October 16, 1846 is a famous date not only in surgery, but also in the history of mankind. On this day, for the first time, a major surgical operation was performed under full ether anesthesia. Complete anesthesia was achieved, muscles were relaxed, reflexes disappeared. The patient fell into a deep sleep with loss of sensation. At the end of the 18th century, the inhalation of ether was used to relieve pain from consumption and intestinal colic. However scientific rationale problems of anesthesia belongs to Nikolai Ivanovich Pirogov, then to Russian scientists A.F. Filomafitsky, dean of the medical faculty of Moscow University, and anatomist L.S. Sevryuk. they checked the effect of ether on the nervous system, on the blood, checked the dosage, the duration of action ether anesthesia. Like any innovation, ether anesthesia immediately found both overly ardent adherents and prejudiced critics. Pirogov did not join any camp until he tested the properties of ether in laboratory conditions, on dogs, on calves, then on himself, on his closest assistants, and, finally, on a mass scale on the wounded on the Caucasian front. Here is how B.L. Mogilevsky describes the work of N.I. Pirogov in the Caucasus: “... a military fire was burning in the Caucasus. Shamil waged a "Holy War" against Russia ... Nikolai Ivanovich managed to deploy a field infirmary near the Salty fortress ... Among the few wounded Cossacks was the centurion Yuri Gagarin, who was wounded in the leg. An operation under anesthesia saved his life. They brought the first wounded murids. Clenching their teeth, the mountaineers silently endured the terrible pain of their wounds. Seeing that no amount of persuasion could convince the Murids to undergo surgical operations, Pirogov resorted to a trick. He approached one of the most suffering mountaineers and asked in all seriousness: “Would you like to rest a little, kunak (friend)? I have a medicine that can temporarily transfer you to heaven, to the heavenly houris. Just say the word and I will keep my promise." There was a nod of the head in agreement.

Throwing a mask over the mountaineer's face, Pirogov irrigated it with ether. The wounded man quickly fell asleep. The operation was carried out at lightning speed - a bullet was removed from the leg and crushed fingers were taken away from the hand. The time of action of anesthesia passed, and the murid woke up. He warmly thanked Pirogov for the fact that he did not deceive him and reduced the suffering from pain. After this incident, the wounded mountaineers vying with each other asked the wonderful doctor to operate on them. While the West was arguing about whether it is possible or not to use anesthesia in surgical practice, Nikolai Ivanovich Pirogov performed seven hundred operations under anesthesia on the battlefield.

The invention of the plaster cast

Among the many merits of Pirogov to medicine, in particular to military medicine, one cannot help but point out the plaster cast invented by him, which was first used in the field in 1854. Pirogov did not immediately come up with the idea of ​​​​using plaster: first, in his surgical work, he replaced wooden overlays with starch bandage. Here's how it happened.

The first expedition to clear the Salt region of the enemy was followed by a second, also successful. There were terrible hand-to-hand fights. Bayonets, daggers, sabers were used. The positions of the detachment were held at a high price. Three hundred killed and wounded Russian soldiers and officers remained on the battlefield. For Pirogov, the fighting began. He worked twelve hours a day, forgetting about food. The surgeon widely used ether anesthesia in a combat situation. In the same days, the brilliant scientist made another remarkable discovery. For the treatment of bone fractures, instead of linden bast (bark), he began to use a starch motionless bandage. Starch-soaked long pieces of canvas were laid layer upon layer on the broken limb. The starch solidified, and in a calm state, the bone grew together over time. A strong callus formed at the site of the fracture. Here, to the whistle of the path flying over the tents of the infirmary, Nikolai Ivanovich realized what a huge benefit a medical scientist can bring to soldiers.

In 1854, Pirogov came up with the idea to replace the not quite comfortable starch dressing with plaster. Gypsum (calcium sulphide) is a very fine powder with high hygroscopicity. When mixed with water, it hardens within 5-10 minutes. Before Pirogov, gypsum was used by builders, architects, and sculptors. In medicine, Pirogov used a plaster bandage to fix and consolidate injured tissues. Plaster bandages were widely used during transportation and in the treatment of the wounded. Not without feelings of national pride, N.I. Pirogov recalls that “the beneficence of anesthesia and this bandage in military field practice was investigated by us before other nations.”

Do you know that...

The invention and widespread introduction into medical practice of a plaster cast for bone fractures is one of the most important achievements of surgery in the last century. And it was N.I. Pirogov was the first in the world to develop and put into practice a fundamentally new method of dressing impregnated with liquid gypsum.

It cannot be said that before Pirogov there were no attempts to use gypsum. Known are the works of Arab doctors, the Dutchman Hendrichs, Russian surgeons K. Gibental and V. Basov, a surgeon from Brussels Seten, a Frenchman Lafargue and others. However, they did not use a bandage, but a solution of gypsum, sometimes mixing it with starch, adding blotting paper to it.

An example of this is the Basov method proposed in 1842. The broken arm or leg of the patient was placed in a special box filled with alabaster solution; the box was then attached to the ceiling through a block. The victim was essentially bedridden.

