Insensibility During Surgical Operations Produced by Inhalation
Insensibility During Surgical Operations Produced by Inhalation
Anesthesia Gives Rise to Modern Surgery
By: Henry J. Bigelow
Source: Henry J. Bigelow. "Insensibility During Surgical Operations Produced By Inhalation." Boston Medical and Surgical Journal 35 (1846): 309-317.
About the Author: Henry J. Bigelow (1818–1890) was a clinical pharmacologist and surgeon, who wrote many essays based on his observations, research, and experience with the early use of anesthesia in the performance of surgical procedures. Among his best known publications is the extended essay entitled A History of the Discovery of Modern Anesthesia. It was Dr. Bigelow's assertion that the optimal agent for surgical anesthesia should result in safe, total, and sustainable insensibility throughout the course of the entire procedure. Although he did not believe ether to be completely perfect as an agent of insensibility, as it was flammable, he deemed it adequate for the performance of successful surgeries. Indeed, it is the use of ether during operative procedures that has been credited with the inception of the anesthetic revolution and the dawn of the modern surgical era. Throughout his career, Henry J. Bigelow wrote extensively on various anesthetic preparations and techniques, most notably on the use of ether and of chloroform for induction of insensibility.
Before the introduction of modern methods of anesthesia, surgery was a rare, and often life-threatening, event. Before insensibility-causing agents were discovered, a variety of non-pharmaceutical methods were employed, including the use of mandrake root, henbane, opium, jimsonweed, cannabis, datura, coca, and hemp as means of clouding consciousness. Ingestion of large amounts of alcohol was also used for this purpose. None of these methods were particularly satisfactory, as they did not completely prevent the perception of pain, and all had unpredictable side effects, including possible death.
Surgery was considered a treatment of last resort, and the agony endured by surgical patients was substantial. Typically, a large and brawny surgical assistant was employed for the purpose of holding down the patient who was tightly strapped to the table. Patients screamed in fear and pain throughout the procedure, and were considered fortunate if they fainted from pain early on in the proceedings. The operation was necessarily extremely quick, taking not more than a few minutes from start to finish, in order for the patient to survive. As a result, accuracy was often lacking and complications such as postoperative bleeding and infection were common.
Hypnosis, or mesmerism, was sometimes used as a means of altering consciousness, as was acupuncture. Other non-pharmacological methods used included the application of a mixture of cold and salt to the surgical site, compression of blood flow to the area, concussion (usually a sharp blow to the jaw) in an effort to mechanically induce a state of unconsciousness, compression of blood flow through the carotid arteries in the neck, bleeding or blood-letting, and the use of counterirritants as a means of distraction (rubbing the patient elsewhere on the body with stinging nettles, for example).
In 1846, Henry J. Bigelow read a local newspaper article concerning dentist William Morton's painless surgical removal of an ulcerous tooth through the use of inhaled ether. Bigelow met Morton, and arranged for him to demonstrate his painless surgical technique at the Massachusetts General Hospital, where Bigelow was a junior surgeon. Dr. John Collins Warren, head surgeon at the Massachusetts General Hospital, agreed to perform the operation, with Morton providing the anesthesia. Henry J. Bigelow's account of several similar proceedings follows.
It has long been an important problem in medical science to devise some method of mitigating the pain of surgical operations. An efficient agent for this purpose has at length been discovered. A patient has been rendered completely insensible during an amputation of the thigh, regaining consciousness after a short interval. Other severe operations have been performed without the knowledge of the patients. So remarkable an occurrence will, it is believed, render the following details relating to the history and character of the process, not uninteresting.
On the 16th of Oct. 1846, an operation was performed at the hospital upon a patient who had inhaled a preparation administered by Dr. Morton, a dentist of this city, with the alleged intention of producing insensibility to pain. Dr. Morton was understood to have extracted teeth under similar circumstances, without the knowledge of the patient. The present operation was performed by Dr. Warren, and though comparatively slight, involved an incision near the lower jaw of some inches in extent. During the operation the patient muttered, as in a semiconscious state, and afterwards stated that the pain was considerable, though mitigated; in his own words, as though the skin had been scratched with a hoe. There was, probably, in this instance, some defect in the process of inhalation, for on the following day the vapor was administered to another patient with complete success. A fatty tumor of considerable size was removed, by Dr. Hayward, from the arm of a woman near the deltoid muscle. The operation lasted four or five minutes, during which time the patient betrayed occasional marks of uneasiness; but upon subsequently regaining her consciousness, professed not only to have felt no pain, but to have been insensible to surrounding objects, to have known nothing of the operation, being only uneasy about a child left at home. No doubt, I think, existed, in the minds of those who saw this operation, that the unconsciousness was real; nor could the imagination be accused of any share in the production of these remarkable phenomena.
