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September 1996
Volume 60 |
Number 9
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| Surgery Before
Anesthesia |
John T. Sullivan, M.D.
In October 1896, a distinguished group celebrated the 50th anniversary
of the first public demonstration of ether anesthesia at Massachusetts
General Hospital. Among those present were a few re-maining physicians
who had witnessed the horrors of sur-gery before anesthesia. They
recounted ghastly images that a modern anesthesiologist can barely
fathom. Now 100 years later, we celebrate the 150th anniversary
of Morton's demonstration -- with an ever-diminishing concept
of what surgery was like be-fore anesthesia.
Elective surgery was performed very infrequently prior to the
advent of effective anesthesia. From 1821 to 1846, the annual
reports of Massachusetts General Hospital recorded 333 surgeries,
representing barely more than one case per month.1
Surgery was a last and desperate resort. Reminiscing in 1897 about
preanesthesia surgery, one elderly Boston physician could only
compare it to the Spanish Inquisition. He recalled "yells
and screams, most horrible in my memory now, after an interval
of so many years. ... In one of these operations, performed by
the hospital's senior surgeon, John Collins Warren, M.D., the
cancerous end of a young man's tongue was cut off by a sudden,
swift stroke of the knife, and then a red-hot iron was placed
on the wound to cauterize it. Driven frantic by the pain and the
sizzle of searing flesh inside his mouth, the young man escaped
his restraints in an explosive effort and had to be pursued until
the cauterization was complete, with his lower lip burned in the
process.
In another operation, an unsuccessful attempt to reduce a dislocation
of the thigh, a man was literally put to the rack for half an
hour with a block and tackle arrangement."2
Before surgery, patients felt like condemned criminals awaiting
execution, and if they survived the experience, the memory of
it haunted them for the rest of their lives. In a letter written
to Sir James Young Simpson, the renowned Scottish anaesthetist,
a fellow physician who underwent amputation of the limb said,
"I at once agreed to submit to the operation but asked a
week to prepare for it, not with the slightest expectation that
the disease would take a favorable turn in the interval, or that
the anticipated horrors of the operation would become less appalling
by reflection on them, but simply because it was so probable that
the operation would be followed by a fatal issue...." Of
the procedure itself, he recollected, "Suffering so great
as I underwent cannot be expressed in words. ... The particular
pangs are now forgotten; but the blank whirlwind of emotion, the
horror of great darkness and the sense of desertion by God and
man ... I can never forget, however gladly I would do so. ...
Those are not pleasant remembrances ... and even now they are
easily resuscitated and ... they can occasion a suffering of their
own."3
One of the most thorough descriptions of preanesthetic surgery
can be found in a 12-page letter written by English author Fanny
Burney to her sister Esther in March 1812, after surviving a mastectomy
in 1811. For pain and induration in her breast, she sought the
opinions of several respected medical and surgical consultants
and was devastated when they concluded she had a life-threatening
cancer: "[I]n time I was formally condemned to an operation
by all three."
When the fateful day arrived, her only premedication was a "wine
cordial," and she courageously submitted to the team of seven
physicians who had arrived at her home in Paris. She tried to
ignore the entire closet they filled with compresses and bandages,
and one tactfully "inquired whether I had cried or screamed
at the birth of [my son] Alexander ... what terrible inferences
were here to be drawn." She lay on her bed, and although
her face was covered with a light handkerchief, she could see
the surgeon outline his intended incision with a forefinger and
"the glitter" of his knife. "When the dreadful
steel was plunged into the breast, cutting through veins, arteries,
flesh, nerves, I needed no injunction not to restrain my cries.
I began a scream that lasted unintermittingly during the whole
time of the incision, and I almost marvel that it rings not in
my ears still! So excruciating was the agony."
A second incision was made, and when the knife was withdrawn,
"I concluded the operation over. Oh no! Presently the terrible
cutting was renewed and worse than ever...." Even when the
tissue was severed from her body, "yet again all was not
over," I then felt the knife rackling against the breastbone,
scraping it! This performed, while I remained in utterly speechless
torture...." When it was over, she was carried virtually
lifeless from the bed but did recall looking up at her surgeon
who was "pale nearly as myself, his face streaked with blood
and its expression depicting grief, apprehension, and almost horror."
