where a number of other stunned and stupefied children were sitting, each grappling their own little enamel bowl and staring at pieces of their flesh, blood dripping from their nose and mouths.

I grew up in a former eastern bloc country and didn’t experience anaesthesia at a dentist until I was in my thirties and living in the UK.

Something I've never understood is why anesthesia was ever something that needed to be invented or discovered in the first place. Haven't people been aware of opium for hundreds, maybe thousands of years? Seems like every surgeon in town would have had his own garden for raising opium poppies.

I'm sure there are other plants with soporific or dissociative effects that would make surgery less painful. (Coca leaves, maybe?) But Papaver somniferum is the one that mostly comes to mind.

Alcohol was a popular drug for this.

...and also a blood thinner :/

The history, traditional nature, and arrogance of the medical profession has much to do with this.

I just finished reading _The Ghost Map_, the story of John Snow's study of London's cholera epidemic. There's a good section of the book about his studious study of ether and chloroform. Good book, highly recommended in our current pandemic timeline.

I have Brugada Syndrome, which is a genetic condition that affects the sodium ion channels in cardiac tissue. To prevent sudden unexpected death, I have an implantable defibrillator. Every few years I get upgraded, sometimes leads fail and need to be revised as well.

General anaesthetics are dangerous for Brugada patients, so most of the surgery is done under local anaethetics. I have to tell the surgeons when I can feel pain, so they can put a bit of local where it's hurting. Given how "special" the sensations are when they get to a bit where there's not enough numbing, I can only imagine what it must have been like before modern anaethesia.

My last procedure was in March this year, and involved a lead revision, a defib upgrade and moving the unit deeper into my chest. Surgery lasted 3 and a half hours, so numbing wore off during the surgery. Not a lot of fun.

Next time, I suggest trying to ask for a locoregional anesthesiologist to perform a pectoral block. Long-lasting local anesthetics work far longer than 3.5 hours, and no reinjection required.

They might refuse due to fear of toxic dose, but worth trying.

Unfortunately, they have to use absolute minimal doses of locals as well, as they also increase cardiac arrythmias in Brugada patients, especially those of us with very distinct type I Brugada ECG patterns.

It kinda sucks, but hey, despite many cardiac episodes (my first VF was at 14, and I'm 58 now) I'm still alive. And I'm a cyborg.

I understand and I agree.

Another thing you might try is hypnosis or autohypnosis. It works pretty well for that kind of thing. Besides, that would also allow the anesthesiologist to give you efficient painkillers and sedation that does not interact with sodium channels.

However, I think you would find the cumulative dose of 3.5 h of intermittent lignocaine injections surprisingly high. And let me assure you that they have absolutely no idea of your true lignocaine plasma level. The comparative peak with long-lasting drugs will likely be much lower.

All in all, I guess my main point is that if by chance you're doing that without an attending anesthesiologist you should try to ask for one and you might find it far more comfortable.

You probably already know this, but:

https://www.google.com/url?sa=t&source=web&rct=j&url=http://...

Yeah, I did know most of that. But a nice summary anyway. One big difference is that they monitor me with 7 (in the ward) and 12 (during surgery) lead ECG, not 5.

Fortunately, being in Australia where there is universal health care, I have an excellent team working with me. Typically in the Cardiac Catheter Laboratory there's the Professor (surgeon), a cardiac aneathetist, several registrars and students, several nurses, a technician from Biotronik, and a cardiac scientist.

They use absolutely minimal doses of lignocaine, based on my reporting pain levels during surgery. They do give me a very small dose of propofol during the test at the end, when they induce VF and AF to test the unit. I'm told this is much less stressful than being awake while fibrilating and being shocked (twice). I know that going into VF and AF feels bloody aweful, and syncope often results in nasty falls, so being knocked out for that makes sense. I did break my arm once when shocked though - those stainless steel tables are bloody hard!