In 1851, the Dutch doctor Mathyssen had already begun to use a plaster cast. He rubbed strips of cloth with dry gypsum, wrapped them around the injured limb, and only then wetted them with water.

To achieve this, Pirogov tries to use various raw materials for dressings - starch, gutta-percha, colloidin. Convinced of the shortcomings of these materials, N.I. Pirogov proposed his own plaster cast, which is used almost unchanged at the present time.

The fact that gypsum is just the best material, the great surgeon made sure after visiting the workshop of the then-famous sculptor N.A. Stepanov, where "... for the first time I saw ... the effect of a gypsum solution on the canvas. I guessed," writes N.I. Pirogov, "that it can be used in surgery, and immediately applied bandages and strips of canvas soaked with this solution , on a complex fracture of the lower leg. The success was remarkable. The bandage dried up in a few minutes: an oblique fracture with a strong blood streak and perforation of the skin ... healed without suppuration ... I was convinced that this bandage could find great application in military field practice, and therefore published a description of my method.

For the first time, Pirogov used a plaster cast in 1852 in a military hospital, and in 1854 - in the field, during the defense of Sevastopol. The wide distribution of the method of bone immobilization created by him made it possible to carry out, as he said, "saving treatment": even with extensive bone injuries, not to amputate, but to save the limbs of many hundreds of wounded.

The correct treatment of fractures, especially gunshot ones, during the war, which N.I. Pirogov figuratively called "traumatic epidemic", was the key not only to the preservation of the limb, but sometimes the life of the wounded.

Portrait of N.I. Pirogov by artist L. Lamm

The creation and rather widespread use in medical practice of plaster casts for bone fractures is the most important achievement of surgery of the past century. It was N.I. Pirogov was the first in the world to create and put into practice a completely different bandage method, which was impregnated with liquid gypsum. However, it is impossible to say that Pirogov did not try to use gypsum before. Most famous scientists: these are Arab doctors, the Dutchman Hendrichs, the Russian surgeons K. Gibental and V. Basova, the Brussels surgeon Seten, the Frenchman Lafargue and others also tried to use a bandage, but it was a plaster solution, which in some cases was mixed with starch and blotting paper.

A striking example of this is the Basov method, which was proposed in 1842. A broken arm or leg of a person was placed in a special box, which was filled with alabaster solution; the box was then attached to the ceiling by means of a block. The patient was practically chained to his bed. In 1851, the Dutch physician Mathyssen began using a plaster cast. This scientist rubbed dry plaster on strips of material, wrapped them around the patient's leg, and then moistened with liquid.

To get the desired effect, Pirogov tried to use any raw material for dressing - starch, colloidin and even gutta-percha. However, each of these materials has its drawbacks. N.I. Pirogov decided to create his own plaster bandage, which is used in almost the same form today. Realize that gypsum is the most best material, the famous surgeon was able after visiting the workshop of the sculptor N.A. Stepanova. There he first saw the effect of a plaster solution on a canvas. He immediately guessed that it could be used in surgery, and immediately applied bandages and strips of canvas, which were wetted with this solution, on a rather complex fracture of the lower leg. He had a wonderful effect before his eyes. The bandage dried up instantly: the oblique fracture, which also had a strong bloody smudge, healed even without suppuration. Then the scientist realized that this bandage could be widely used in military field practice.

First use of a plaster cast.

For the first time, Pirogov used a plaster cast in 1852 in a military hospital. Let's take a closer look at those times when a scientist under flying bullets tried to find a way to save the limbs of most of the wounded. During the first expedition to clear the Salt area from the invasion of enemies, a second one followed, also successful. At this time, there were quite terrible hand-to-hand fights. During the hostilities, bayonets, sabers and daggers were used. The positions of the army managed to hold high price. On the battlefield there were approximately three hundred killed and wounded soldiers of our troops, as well as officers.

Pirogov has already begun suffering in battle. He had to work for about twelve hours a day, while he even forgot to eat something. Ether anesthesia by the surgeon was widely used in combat situations. In the same period, the brilliant scientist managed to make another amazing discovery. In order to treat bone fractures, instead of lime bast, he began to use a fixed bandage made of starch. Pieces of canvas soaked in starch were applied layer after layer to a broken leg or arm. The starch began to solidify, and in a stationary state, the bone began to grow together over time. There was a fairly strong callus at the fracture site. Under the whistle of numerous bullets that flew over the tents of the infirmary, Nikolai Ivanovich realized what a great benefit a medical scientist could bring to the soldiers.

And already at the beginning of 1854, the scientist Pirogov began to understand that it was quite possible to replace the rather convenient starch dressing with plaster. Gypsum, which is calcium sulphate, is a very fine powder that is extremely hygroscopic. If it is mixed with water in the required proportions, then it begins to harden in about 5-10 minutes. Prior to this scientist, gypsum began to be used by architects, builders, and also sculptors. In medicine, Pirogov widely used a plaster cast to fix and consolidate an injured limb.