Out of necessity, the most valued surgical skill before anesthesia
was quickness. [View first known picture
of an amputation.] English physician and medical historian
Sir Clifford Allbutt recalled of preanesthetic surgery: "When
I was a boy, surgeons operating upon the quick were pitted one
against the other like runners on time. He was the best surgeon,
both for the patient and onlooker, who broke the three-minute
record in an amputation or a lithotomy."4
Under these circumstances, there was little opportunity for careful
dissection or improvements in surgical technique. In fact, the
atmosphere seemed to favor showmanship most of all. Langeback,
a surgeon of Napoleon's day, claimed boldly that he could "amputate
a shoulder in the time it took to take a pinch of snuff."5
The experience for surgeons ranged from those who emerged from
the operating theater pale and sick themselves at the end of the
case to some callous enough to tell their patients "Hush!"
amid their agony. One young surgeon, who himself had to undergo
an extremely painful incision of the hand for a deep abscess,
said after it was over, "I never again shall swear at a patient
I am operating on."2
Over the centuries, numerous techniques had been used to dull
sensation for surgery. Soporifics and narcotics were prepared
from a wide range of plants, including marijuana, belladonna and
jimsonweed. Healers attempted to induce a psychological state
of anesthesia by Mesmerism or hypnosis. Distraction could be provided
by rubbing the patient with counterirritants such as stinging
nettles. A direct but crude way of inducing a state of insensitivity
was to knock the patient unconscious with a blow to the jaw.6
But by 1846, "opium and alcohol were the only agents which
continued to be regarded as of practical value in diminishing
the pain of operations."3
Unfortunately, the large doses of alcohol needed to produce stupefaction
were likely to cause nausea, vomiting and death instead of sleep.
Opium, while a strong analgesic, had significant side effects
itself and was typically not powerful enough to completely blunt
a surgical stimulus.
The fact that a half century passed between the discovery of the
anesthetic effects of the inhalational drugs and their widespread
clinical use is remarkable and tragic. Sir Humphry Davy inhaled
nitrous oxide to eliminate the pain of a toothache in 1795 and
actually suggested its use as an analgesic during surgical operations.
Shortly thereafter, his colleague Michael Farraday reported similar
results with ether.6 Experimentation,
recreational use and a few isolated clinical applications of inhaled
anesthetics persisted until William T.G. Morton publicly demonstrated
the value of ether for surgery at Massachusetts General Hospital
on October 16, 1846.
The accounts and recollections of surgery before the days of effective
anesthesia are gruesome. Remarkably, they were a reality only
a few generations ago. Today, it is easy to forget the burden
of surgical pain. On this 150th anniversary of the first public
demonstration of anesthesia, we can reflect proudly on the achievements
of Morton and others like him who have advanced the art and science
of our field.
References:
1. Greene NM. Anesthesia and the development
of surgery (1846-1896). Anesth Analg. 1979; 58:5-12.
2. Pullen JJ. The men who brought us anesthesia.
1976. Available in: Massachusetts General Hospital Archives, Boston,
Massachusetts.
3. Ashhurst J. Surgery before the days of anesthesia.
Boston Medical and Surgical Journal. October 1896; 135(16):378-380.
4. Beecher HK. Anesthesia. Scientific American.
January 1957; 196:70-82.
5. Hoffman SA. Under the Ether Dome.
New York: Charles Scribner and Sons; 1986:267.
6. Magner LN. The History of Medicine. New
York: M. Dekker; 1992:279-304.
Acknowledgment:
Special thanks to Charles C. Tandy, M.D., who provided the translation
and transcription of the Fanny Burney letter.
John T. Sullivan, M.D., is a CA-2 anesthesiology
resident at Massachusetts General Hospital, Boston, Massachusetts.
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