In 1812, the English novelist Frances Burney described her mounting terror as she prepared to undergo a mastectomy without any anaesthetic. Having two hours to wait until the dreaded event (her ‘execution’, as she put it), she wandered into the room where the operation was going to take place and ‘recoiled’. In an effort to control her fear she ‘walked backwards & forwards till I quieted all emotion, & became, by degrees, nearly stupid – torpid, without sentiment or consciousness’.
When seven men arrived, all dressed in black, and began laying down two ‘old mattresses’, covering them with an ‘old sheet’, Burney ‘began to tremble violently, more with distaste & horrour of the preparations even than of the pain’. When told to mount the bed, she stood ‘suspended, for a moment, [contemplating] whether I should not abruptly escape – I looked at the door, the windows – I felt desperate’.
Submission, however, was necessary. The surgeon spread a cambric handkerchief over her face and took up the knife. Burney was consumed by a ‘terror that surpasses all description’. When ‘the dreadful steel was plunged into the breast – cutting through veins – arteries – flesh – nerves’, she wrote: ‘I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incident – & I almost marvel that it rings not in my Ears still! so excruciating was the agony.’
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Burney underwent surgery more than three decades before the first use of modern anaesthetics as part of human medicine. When she sat down to record her experiences there was a rich language of suffering she could draw upon. It was widely believed that this language of pain held clues to the original causes of distress that were embedded within its metaphors. Medical textbooks encouraged physicians to elicit complex accounts of pain from their patients. In 1730, for instance, the influential physician Bernard Mandeville recalled a patient asking his doctor whether he was tired of hearing ‘so tedious a Tale’ of pain. His physician gently murmured: ‘Your Story is so diverting that I take abundance of delight in it, and your Ingenious way of telling it, gives me a greater insight into your Distemper, than you imagine.’
A century later, physicians took a very different view of pain narratives. Writing in the 1860s, Peter Mere Latham (physician extraordinary to Queen Victoria) inverted Mandeville’s comment, grumbling that ‘every person’s complaint is interesting to himself, he is apt to discourse about it rather too much at large, and too little to edification’. Latham lamented that ‘among the upper classes of life, we are obliged to listen to the patients’ tale’ – presumably because their social status entitled them to opine – but he confessed that ‘we generally cut [their accounts of pain] as short as possible, in order to get to our plan of investigation’.
With the invention of chloroform in the 1840s, doctors celebrated the fact that the ‘groans and shrieks of sufferers beneath the surgeons’ knives and saws, were all hushed’. So said the surgeon-dentist Walter Blundell. According to Blundell, writing in 1854, surgeons were now able to carry out their work ‘as on breathless, lifeless forms’. Anaesthetics rendered patients passive, unconscious bodies, stripped of sensibility, agency and, critically, words.
This shift from encouraging the active, even verbose, person-in-pain to cherishing the silenced is evident even within different editions of a single textbook. For example, in early editions of William Coulson’s popular clinical text On the Diseases of the Bladder and Prostate Gland (first published in 1838 and going through a number of editions until 1865), readers are told that a man with kidney stones would suffer intensely. The
jolting of a carriage is insupportable to him…. As the evil increased, micturition becomes more and more frequent and distressing; the pain following the act is very severe, – patients writhe with their bodies, and grind their teeth in agony.
Compare this with the same passage from the 1881 edition of his book:
The jolting of a carriage increases his symptoms…. As the stone increases in size, micturition becomes more frequent and distressing, and the pain or uneasiness at the end of the penis becomes more constant and severe.
The earlier focus was on the ‘evil’ of suffering. Now there’s a more detached description of ‘symptoms’ and the suffering itself has been downgraded to ‘pain or uneasiness’. Patients no longer ‘writhe with their bodies, and grind their teeth in agony’, but simply hurt more.
The emotional and aesthetic ‘thinning’ of clinical languages has continued ever since, moving the subjective experience of pain further towards the periphery of medical discourse. The introduction of Visual Analog Scales (a line with ‘no pain’ and ‘the worst pain imaginable’ at either pole) denies the importance of detailed narratives entirely. Meanwhile, Functional Magnetic Resonance Imaging (or fMRI) promises to eradicate the subjective person-in-pain altogether: she is not required to speak, nor even to point. Pain is little more than ‘an altered brain state’. The complex pain narratives of earlier periods have been decisively dismissed.
