The first volume of the New England Journal of Medicine and Surgery, and the Collateral Branches of Science, published in 1812, gives a sense of the constraints faced by surgeons, and the mettle required of patients, in the era before anesthesia and antisepsis. In the April issue for that year, John Collins Warren, surgeon at the Massachusetts General Hospital and son of one of the founders of Harvard Medical School, published a case report describing a new approach to the treatment of cataracts.1 Until that time, the prevalent method of cataract treatment was “couching,” a procedure that involved inserting a curved needle into the orbit and using it to push the clouded lens back and out of the line of sight.2 Warren's patient had undergone six such attempts without lasting success and was now blind. Warren undertook a more radical and invasive procedure — actual removal of the left cataract. He described the operation, performed before the students of Harvard Medical School, as follows:

The eye-lids were separated by the thumb and finger of the left hand, and then, a broad cornea knife was pushed through the cornea at the outer angle of the eye, till its point approached the opposite side of the cornea. The knife was then withdrawn, and the aqueous humour being discharged, was immediately followed by a protrusion of the iris.

Into the collapsed orbit of this unanesthetized man, Warren inserted forceps he had made especially for the event. However, he encountered difficulties that necessitated improvisation:

The opaque body eluding the grasp of the forceps, a fine hook was passed through the pupil, and fixed in the thickened capsule, which was immediately drawn out entire. This substance was quite firm, about half a line in thickness, a line in diameter, and had a pearly whiteness.

A bandage was applied, instructions on cleansing the eye were given, and the gentleman was sent home. Two months later, Warren noted, inflammation required “two or three bleedings,” but “the patient is now well, and sees to distinguish every object with the left eye.”

The implicit encouragement in Warren's article, and in others like it, was to be daring, even pitiless, in attacking problems of an anatomical nature. As the 18th-century surgeon William Hunter had told his students, “Anatomy is the Basis of Surgery, it informs the Head, guides the hand, and familiarizes the heart to a kind of necessary inhumanity.”3 That first volume of the Journal provided descriptions of a remarkable range of surgical techniques, including those for removing kidney, bladder, and urethral stones; dilating the male urethra when strictured by the passage of stones; tying off aneurysms of the iliac artery and infrarenal aorta; treating burns; and using leeches for bloodletting. There were articles on the problem of “the ulcerated uterus” and on the management of gunshot and cannonball wounds, not to mention a spirited debate on whether the wind of a passing cannonball alone was sufficient to cause serious soft-tissue injury.

Surgery, nonetheless, remained a limited profession. Pain and the always looming problem of infection restricted the extent of a surgeon's reach. Entering the abdomen, for instance, was regarded with reproach — attempts had proved almost uniformly fatal.4 The chest and joints were also out of reach. The primary remit of surgery was therefore the management of external conditions, and medicine dealt with the internal ones (hence the term “internal medicine,” which persists to this day). Even for those conditions that appeared to be externally accessible, surgical accounts often spoke of failure more than derring-do. For example, in an article on spina bifida that appeared in the January 1812 issue of the Journal, a surgeon noted the uniform fatality of the condition and recounted an effort to repeatedly lance, drain, and bandage an infant's meningocele, which proved to be utterly futile.5 The skin “had become thickened, and as inelastic . . . as the upper leather of a shoe; it also ulcerated,” the author wrote. “Pus was formed in the sac, and the infant died.” Such reports often maintained an almost defiant optimism. (“We have no doubt,” this surgeon concluded, “that if performed with due caution,” a technique of draining meningoceles will be engineered and “the disease of Spina Bifida may cease to be an opprobrium of medicine.”) Nonetheless, breakthrough surgical successes were, for a long time, few and far between.

They were also often illusory. In 1831, for instance, a Mr. Preston reported in the Journal his treatment of a man with an acute stroke that had resulted in left hemiparesis and speech difficulties.6 He did not use the usual, ineffective method of bloodletting and applying leeches but instead decided to take the curious approach of ligating the patient's right common carotid artery. Preston conjectured that by diminishing the supply of blood to the affected side of the brain, the treatment would reduce congestion and inflammation. By luck, the man survived. He was discharged 1 month later, walking with the aid of a stick and speaking normally, leading Preston to propose that surgeons might consider tying both carotids in future cases. Fortunately, his case notwithstanding, the procedure failed to catch on.

Figure 1. Figure 1. Operation Being Performed with the Use of Ether Anesthesia. This daguerreotype was taken in the spring of 1847 by Josiah Hawes in the Operating Room (now known as the Ether Dome) of the Massachusetts General Hospital. The first public demonstration of surgical anesthesia occurred in the same room on October 16, 1846, presided over by the surgeon John Collins Warren, seen here touching the patient. Although it is believed that a photographer was present during the first event as well, he took no pictures because the sight of blood made him nauseated.8 Courtesy of the Massachusetts General Hospital, Archives and Special Collections.

