Thursday, May 19, 2016

“I saw the glitter of polished steel”

The tools of the trade
It is almost impossible for us to imagine the pain that was a part of surgery before the development of anæsthetics in the middle years of the nineteenth century. Yet even when the efficacy of ether and chloroform had been demonstrated, there were those who opposed the use of these agents on moral and biblical grounds.  There were, inevitably, deaths in the early use of anæsthetics, some of which, with greater knowledge of the most appropriate procedures for the use and delivery of these powerful agents might have been avoided. But there were also successes, and with their use surgeons were granted two great gifts, the gift of time and capacity to engage in operations which previously had been too difficult to achieve while the patient was conscious.

Fanny Burney
In order to get some sense of what surgery was like prior to the use of anæsthetics, we have the descriptions of patients who survived major operations while fully awake. On 30 September 1811, the 59-year-old Madame d’Arblay, better known as the writer, Fanny Burney, underwent a Mastectomy while living in France. Over the next several months, following the operation, she composed a letter to her sister, Esther, describing her experience.  It was, she wrote,
… a terror that surpasses all description, & the most torturing pain.  Yet – 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 - & I almost marvel that it rings not in my Ears still! so excruciating was the agony.  When the wound was made, & the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp & forked poniards … presently the terrible cutting was renewed … I then felt the Knife ling against the breast bone – scraping it! –
The operation was over, including the dressing of the wound, in twenty minutes.  All those involved were deeply affected and the surgeon, Dominique Jean Larrey, one of founders of modern military surgery, was described by Fanny Burney as “pale nearly as myself, his face streaked with blood, its expression depicting grief, apprehension & almost horror.”

Not only was there the horror of the operation so terrifyingly described, there was the fear, the dread, that the patient inevitably felt leading up to the actual surgery.  Florence Nightingale, summed it up when she said,
Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion.  Remember, he is face to face with his enemy all the time, internally wrestling with him, having long imaginary conversations with him.
In a footnote on the same page, she goes on, “There are many physical operations where … the danger is in a direct ratio to the time the operation lasts; and … the operator’s success will be in direct ratio to his quickness.”

 In this regard, clearly, battlefield amputations, despite the dread with which they were surely faced, at least did not engender the prolonged sense of panic that would have been the case for those, like Fanny Burney, as they anticipated surgery without anæsthetics. As terrible as her ordeal was, Fanny Burney survived and went on to live another 28 years, dying in Bath at the age of 87.

One would have to think, that with the advent of anæsthetics in the mid-1840s, their use would quickly become commonplace.  But that was not the case.  The use of such agents, it was argued, was against the law of God, pain was required for survival during and after an operation, individuals were somehow robbed of their awareness and this was dangerous during surgery.  Surgery was always the last resort and then, in most cases, it was fast, fierce and incredibly painful. Yet, as Stephanie Snow has pointed out, “from December 1846 until at least the 1860s, anæsthesia was a selective practice.” For many surgeons, pain was seen as an important element of a successful operation.

While pain may have been viewed as necessary, surgeons were not sadist.  They did not enjoy the pain they caused.  John Abernathy, of Barts, on his way to operate, when asked how he felt responded “as if I was going to a hanging,” and one of his students recalled seeing him, following a difficult amputation, “with tears streaming down his face, vomiting.”

By the 1840s, the most outstanding surgeon in Britain would have had to have been Robert Liston. Known for his speed, skill and, when operating, the utter ruthlessness required in the pre-anæsthetic years, he offers a useful insight into how some of the best surgeons were quickly converted to pain relief in operations. Liston straddled the years from before the advent of anæsthesia to the period in which, although not yet fully accepted, it was coming into more common use.  Before his own use of anæsthetics, Liston was known for the speed with which he could perform an amputation.  As he reached for the knife he would address the gallery, “time me gentlemen.” And time him they did.  It was not uncommon for him to remove a limb and tie off the blood vessels in around thirty seconds.
Thirty seconds of remarkable dexterity, flashing blades, rapid movements and brilliant showmanship.  Thirty seconds of such pain that few patients are ever able to put it adequately into words.  The memory of those thirty seconds will haunt them for the rest of their lives. If they live.
According to his biographer, “it was said of Liston that when he amputated the gleam of his knife was followed so instantaneously by the sound of sawing as to make the two actions appear almost simultaneous.”
Robert Liston in the operating theatre
On 21 December 1846 Liston entered the operating theatre and announced, “We are going to try a Yankee dodge today, gentlemen, for making men insensible.”  The Yankee dodge, was using ether to anæsthetize a patient, in this case, before removing his leg above the knee. The notes for the operation indicate that the entire procedure, including the tying off of the blood vessels, took twenty-five seconds. As the patient regained consciousness, he asked “when are you going to begin?” Post-operatively Liston comments, “this Yankee dodge, gentlemen, beats mesmerism hollow!” Liston was well aware of what was going on in the medical world and he soon had John Snow on his team, administering ether to his surgical patients.

Although by mid-century, chloroform was increasingly become a tool for surgery on the battlefield, there were still those who either opposed it or had serious doubts about its use. One of these was the Principal Medical Officer of the British Expeditionary Army in the Crimea, Sir John Hall, M.D., K.C.B., F.R.C.S. In a letter to Lord Raglan, Commander of the British troops in the Crimea, Hall wrote, cautioning against the use of chloroform, “for, however barbarous it may appear, the smart of the knife is a powerful stimulus, and it is much better to hear a man howl lustily, than to see him sink silently into his grave.”
Amputees before anæsthesia recorded amazing examples of sangfroid during surgery, including that of children, often buttressed by strong religious convictions.  Others admitted to real pain and terror. … general anæsthesia not only relived patients but gave surgeons time to operate more accurately and also pursue alternative operations which avoided amputation.
It is hard today to even imagine what it must have been like to undergo surgery in the years before the use of anesthetics. Certainly, though, by the 1860s, pain in surgery was becoming a thing of the past.  The next big step forward was to figure out why so many patients died after what appeared to be successful surgery and to determine what to do to reduce those numbers.

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