Pain is a ‘monster’, an ‘intruder’, a knife that cuts, a dog that bites, a fire that burns
Or have they? Perhaps the ‘thinning’ of pain narratives is simply a clinical conceit that ignores the way actual patients communicate their pain. In other words, physicians might no longer be listening, but people-in-pain have continued talking. What is especially intriguing is that the metaphors and analogies they’ve used to describe what they are feeling have changed over time.
In all periods, pain is described as an independent entity. It is a ‘sulky visitor’, a ‘monster’, an ‘intruder’, as well as a knife that cuts, a dog that bites, a fire that burns. But the rich religious language of pain, common in past centuries has largely disappeared. For Christians in the 19th century and earlier, the Bible provided extravagant narratives of suffering, from Job to Jonah, from the Psalms to Jeremiah. Above all, Christians could turn to the sufferings of Christ to speak their agony. They need only ‘Clasp the Rood Divine Of Him Whose Blood-sweat dyed Gethsemane!’ and plead, ‘Forgive me, Lord, who caused Thee agony… hear my anguish’d prayer – “O Crucified, thy will, not mine, be done”.’
Today, arrows of pain are not seen to be flung by an infuriated deity but are blindly caused by a penetrating germ or virus. When the pharmaceutical ability to eradicate chronic pain was limited, endurance could be valorised as a virtue: but with effective pain relief passive endurance became perverse. Bodily agony is no longer conceived of as ‘a warning angel’, and therefore as something that should be used as a mechanism either for spiritual renewal, or to be passively endured in imitation of the Calvary. Rather, pain is an ‘enemy’ to be fought and defeated, and it is the duty of patients and physicians to tackle it with all guns blazing. Hence the prevalence of military metaphors in contemporary pain narratives and ‘sickness memoirs’ such as A Private Battle (1979) by Cornelius and Kathryn Morgan Ryan, or Winning the Chemo Battle (1988) by Joyce Slayton Mitchell.
Secular belief systems also dealt a fatal blow to the notion of an afterlife – and therefore the idea that the pain suffered in this life can be somehow set against any suffering in the next one. As a consequence, pain has become the ultimate assault on an individual’s identity. It is common to hear chronic pain patients describe pain as an ‘an enemy… unbelievable… without reason… why should this happen to me’, or as something that ‘has to be taken away… must be tackled’. Because there is no ‘self’ that survives the death of the body, any attack on the individual in the here-and-now is particularly distressing.
Patients themselves are no less eloquent about their pain, despite this new secular approach to it. To take some examples from the medical, legal and academic literature of the past few decades, one paraplegic explained that he felt as if ‘a family of snakes’ was ‘squirming’ in his buttocks. Another patient described pain as ‘like a demand from Her Majesty’s Inspector of Taxes’. A woman who experienced phantom limb pain after her arm was amputated observed that it felt like ‘champagne bubbles and blisters’. A man with chronic back pain said; ‘my back hurt so bad I felt like I had a large grapefruit down about the curve of the back’. Even more creative was the woman who said her headache felt ‘like a bowl of Screaming Yellow Zonkers popping hard behind my forehead’.
Young children also possess a richly figurative language of pain. They might describe their pain as ‘a war in my stomach’, ‘lots of banging’, ‘mean’, ‘snow’, ‘ouch’, ‘sounds funny’, ‘cymbals clapping’, ‘grody to the max’, and ‘like mosquitoes poking around’. Or, as one six-year-old child eloquently put it: ‘Whenever my ears start to pain, I lose my smile and feel bad.’ Witnesses to such stories of pain instinctively grasp their meaning.
The chief difference between Burney’s time and ours is that patients’ metaphors are often ignored rather than elicited by the medical fraternity. This has not silenced patients. Like people-in-pain in past centuries, they want to know what has ‘gone wrong’, and to make sense of the disconnect between ‘me’ and ‘my pain’, and communicate their experiences to others.