Quite widely, plaster bandages began to be used during transportation and in the treatment of patients who had injured limbs. Not without a sense of pride for his nation, N.I. Pirogov recalls that "the benefit of anesthesia and this bandage in military field practice was investigated by our nation earlier than other nations." The rather wide application of the method of bone immobilization invented by him made it possible to carry out, as the creator himself claimed, "savings treatment." Even with fairly extensive damage to the bones, do not amputate the limbs, but save them. Competent treatment of various fractures during the war was the key to saving the limbs and life of the patient.

Plaster cast today.

Today, a plaster cast is used both in trauma and surgical clinics in all parts of the world. Scientists today are trying to create different kinds such dressings, improve the composition of its components, devices that are designed for applying and removing plasters. Essentially, originally created by Pirogov, the method has not changed. The plaster cast has passed one of the most severe tests - it is the test of time.

The word "anesthesia" comes from the Greek word meaning "stupor", "numbness".

Anesthesia is necessary to block pain signals from the affected organs to the brain. Too strong a signal can overexcite one part of the brain so much that the work of the rest will go wrong. As a result, cardiac or respiratory arrest may occur.

Narcosis traces its history back to anesthesia used in surgical operations in Assyria, Egypt, India, China and other countries. ancient world. The first painkillers were made from plants and used in the form of infusions, decoctions and "sleepy sponges" soaked in the juice of henbane, hemp, opium, and hemlock. The sponge was soaked in tincture or set on fire, resulting in the formation of vapors that lulled the sick. In addition, anesthesia was caused by squeezing the vessels of the neck and limbs, releasing a large amount of blood, giving the patient wine or alcohol, applying cold.

In the XII century. at the University of Bologna, about 150 prescriptions for painkillers were collected. Around 1200, R. Lull discovered ether, the painkillers of which were described in 1540 by Paracelsus.

Despite these studies, during operations, in order to cause loss of consciousness, a wooden mallet was often used, with which the patient was beaten on the head.

AT early XIX in. the English scientist G. Devi accidentally inhaled a large dose of nitrous oxide N 2 O. At the same time, he felt extremely excited and intoxicated, he danced like a madman. Having learned about the properties of "laughing gas", respectable ladies and gentlemen began to come to Devi's laboratory to breathe in an amazing substance. Laughing gas acted in different ways: some jumped on tables and chairs, others spoke incessantly, others got into a fight.

In 1844, the American dentist X. Wells used the narcotic effect of nitrous oxide for pain relief. He first asked his assistants to extract a tooth from him using this gas as an anesthetic. However, he did not feel pain at all. Later, he tried this anesthesia on his patients, but the public demonstration of tooth extraction ended in failure: the patient screamed loudly either from pain, or at the sight of medical instruments. Failure and ridicule drove the pioneering dentist to suicide.

On October 16, 1846, N. I. Pirogov for the first time performed an abdominal surgical operation under full ether anesthesia. During it, complete anesthesia was carried out, muscles were relaxed, reflexes disappeared. The patient was immersed in a deep sleep, having lost sensitivity.

On February 14, 1847, N. I. Pirogov performed the first operation under ether anesthesia in the 2nd military land hospital.

Having tested etherization (ether anesthesia) on healthy people, again on himself, and having the material after 50 operations under ether anesthesia (using it in hospital and private practice), Pirogov decided to use ether anesthesia directly when providing surgical assistance on the battlefield.

In the same year, Pirogov performed intracheal anesthesia - the introduction of an anesthetic directly into the windpipe.

July 8, 1847 Pirogov leaves for the Caucasus, where there was a war with the highlanders, in order to test the effect of ether anesthesia as an anesthetic on a large scale. On the way to Pyatigorsk and Temir-Khan-Shura, Pirogov introduced doctors to the methods of etherization and performed a number of operations under anesthesia. In Ogly, where there was no separate room for operations, Pirogov began to operate on purpose in the presence of other wounded, in order to convince them of the analgesic effect of ether vapors. Thanks to a clear example, other wounded were also fearlessly subjected to anesthesia. Arriving at the Samurt detachment, Pirogov conducted about 100 operations in a primitive "infirmary". Thus, Pirogov was the first in the world to use ether anesthesia on the battlefield. During the year, Pirogov performed about 300 operations under ether anesthesia (a total of 690 were performed in Russia from February 1847 to February 1848).

On November 4, 1847, the Scottish physician J. Simpson performed the first operation under chloroform sedation. The first operations under chloroform anesthesia in Russia were carried out: on December 8, 1847, Lossievsky in Warsaw; on December 9, 1847, Paul in Moscow; on December 27, 1847, in St. Petersburg at the Pirogov clinic.

Pirogov vigorously introduced anesthesia into clinical practice. He continuously worked on improving the methods and techniques of anesthesia. Pirogov proposed a rectal method of anesthesia (introduction of ether into the rectum). For this, the great surgeon designed a special apparatus and improved the design of existing inhalation devices.

While studying ether anesthesia, Pirogov also injected ether into the carotid and femoral arteries, into the internal jugular vein, femoral and portal veins. On the basis of experimental data, Pirogov came to the conclusion that when liquid ether is injected into a vein, instant death occurs.

