The Knife and the Cutting Edge

Posted by Rena Xu • July 29th, 2010

The NEJM Archive is a vital resource for teaching and research. With over 150,000 articles, 8,657 issues, 478,000 pages, 85,316 images, and 610,000 references an array of search, filter, and sort features, the NEJM Archive makes it easy to find what you’re looking for quickly. Articles are fully searchable, tabbed for easy access, and available as PDFs (1812-1944) or full-text HTML  (1945-1989) with downloadable graphics. You can browse and sort articles using search filters; search the entire Archive by specialty, topic, or article type; and filter search results for greater precision.  Archive access is available by subscription or pay-per-view.  We’ve provided free access to the article referenced below.  And, be sure to read our post on The History of AIDS to access those historical articles.

"First Operation Under Ether" by Robert C. Hinckley (Boston Medical Library in the Francis A. Countway Library of Medicine)

Prior to the advent of anesthesia, undergoing surgery – whether for a tooth extraction or an amputation – was torturously painful. Patients were awake for the procedure and often had to be strapped down; shouting and screaming were standard. Attempts were made to dull the pain, but these were either themselves cruel – knocking the patients out with a blow to the jaw, for instance – or only partly effective, as with alcohol and opiates.  As a result, surgery brought suffering, and elective surgical procedures were used infrequently and only as a last resort. The discovery that an inhalable ether vapor preparation could produce insensibility to pain was nothing short of revolutionary.

An article published in the Journal in 1846, “Insensibility during Surgical Operations Produced by Inhalation,” by Dr. Henry Jacob Bigelow, a surgeon at Massachusetts General Hospital (MGH), described the successful use of ether in surgery on October 16, 1846, a watershed moment now considered the birth of modern anesthesia. The article is available online as part of the NEJM Archive.

In the article, Bigelow recounted the momentous events that unfolded at MGH.  The operation consisted of the removal of a vascular tumor from a patient’s jaw. The surgery was performed by Dr. John Collins Warren, one of the most eminent surgeons of the time. The ether preparation was provided by Dr. Morton, a Boston dentist who had previously experimented with extracting teeth using similar vapor preparations on his patients.

Bigelow described the event as largely successful, with minor defects: “During the operation the patient muttered, as in a semi-conscious 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.”

Although most physicians are familiar with this story, the article describes a number of additional cases.  For example, on the following day, ether anesthesia was used on a woman for removal of a fatty tumor from her arm. Bigelow wrote, “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.”

Many other patient responses to the use of ether, as detailed in Bigelow’s report, were similarly positive. A 16-year-old boy said “he had had a ‘first rate dream – very quiet’,” adding that he had dreamed of Napoleon. A “stout boy of 12” described a tooth extraction as “‘the best fun he ever saw’” and “insisted upon having another tooth extracted upon the spot.” It was quite a change from the dread that tooth extractions had previously evoked.

Some patients responded in unexpected ways. Bigelow reported that one young man, “taking his seat in the chair and inhaling a short time, rejected the globe, and taking from his pockets a pencil and card wrote and added figures.” The physician guessed that the patient was already under the effects of the inhaled ether.  Upon wakening after the surgery, the patient reported having no recollection of what he had done in his sleep.

Bigelow also foresaw the “probable character of future accidents.” In one case, a young man awoke two minutes into surgery, was re-inebriated, and then later in the operation experienced a sudden decline in pulse. Bigelow reported, “Complete consciousness returned only at the expiration of an hour.”

Even acknowledging that there were problems still to be worked out, Bigelow and his contemporaries knew they had made an achievement of lasting importance. Bigelow called it “one of the important discoveries of the age.” More than 150 years later, every surgery performed under anesthesia reaffirms the accuracy of his prediction.

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