The crucial spark of transformation — the moment that changed not just the future of surgery but of medicine as a whole — was the publication on November 18, 1846, of Henry Jacob Bigelow's groundbreaking report, “Insensibility during Surgical Operations Produced by Inhalation”7 (Figure 1). The opening sentences crisply summarized the achievement: “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.” Bigelow described how William Morton, a Boston dentist, had administered to his own patients, and then to several more who had undergone surgery at the Massachusetts General Hospital, a gas he called “Letheon,” which successfully rendered them insensible to pain. Morton had patented the composition of the gas and kept it a secret even from the surgeons. Bigelow revealed, however, that he could smell ether in it. The news burst across the world. The Letters to the Editor pages were occupied for months with charges and countercharges over Bigelow's defense of Morton's secrecy and credit for the discovery. Meanwhile, ether anesthesia rapidly revolutionized surgery — how it was practiced, what could be attempted with its use, and even what it sounded like.

Figure 2. Figure 2. Methods of Amputation in the Early 19th Century. Panel A is a drawing by Charles Bell from 1821 showing the circular method of amputation.9 Panel B shows the flap method of amputation being used in 1837, with an assistant retracting the tissue flap to allow the surgeon to saw through the femur.10

Consider, for instance, amputation of the leg. The procedure had long been recognized as lifesaving, in particular for compound fractures and other wounds prone to sepsis, and at the same time horrific. Before the discovery of anesthesia, orderlies pinned the patient down while an assistant exerted pressure on the femoral artery or applied a tourniquet on the upper thigh (Figure 2A, upper drawing). Surgeons using the circular method proceeded through the limb in layers, taking a long curved knife in a circle through the skin first, then, a few inches higher up, through the muscle, and finally, with the assistant retracting the muscle to expose the bone a few inches higher still, taking an amputation saw smoothly through the bone so as not to leave splintered protrusions (Figure 2A, lower drawing). Surgeons using the flap method, popularized by the British surgeon Robert Liston, stabbed through the skin and muscle close to the bone and cut swiftly through at an oblique angle on one side so as to leave a flap covering the stump (Figure 2B).

The limits of patients' tolerance for pain forced surgeons to choose slashing speed over precision. With either the flap method or the circular method, amputation could be accomplished in less than a minute, though the subsequent ligation of the severed blood vessels and suturing of the muscle and skin over the stump sometimes required 20 or 30 minutes when performed by less experienced surgeons.9 No matter how swiftly the amputation was performed, however, the suffering that patients experienced was terrible. Few were able to put it into words. Among those who did was Professor George Wilson. In 1843, he underwent a Syme amputation — ankle disarticulation — performed by the great surgeon James Syme himself. Four years later, when opponents of anesthetic agents attempted to dismiss them as “needless luxuries,” Wilson felt obliged to pen a description of his experience11:

The horror of great darkness, and the sense of desertion by God and man, bordering close on despair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so. During the operation, in spite of the pain it occasioned, my senses were preternaturally acute, as I have been told they generally are in patients in such circumstances. I still recall with unwelcome vividness the spreading out of the instruments: the twisting of the tourniquet: the first incision: the fingering of the sawed bone: the sponge pressed on the flap: the tying of the blood-vessels: the stitching of the skin: the bloody dismembered limb lying on the floor.

Before anesthesia, the sounds of patients thrashing and screaming filled operating rooms. So, from the first use of surgical anesthesia, observers were struck by the stillness and silence. In London, Liston called ether anesthesia a “Yankee dodge” — having seen fads such as hypnotism come and go — but he tried it nonetheless, performing the first amputation with the use of anesthesia, in a 36-year-old butler with a septic knee, 2 months after the publication of Bigelow's report.10 As the historian Richard Hollingham recounts, from the case records, a rubber tube was connected to a flask of ether gas, and the patient was told to breathe through it for 2 or 3 minutes.12 He became motionless and quiet. Throughout the procedure, he did not make a sound or even grimace. “When are you going to begin?” asked the patient a few moments later. He had felt nothing. “This Yankee dodge beats mesmerism hollow,” Liston exclaimed.

It would take a little while for surgeons to discover that the use of anesthesia allowed them time to be meticulous. Despite the advantages of anesthesia, Liston, like many other surgeons, proceeded in his usual lightning-quick and bloody way. Spectators in the operating-theater gallery would still get out their pocket watches to time him. The butler's operation, for instance, took an astonishing 25 seconds from incision to wound closure. (Liston operated so fast that he once accidentally amputated an assistant's fingers along with a patient's leg, according to Hollingham. The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300% mortality.)