The method of intravenous anesthesia with pure ether has not gained popularity. However, Pirogov's idea about the possibility of introducing drug directly into the blood was put into practice by Russian scientists N. P. Kravkov and S. P. Fedorov, who at the beginning of the 20th century. suggested to inject the hypnotic hedonal directly into the vein.

Along with general anesthesia, local anesthesia developed. For this, rubbing was used. various substances, compression of nerve trunks, etc.

In 1859, cocaine, an alkaloid from the leaves of the coca bush, was discovered. Studies have shown that it has analgesic properties. In 1884, the Russian doctor V.K. Anrep proposed the use of cocaine as an anesthetic, and in 1884 the Austrian Keller used cocaine anesthesia for eye operations. But unfortunately, long-term use of cocaine caused painful addiction.

A new stage in local anesthesia began with the advent of novocaine, created on the basis of cocaine, but not addictive. With the introduction of novocaine solutions into practice, various methods of local anesthesia began to develop: infiltration, conduction and spinal anesthesia.

In the first half of the XX century. anesthesia, the science of pain relief, has become an independent branch of medicine. She is engaged in preparing the patient for surgery, conducting anesthesia and monitoring during surgery and in the postoperative period.

During anesthesia, the patient's condition is monitored using electroencephalography and monitoring of the pulse and blood pressure. An important stage is the exit from anesthesia, since reflexes in patients are restored gradually and complications are possible.

The use of anesthesia made it possible to carry out operations on the heart, lungs, brain and spinal cord, which were previously impossible due to a powerful pain shock. Therefore, the anesthesiologist is no less important than the surgeon.

This article about the great Russian doctor, scientist, surgeon and anesthesiologist was sent to us by our friend and colleague prof. Y. Moens. It was written by colleagues from the Netherlands and published in an anesthesiology journal. This is the story of a truly outstanding doctor and scientist.

1. F. Hendricks, J. G. Bovill, F. Boer, E.S. Houwaart and P.C.W. Hogendoorn.
2. PhD Student, Executive Board Department, 2. Emeritus Professor of Anesthesia 3. Staff Anesthetist and Director of Health Innovation, 4. Dean of the Leiden Faculty of Medicine, Leiden University Medical Center; Leiden, the Netherlands. 5. Professor of Medical History, Department of Public Health, Ethics, Society Studies, University of Maastricht; Maastricht, the Netherlands.

Summary:
The key figure who influenced the development of anesthesiology in Russia was Nikolai Ivanovich Pirogov (1810-1881). He experimented with ether and chloroform and organized the widespread use of the technique of general anesthesia in Russia in patients who were undergoing surgery. He was the first to conduct a systematic study of morbidity and mortality due to anesthesia. In more detail, he was one of the first who conducted anesthesia with the help of ether on the battlefield, where the very basic principles laid down by him military medicine remained virtually unchanged until the outbreak of World War II.

Introduction

On Friday, October 16, 1846, in the operating theater of the Massachusetts General Hospital in Boston, William Morton conducted the first successful demonstration of the use of ether for anesthesia on adults. News of this discovery was reported in the Russian press in early 1847. Although B.F. Berenson January 15, 1847 in Riga (at that time part of the territory Russian Empire) and F. I. Inozemtsev February 7, 1847 - in Moscow, were the first in Russia to use ether anesthesia, Nikolai Ivanovich Pirogov (Fig. 1) was the first surgeon who introduced the widespread use of general anesthesia in this country , adapting it for use in military field conditions.

Rice. one. Portrait of Nikolai Ivanovich Pirogov. Oil, canvas. The artist and date of execution of the portrait are unknown. Wellcome Library (published with permission)

Nikolai Ivanovich Pirogov was born on November 25, 1810 into a merchant family. At the age of 6, he taught himself to read. Later, home teachers were invited to him, thanks to whom he learned French and latin languages. At the age of 11, he was sent to a boarding school, but he stayed there for only two years, as the family had financial difficulties and the boarding school became too expensive for his parents. A family friend, Efrem Osipovich Mukhin, Professor of the Department of Anatomy and Physiology of Moscow University, helped young N.I. Pirogov to enter the Faculty of Medicine, although at that time N.I. Pirogov was only 13 years old, and was accepted there from 16. Medical education was of poor quality, students studied from outdated textbooks. Lectures were also given on the basis of old materials. By the fourth year of study, Pirogov had not yet performed a single independent autopsy and was present at only two operations. Nevertheless, in 1828 he was awarded the title of doctor. N.I. Pirogov was then only 17 years old.

After graduating from Moscow University, Pirogov continued his studies at the German-Baltic Derpt University (now Tartu, Estonia) in order to expand and deepen his knowledge and skills. He completed his studies in Dorpat in August 1832 and brilliantly defended his thesis on the topic “Num vinctura aortae abdominalis in aneurismate inhunali adhibitu facile ac turtum sut remedium” (“Is the ligation of the ventral aorta easy and effective method therapy to treat an inguinal aneurysm?”) while receiving his Ph.D. Derpt University closely cooperated with many specialists and scientists from educational institutions throughout Western Europe, which helped Pirogov to expand and accumulate knowledge in order to become an international-level specialist.

