Anesthesia and Painless Surgery

Painless surgery is taken for granted by most of us who are in the business of doing surgery. But the history of painless surgery started 153 years ago.

On October 16, 1846, Dr. William Morton, a young Boston dentist, administers ether to Edward Gilbert Abbott, so that Dr. John Collins Warren can do painless surgery.

This is an important day for patients and surgeons. Prior to that the operating room was seen as a torture chamber. Patients would scream with pain until they fainted. Surgeon and his assistant had only a minute or two to complete their procedure. Amputation took less than two minutes.

“Very few operations were done and they were dreaded by all,” says Dr. Robb Rutledge, attending surgeon at Fort Worth, Texas, in an article in Bulletin of the American College of Surgeons.

Before 1846, there were some isolated attempts to make surgery painless. In 1800, nitrous oxide (laughing gas) was used by Humpry Davy to relieve pain of surgical operation. There were some unpublished reports of ether use as well. But it was Morton’s success at Massachusetts General Hospital that changed the practice of surgery.

Both ether and nitrous oxide became well known in social circles. There were “ether frolics” and “laughing gas parties.”

During one of these laughing gas parties, Horace Wells, a successful young dentist, observed that one of the guests had bruised his leg but felt no pain. Next morning, Wells had his colleague use nitrous oxide to pull Wells’ own wisdom tooth. Wells was impressed.

Dentists and surgeons used nitrous oxide and ether to do more cases. It was Oliver Wendell Holmes who suggested etherisation be called anaesthesia, which means insensitive to objects of touch. “This name caught on and was adopted around the world,” says Dr. Rutledge.

But there is a sad end to this wonderful story. Some of the individuals involved in the discovery of anaesthesia started to fight over priority and financial gain. The battle raged in front of the U.S. Congress. But nobody won. “No one ever received any financial governmental award for the discovery,” says Dr. Rutledge.

Horace Wells was so disappointed that he left his wife and son and moved to New York City. He became addicted to chloroform. Was jailed on his 33rd birthday for throwing sulfuric acid on prostitutes. In 1848, while in prison, he committed suicide.

William Morton destroyed himself trying to get recognition for his role in the discovery of anaesthesia. He was censured by the American Medical Association for unworthy conduct. He died of apoplexy at the age of 48.

Sad endings. But things have not changed in the last 153 years. Money and recognition continues to be at the heart of many battles – big or small. Some things in life never change!

Same as the fear of pain. Every individual I have “surgerised” has had fear of pain and needles. Needles are painful. When we discuss surgery with patients, their first question is: Is this going to hurt? Rarely a patient wants to know about complications, risk of permanent damage from the procedure or the worst of all complications – death.

Pain is scary. Pain is a complex experience. Response to pain is physical as well as emotional. Response to pain varies among individuals because the emotional component is variable. Nobody likes to be in pain.

So, next time you have painless surgery, remember it was pioneers like Wells and Morton who made this possible.

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Influenza (Flu)

Flu and pneumonia can be serious illnesses.

“Influenza (flu) is a highly contagious acute respiratory disease of global importance,” says an editorial in the New England Journal of Medicine.

The editorial says that vaccination is currently the most effective measure to reduce the impact of influenza. But it is not easy to formulate a vaccine for a constantly changing virus. For the last 50 years, World Health Organization has monitored the appearance and spread of new variants of the virus worldwide that may cause the next epidemic. This usually results in producing well-matched vaccines.

How does the vaccination work?

It works by exposing an individual to modified form of influenza virus in order to generate an immune response.

For many years, attempt has been made to prevent and control influenza by vaccinating people over 65, those with chronic medical conditions (heart disease, lung problems, diabetes, kidney disease etc.), medical care providers and others who might transmit the virus to those at risk.

This effort has considerably reduced deaths from this disease. The flu epidemic of 1918 killed 21 million people worldwide. The epidemics come every two years but we have better tools now to save lives.

There is also some comfort in the news that research has produced new ways of dealing with this challenging problem – by way of producing oral antiviral agents. There are few in the market and the newest one – Relenza – has been approved by Health Canada and should be in the drug stores soon.

This takes us to another related disease – pneumonia.

“Invasive pneumococcal disease can be deadly,” says Dr. Ross Pennie, Professor in the Faculty of Health Sciences at McMaster University in Hamilton, Ontario. In an editorial in the Canadian Family Physician, Dr. Pennie says that fewer than 5 percent of the population at increased risk of pneumonia has received the pneumococcal vaccine.

Alberta Health says that the pneumococcal vaccine is now available – free of charge – to all Albertans over the age of 65 through community health clinics and physicians’ offices. The vaccine can prevent serious infections caused by the bacteria Streptococcus pneumoniae.

The organism can cause pneumonia, meningitis, and sinusitis. About 400 people die each year in Alberta from pneumococcal infection.

Among those at greatest risk for the disease are seniors, people living in a nursing home or other long term care facility, or those over two years of age who have medical conditions that may affect their body’s ability to fight diseases, says Alberta Health.

These conditions are: people who have had their spleen removed, who have diabetes, lymphoma, chronic diseases of the heart, lungs, liver, and kidneys. The current vaccine is ineffective for children younger than 2 years.

“In most cases, one pneumococcal vaccination is all a person will ever need,” says Dr. Karen Grimsrud, deputy provincial health officer.

