SURGICAL PROCEDURES BEFORE 1846

Greek and Roman surgeons used a variety of surgical instruments that we would recognize today. Drills, saws, syringes, cannulas, probes, and scalpels can all be viewed in the excavations at Herculaneum, Pompeii, and Rheims. Hippocrates (460–377 BC) wrote a treatise on surgery but provided little sympathy for the patient. His advice to the patient was "to accommodate the operator ... and maintain the figure and position of the part operated on ... and avoid sinking down, and shrinking from or turning away."^[100] The most famous Roman surgeon was Peanius Dioscorides (40–90 AD), a Greek physician who served in the armies of Nero. His Materia Medica, written in 77 AD, was the authoritative work on pharmacology for more than 15 centuries. In this book, he described the effects of mandragora and wine that produced "anesthesia" in the patient being cut or cauterized. He also described local anesthesia produced by the "stone of Memphis," which "being cut small, and smeared upon the places to be cut or cauterized, it produces anesthesia without danger."^[6] Unfortunately, neither Dioscorides nor his students identified this stone so that it could be used by later generations.

During the Middle Ages, attempts were made to use alcohol fumes as an analgesic during surgery ( Fig. 1-4B ). The soporific sponge is mentioned in numerous manuscripts written in the Middle Ages. One example^[6] from the 9th century comes from a Benedictine monastery at Monte Cassino, near Salerno, Italy:

A hypnotic aid, that is a soporific suitable for those who are treated by surgery, so that asleep, they do not feel the pain of cutting. Rx: opium one half ounce, mandragora the juice from the leaves, eight ounces, the juice of fresh hemlock, hyposcyanus three ounces of the juice together with sufficient water so that it forms a liquor, and then absorb in a fresh dry sponge and dry it carefully. And when thou wouldst employ this sponge, dip it in warm water, place it over the nose and cause the patient to breathe deep until he sleeps. And when thou wouldst wake him up, apply to his nose another sponge well soaked with vinegar and thou willst end the sleep.

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The sponge used by Theodoric of Cervia (1205–1296), a member of the Dominican order who practiced in Bologna, contained the same ingredients as the Salernitan sponge. Theodoric was one of the first surgeons to promote methods to ablate pain during surgery (see Fig. 1-4A ). A notable German physician of the 15th century, Heinrich von Pfolspeundt, mentioned the same sponge in a book on surgery dating from the year 1460. The effective agents in this sponge were very likely opium and scopolamine.^[6]

One of the great physicians of the Renaissance, Theophrastus Bombastus von Hohenheim, otherwise known as Paracelsus (1493–1541), was familiar with the soporific action of sulfuric ether, a compound that had been synthesized from sulfuric acid and alcohol by the chemist Valerius Cordus (1515–1544). Cordus called the flammable, volatile liquid sweet vitriol, and in 1740, Frobenius named it ether (from the Greek word for "ignite" or "blaze"). Paracelsus described the effect of ether on chickens and stated that it "quiets all suffering without harm, and relieves all pain."^[101] Although he was appointed "surgeon to the Danish army" when they besieged Stockholm in 1518, he had little interest in surgery, and these ideas were not expanded into the clinical arena.

Before the mid-19th century, the desire to relieve the pain of surgery was not intense enough for surgeons to develop the idea of general anesthesia. Textbooks on surgery are numerous before 1846, but rarely is there

Figure 1-4 A, "Operating on the Upper Arm" is taken from the textbook entitled Chirurgia by Theodoric of Cervia. It is noteworthy because it shows an intense focus by the patient directly into the gaze of an assistant. Although hypnosis is a 19th century term and its use for pain relief during surgery was not widely promoted until then, the induction of trances and altered states of being was known to the ancients. Theodoric apparently realized the value of diverting the patient's attention away from pain of surgery. B, Inhalation of the vapor of alcohol was tried in the Middle Ages as a method for pain relief during surgery. The inhaler shown here is remarkably similar to that used by William T. G. Morton on October 16, 1846, with ether as the volatile agent (compare with Fig. 1-6 ).

Anyone with questions about the dramatic break with the past that occurred in the 1840s has only to examine the accounts written by patients who survived major surgical procedures before that time. One comes from Fanny Burney^[104] (1752–1840), a novelist and celebrity of the early part of the 19th century. Here is an abbreviated account of her mastectomy for breast cancer by the surgeon Dominique J. Larrey (1766–1842), the celebrated military surgeon in Napoleon's army, and the date was September 30, 1811:

I mounted the bed and a cambric handkerchief was placed upon my face. The bed was then surrounded by 7 men and my nurse. Through the cambric I saw the glitter of the polished steel knife. A silence ensued. ... Oh what a horrible suspension! ... When the dreadful steel was plunged into the breast, I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittently during the whole time of the incision and I almost marvel that it rings not in my ears still, so excruciating was the agony.

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Although Fanny Burney lived for another 29 years after this operation, she observed that anything that would recall the surgery to her mind would reactivate the terror of the horrible experience. Apparently, operations performed without anesthesia produced long-lasting emotional and painful side effects. A modern interpretation of this phenomenon could conclude that these patients lacked any form of "preemptive analgesia"^[105] and that they therefore experienced lingering side effects after their surgical wounds had healed.

In addition to patients who experienced the terror of an operation, there were countless others who suffered with chronic ailments because the risk of surgery was too high or because they feared death or severe pain during the operation more than they suffered with the chronic condition. For example, even after the introduction of anesthesia in 1846, textbooks on treatment for hernia continued to have extensive descriptions of hernia belts and trusses.^{[106] [107]}

When the old operating room (1830) was recently restored at St. Thomas Hospital in London, the workers found dried poppy seed pods in the rafters. The apparent ineffectiveness of their analgesic methods, which presumably included alcohol and opium, and the clearly religious connotations of pain and suffering can be assumed by a review of the prayer^[108] that was read to patients before their departure to the operating theater:

As sickness is the usual forerunner of death, it should therefore lead you seriously to consider and reflect on your behavior in life. Man's life is but a succession of sorrows and a state of sufferings, that at most it is but of short duration, and at the best, of an uncertain continuance.