Fig. 2.1
Humphry Davy, the precocious superintendent of the Pneumatic Institution in Bristol, described the capacity of nitrous oxide to prevent pain, suggesting its use in surgical procedures, but no one took up his suggestion
On page 465 of Davy’s book, he described his self-treatment for the pain associated with eruption of a wisdom tooth:
“In cutting one of the unlucky teeth called dentes sapientiae, I experienced an extensive inflammation of the gum, accompanied with great pain, which equally destroyed the power of repose and consistent action. On the day when the inflammation was most troublesome, I breathed three large doses of nitrous oxide. The pain always diminished after the first four or five respirations; the thrilling came on as usual, and uneasiness was for a few minutes swallowed up in pleasure. As the former state of mind returned, the state of organ returned with it; and I once imagined that the pain was more severe after the experiment than before.”
Part of this fits with what we now believe about the effects of nitrous oxide. It may decrease the perception of pain (i.e., cause analgesia), in part, by activating the receptors turned on by opioids such as morphine [4]. Tolerance (a decreased effectiveness) develops with nitrous oxide, especially with repeated administration, possibly explaining enhanced pain on recovery [5].
On page 556 of his book, we find Davy’s famous quotation suggesting the possibility of surgical anesthesia: “As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place [3].” His suggestion went unnoticed. This meteor of a man went on to discover several elements including sodium, and construct the miners’ safety lamp, but his inaction regarding nitrous oxide cost him anesthesia’s gold ring, the greatest discovery in all of medicine. He was immortalized by Edmund Clerihew Bentley’s poem (aclerihew is a poetic 4-line verse that takes the form AA, AA, BB, BB). The first-ever clerihew was perhaps written during a particularly boring chemistry lecture:
Sir Humphry Davy
Was not fond of gravy
He lived in the odium
Of having discovered sodium.
1800–1810
As the nineteenth century began, the US had but 4 medical schools. Benjamin Rush (1745–1813), professor at the foremost school, the University of Pennsylvania, had attempted to minimize labor pain by applying leeches to remove blood. Since the pain of childbirth caused stimulation, he reasoned that bloodletting would offer relief by producing an opposing depression. In defense of higher learning in the US, note that Rush obtained his medical education at the University of Edinburgh and St Thomas’ Hospital in London. Others shared his belief in the curative power of the removal of blood by venesection (Stanley, p 54) [6]: “In 1809, The Times reported on an American, Captain James Niblett, who over two months had been bled of 600 ounces of blood, more than fifty instances in addition to leeches.”
In 1803, Serturner isolated morphine from opium.
1810–1820
Numerous reports describe the agony of surgery and the lingering after effects, what we might now call post traumatic stress disorder (PTSD). Columnist David Brooks wrote [7]: “In 1811, the popular novelist Fanny Burney learned that she had breast cancer and underwent a mastectomy without anesthesia:
“‘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,..I began a scream that lasted intermittingly during the whole time of the incision’& I almost marvel that it rings not in my ears still.’ The surgeon removed most of the breast but then had to go in a few more times to complete the work: ‘I then felt the Knife rackling against the breast bone’scraping it! This performed while I yet remained in utterly speechless torture.’”
Brooks noted that Burney wrote about more than the immediate experience. She described the recurring impact on her emotions. “Not for days, not for weeks, but for months I could not speak of this terrible business without nearly again going through it!… I dare not revise, nor read, the recollection is still so painful.” PTSD, indeed!
A patient of Scottish surgeon James Simpson provided another vivid description of the agony of remembrances of surgery [8]:
“Suffering so great as I underwent cannot be expressed in words…but the blank whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, which swept through my mind, and overwhelmed my heart, I can never forget…Those are not pleasant remembrances. For a long time they haunted me, and even now they are easily resuscitated; and though they cannot bring back the suffering attending the events which gave them a place in my memory, they can occasion a suffering of their own, and be the cause of a disquiet which favors neither mental nor bodily health.”
It might have been nearly impossible for four strong men to restrain a terrified woman or man subjected to the knife (Fig. 2.2). And the struggles of the consenting patient could be sufficient to cause the operating table to disintegrate [9].
Fig. 2.2
The agony of surgery without anesthesia and the violence of the response to surgery are readily imagined
Yet surgery continued despite the woe it induced, despite the agony, despite the haunting memories. For some, pain was something to be borne, a misery that nonetheless did not preclude surgery or surgical advancement.
“When the vapour of ether mixed with common air is inhaled, it produces effects very similar to those occasioned by nitrous oxide…In trying the effects of the ethereal vapour on persons who are peculiarly affected by nitrous oxide, the similarity of sensation produced was very unexpectedly found to have taken place. One person who always feels a depression of spirits on inhaling the gas, had sensation of a similar kind produced by inhaling the vapour.”
Faraday raised a caution regarding ether [10]: “By the imprudent inspiration of ether, a gentleman was thrown into a very lethargic state, which continued with occasional periods of intermission for more than 30 hours, and a great depression of spirits; for many days the pulse was so much lowered that considerable fears were entertained for his life.”
Surgeons used counter-irritants “to inflict pain in the hope of healing [6].” They would apply blistering agents. They would remove blood with lances and leeches. In 1819, Sir Walter Scott, plagued with stomach cramps was subjected to
“profuse bleeding and liberal blistering” causing him to scream “without interval through the night, terrifying his family and servants…Looking back on the ordeal Scott reflected wryly that his doctors had told him that ‘mere pain cannot kill’…The suffering inseparable from treatment before or besides surgery, however, explains how the acute pain of surgery was perhaps merely an intensification of a regime in which prolonged pain was seen as an inevitable part of healing [6].” (p 56)
1820–1830
In the first half of the nineteenth century, surgeons devised operations of increasingly greater complexity, invasiveness and duration. Stanley [6] reported (pp 64–5) that in 1822,
“Working in a cottage in poor light Liston excised a tumour beneath McNair’s shoulder blade…’I began by making an incision of a foot long…I felt my finger and knife dip into the body of the tumour…I immediately thrust my sponge into the cavity, so as to command the haemorrhagy. The patient, who had borne the operation well…now dropped his head off the pillow, pale, cold, and almost lifeless. I then…saw that nothing but a bold stroke of the knife could save the boy from immediate death. Pulling out the sponge, therefore, with one rapid incision I completely separated the upper edge of the tumour…After removing the tumour, I found it necessary to saw off the ragged and spongy part of the scapula, so as to leave only a fourth part of that bone….’ Liston’s patient survived the operation but died four months later….”Related posts:
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