J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from JR A rmy Med CUrp5. 1985; 13 1: 109· 115 'The Smart of the Knife' - Early Anaesthesia in the Services Surgeon-Captain RNR (Ret'd) John A Shepherd VRD, MD, FRCS In October 1846 \Villiam Morton gave ether to a Plymouth, a Naval surgeon, inlroduced the flap techni· patient operated upon by John Warren of Massachuseus. que, but it was to be long before the more rapid guillotine Accounts of the event reached England in mid·Dcccmber. amputation was discarded. In 1786 Haire, also a naval On December 21st Robert Liston of United College su rgeon, advocated that ligatures on major vessels should Hospital amputated at the thigh under etber. The scene be cut shofl and not, as was the custom, left long. But is recorded in a well· known picture. for long accepted this advance was also slow lO be generally adopted. as accurate in detail (Fig. I). There are (WO alleged spec­ The conditions under which the Service surgeons work· la[Ors. At the foot of the table Thomas Spencer Wells cd were primitive and scarcely conducive to any is depicted, in white trousers and a short jacket suggesting refi nements. The naval surgeon in evitably operated on naval uniform. Then aged 29. he was a surgeon in the board ship. When a ship was about to go into action it Royal Navy. But the features are those of Wells many was traditional to set up a receiving and operating area by guest. Protected copyright. years later. To his right is Joseph Lister, then aged 19, in the cockpit, a small space below the waler·line, nor· and a student at UCH. But the likeness is of a much morc mally the unhealthy living quarters of the midshipmen mature Lister. In fact the group was painted 40 years after and the surgeon's mates. If casualties were severe, the the event. Spencer Wells was not present for he was then cockpit became a shambles. The transfer of the wound· serving in Malta; his inclusion however has some ed to the cockpit was not easy, there were no stretchers relevance. It is doubtful if Lister was there; he was at the and the injured seamen were manhandled through the hat· time a preclinical studem and there is other evidence which ches and down steep ladders. refutes his presence. No Army or Navy medical officer It has been recorded that considering the conditions witnessed this operation, which was at once well publicis· under which the naval surgeon peformed his operations ed and which triggered off an almost in stantaneous adop· as a surgical technician he was unsurpassed . This may tion of ether anaesthesia in civilian practice. be rather an exaggerated statement although a few did Before 1846 the surgeon's repertoire was limited. Am· acquire remarkable dexterity. In the novel "Roderick putations of the limbs were the most frequent major Random" Smollett writes of his experience during an ac· operations. Abdominal procedures were limited almost tion. "Our patients had increased to such a number that entirely to explorations for ovarian cysts. Ligations of we did not know which to begin with, and the first mate the major arteries for aneurysm were not infrequent. It plainly told the surgeon, that, if he did not get up im· is surprising what had been attempted without mediately and perform hi s duty he would complain of http://militaryhealth.bmj.com/ anaesthesia, for example, in 1816 Astley Cooper tied the his behavio ur to the Admiral ... " (The surgeon was abdominal aorta. In civilian practice the patients were meanwhile prostrate on the deck in fear of his own strapped to the table and were given sips of wine. Some safety) ... "This remonstrance eventually aroused the were remarkably stoical but for most the experience was surgeon, who was never deaf to an argument in which harrowing, and their best hope was that they should faint he thought hi s own interest was concerned. He therefore right out. rose up, and in order to st rengthen his resolution, had If the patient had to be tough. so too had the surgeon. recourse more than once to a bottle of rum ... being Liston was one who had achieved remarkable success thus supported he went to work and arms and legs were before anaesthesia, courageous, of iron nerve , and, hewed down without mercy" ]. perhaps, callous to some extent. His sound anatomical There are many other such descriptions which bring knowledge, his skill in ligating the large vessels, and his out the atrocious environment in which casualties were physical strength allowed the essential of completing an [reated, the crudeness of most of the surgery and the for· on September 