After graduating from the University of Dorpat, N.I. Pirogov continued his studies in Göttingen and Berlin. At the age of 25, in March 1826, N.I. Pirogov becomes a professor at Dorpat University and succeeds his mentor and predecessor, Professor Moyer. In March 1841, he received the position of professor of hospital surgery at the Military Medical Academy and also the position of chief surgeon of the Medical and Surgical Academy of St. Petersburg (until 1917 it remained the capital of the Russian Empire), in which he remained for 15 years, until his resignation. In April 1856, Pirogov moved to Odessa, and later to Kyiv.

In St. Petersburg, he has to face the envy of his colleagues and the constant opposition of the local administration. But this did not stop N.I. Pirogov - he continued to engage in private and academic practice and teaching.

From newspapers and magazines, such as "Northern Bee", from the medical journals "Friend of Health", "St. Petersburg Vedomosti" N.I. Pirogov learns of Morton's demonstration of ether anesthesia.

Initially, N.I. Pirogov was skeptical about ether anesthesia. But the tsarist government was interested in conducting similar experiments and researching this method. Foundations were founded to study the properties of the ether.

In 1847 N.I. Pirogov begins his research and is convinced that all his fears were unfounded and that ether anesthesia was "a tool that can transform all surgery in an instant." In May 1847 he publishes his monograph on the subject. . In the monograph, he gives recommendations that it is first necessary to conduct a test anesthesia, since the reaction of the body to the introduction of anesthesia in each person is strictly individual. For patients who do not wish to inhale ether vapors, he suggests rectal anesthesia.

Figure 2. A device for inhalation of ether vapors, developed by N. I. Pirogov.

The ether vapors from the flask (m) enter the inhalation valve (h), where they mix with the inhaled air through the holes in the valve. The quantity of the mixture, and thus the concentration of ether inhaled, is controlled by a tap (i) in the upper half of the inhalation valve. The ether/air mixture was inhaled by the patient through a tight-fitting mask connected to an inhalation valve by a long tube containing an exhalation valve. The face mask was designed by N.I. Pirogov for comfortable fixation on the patient's mouth and nose, it was an innovative invention at that time.

N.I. Pirogov studied the clinical course of anesthesia on himself and his assistants before using it on patients. In February 1847, he performed the first two operations using ether anesthesia at the Second Military Land Hospital in St. Petersburg. To introduce the patient into a state of anesthesia, he used an ordinary green bottle with a simple rubber tube for inhalation through the patient's nose.

February 16, 1847 N.I. Pirogov performs the same operation at the Obukhov hospital. On February 27, the fourth operation with the use of ether anesthesia took place at the Peter and Paul Hospital in St. Petersburg. This operation was a palliative procedure that was performed on a young girl with purulent inflammation of the stump after amputation of the leg. This time, the primitive equipment has been replaced by a device invented by the Frenchman Charrière. But it did not satisfy N.I. Pirogov, so he, together with the toolmaker L. Rooh, designed his own device and mask for ether inhalation (Fig. 2) . The mask made it possible to begin the introduction of anesthesia directly during the operation, without resorting to the help of an assistant. The valve made it possible to regulate the mixture of ether and air, enabling the doctor to track the depth of anesthesia. A year after Morton's demonstration of ether anesthesia, Pirogov performs more than 300 operations using ether anesthesia.

March 30, 1847 N.I. Pirogov sends an article to the Academy of Sciences in Paris, in which he describes his experiments on the use of ether by the rectal route. The article was only read in May 1847 . On June 21, 1847, he presents his second publication on the use of ether in animals by rectal administration. . This article became the material for his book, in which he described his experiments in administering ether to 40 animals and 50 patients. The goal was to provide practitioners with information about the effects of ether anesthesia and the design details of the device used for inhalation. This book deserves to be included in Sescher and Dinnik's list of the earliest manuals on general anesthesia.

Research on the rectal method of administering anesthesia N.I. Pirogov conducted mainly on dogs, but among the subjects were both rats and rabbits. His research was based on the work of the French physiologist François Magendie, who conducted experiments on animals using ether rectally. The ether, introduced in the form of vapors into the rectum with an elastic tube, was instantly absorbed by the blood and soon after that it could be detected in the exhaled air. Patients entered the state of anesthesia after 2-3 minutes from the beginning of the introduction of ether. Compared to inhalation, patients entered a deeper state of anesthesia with greater muscle relaxation. Such anesthesia lasted longer (15-20 minutes), making it possible to perform more complex operations. Due to the stronger relaxation of the muscles, this method of anesthesia is well suited for surgical intervention for inguinal hernia and habitual dislocations. However, this method had disadvantages. Among which it is noted: always needed hot water for the tube, the rectum must first be cleaned with an enema, after cooling and liquefying the ether, patients often got colitis and diarrhea. At the beginning of his research, Pirogov was enthusiastic about the widespread use of this method of anesthesia, but later inclined to use this method as an antispasmodic in the elimination of stones in the urinary canal. However, rectal ether has never received such widespread, although it was used in London by Dr. Buxton, at the King's College Hospital in the operations of Sir Joseph Lister and Sir Victor Hosley. There were also reports of the use of ether anesthesia in obstetric practice in the 1930s in Canada. . Also N.I. Pirogov conducted experiments on animals on the intravenous administration of anesthesia. He demonstrated that narcosis occurs when and only when ether can be detected in the exhaled air: nervous system» . Scientific work and innovations of N.I. Pirogov had a huge influence on what in Russia at that time was called the "etherization process". Although he was convinced that the discovery of ether anesthesia was one of the most significant scientific achievements, he was also quite aware of the existing limitations and dangers: "This type of anesthesia can disrupt or significantly weaken the activity of reflexes, and this is just one step away from death."