This inherently social nature of pain provides a clue as to why talking about pain is so important – indeed, necessary – in human societies. It is why Burney wanted her sister Esther to hear about her mastectomy from her own pen, rather than second-hand. She recognised that ‘from the moment you know any evil has befallen me your kind heart will be constantly anxious to learn its extent, & its circumstances as well as its termination’. For Burney, sharing the story of suffering would draw loved ones, such as her sister, closer.
pain exposes our fragile connection to other people and serves as a reminder of our need for those around us
Talking about pain is a way of cementing interpersonal bonds: when people ‘suffer with’ their loved ones, they are bearing testimony to their closeness to that person. Witnesses to pain often find the experience agonising themselves, which can lead them to further intimacy with sufferers. This is what Claire Tisdall alluded to in her memoir based on the First World War. Tisdall, a nurse, admitted she’d been ‘burning with the agony of losing a dearly loved brother at Ypres’ and so her ‘feelings towards them [Germans] were less than Christian’. Nevertheless, one day she was given the job of looking after some German prisoners on their way to the hospital. One ‘very young, ashen-faced boy’ with a leg-wound looked up at her and murmured ‘Pain, pain’, an episode about which Tisdall wrote: ‘a bit of the cold ice of hatred in my heart… softened and melted when that white-faced German boy looked up at me and said his one English word – “Pain”.’
More than half a century earlier, the physician Samuel Henry Dickson in his Essays on Life, Sleep, Pain, Etc (1852) put the case more strongly: ‘Without suffering there could be no sympathies,’ he concluded, ‘and all the finer and more sacred of human ties would cease to exist.’ At the very least, pain exposes our fragile connection to other people and serves as a reminder of our need for those around us.
In the late 20th and early 21st centuries, these communities of fellow-sufferers have been bolstered by the internet. Feeling belittled or ignored by their physicians (who, to be fair, face immense pressure to ‘process’ patients ‘efficiently’), people-in-pain have turned to social media and online communities. These sites offer sufferers a language with which to frame their pain; they enable them to communicate this pain to others; and they provide sufferers with a community in which they feel that their experiences are validated. ‘Bodying forth’ (a term coined by the Swiss psychotherapist Medard Boss in the 1970s) into cyberspace enables pained bodies to fling themselves out of the constraints of geography, medical power regimes and social stigmatisation.
As Frances Burney discovered in the early 19th century, writing about her agonising experience allowed her to defy conventions that required surgical patients to endure their torments stoically and that women in particular remain silent about breast cancer. She was proud of the fact that when her surgeon asked: ‘Qui me tiendra se sein?’ (‘Who will hold this breast for me?’), she’d replied: ‘C’est moi, monsieur!’ In recording her experiences and encouraging her sister and friends to circulate her story, she could reclaim social agency and also excise her memory of suffering.
Against the isolating effects of suffering, Burney’s narrative of pain enabled her to create communities of sympathy. And in this, mercifully, there is continuity. For, today as then, the creative ways in which people-in-pain frame their experiences provide important clues to the unspoken meanings they attach to their suffering, and offer critical guidance to those around them about how they might reach out to help.
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is a professor of history at Birkbeck College, University of London. She has published nine books, with her latest The Story of Pain: From Prayer to Painkillers out in June 2014.
General anesthesia is, essentially, a medically induced coma, not sleep. Drugs render a patient unresponsive and unconscious.
They are normally administered intravenously (IV) or inhaled. Under general anesthesia, the patient is unable to feel pain and may also have amnesia.
The drugs will be administered by an anesthesiologist or nurse anesthetist, a specially trained doctor or nurse who will also monitor a patient's vital signs and rate of breathing during the procedure.
General anesthetics have been widely used in surgery since 1842, when Crawford Long administered diethyl ether to a patient and performed the first painless operation.
In this article, we will cover a number of topics, including the potential side effects of general anesthesia, associated risks and some theories regarding their mode of action.
Here are some key points about general anesthesia. More detail and supporting information is in the main article.