I know a patient in the US who had a bill for $145k after getting his ICD. I on the other hand pay nothing, except a lifetime of higher taxes than Americans pay.

I think it's in one of Atul Gawande's books but he mentions how before anaesthesia, the incentive was to have surgeries be as fast as possible to minimize the duration of pain endured by the patient.

He then goes on to recount a story of a surgeon performing an operation in front of a group and the following happened:

- He accidentally cut the person assisting him

- A woman in the crowd suffered a heart attack from the shock of watching the above

- The assistant ended up dying of infection from the cut

- The patient also ended up dying.

As he tells it, it was the only operation where the mortality rate was 300%

Its crayz how young everything is.

1970 for co2 monitoring.

How much money does an anesthesiologist make these days?

$400k+ last I heard

Double that if you’re crooked :)

No complaints here given how your life is in their hands during surgery

Not to mention the nurse inventorising the clamps and pads that the surgeon is stuffing inside your belly. Heck, even the cleaner carefully mopping every crevice in the surgery room to kill all those pesky MRSA bacteria before they spoil your day.

Surgery is a team effort

Team effort, my ass. In the OR, everyone except the surgeon is treated like shit and especially anesthesiologists, since they're first to arrive, last to leave and have no choice but to handle whatever comes their way.

Yeah, definitely not the kind of job you give to the lowest bidder.

Stupid question, because I never understood this. Anesthetics seems like a mostly mechanical process with little room to deviate from the established procedures both for medical and legal reasons. What am I missing, what makes anesthesiologist that highly paid?

A common comparison is drawn to flying a plane - its a proceduralised and mechanical process for a lot of the time, but occasionally unexpected things happen and you need knowledge and skills to react quickly and prevent serious injury and death. Its like flying a plane but if every plane was built differently with no instruction manual, some of the planes are badly broken before you take off, and someone's trying to repair the engines in mid air.

I'm currently revising for my anaesthetics exams. The things I'm meant to know include:

* The physics and mechanical principles of all the equipment I use, from the ventilator to the pulse oximiter - so that I can identify when and how it might fail and how to respond

* The pharmacokinetics, pharmacodynamics, and mechanism of all the drugs I might use - so I can understand their effects, side-effects, and interactions

* The physiology and function of the human body, including the respiratory, circulatory, neurological, renal, gastrointestinal, musculoskeletal, and immune systems - so I can understand how anaesthesia effects these systems, and how diseases and disorders of the systems will interact with the anaesthetic and how problems can be identified and treated

* The anatomy of the body, with particular focus on the head and neck anatomy to aide in intubation and airway procedures, and neuro-anatomy to aide in regional anaesthetic techniques

* The anatomical, phsiological, and pharmacological consequences of pregnancy, childhood, old-age, and a huge variety of acute and chronic diseases - so I can understand and adapt anaesthetics to these conditions

You would have to read up on the science of anaesthesiology for a full understanding. I'll describe just a few of the subtleties I've encountered. About two decades back, I was a medical researcher who did all the vetinary qualifications for animal research including general anaesthesia, all the different types of analgesics and dissociatives, and I subsequently spent a few months working with mice and injectable liquid anaesthetics.

You're playing a fine balance between keeping the animal under, and killing it. You have to continually observe and balance the degree of anaesthesia which you can test with pain reflexes and core reflexes, and adjust the dosage accordingly. Too much and you depress the core functions to the point breathing stops. Too little and the animal retains consciousness along with pain reflexes. With larger animals you can use similar equipment to what you would use with humans. Small ones require direct physical observation.

There's a simple dosage rule: n ml anaesthetic per gram bodyweight. So you would weigh the mouse, calculate the dose and then inject it. Sounds easy enough.

