Soldiers were often more afraid of anesthesia than of the operation itself. This is how the beginnings of anesthesiology looked like [FRAGMENT]

Streaks of sunlight filtered through the high windows of the operating room, seeming to ignite anything they touched. Despite the glow, Gillies felt a sudden drowsiness creep over him. His scalpel hovered precariously over the patient, and his eyelids, heavy as lead, began to droop. There was an ether in the air, escaping with the patient’s exhalation, and now it was threatening to anesthetize everyone nearby. Gillies was the most vulnerable because he bent over the soldier’s face.

While the challenges Gillies faced in the operating room were colossal, even greater ones awaited the anesthesiologists at Sidcup2. Anesthesia, like many other aspects of medicine, was underdeveloped during the First World War. The way it is used has changed little since the mid-nineteenth century, when the anesthetic properties of ether were discovered. Anaesthesiology as a medical specialty did not yet exist. This meant that anesthetics, at the beginning of the war, were often administered by a junior doctor, rather than by a specialist who was aware of the effect of some anesthetic agents on the seriously injured. In fact, in Great Britain, anesthesia did not enter the medical curriculum until 1912.

As expected, there was a great need for anesthetics at the front. During the war, the British alone used about one hundred and eighty-seven tons of ether and one hundred and thirteen tons of chloroform, not to mention hundreds of thousands of liters of nitrous oxide (laughing gas). The demand was so great that sometimes non-medical personnel were recruited to put patients to sleep. Pastor Leonard Pearson recalled performing these duties at the 44th Field Hospital during the Battle of the Somme:

I spent most of my time administering anesthetics. Of course, I had no authority to do that, but we just acted in such a rush. We couldn’t get the wounded to the hospital fast enough, and the road from the battlefield was terrible for those unfortunate boys. If they had to wait their turn as normal until a surgeon can perform the operation and another doctor administers an anesthetic, it would be too late for many of them. And so many died.

British soldiers during the fighting on the Somme in July 1916 Royal Engineers No 1 Printing Company – Imperial War Museums collection, Public Domain, Wikimedia.org

However, the sheer number of patients requiring anesthesia was another of the numerous problems faced by the medical staff. And there were additional challenges when patients with facial wounds had to be anesthetized.

The conventional method of administering ether or chloroform, which involved placing a gauze mask over the face, often obscured the operated area. Even when a rubber tube was inserted into the nose or mouth to administer ether or chloroform gas by hand bellows, the surgeon and the anesthetist could get in each other’s way because they both needed direct access to the face. As a result, putting a patient to sleep could turn into a logistical nightmare in the operating room. Captain Rubens Wade, who worked with Gillies as an anesthetist at both Aldershot and Sidcup, wrote that “the surgeon must necessarily be entering territory usually considered by the anesthesiologist as his own.”

The anesthetics themselves were also a problem as they often made the patient extremely nauseated, a rather undesirable situation for someone with severe facial injuries. “When the boy was notified of the operation the following Monday, he started throwing up on Saturday,” joked Gillies. Patients were often more afraid of anesthesia than of the surgery itself: “The sight of a man in a white coat hanging around with a bottle of chloroform and a gauze pad in one hand and tongue forceps in the other often terrified patients of a generation raised in fear of the surgeon’s knife.” Also, many of the soldiers were heavy smokers and therefore difficult to anesthetize them with, whether ether or chloroform, because nicotine can affect how the body metabolizes certain drugs. Some suffered from chronic bronchitis or other upper respiratory diseases, which caused even more complications.

One of the biggest challenges by far, however, was the number of blood vessels in the face. If the patient had high blood pressure, was bleeding excessively, then not only did the blood obscure the area requiring attention, but it could also drip down the throat and into the lungs, causing the patient to choke on his own bodily fluids. One solution was to sit the patient in an upright position, but this was also a challenge. “Positive pressure was necessary to prevent blood from entering the trachea,” noted Ivan Magill, an anesthesiologist at Sidcup, “but the blast of the patient’s ether-saturated exhalations reached the surgeon, who was often enveloped in a haze of spattering blood.” Gillies often fell prey to this unpleasant effect.