Over the years, flu and pneumonia has taken many lives in nursing homes and seniors living at home. Remember, help is here. It is free. So, if you are not sure whether you need to take these vaccines then speak to your doctor or a public health nurse. Do it soon.

Have a healthy winter!

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Breast Pain

Fear of cancer makes Susan seek help when she discovers a lump in her breast.

“Fear is not an unknown emotion to us,” says Neil Armstrong, the first man to walk on the moon.

“Just as courage imperils life, fear protects it,” says Leonardo da Vinci.

It is this protection women look for when they visit their physician with a breast lump.
The scenario of fear and protection leads to frequent office visits, multiple negative needle and surgical biopsies, and sometimes-more anxiety and more fear.

In fact, only 10 to 20 percent of biopsies of breast lumps show cancer. But this is necessary if we are to treat every breast lump as malignant until proven otherwise.

In the last column, we discussed about fibrocystic changes in the breast and the pain associated with this condition. Susan wants to know how this condition is treated.

Painful breasts can be cyclic (associated with menstruation) or non- cyclic. Two thirds of the women have cyclic pain and one- third experience non-cyclic pain.

First step in the management of this problem is to rule out cancer. This is done by history, physical examination, needle biopsy and if indicated, by mammography. If there is a persistent lump after all this then surgical removal becomes necessary. A pathologist’s report will give a definitive answer.

This process will help reassure 85 percent of the women. Their pain is not significant enough to require more than regular painkillers or anti-inflammatory medications. The remaining 15 percent will continue to have severe pain, which will affect their lifestyle and warrant more than regular painkillers.

This is where we are long on drug choices but short on effective uncomplicated therapy.

Here is a list of substances tried: birth control pills, progesterone, bromocriptine, danazol, thyroid hormones, tamoxifen, vitamins A, B-complex, and E, diuretics (water pills), prostaglandin inhibitors, iodine, primrose oil, restriction of methylxanthine (coffee, chocolate), and the list goes on.

In young women in their 20s, the birth control pill may be helpful as it provides a stable amount of hormones each month.

Bromocriptine (a prolactin hormone antagonist), and danazol (a synthetic anti-estrogen) have been found to be helpful to large number of women but these drugs have significant side effects. Side effects of bromocriptine are – nausea, headaches, and dizziness. Side effects of danazol are – loss of menstruation, weight gain, acne, hirsutism, and voice change.

Other popular remedies advocated are the use of primrose oil, iodine, and restriction of chocolates, and caffeine containing substances. Whether the benefits obtained are real or psychological is debatable. But the use of or restriction of these substances have no side effects and in fact may be beneficial for other reasons!

There is no effective uncomplicated therapy applicable to all women with painful lumpy breasts. There is lack of research on breast pain. But it is important to remember that pain is usually not an indicator of cancer in the breast. And a breast lump is considered malignant until proven otherwise.

Well, Susan, are you better informed now? She smiles and says: Thank you for now, Dr. B!

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Breast Pain

Breast pain is a common complain among women of menstruating age.

Susan is no exception. Besides pain, she has lumps in both breasts. Her symptoms are cyclic – associated with menstruation.

Since October is Breast Month, Susan wants her breasts examined. She is worried about cancer.

Susan’s physical examination reveals diffuse lumpy areas in both breasts with one discreet lump (about 3 cm in size) in the right breast. A fine needle aspiration of the lump confirms the presence of clear fluid and the lump disappears.

Susan’s mammogram reveals no suspicious lesions to suggest cancer. She is aware that 15 percent of mammograms fail to detect cancer (false negative).

Therefore, the conclusion is that Susan has fibrocystic changes in her breasts. The old term “Fibrocystic Disease” has now been replaced with fibrocystic changes. It cannot be a disease if the condition is very common, responds to physiological hormonal changes, and disappears later in life.

Women with fibrocystic changes not only suffer from pain but also have significant anxiety about cancer. One can easily miss a malignant lump among the multitude of benign appearing lumps.

Physicians and patients have to be vigilant at all times. The principle of management should be that a breast lump is malignant until proven otherwise.

Dr. B, can you tell me more about the fibrocystic changes of the breasts?

Susan, this condition is known by many different names and encompasses many benign conditions of the breast.

One textbook says that it is virtually impossible to estimate the incidence of benign breast disorders. But it is believed that 50 percent of women experience symptoms of fibrocystic changes at some point in their lifetime.

Usually the symptoms occur in women of menstruating age, with a mean age of 39years and a range of 18 to 67 years.

Solid benign lumps (fibroadenomas) occur in younger women, but cysts occur few years before and after menopause (35 to 60 years).

This condition is associated with a history of premenstrual breast discomfort, irregular menses, and spontaneous abortions; a family history of both benign and malignant breast disease; lack of use of oral contraceptives; a low incidence of obesity; small breasts, and late natural menopause (Breast Diseases by Harris and others).

The cause is unknown. It is likely due to imbalance of the female sex hormones as the condition occurs after the onset of menstruation and rarely appears after menopause.

Dr. B, do fibrocystic changes cause cancer of the breast?

Susan, there is inadequate evidence to suggest that fibrocystic changes lead to cancer of the breasts. Usually the fear is that cancer may be missed in women who have “lumpy” breasts. These women do and get regular breast checkups.

The management of this condition is not easy. We will discuss this next week. In the meantime remember: A breast lump is malignant until proven otherwise.

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!