Not so. It also depends upon the percentage of fat tissue. If the mouse is fat, the fat tissue will absorb the anaesthetic and then slowly release it. This changes the dynamics of how fast the anaesthetic takes effect, and how deep and how long lasting the anaesthesia will be. Skinny mice would go under almost immediately. Fat mice might take 10 minutes. But if you topped up the dose, you would risk the dosage reaching fatal levels a few minutes down the line as the fat tissue released its stored anaesthetic. You would learn to adapt the formula by experience, but this is just one factor to consider.

Now imagine how difficult this is with obese human patients. Or anorexic patients. Or sick patients. Patients on various drugs. Or patients with different metabolic rates. There are dozens of factors, making each case unique. Anaesthesiologists have a huge responsibility, and taking great care and skill to keep their patients alive. We think of this as routine, and it is, but that doesn't make it simple or easy to do. This stuff looks simple on paper. Doing it in practice is far, far more difficult and demanding.

There's also the difficulty that unexpected things happen, and the anaesthesiologist has to know how to keep a patient alive and well when they do. There are tricky genetic conditions such as malignant hyperthermia https://en.wikipedia.org/wiki/Malignant_hyperthermia that can cause serious reactions to certain anaesthetics with no warning.

Thanks for the explanation, but I'm not sure whether I'm 100% convinced by the example. Monitoring multiple signals and reacting to them is what machines good at, in fact, a human in the control loop can be a liability for many industrial processes.

Anesthesia is not a problem for machines because of signal complexity. The problem lies in the everchanging environment and the practical aspects of the job. Things are not fixed enough for machines to perform well. Just as in surgery. For example, venous catheterization is a very difficult task for machines while it's pretty simple for humans.

There's a role for a human-machine hybrid, and indeed there are also quite complicated control systems in work in anaesthesia. As an example, syringe pumps which perform pharmacokinetic calculations: you enter the patient's height, weight, sex, and age, then set a target plasma drug concentration and the pump uses complex pharmacokinetic models to determine how much drug to deliver to acheive that goal and maintain it. I can imagine more elegant systems coming in the future - ie a pump that can adjust drug delivery rates to maintain a given blood pressure. But the overall process of safely delivering an anaesthetic, from pre-operative assessment to post-operative recovery and discharge, is far beyond automating at the moment.

The problem is the unpredictability and the nature of the feedback.

Living creatures are not industrial processes. Each one is unique and will behave differently. So while you can draw some generalisations, you can't safely put a machine in ultimate control, or even in a position to provide unreliable feedback. Even industrial processes aren't usually automated in their entirety and usually have 24/7 oversight; "simple" PID loops can misbehave, and this is far more complex with many more variables. The consequences here are death at one extreme and extreme suffering at the other, and so the stakes are too high to delegate it to a machine. This isn't some theoretical problem--a life is literally on the line and machines can not hold responsibility for a life.

Also note that answering the questions of "is the animal conscious", "is the animal in respiratory distress", "is the animal in pain", "are the core reflexes functioning" or "have the core reflexes stopped functioning" all require complex assessment, which a machine can't do. And if any of those are true or false, the complex dynamics make the decision of giving more or less anaesthetic dose a very complex question to answer. If anything goes wrong, it requires intelligent and informed decisions to be made. In some circumstances that includes killing with an overdose for ethical and legal reasons. It would be unethical and cruel to let a machine make decisions of such consequence.

Having another life in your hands is a huge burden. It's both humbling and scary to be given such power and responsibility over another living being, and having done it I'd have to say I find the notion of giving a machine control or even moderate influence over the process grossly irresponsible. Automating every last aspect of our existence is a horrifying concept. Some things need humans in absolute control, and this is one of them. And I say this as someone who eventually became an software engineer for embedded medical diagnostic devices. Think about the ethics of what you are suggesting.

There are multiple things to unpack here. First, human lives in the hands of machines or even just software is completely normal, like directly like handing it over to autopilot for example. I don't think there is an ethical angle here, though I can understand if there is a personal preference for human anesthesiologists for some.

