L’anaesthésie à la reine: Queen Victoria
VICTORIA OF HANOVER was Queen of the United Kingdom and Empress of India. The sun never set on her empire: her children and grandchildren belonged to many of the royal families of Europe and the era in which she reigned was even named after her. She married her cousin Prince Albert of Saxe-Coburg and Gotha and together they seemed like the dream couple, considered the most in-love of all couples in British royal history. Less well known is that they fought constantly, sometimes coming to blows, and it was often the same issue that repeatedly soured the mood in Buckingham Palace. Victoria could not bear the insufferable pain that accompanied what she called the ‘animalistic’ experience of giving birth. She would become so enraged that Prince Albert finally threatened to leave her if she hit him just once more. Queen Victoria may have been a strong woman, but she felt these assaults on her spirits and her nerves were intolerably sordid. And, although the births of her first seven children had all passed off without problems, she had experienced them as an indescribable trauma. Each was followed by a post-natal depression of at least a year, which ran seamlessly into her next pregnancy. In 1853, Victoria was pregnant again and was again becoming hysterical about the impending drama. Albert decided that this could go on no longer and called in a doctor named John Snow. It was time for anaesthesia.
The technique of putting a patient to sleep, or inducing complete unconsciousness is known as general anaesthesia or narcosis (Greek ‘sleep’). The first operation performed under general anaesthesia had, at that time, been performed seven years earlier, on 16 October 1846, at the Massachusetts General Hospital in Boston, United States. A dentist called William Morton had anaesthetised a patient called Edward Abbott, by getting him to inhale ether, diethyl ether to be exact. Abbott had a tumour in his neck that had to be removed. While he was asleep, a surgeon called John Warren cut the tumour out. Everything went well, the patient had felt nothing and simply woke up after the operation. Warren was very impressed, uttering the historic, if understated, words ‘Gentlemen, this is no humbug.’ It was a turning point in the history of surgery.
Ever since the invention of sharp tools, anyone wishing to help someone else by cutting them open had to contend with the patient thrashing around during the operation. Being cut open is not only painful, but the patient is afraid, above all of not surviving the ordeal. Surgeons therefore always had to be quick, not only to keep the duration of the pain as short as possible, but also because there was little opportunity to take your time while the patient was being held down by your assistants or other helpers. It was therefore a matter of ‘the faster, the better’. London surgeon Robert Liston would always start his operations by calling out to his audience: ‘Time me, gentlemen, time me!’ If you had not completed your work before the patient wrested himself free from the helpers who were pinning him down to the table, the consequences were disastrous. The victim would still be bleeding profusely and, with all the thrashing around and the panic, blood would be spraying in all directions. That would cause the unfortunate patient to become even more terrified and frantic, making it much more difficult to hold him down. This gave rise to a very specific dress code. Until around a hundred and fifty years ago, surgeons would always wear a black coat when operating. That made it less obvious that it was covered in blood and they did not have to wash it so often. Some surgeons used to boast that their coats were so stiff from all the blood that they could stand upright on their own.
So you had to be quick, otherwise it would end badly. Speed meant safety. And that called for short, deep and accurate incisions – in the right place, and passing through as many layers of tissue as possible with one cut. The flow of blood was therefore always stemmed at the end, ‘on the way back’, by tying off the tissue layers with thread, searing them closed with a branding iron or simply applying a very tight bandage. This method was effective, but not very secure. It left no time to examine closely what you were doing and there was little time or space for unexpected circumstances. So, that was what operations were like until 16 October 1846: quick and bloody – and standardised, with no time for specifics.
Administering a general anaesthetic was therefore considered a waste of time for a quick surgeon and, in Europe, it took a long time for it to become regular surgical practice. Many surgeons were openly opposed to what they saw as dangerous and unnecessary nonsense. Anaesthesia was known in England as ‘Yankee humbug’ only good for quacks who were not good enough to operate quickly. But that was to change, thanks to the temper of Queen Victoria. After she had dared to try anaesthesia and had benefited so tremendously from it, no one could dismiss it any longer. It was exactly the boost that this new, unknown, but welcome discovery needed to convince the public at large.