28, 2021 operation in a matter of minutes. Not all surgeons were titude of the injured sailor. Conditions were little better so able. Of a contemporary, in the Quest of a virtuoso when Nelson was taken below in the "Victory", to sur· performance, it is said, "with onc sweep of his knife Cut vive only a few hou rs after a penetrating wound of the off a limb. as well as three fingers of his assistant and chest. In 1854 the cockpit was still the operating area. the coat tails of a spectator." The Army surgeon in the pre-anaesthetic era had some The Service surgeons before 1846 had Hale experience advantages. At least he operated on dry land and not on of major surgery in peacetime. They came into their own a rolling ship, in a stuffy, i11·lit space rendered almost in war and their ability was measured largely by their suc· intolerable by an increasing stench of blood and the cess in performing amputations. Before 1700 Yonge of smoke of battle. But his equipment was sparse. He had Fanlnnlc: A l":1ptT @ivclI to the ~l il ila T~' Suriical Socrtty 3lh November. 1983. J R Army Med Corps: first published as 10.1136/jramc-131-02-11 on 1 January 1985. Downloaded from 110 'The Smart of the Knife' - Early Anaesthesia in the Services ing the teaching of J ohn Hunte r). In the Navy early am­ putation was accepted much earl ier. The Naval surgeon, of course, unlike the Army surgeon, received casualties wit hin minutes of injury. In 1732 John Atkins recom­ mended immediate removal of the severely damaged limb. He wrote: " The heat and surprise in ac ti on made il Ihe properest time for amputation, men meeting their mi sfor­ tune with greater strength and resolution than when Ihey have spent a night in thought and reflection"J. Atkins, quite unwittingly, was preaching the meri ts, now so well understood, of the early excision of damaged tissue, as a means of preventing gangrene and of reducing secon­ dary shock. But there were no refinements of resuscita­ tion or pain relief. Indeed venesection was often done for the exsanguinated patient: some saw th is as a means of Fi~. 1. - USfoll'S Amputation under Ether relievi ng shock and pain. It was all too readily accepted, both in civilian and ser­ his case of instruments. ligature material, dressings and vice practice, that pain was a necessary accompaniment a tourniquet. On or near a baulefield simple regimelllai o f any opera tion. Liule was done for its relief. In thby guest. Protected copyright. e hospitals or aid posts were established in requisitioned Navy it is the tradition that a strong tot of rum was of­ buildings or in tents, but the wounded were not always fered but the practice was nOl universal. The soldier was brought to these units and the surgeon frequently given a bullet on wh ich to bite! It must be said that there operated, as at Waterloo, in the open, with the patient was, in an era of vicious flogging a nd harsh discipline, on the ground. He was usually single-handed and Ihere little regard for the feelings of the wounded sail or or were no trained orderlies. Even in general hospitals behind ~~. the lines there was no room set aside for operating and After 1846 the Service doctors were slow 10 recognise . the surgeon worked with hi s patient on a bed, if there the potential value of general anaesthesia. In 1847 the were beds, or on a makeshift. table . medical journals were inundated with reports of the suc­ An observer in the Peninsular War describes a general cessful appli ca tion of erher, from every corner of the hospital thus: " ( saw two hundred soldiers waiting to have British Isles. Only onc report can be found frolll a Ser­ their limbs amputated ... the smell from the gun-shot vice source. The young Naval surgeon Spencer Wells was wounds was dreadful ... There they sat wailing for their quick to seize upon the new technique (Fig 2). He was turn to be carried to the amputating table. A little fur­ then serving in the Naval Hospital at Bighi, Malta, and ther on, in an inner court. were the surgeons. They were had already proved one of the brightest of the younger stripped to their shirts and bloody: a number of doors, naval doctors. Soon after hearing of Li ston's success placed on barrels. served as temporary operating tables: Wells se nt 10 London for a Hooper's inhaler, one of the http://militaryhealth.bmj.com/ to the right and left were arms and legs flung here and earliest devices for administering ether. He reported a suc­ there wi thout distinction, and the ground was dyed with cessful dental ex traction and demonstrated the apparatus blood"'.