Second, I understand there are very fine details at play. However I disagree with the point that complex assessment is out of a computer's reach, on the contrary, they are especially good at it. I would trust a machine to consider a patients full medical history in accordance with their momentary markers more thoroughly and faster than a human ever could. Not to mention the human factor of being less educated, tired, in a bad mood or simply not available.

Admittedly I know nothing about the protocols in anesthetics, and indeed, it is my preconception there is little more to it than a tight control loop with not much room for wiggle. What do anesthesiologist base their decisions if not data? Perhaps some of the data is not obvious to a machine and we need humans sensors for input, but the thought of people playing god with ad hoc ideas makes me more uneasy than a computer involved. Granted I live in a second world country and capable doctors are few and far between and it must count for some of my bias.

You'd have to come and see what anesthesia really is to understand the obstacles to automation. You are right that these obstacles do not lie in complexity. Ironically, they lie in practicality: anesthesiologists perform in extremely diverse environments where implementing reliable feedback mechanisms is impossible at the time (think crisis situation in the ER). In opposition to your preconception, we very often are driven by intuition instead of hard data because said data is so often completely unreliable. It would actually likely be easier to automate internal medicine because it leaves more time to check and correct equipment failure, and requires far less practical procedures.

In many countries, if you're from any other specialty and you've got any kind of complication that puts the patient at immediate serious risk, you'll call anesthesia to handle it. Surgery, resuscitation, airway problem, paediatrics, obstetrics, you name it... there will be an anesthesiologist around for your own protection (not only to put you under). That should give you an idea of the breadth of anesthesia.

Very much depends on where you work.

Thank you for such a useless response.

Please don't do this here.

They make $400K+, and also have the highest malpractice insurance rates of all the disciplines. On the upside, they have low overhead, since they don't need an office to see patients in.

Actually, anesthesiologists are middle of the pac in regards to malpractice. Whenever someone quotes income levels for physicians, it's usually after all expenses, including malpractice. It really doesn't matter how much a doctor pays in malpractice, it's what their net income is after. Neurosurgeons pay close to $100k / year, but make $500k+.

Anyway, anesthesia is much safer than 30 years ago

https://theanesthesiaconsultant.com/do-anesthesiologists-hav...

I’m amazed at how American medical salaries are orders of magnitude out of proportion with other western countries. Here in Ireland an anaesthesiologist makes about 100k€/year, and about 60k€/year after tax. That wouldn’t even cover malpractice insurance in the US.

Salaries for other doctors and surgeons are similar - a neurosurgeon will make perhaps 4x-5x less money here than in the States. Meanwhile cost of living in Dublin is about the same as major American cities like Seattle with one of the highest rents in Europe.

Comparing cost of living in a country with proper healthcare and a significantly less litigious population isn't like-for-like.

Perhaps this means that Ireland has a better health care system? Assuming that your surgical mortality rate is similar to that of the United States.

Realize that the cost of basic medical insurance in the United States, for you and your family (spouse and children), is now approaching $7,000/year USD. It can easily exceed $550/month. This is tied to your employer. And this is just insurance. You still have to pay some percentage of the cost if you actually have to perform the procedure.

Actually, without subsidies, it's around $3500 / month for a family and that's with a $5k - $10k deductible. I have a collegue that retired after inheriting a lot of money and that's what he pays for health insurance.

Most small business owners that I take care of are on their spouse's insurance.

If Americans don't think that the cost of health insurance is destroying entrepreneurship, they're idiots. For example, if you're single and want to open your own garage to fix cars, you may have to compete with the shop down the road that doesn't worry about insurance bc they're on their spouses. So that shop has $3500 a month less costs than yours.

Keep in mind your med schools are nearly free for EU citizens. American doctors usually graduate with $500K or more in debt, so their salary has to cover debt payments plus insurance.

And still, nobody knows how it actually works.

The first half of the article is very entertaining.

Note that Russian dentists were late in adopting anesthesia, and the result was patiencs flinching during procedures, causing broken teeth and other complications.

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