Caucasian War and anesthesia in the conditions of hostilities

In the spring of 1847, the highlanders in the Caucasus raise an uprising. Thousands of dead and seriously wounded. Field military hospitals are overflowing with soldiers with terrible wounds and injuries. The tsarist government insisted that anesthesia be used in all surgical operations for the duration of the entire military campaign. This decision was made not only on the basis of humane considerations. It was decided that soldiers, seeing how their comrades no longer experience excruciating pain during operations or amputations, would be sure that if they were injured, they would also not experience pain during the operation. This was supposed to raise morale among the soldiers.

May 25, 1847 at the conference of the Medical-Surgical Academy N.I. Pirogov was informed that he, as an ordinary professor and state adviser, was being sent to the Caucasus. He will have to instruct young doctors in the Separate Caucasian Corps on the use of ether anesthesia during surgical intervention. Assistants N.I. Pirogov were appointed Dr. P.I. Nemmert and I. Kalashnikov, senior paramedic of the Second Military Land Hospital. Preparations for departure took a week. They left St. Petersburg in June and went to the Caucasus in a carriage. N.I. Pirogov was very worried that due to strong shaking and heat (the air temperature was above 30 0 C), ether could leak. But all his fears were unfounded. Along the way, Pirogov visited several cities where he introduced ether anesthesia to local doctors. With him, Pirogov took not only ether, in a volume of 32 liters. From the factory for the production of surgical equipment (of which Pirogov was part-time director), he also captured 30 inhalers. Upon arrival at the destination, the ether was bottled in 800 ml bottles, which were placed in special boxes covered with a mat and oilcloth. . In the city of Pyatigorsk, in a military hospital, N.I. Pirogov organized theoretical and practical classes for local doctors. Together with Dr. Nemmert, he performed 14 operations of varying degrees of complexity.

In the city of Ogly, the wounded were placed in tents in full view. N.I. Pirogov deliberately did not conduct operations indoors, allowing other wounded to see that their comrades did not experience inhuman pain during operations. And the soldiers were able to make sure that their comrades were just sleeping throughout the operation and did not feel anything. In his account of a trip to the Caucasus, he writes: “For the first time, operations were carried out without the groans and cries of the wounded ... the most comforting effect of etherization was that the operations were carried out in the presence of other wounded men who were not afraid, but, on the contrary, the operations encouraged them about their own position."

Then N.I. Pirogov arrives at the Samurt detachment, located near the fortified village of Salta. There, the field hospital was the most primitive - just stone tables covered with straw. Operate N.I. Pirogov had to kneel. Here, near Saltami, Pirogov performed more than 100 operations under ether anesthesia. Pirogov writes: “Of the surgical operations performed with the use of ether, 47 were performed personally by me; 35 by my assistant, Nemmert; 5 - under my supervision by the local doctor Dushinsky and the remaining 13 - under my supervision by the regimental doctors of the battalions. Of all these patients, only two received anesthesia by the rectal method, since it was impossible to put them into a state of anesthesia by inhalation: the conditions were very primitive and there was a source of open fire nearby. This was the first time in military history that soldiers underwent operations and amputations under general anesthesia. Pirogov also found time to demonstrate the technical aspects of ether anesthesia to local surgeons.

For a year (from February 1847 to February 1848) Pirogov and his assistant Dr. Nemmert collected enough data on operations using ether anesthesia in military and civilian hospitals and hospitals. (Table 1)

Table 1. Number of patients operated on by Nikolai Ivanovich Pirogov between February 1847 and February 1848, classified according to the type of anesthesia performed and the type of surgical procedure.

Of the 580 surgeries, 108 patients died, accounting for a mortality rate of 1 in 5.4 surgeries. Of these, 11 patients died within 48 hours after surgery. N.I. Pirogov describes his experiences in the Caucasus and his statistical analysis in the book Report on a Journey through the Caucasus, in which he points out: “Russia, ahead of all Europe, shows the world by its actions not only the possibilities of application, but also the undeniable benefits of the etherization method for the benefit of the wounded on the battlefield. We hope that from now on, etherization will be, like the surgeon's knife, an indispensable attribute of every doctor during his actions on the battlefield. This unites his point of view on general anesthesia in particular and the importance of its use in surgery in general.

