Nanomedicine, Volume I: Basic Capabilities
© 1999 Robert A. Freitas Jr. All Rights Reserved.
Robert A. Freitas Jr., Nanomedicine, Volume I: Basic Capabilities, Landes Bioscience, Georgetown, TX, 1999
Pain did not prevent surgery but made it almost unbearable, and the accompanying trauma often proved dangerous. Before the anesthetic era, which commenced in the late 1840s, surgical operations were agonizing. Of course, if the patient had a broken leg or amajor wound, there was no choice but submit to a surgeon's knife. But non-emergency elective operations would only be undergone if the condition itself was so painful or life-threatening that the victim could even consider allowing surgery. In this event, patients would choose a surgeon with the best reputation for quickness -- a limb might be removed or a bladder stone evacuated in a couple of minutes. Progress in technique was often rapid. For example, in 1824, Astley Cooper (1768-1841) took 20 minutes to amputate a leg through the hip joint; ten years later, James Syme (1799-1870) was doing it in just 90 seconds.
In pre-anesthetic days, operations were rushed through at lightning speed and under conditions of appalling difficulty. The most hardened surgeons had to steel themselves to perform operations which they knew would cause agony to their patients and nerve-wracking distress to themselves. It is hard for any 20th century inhabitant of an industrialized nation to imagine what a major surgical operation must have meant to the patient in the days before anesthesia. The following is a personal account by a male patient who suffered the removal of a stone from the bladder by Henry Cline (1750-1827), surgeon to St. Thomas's Hospital and one of the leading operators of the day, on 30 December 1811, just three decades before the widespread adoption of anesthesia:
"My habit and constitution being good it required little preparation of body, and my mind was made up. When all parties had arrived I retired to my room for a minute, bent my knee in silent adoration and submission, and returning to the surgeons conducted them to the apartment in which the preparations had been made. The bandages &c. having been adjusted I was prepared to receive a shock of pain of extreme violence and so much had I overrated it, that the first incision did not even make me wince although I had declared that it was not my intention to restrain such impulse, convinced that such effort of restraint could only lead to additional exhaustion. At subsequent moments, therefore I did cry out under the pain, but was allowed to have gone through theoperation with great firmness."
"The forcing up of the staff prior to the introduction of the gorget gave me the first real pain, but this instantly subsided after the incision of the bladder was made, the rush of urine appeared to relieve it and soothe the wound."
"When the forceps was introduced the pain was again very considerable and every movement of the instrument in endeavoring to find the stone increased. Still, however, my mind was firm and confident, and, although anxious, I was yet alive to what was going on. After several ineffectual attempts to grasp the stone I heard the operator say in the lowest whisper, "It is a little awkward, it lies under my hand. Give me the curved forceps," upon which he withdrew the others. Here, I think, I asked if there was anything wrong -- or something to that purport -- and was reanimated by the reply conveyed in the kindest manner, "Be patient, Sir, it will soon be over." When the other forceps was introduced I had again to undergo the searching for the stone and heard Mr. Cline say, "I have got it." I had probably by this time conceived that the worst was over; but when the necessary force was applied to withdraw the stone the sensation was such as I cannot find words to describe. In addition to the positive pain there was something peculiar in the feel. The bladder embraced the stone as firmly as the stone was itself grasped by the forceps; it seemed as if the whole organ was about to be torn out. The duration, however, of this really trying part of the operation was short and when the words "Now, Sir, it is all over" struck my ear, the ejaculation of "Thank God! Thank God!" was uttered with a fervency and fulness of heart which can only be conceived....I never heard what was the precise duration of the operation but conceive it to have been between twelve and fifteen minutes."
And now, a woman's point of view. In 1810, Napoleon's famed military doctor Dominique Jean Larrey performed a radical mastectomy without anesthetic on the popular female novelist Fanny Burney (1752-1840). Burney later wrote a long account of the operation which, despite the excruciating agony, she believed had nevertheless saved her life:
"M. Dubois placed me upon the Mattress, & spread a cambric handkerchief upon my face. It was transparent, however, & I saw through it that the Bed stead was instantly surrounded by the 7 men and my nurse. I refused to be held; but when, bright through the cambric, I saw the glitter of polished steel -- I closed my eyes..."
"Yet -- when the dreadful steel was plunged into the breast -- cutting through veins -- arteries -- flesh -- nerves -- I needed no injunctions 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 [small pointed daggers], that were tearing at the edges of the wound. But when again I felt the instrument, describing a curve, cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose & tire the hand of the operator, who was forced to change from the right to the left -- then, indeed, I thought I must have expired, I attempted no more to open my eyes....The instrument the second time withdrawn, I concluded the operation over -- Oh no! presently the terrible cutting was renewed -- & worse than ever, to separate the bottom, the foundation of the dreadful gland from the parts to which it adhered...yet again all was not over...."
This chilling account continued for several more pages.