John Snow was a farmer’s son and amateur anaesthetist who had written a book about ether and chloroform and designed a special mask to administer chloroform slowly and in controlled doses. In 1847, a year after the first ether anaesthesia was performed in Boston, James Young Simpson performed the first chloroform anaesthesia in Edinburgh. What John Snow did in 1853 was thus nothing new, but it was rare. Did Victoria know that Snow was not actually an expert, or that he didn’t know the risks of what he was going to do to her, or her unborn child? Snow’s heart must have been pounding as he climbed the stairs to the royal bedrooms in the palace. It was evening and the corridors, reception rooms and stairways were illuminated by gaslight. The staff would have been nervous. The cabinet was on stand-by, the people waited in suspense and there, beyond the antechambers and yet more doors, Snow would have heard the queen moaning. No doubt, Snow would have wondered whether the queen was able to receive him, a complete stranger, a commoner, calmly and with respect. When he entered, he would have positioned himself at the head of the bed and, not permitted to use the dosing mask he himself had designed, laid a clean handkerchief over Her Majesty’s nose and mouth. Using a pipette, he would have dripped a few droplets of chloroform from a bottle onto the handkerchief. He would certainly also have inhaled a little of the chloroform – that is unavoidable – so he would have turned his head to the side now and again to breathe deeply clean air.
Anaesthesiology
Today, anaesthesiology is rightly a full-scale discipline in itself. The days of a few drops of ether on a handkerchief are long over. Three kinds of medicine are used in modern general anaesthesia. A narcotic reduces consciousness, causing sleep (narcosis) and forgetfulness (amnesia). As the narcotic does not completely repress physical reactions to the pain of the operation – such as increased heartbeat and blood pressure, goose bumps and sweating – powerful painkillers (analgesics) are also administered. These are often opium derivatives. Anaesthesia means literally ‘without feeling’. To repress the tensing of the muscles in response to manipulation during the operation, a muscle relaxant is often included in the cocktail. These are derived from curare, the poison that Amazonian Indians use for their arrows. This combination of three medicines results in a relaxed, sleeping patient with no physical reactions to the operation. The anaesthetist uses a ventilator, a respiration machine to take over the patient’s breathing, inserting a tracheal tube into the windpipe (trachea) via the nose or mouth (intubation). While the patient is under general anaesthetic, the heartbeat, oxygen content in the blood, and carbon dioxide content in the exhaled air, are continually monitored via a blood pressure band and electrodes on the chest and finger. During the operation, the anaesthetist checks a lot more, including the blood count, urine production, blood-sugar level and blood coagulation. The stage of putting the patient to sleep is known as ‘induction’, and the waking stage as ‘emergence’.
Snow recorded every detail. He administered the chloroform to the queen, drop by drop, until she indicated that she felt no more pain, noting that the chloroform had no impact on the contractions, which remained just as severe. From twenty minutes past midnight on 7 April 1853, he gave Victoria fifteen drops of chloroform on the handkerchief with every contraction. ‘Her Majesty expressed great relief from the application,’ he wrote, ‘the pains being trifling during the uterine contractions, and whilst between the periods of contraction there was complete ease.’ The queen was not for one moment stupefied by the chloroform, and remained conscious throughout the birth. The child was born 53 minutes later, at 1.13 in the morning. The placenta followed a few minutes later, and the queen was delighted, ‘… expressing herself much gratified with the effect of chloroform’. She herself described it as ‘… that blessed chloroform, soothing and delightful beyond measure’. The newborn prince was christened Leopold; he was their eighth child and fourth son.
Albert was over the moon, though their delight didn’t last long: shortly afterwards, the queen fell into her usual post-natal depression, the worst she had ever experienced. The medical journal the Lancet published a damning comment and biblical scholars were outraged as the Scriptures state that women must endure pain when giving birth. But the news came as a bombshell to the wider public throughout Europe. In France, the use of chloroform became immensely popular and was given the catchy name ‘l’anaesthésie à la reine’. Patients no longer wished to be operated on without anaesthesia and surgeons were forced to comply with their demands.
