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01Surgery Before Anaesthesia

For most of the history of surgery the operator's first virtue was speed, because there was nothing else to offer the patient. Understanding what that constraint did to the work explains why 1846 is treated as a dividing line rather than an improvement.

Speed as a surgical virtue

Before the middle of the nineteenth century a surgical operation was a race conducted in public against the endurance of a conscious person. The measure of a good operator was how quickly the thing could be finished, and reputations were built on times that would be meaningless in any later period. An amputation at the thigh was a procedure of seconds, not minutes, and every part of the technique was arranged around that fact: the incisions were few, the instruments were laid out to be seized in a fixed order, and assistants were employed as much to hold the patient still as to help with the work.

The consequence was that the range of possible surgery was set not by anatomy or by the operator's knowledge but by how long a person could be held down. Procedures on the surface of the body were feasible. Anything requiring careful dissection, anything inside the abdomen or the chest, anything that could not be completed in the time available, was effectively outside the field. Surgical texts of the period read less like accounts of what could be done than inventories of what had been survived.

What was tried instead

It is a mistake to imagine that the problem was ignored. Attempts to blunt the experience are as old as the operation itself: preparations of opium and mandrake, alcohol in quantity, cold applied to a limb until it lost feeling, compression of nerves and vessels, and simple exhaustion. Each of these works to some degree, and none of them works reliably or reversibly. That is the crucial distinction. A method that sometimes produces insensibility and sometimes produces a dead patient is not a technique; it is a gamble, and surgeons treated it as one.

The eighteenth century added a strand of pure chemistry that would eventually matter. Ether had been described in 1540 and its effects on animals noted without much interest. Nitrous oxide was prepared in 1772, and by 1800 there was a substantial published account of what breathing it felt like, including an explicit suggestion that it might be used during surgical operations. In 1824 a written argument appeared that insensibility could be induced deliberately for exactly that purpose. None of this was taken up. The materials and the idea were both available for decades before anyone put them together in front of witnesses.

Why the delay

The gap between availability and use is the genuinely interesting historical question, and no single explanation covers it. Part of the answer is that pain was widely understood as a necessary accompaniment of healing rather than an obstacle to be removed, and some practitioners held that it was actively useful, a stimulus that kept the patient alive through the shock of the knife. Part of it is that both ether and nitrous oxide were firmly associated with entertainment. They were exhibited at fairs and at private parties for the sake of the intoxication they produced, and a substance known chiefly as an amusement carried no professional standing.

Part of it, too, is that the demonstration is harder than it looks. An inhaled vapour of unknown concentration, given from an improvised apparatus to a frightened person, does not reliably produce a quiet patient. The failures of the early attempts were public, and a failed public demonstration set the whole idea back further than no demonstration at all. What changed in 1846 was not the discovery of a substance. It was a successful, witnessed, promptly reported case, performed in an institution whose word carried weight, at a moment when a printed account could travel across the Atlantic in a few weeks.

The change in what surgery is

The immediate effect of insensibility was not that operations became painless. It was that operations became slow. Once the patient was still, the operator could take the time to see what he was doing, and the internal logic of the craft inverted: care replaced speed as the mark of competence. That inversion is the reason the date matters. It did not make existing operations more comfortable so much as it made a different kind of surgery thinkable, and the abdominal and thoracic work of the following decades depended on it entirely.

It also created a new problem which had not existed before. Somebody now had to manage the state of the patient throughout, and that person's attention was on the breathing and the pulse rather than on the wound. The whole subsequent history of monitoring, of agents, and of the speciality itself follows from that division of labour, which nobody planned.