I subsequently undertook a number of experiments, with the view of ascertaining the nature of this new agent, and shall briefly state them, and also give some notice of the previous knowledge which existed of the use of the substances I employed.
The first experiment was with sulphuric ether, the odor of which was readily recognized in the preparation employed by Dr. Morton. Ether inhaled in vapor is well known to produce symptoms similar to those produced by the nitrous oxide….
It remains briefly to describe the process of inhalation by the new method, and to state some of its effects. A small two-necked glass globe contains the prepared vapor, together with sponges to enlarge the evaporating surface. One aperture admits the air to the interior of the globe, whence, charged with vapor, it is drawn through the second into the lungs. The inspired air thus passes through the bottle, but the expiration is diverted by a valve in the mouth piece, and escaping into the apartment is thus prevented from vitiating the medicated vapor. A few of the operations in dentistry, in which the preparation has as yet been chiefly applied, have come under my observation. The remarks of the patients will convey an idea of their sensations.
A boy of sixteen, of medium stature and strength, was seated in the chair. The first few inhalations occasioned a quick cough, which afterwards subsided; at the end of eight minutes the head fell back, and the arms dropped but owing to some resistance in opening the mouth, the tooth could not be reached before he awoke. He again inhaled for two minutes, and slept three minutes, during which time the tooth, an inferior molar, was extracted. At the moment of extraction the features assumed an expression of pain, and the hand was raised. Upon coming to himself he said he had had a "first rate dream—very quiet," he said, "and had dreamed of Napoleon—had not the slightest consciousness of pain—the time had seemed long;" and he left the chair, feeling no uneasiness of any kind, and evidently in a high state of admiration. The pupils were dilated during the state of unconsciousness, and the pulse rose from 130 to 142.
A girl of sixteen immediately occupied the chair. After coughing a little, she inhaled during three minutes, and fell asleep, when a molar tooth was extracted, after which she continued to slumber tranquilly during three minutes more. At the moment when force was applied she flinched and frowned, raising her hand to her mouth, but said she had been dreaming a pleasant dream and knew nothing of the operation.
A stout boy of twelve, at the first inspiration coughed considerably, and required a good deal of encouragement to induce him to go on. At the end of three minutes from the first fair inhalation, the muscles were relaxed and the pupil dilated. During the attempt to force open the mouth he recovered his consciousness, and again inhaled during two minutes, and in the ensuing one minute two teeth were extracted, the patient seeming somewhat conscious, but upon actually awaking he declared "it was the best fun he ever saw," avowed his intention to come there again, and insisted upon having another tooth extracted upon the spot. A splinter which had been left, afforded an opportunity of complying with his wish, but the pain proved to be considerable. Pulse at first 110, during sleep 96, afterwards 144; pupils dilated.
The next patient was a healthy-looking, middle-aged woman, who inhaled the vapor for four minutes; in the course of the next two minutes a back tooth was extracted, and the patient continued smiling in her sleep for three minutes more. Pulse 120, not affected at the moment of the operation, but smaller during sleep. Upon coming to herself, she exclaimed that "it was beautiful—she dreamed of being at home—it seemed as if she had been gone a month." These cases, which occurred successively in about an hour, at the room of Dr. Morton, are fair examples of the average results produced by the inhalation of the vapor, and will convey an idea of the feelings and expressions of many of the patients subjected to the process. Dr. Morton states that in upwards of two hundred patients, similar effects have been produced. The inhalation, after the first irritation has subsided, is easy, and produces a complete unconsciousness at the expiration of a period varying from two to five or six, sometimes eight minutes; its duration varying from two to five minutes; during which the patient is completely insensible to the ordinary tests of pain. The pupils in the cases I have observed have been generally dilated; but with allowance for excitement and other disturbing influences, the pulse is not affected, at least in frequency; the patient remains in a calm and tranquil slumber, and wakes with a pleasurable feeling. The manifestation of consciousness or resistance I at first attributed to the reflex function, but I have since had cause to modify this view.
