In 1811 the novelist Fanny Burney underwent a mastectomy for suspected breast cancer. The operation was a total success: she lived for another 28 years without any recurrence of the tumour. Burney recorded her experience in a searing letter to her sister Esther. It’s a masterpiece of descriptive writing, an account so vivid that every agonising touch of the scalpel makes you wince.
It is scarcely possible to imagine the excruciating pain that many patients must have endured in the early nineteenth-century era of so-called ‘heroic’ surgery – when surgeons undertook ambitious and aggressive procedures without the benefit of anaesthesia.
This case report, published in The Lancet in 1832, documents one particularly extreme example: a major operation to remove a tumour of the facial bones. This would be a challenging procedure for an experienced maxillofacial surgeon even today. But the most striking thing about this case is the demeanour of the patient:
After the necessary arrangements for the operation were completed, the patient, a strong-looking man, about 45 years of age, was laid on the operating table. There was a swelling over the situation of the antrum…
The antrums are the maxillary sinuses, bony cavities on either side of the nose.
…on the right side of the face, about the size of a pullet’s egg, which passed on the nostril and eye, so as to give a very unsightly appearance to the countenance. We were informed that the diseased growth first appeared about four months since, and had not occasioned much inconvenience until lately, when some lancinating pains were experienced.
‘Lancinating’ means ‘stabbing’. The rapid growth of this tumour must have caused considerable alarm.
An assistant having compressed, with his finger, the common carotid artery, Mr. Scott commenced by making an incision through the integuments of the face, from within half an inch of the inner canthus of the right eye to the commissure of the lips.
The two common carotid arteries (right and left) are located in the upper thorax and neck, and constitute the main blood supply to the head. The assistant’s job was to press firmly on the neck to reduce the flow of blood through one of these vessels, in the hope of slowing any bleeding.
On dissecting back the cheek, rather profuse haemorrhage from the facial artery and surrounding small branches ensued; ligatures were consequently applied, and pressure made by lint on the bleeding surface.
Let’s pause for a moment to remind ourselves that the patient was fully conscious. An incision had been made from the corner of his eye to his upper lip, and his entire cheek peeled back. But worse – far worse – was to come.
It was then thought necessary to tie the common carotid, which was accomplished after an interval of twenty-two minutes, occupied in securing the vessel.
An agonising length of time. The surgeon had decided that he needed to stop the flow of blood through the carotid entirely. This entailed making a second incision in the neck, dissecting the artery free of surrounding tissue, and finally tieing ligatures around it.
The integuments were then completely reflected from the bone, and the strong cutting forceps applied to the symphysis of the upper jaw, by which it was instantly divided; the ascending process of the superior maxillary bone, near the point of its attachment to the nasal, and the junction of the superior maxillary and malar bones, were cut through successively in a similar manner, and the mass, consisting of the superior maxillary bone, diseased antrum, and a small strip of the anterior portion of the floor of the orbit, was taken away with the assistance of a scalpel.
There’s a lot of jargon here, but the gist is fairly simple: a large lump of bone, including much of the upper jaw, the sinus and part of the eye socket, was cut out of the man’s skull. This included the tumour itself. The extent of this frightful procedure is apparent from the diagram below:
Two or three minutes were then employed in removing some spiculae [shards] of bone and small portions of the disease, that remained.
The surgeon then placed lint swabs inside the wound and repaired the upper lip, which had been cut in two by this drastic operation. Adhesive plasters completed the dressing. As for the poor man who had to undergo this brutal procedure, he coped surprisingly well:
The patient throughout behaved with the most stoical fortitude. On being asked by Mr. Scott whether he suffered much during the operation, he answered, with a smile, “Oh, I’ll tell you another time,” and cheerfully undertook to walk to his bed. He was greeted with the hearty plaudits of all the spectators.
Understandably! It is impossible to imagine the agonies he must have endured.
The operation, which occupied three-quarters of an hour, was conducted with coolness and decision.
Forty-five minutes must have felt like an eternity. In this pre-anaesthetic era, surgeons worked as quickly as possible in order to spare the patient unnecessary suffering – and to prevent them from going into shock. This was an unusually long operation.
The patient’s jaunty manner – even walking out of the operating theatre! – was, alas, misleading, as a postscript makes clear:
We find, since the above report was written, that the patient is dead, having expired in convulsions.