N.I. Pirogov and chloroform

After the return of N.I. Pirogov from the Caucasian War, December 21, 1847, he performed the first anesthesia using chloroform in Moscow. The test subject was a large dog. He meticulously recorded every detail of his operations and animal experiments. He describes the impact of anesthesia on the postoperative clinical course, in addition to his publications. As well as surgical mortality rates, he reports general anesthesia-induced side effects, which he defines as prolonged loss of consciousness, vomiting, delirium, headache, and abdominal discomfort. He spoke of "death due to the use of anesthesia" if death occurred within 24-48 hours. At autopsy, no surgical reasons or other explanations of the reason for its onset could be found. Based on his observations and analyses, he was convinced that mortality did not increase with the introduction of ether or chloroform. This conflicted with the observations of French and British doctors (who may have been influenced by the Hannah Groener case) that the administration of chloroform could lead to cardiac arrest, or, as Glover suggested, death from toxic lung blockage during anesthesia. N.I. Pirogov suggested that the deaths described by French and British doctors were the result of too rapid administration of anesthesia or a violation of the dosage of anesthesia. Acute cardiac arrest, according to N.I. Pirogov, was the result of an overdose of chloroform. He demonstrated this in dogs and cats. In 1852 John Snow reported similar results.

On the battlefield, chloroform had a number of advantages over ether. The amount of the substance was much smaller, chloroform is not flammable and did not require sophisticated equipment in its application. From start to finish, the anesthesia process was carried out with simple items: bottles and rags. In the French medical service, chloroform was used during Crimean War, it was also used by some British Army surgeons.

From the practice of N.I. Pirogov on the use of chloroform, not a single death was associated with anesthesia. There were also no cases of death from the use of chloroform in Russian field hospitals. However, five patients developed severe shock during the operation. Of these, one patient died from blood loss, and the other four recovered within a few hours. One of these patients underwent a knee extensor contracture repair procedure under deep anesthesia. After a small amount of chloroform given to induce muscle relaxation, bradycardia suddenly began to be observed. The patient's pulse ceased to be felt, breathing ceased to be recorded. The patient spent 45 minutes in this state, despite the use of all resuscitation means that existed at that time. Dilatation of the neck and arm veins was noted. Pirogov bled from the middle vein and found a release of gas with an audible hiss, but with little blood loss. Then, when massaging the neck veins and veins of the hands, even more blood appeared with gas bubbles and later - pure blood. And although N.I. Pirogov conducted his observations very carefully, he could not give an explanation for these extraordinary manifestations in the patient. Fortunately, the patient made a full recovery.

N.I. Pirogov formulated the following directions for the use of chloroform:

1. Chloroform should always be administered fractionally. This is especially true for severe injuries. Pirogov himself kept chloroform in bottles of dramm (3.9 grams)
2. Patients should be anesthetized in the supine position in any case.
3. Do not perform anesthesia immediately after eating or, conversely, after a long fast
4. Induction of anesthesia should be carried out by applying a cloth or sponge soaked in chloroform at a distance from the patient. Gradually, this distance is reduced until it reaches the patient. This will avoid laryngospasm or coughing.
5. The patient's pulse should be monitored by an experienced assistant or by the surgeon himself, managing the anesthesia process. If bradycardia sets in, chloroform should be withdrawn immediately.
6. Special care must be taken when anaesthetizing anemic patients, as they experience shock in the supine position if chloroform is administered too rapidly.

Also N.I. Pirogov gives several recommendations for resuscitation of patients, including compression chest and opening the mouth, clearing the accumulated sputum and blood in the pharynx and protruding the tongue completely out. Although these actions are considered the standard in modern practice, in the time of N.I. Pirogov they were an innovation. He also insisted that during surgery, the surgeon should examine the color and amount of blood lost. If the arterial blood was black in color and its flow was weak, the administration of chloroform should have been discontinued. Pirogov believed that the amount of the substance should be limited and amount to about 3 drams, although for some patients, in his opinion, higher doses are possible. Even if shock did not occur, there was still a risk of its onset if the amount of anesthesia was applied inappropriately or if it was administered too quickly. Pirogov also used chloroform during operations to correct strabismus in children, in newborns, and for diagnostic procedures such as the diagnosis of hidden fractures.

Crimean War (1853 - 1856)

Pirogov served in the army as a surgeon during the Crimean War. On December 11, 1854, he was appointed chief surgeon of the besieged city of Sevastopol.

During the Crimean War, many operations were carried out in the besieged Sevastopol, which were led by N.I. Pirogov. He was the first who (with the assistance of Grand Duchess Elena Pavlovna Romanova von Wüttemberg, cousin of Nicholas I) began recruiting women for nursing courses, who later became the "Sisters of Mercy". N.I. Pirogov trained them to assist the surgeon during operations, conduct general anesthesia and perform other nursing duties. This group of women became the founders of the Russian Red Cross. Unlike the British sisters of Florence Nightingale, the Russian sisters worked not only in a small area of ​​​​medical units, but also on the battlefield itself, often under artillery fire. Seventeen Russian sisters died while doing their duty during the Crimean War, and six of them in the city of Simferopol alone.