It is natural to inquire whether no accidents have attended the employment of a method so wide in its application, and so striking in its results. I have been unable to learn that any serious consequences have ensued. One or two robust patients have failed to be affected. I may mention as an early and unsuccessful case, its administration in an operation performed by Dr. Hayward, where an elderly woman was made to inhale the vapor for at least half an hour without effect. Though I was unable at the time to detect any imperfection in the process, I am inclined to believe that such existed. One woman became much excited, and required to be confined to the chair. As this occurred to the same patient twice, and in no other case as far as I have been able to learn, it was evidently owing to a peculiar susceptibility. Very young subjects are affected with nausea and vomiting, and for this reason Dr. M. has refused to administer it to children. Finally, in a few cases, the patient has continued to sleep tranquilly for eight or ten minutes, and once, after a protracted inhalation, for the period of an hour….
Two recent cases serve to confirm, and one I think to decide, the great utility of this process. On Saturday, the 7th Nov., at the Mass. General Hospital, the right leg of a young girl was amputated above the knee, by Dr. Hayward, for disease of this joint. Being made to inhale the preparation, after protesting her inability to do so from the pungency of the vapor, she became insensible in about five minutes. The last circumstance she was able to recall was the adjustment of the mouth piece of the apparatus, after which she was unconscious until she heard some remark at the time of securing the vessels—one of the last steps of the operation. Of the incision she knew nothing, and was unable to say, upon my asking her, whether or not the limb had been removed. She refused to answer several questions during the operation, and was evidently completely insensible to pain or other external influences. This operation was followed by another, consisting of the removal of a part of the lower jaw, by Dr. Warren. The patient was insensible to pain of the first incision, though she recovered her consciousness in the course of a few minutes.
The character of the lethargic state, which follows this inhalation, is peculiar. The patient loses his individuality and awakes after a certain period, either entirely unconscious of what has taken place, or retaining only a faint recollection of it. Severe pain is sometimes remembered as being of a dull character; sometimes the operation is supposed by the patient to be performed upon somebody else. Certain patients, whose teeth have been extracted, remember the application of the extracting instruments; yet none have been conscious of any real pain….
The successful public use of inhaled ether and chloroform for the performance of surgical procedures heralded the start of the modern anesthetic era. The senior Oliver Wendell Holmes, who was both a physician and a poet, wrote a letter to William Morton, in which he first made use of the words anaesthetic and anaesthesia for inhaled agents producing insensibility to pain. Anesthetic and anesthesia were derived from Greek words, and meant "without (an) sensibility (esthesia)."
In addition to the production of unconsciousness, ether served to stabilize cardiovascular function. As a result, ether has remained a model for the synthesis of myriad inhaled anesthetic agents until the present day.
Anesthetics had been used sporadically since the early 1840s, but were not widely recognized until October 16, 1846, when William T. G. Morton, at the Massachusetts General Hospital, assisted Dr. John C. Warren in the removal of a tumor from the neck of Gilbert Abbot, by providing the inhalation agent sulfuric ether.
The use of ether as an inhaled anesthetic quickly spread to Europe. Dental surgeon James Robinson was the first to administer anesthesia by ether in England on December 19, 1846. On January 19, 1847, Sir James Young Simpson, professor of obstetrics at the University of Edinburgh, was the first to employ the use of ether during labor. In November of the same year, Dr. Simpson first used chloroform as an anesthetic agent. Although it was considered to be more potent, it also could cause major side effects, such as severe, late-onset liver damage and could even result in death. It enjoyed a substantial degree of popularity because it was both effective and easier to use than ether.
Sulfuric ether was first used in wartime on March 29, 1847. Edward H. Barton used it in Vera Cruz, Mexico, in order to perform an amputation.
Local anesthesia was developed in 1877. This was a monumental scientific breakthrough as well, because it led to the development of infiltration anesthesia, spinal, and epidural anesthesia, and nerve blocks. By the start of the twentieth century, stabilization and protection of the airways during surgery became possible through the development and implementation of breathing tubes placed in the trachea during surgical procedures.
By the second decade of the twentieth century, the use of intravenous induction methods of anesthesia had been standardized; these permitted the patient to fall asleep in a more relaxed and normal manner. In the 1940s, muscle relaxants were developed.
Anesthesiologists are now highly trained physicians, often aided by nurse anesthetists and other skilled paraprofessionals. Anesthesia is no longer used simply for inducing unconsciousness during surgery, it is also used in labor and delivery, trauma and emergency medicine, for the induction of therapeutic coma in critical care, for extensive treatments such as burn debridement, and for the management of chronic and severe pain syndromes. Anesthesiologists can now adjust anesthetic agents to produce varying levels of consciousness or sedation in their patients, allowing for a safer surgery or treatment procedure.
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