When did the practice of anesthesia begin? The Herbal of Dioscorides (ca. 40-90 AD) contains specific directions for giving a decoction (boiled extraction) of mandragora "to such as shall be cut or cauterized," one of the earliest references to surgical anesthesia. Bernard de Gordon (ca. 1260-1308) tells us that the Salernitans rubbed up poppy seed and henbane and used them as a plaster to deaden the sensibility of a part to be cauterized. Arnold of Villanova (1235-1311) gives the following recipe:
"To produce sleep so profound that the patient may be cut and will feel nothing, as though he were dead, take of opium, mandragora bark, and henbane root equal parts, pound them together and mix with water. When you want to sew or cut a man, dip a rag in this and put it to his forehead and nostrils. He will soon sleep so deeply that you may do what you will. To wake him up, dip the rag in strong vinegar."
Some of the surgical textbooks of the Middle Ages contain references to anesthetic sponges which were prepared by soaking them in various herbs reputed to have soporific properties. The favorite herb for this purpose was the mandrake. Another simple method of producing analgesia used intermittently from early times was compression. Writing in 1564 about the various uses of the tourniquet, the French surgeon Ambrose Pare noted that "it much dulls the sense of the part by stupefying it." Amusingly, reliable witnesses claim that as late as the 19th century, a method of anesthesia practiced at the Imperial Court of China was to "knock the patient out by a sudden blow on the jaw."
The almost complete absence of any mention of pain-relieving drugs in medical literature of the post-medieval period is not easy to explain. It is, however, probable that the action of crude concoctions employed in early times was very uncertain, and that drugged sleep often ended in death. The active ingredients of the many herbs used in medicine had not been isolated and it would have been very difficult to regulate dosages reliably.
The story of inhalation anesthesia begins in 1799 when Sir Humphry Davy (1778-1829) recorded the effects produced by the inhalation of nitrous oxide. He breathed various concentrations of the gas and noted that a headache and the pain associated with the cutting of a wisdom tooth were relieved. Demonstrations of the effects of nitrous oxide were frequently given, bladders filled with "laughing gas" being passed around at lectures. Gas inhalation became a popular party game. A little book of 1839 contains adescription of the "irresistibly ridiculous" sight of a large room filled with persons each of whom was sucking from a bladder. As the gas began to take effect, "some jumped over the tables and chairs; some were bent on making speeches; some were very much inclined to fight; and one young gentleman persisted in attempting to kiss the ladies." At about the same time, "ether frolics" became equally popular.
In January 1842, William E. Clarke (b. 1818), a young American physician of Rochester, New York, who had acquired some knowledge of ether by attendance at ether frolics, administered the chemical on a towel to a Miss Hobbie who then had one of her teeth extracted painlessly. So far as is known this was the first use of ether for a dental or surgical operation. In March 1842, Crawford W. Long (1815-1878) of Danielville, Georgia, who had also witnessed ether frolics "enjoying sweet kisses from the girls," successfully removed a small tumor from the neck of a patient under the influence of ether. Horace Wells (1815-1848), a dentist of Hartford,Connecticut, attended a public demonstration of the effects of nitrous oxide in December 1844, and the day after he administered the gas to himself and had one of his own teeth pulled out by a colleague. Afterwards, Wells wrote: "I didn't feel it so much as the prick of a pin." His former partner, William Thomas Green Morton (1819-1868), also introduced ether into his dental practice in 1846. By February 1847, the Lancet and other medical journals were reporting anesthetic operations from all parts of Great Britain, and ether had been used in most European countries. In June 1847 the news reached South Africa and a leg was amputated painlessly by W.G. Atherstone of Grahamstown.
Sir James Young Simpson (1811-1870), professor of surgery at Edinburgh, introduced chloroform in 1847. Tradition has it that Simpson had been testing chemicals with his assistants when somebody upset a bottle of chloroform; upon bringing in dinner, Simpson's wife found them all asleep. Unlike ether, chloroform did not irritate the lungs or cause vomiting, and was powerful and easy to administer. In April 1853, Queen Victoria (1819-1901) took chloroform for the birth of Prince Leopold; John Snow (1813-1858) administered the anesthetic. Protests followed -- some objections were religious (e.g., the Bible taught that women were supposed to bring forth in "travail and pain"*) but most were medical, putatively on grounds of safety but ringing with naturophilia (Section 1.3.4): "In no case could it be justifiable to administer chloroform in perfectly ordinary labor," complained the Lancet. Incredibly, some early 19th century surgeons believed that using anesthesia for an operation would weaken a patient's character.
* Others pointed to Genesis 2:21, where Adam is put to sleep as the rib is taken for Eve.
Of course, general anesthesia could indeed prove dangerous, and deep unconsciousness was unnecessary for less invasive procedures, so the search was on for substances that would numb a particular area for local surgery. Cocaine was isolated in 1859 and was first used in ophthalmologic procedures by Carl Koller (1857-1944). Cocaine became the first widely-used local anesthetic, synthesized in 1885 by the Merck drug company.
Last updated on 5 February 2003