Even at this late stage in the war, medicine still had difficulty dealing with the astonishing variety of damage that modern weapons could inflict on the human body, and not all of the problems facing surgeons were to be resolved before the end of the conflict. In 1919, Magill and his team perfected the method of administering anesthetics by using a pump to force ether gas through a catheter placed in the patient’s trachea. Endotracheal insufflation, as it is now called, reduced the risk of anesthesia-induced shock because it allowed the anesthetist to better control the amount of drug entering the patient’s body. Magill eventually added a second tube to his system, one to deliver the anesthetic, the other to prevent the surgeon from getting air laden with ether and blood droplets from the patient’s exhalation. Just as Gillies promoted plastic surgery after the war, Magill was later to become an advocate of making anesthesiology a separate specialty and one of the most important figures in this field in the twentieth century.

In the meantime, however, those arriving at Queen Mary’s Hospital had to wait a little longer to take advantage of such advances.

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War and its aftermath undoubtedly accelerated medical innovation, and Gillies and his team often made good use of new methods, but there were never any guarantees of success at Queen Mary’s Hospital.

Private Stanley Girling, who suffered serious injuries while fighting for the 72nd Seaforth Highland Regiment in France, was transferred to Sidcup shortly after he was wounded, presumably due to severe facial damage. But when he got there, he found that he had lost an alarming amount of blood. Although Gillies rarely had to deal with emergencies resulting from uncontrolled bleeding, any improvements in blood transfusion methods were in the interest of the plastic surgeon, since facial tissues are highly vascularized.

Anesthesiology was to be perfected only after the outbreak of the First World War, as well as blood transfusions, which until then had been rarely carried out due to the high risk involved. Finding a safer and more effective method of blood transfusion was to become an urgent need for doctors helping soldiers at the front.

The first documented blood transfusion took place in 1666, when English physician Richard Lower transfused blood from one dog to another. This was followed by attempts to transfuse animal blood into humans, leading to numerous deaths, accusations of going against nature, and fears of grotesque side effects such as recipients growing horns. As a result, this practice has largely been abandoned.

The first human-to-human transfusions were not experimented with until the 19th century. Between 1818 and 1829, Englishman James Blundell performed a series of transfusions that less than half of the people who received them survived. Blundell had no idea how to explain it. At the beginning of the 20th century, this mystery was solved by the Austrian physician Karl Landsteiner. For decades, doctors have observed that when blood from different donors was mixed, the cells sometimes stuck together.

Since the blood in question often came from the sick, most doctors considered it an anomaly not worth examining. Landsteiner, on the other hand, wondered how blood from two healthy people would interact. So he took blood from himself and his colleagues and found that cell clumping only occurs when some people’s blood is mixed, regardless of their health. He divided the samples into three groups labeled A, B and C (the latter was eventually renamed 0 after the discovery of the fourth group, AB). When he mixed blood within the same groups, it remained liquid, but when A and B were mixed, the cells stuck together. Further joining of A or B with C (ie 0) did not lead to cell sticking.

Landsteiner realized that the immune system was responsible. The blood contains antigens that cause the body to produce antibodies to fight off intruders such as viruses. Each blood group has different types of antigens. When different groups are mixed together, the immune system attacks the foreign antigens, causing blood cells to clump together. When this happens, the recipient develops clots that can lead to death. The exception is group O, which has no antigens and is therefore compatible with three other blood types.

However, even cross-matching has not made blood transfusions suddenly safe and easy. Surgeons still had to cut open the skin to expose the blood vessels, then connect the donor to the recipient with a rubber tube, using a method called direct transfusion. The two had to lie perfectly still for hours next to each other not to break the connection, and it was almost impossible to measure the amount of blood that actually flowed between them.

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