Within a few decades, the days of the old, quick surgery were over and a new order emerged. Thanks to anaesthetics, surgeons now had time to work more precisely, and they were no longer distracted by their patients thrashing around and screaming in pain. Operations became precise, meticulous and dry, with no noise, and no blood spattering everywhere. Incisions were careful and exact. Tissue was no longer cut through in one go, but layer for layer, with the flow of blood being stemmed before the following layer was cut open – ‘on the way’ rather than at the end. And with new heroes like Friedrich Trendelenburg, Theodor Billroth and Richard von Volkmann, surgery became a precision science. Black surgery coats were replaced by white ones.
One of the great new names was the American William Halsted. An innovator in treating inguinal hernias and breast cancer, Halsted had introduced rubber gloves in surgery and with a number of colleagues he had put together a working group to develop local anaesthesia, a wonderful new invention. The procedure, which entailed injecting an anaesthetic drug around a nerve, allowed the patient to remain awake, but to feel nothing in the anaesthetised, numb area. The group met regularly to practise on each other and enjoyed wonderful evenings together. Halsted became not only a pioneer of local anaesthesia, but – because the drug they used was cocaine – he also became an addict. Cocaine has long since been replaced in local anaesthesia by derivative drugs that have the same effect locally, but without the stimulating side effects.
Anaesthesia was a revolution in surgery; the next step was the introduction of hygiene. In 1847, the Hungarian Ignaz Semmelweis discovered that childbed fever – an infection contracted by mothers shortly after childbirth – occurred when medical students returning from the dissecting-room after practising anatomy on dead bodies did not wash their hands before assisting with births. No one believed, however, that something as simple as washing your hands could make the difference between life and death and Semmelweis was dismissed as mad. (It did not help that he unfortunately suffered from a neurological disorder that was gradually driving him insane.) Semmelweis’s basic principle of hygiene was not accepted until Louis Pasteur exposed bacteria as the cause of disease and Joseph Lister was the first, in 1865, to prevent the infection of a surgical wound by using an antiseptic. Though revolutionary, these methods were, initially, very painful, because of the corrosive effect of disinfectant in the wound and the length of time they took to administer. They could therefore only be applied thanks to the invention of anaesthesia.
The chloroform that so delighted Queen Victoria was abandoned in the twentieth century, after it was discovered that it could damage the liver and cause irregular heartbeat. Ether, too, was replaced by something else: nitrous oxide (N2O), also known as laughing gas, a powerful anaesthetic. But it too went out of use when it proved to be a significant greenhouse gas 300 times more damaging to the environment than carbon dioxide.
In modern anaesthesia, the drugs are injected directly into the bloodstream, which means they take effect more quickly and the dose can be more precisely adjusted during the operation. The most commonly used anaesthetic drug at this time is 2,6-Diisopropylphenol, better known as propofol. Propofol has significant advantages and the effects wear off quickly once it is no longer administered. And even better, when patients wake up, they feel as though they have slept very soundly. Because of its milky appearance, it is also known as ‘happy milk’ or ‘milk of amnesia’. But this miracle anaesthetic is not without risks: pop star Michael Jackson became addicted to propofol and died after using it in 2009, because the doctor who administered it to him had not paid sufficient attention to Jackson’s state of health. That is a real medical error; as a good anaesthetist will ensure that a patient is closely monitored for twenty-four hours after waking up.
We do not know whether John Snow was able to monitor his patient in this way. And despite his services to the queen, Dr Snow is not remembered as a great anaesthetist. He is, however, remembered for a completely different reason. In 1854, he described an outbreak of cholera in London, identifying a single public water pump as the source of the infection. He was the first to show how a disease can be contagious, and the founding father of epidemiology, the study of how diseases spread.
Victoria insisted that Snow be present, with his anaesthetic, at the birth of her next child on 14 April 1857. It was a girl, Princess Beatrice. And, much to everyone’s surprise, this time the queen did not suffer from post-natal depression. Beatrice was her ninth – and last – child.