During the defense of Sevastopol, N.I. Pirogov introduced the use of anesthesia and gained invaluable experience by performing thousands of operations. In 9 months, he performed more than 5,000 amputations, that is, 30 per day. Perhaps due to overexertion, he contracted typhus and was close to death for three weeks. But thankfully, he made a full recovery. In the book "Grundzuge der allgemeinen Kriegschirurgie usw" ("The Beginnings of General Military Field Surgery" - translator's note), he described his experiments on the use of general anesthesia. The book was published in 1864 and became the standard in field surgery. The basic principles laid down by N.I. Pirogov, soon found their followers around the world and remained virtually unchanged until the Second World War. On the Crimean front, the soldiers were so confident in the extraordinary abilities of N.I. Pirogov as a surgeon, who once brought him the body of a headless soldier. The doctor, who was on duty at the time, exclaimed: “What are you doing? Where are you taking him, can't you see that he has no head? “Nothing, they will bring the head now,” the men answered. "Doctor Pirogov is here, he'll find a way to put her back in her place."

Civil anesthesiology as a medical specialization

Considering your personal experience, N.I. Pirogov warned against conducting anesthesia by an insufficiently competent assistant. Based on the experience of conducting operations in the Caucasus, he was able to make sure that operations were carried out more efficiently with experienced assistants. His main argument was that operations under general anesthesia were more difficult and took longer. Due to this, the surgeon could not fully concentrate on the course of the operation and at the same time monitor the condition of the patient, immersed in anesthesia. Again, after studying the work of health services during the Franco-Prussian war of 1870 and in Bulgaria in 1877-78, Pirogov spoke out for the strengthening of the role of new means for conducting general anesthesia during surgical intervention. He also advocated the use of anesthesia for other procedures, in particular wound care.

In December 1938, at the 24th Union Congress of Surgeons in the Soviet Union, a decision was made on the special training of anesthesiologists. In 1955, at the 26th Congress of Surgeons of the USSR, this became a reality.

Impact of military anesthesiology on civilian practice

The contribution made by N.I. Pirogov in expanding assistance to medical personnel during the war, including the extensive use of anesthesia, definitely earned him the title of founding father of field medicine. He applied his extensive experience and knowledge, accumulated during the Caucasian and Crimean conflicts, in civilian practice. From his notes it follows that his experiments confirm the belief in the usefulness of general anesthesia. It is also true that the widespread use of N.I. Pirogov of general anesthesia in military surgery, together with colleagues in the medical units of the Russian army, was to have the most significant influence on the subsequent development of the principles and techniques of general anesthesia for the main part of the civilian population of Russia.

Traveling from St. Petersburg to the battlefield, he found time to stop in different cities and demonstrate the use of general anesthesia in surgical interventions. In addition, he left there equipment for the rectal method of administering anesthesia, left masks, taught local surgeons the technique and skills of working with ether. This stimulated interest in the use of general anesthesia in these regions. After the end of the Caucasian and Crimean conflicts, news came from these regions of successfully performed operations using general anesthesia. Military surgeons brought to civilian practice the knowledge that they used during the war. And the returning soldiers carried the news of this miraculous discovery.

In conclusion, it must be said that Nikolai Ivanovich Pirogov was the greatest Russian surgeon in the history of medicine. He played key role in the development of anesthesia in Russia. He possessed a rare combination of scientific talent, an excellent teacher and an experienced surgeon. He taught his followers not only in hospitals, but also on the battlefield, where he was the first to use ether anesthesia. He became the creator of an alternative, rectal method of administering anesthesia, discovered the use of chloroform - first on animals, and then on humans. He was the first to carry out a systematic treatment of the phenomena of mortality and morbidity. He was sure that the discovery of general anesthesia was greatest achievement science, and he also warned of its threats and consequences.

N.I. Pirogov died on December 5, 1881 in the village of Vishnya (now part of the city limits of the city of Vinnitsa, Ukraine). His body was preserved using embalming techniques, which he himself developed shortly before his death, and rests in the church of Vinnitsa. Many recognitions of his achievements followed this event, including the naming of a glacier in Antarctica, a large hospital in Sofia, Bulgaria, and an asteroid discovered in August 1976 by Soviet astronomer Nikolai Chernykh after him. Stamps with his portrait were published in the Soviet Union for the 150th anniversary of his birth. Subsequently, the highest humanitarian award in the Soviet Union became gold medal N.I. Pirogov. However, we believe that Nikolai Ivanovich Pirogov deserves recognition also outside of Russia for his contribution to the spread of general anesthesia.

Thanks

We are grateful for the endless and disinterested help we received from Lyudmila B. Narusova, President of the Anatoly Sobchak Foundation, for access to the museum's archives and libraries in St. Petersburg. We are also very grateful to the administration of the Military Medical Museum in St. Petersburg for their trust, kind support and enthusiasm.