- An anesthesiologist or anesthetist normally administers the general anesthetic prior to an operation
- There are some risks associated with taking general anesthetics, but they are relatively safe when administered correctly
- Very rarely, a patient may experience unintended intraoperative awareness
- Side effects of general anesthesia can include dizziness and nausea
- The mechanisms by which anesthesia works are still only partially understood.
Nausea is a common side effect of general anesthesia.
There are a number of potential side effects of anesthesia.
Some individuals may experience none, others a few. None of the side effects are particularly long-lasting and tend to occur straight after the anesthesia.
Side effects of general anesthesia include:
- temporary confusion and memory loss, although this is more common in the elderly
- difficulty passing urine
- bruising or soreness from the IV drip
- nausea and vomiting
- shivering and feeling cold
- sore throat, due to the breathing tube
Overall, general anesthesia is very safe. Even particularly ill patients can be safely anesthetized. It is the surgical procedure itself which offers the most risk.
Modern general anesthesia is an incredibly safe intervention.
However, older adults and those undergoing lengthy procedures are most at risk of negative outcomes. These outcomes can include postoperative confusion, heart attack, pneumonia and stroke.
Some specific conditions increase the risk to the patient undergoing general anesthetic, such as:
Death as a result of general anesthetic does occur, but only very rarely - roughly 1 in every 100,000 to 200,000.
Unintended intraoperative awareness
Thisrefers to rare cases where patients report a state of awareness during an operation, after the point at which the anesthetic should have removed all sensation. Some patients are conscious of the procedure itself and some can even feel pain.
Unintended intraoperative awareness is incredibly rare, affecting an estimated 1 in every 19,000 patients undergoing general anesthetic.
Because of the muscle relaxants given alongside anesthesia, patients are unable to signal to their surgeon or anesthetist that they are still aware of what is happening.
Unintended intraoperative awareness is more likely during emergency surgery.
Patients that experience unintended intraoperative awareness can suffer long-term psychological problems. Most often, the awareness is short-lived and of sounds only, and occurs prior to the procedure.
According to a recent large-scale investigation of the phenomenon, patients experienced tugging, stitching, pain, paralysis, and choking, among other sensations.
Because unintended intraoperative awareness is so infrequent, it is not clear exactly why it occurs.
The following are considered to be potential risk factors:
- heart or lung problems
- daily alcohol use
- emergency surgery
- cesarean section
- anesthesiologist error
- use of some additional medications
There are three main types of anesthetic. General anesthetic is only one of them.
Local anesthesia is another option. It is given before minor surgeries, such as removal of a toenail. This reduces pain sensations in a small, focused areas of the body, but the person receiving the treatment remains conscious.
Regional anesthesia is another type. This numbs an entire portion of the body - the lower half, for example, during childbirth. There are two main forms of regional anesthesia: Spinal anesthetic and epidural anesthetic.
Spinal anesthetic is used for surgeries of the lower limbs and abdomen. This is injected into the lower back and numbs the lower body. Epidural anesthesia is often used to reduce the pain of childbirth and lower limb surgery. This is administered to the area around the spinal cord through a small catheter instead of a needle injection.
Local vs. general
There are a number of reasons why general anesthesia may be chosen over local anesthesia. In some instances, the patient is asked to choose between general and local anesthetic.
This choice depends on age, state of health, and personal preference.
The main reasons for opting for general anesthetic are:
- The procedure is likely to take a long time.
- There is a likelihood of significant blood loss.
- Breathing may be affected, such as during a chest operation.
- The procedure will make the patient feel uncomfortable.
- The patient may be young, and they may have difficulty remaining still.
The purpose of general anesthetic is to induce:
- analgesia, or removing the natural response to pain
- amnesia, or memory loss
- immobility, or the removal of motor reflexes
- skeletal muscle relaxation
However, using general anesthetic poses a higher risk of complications than local anesthesia. If the surgery is more minor, an individual may choose local as a result, especially if they have a underlying condition, such as sleep apnea.
Before general anesthesia is administered, patients will have a pre-surgery assessment to determine the most appropriate drugs to use, the quantities of those drugs and in which combination.
Some of the factors to be explored in a pre-surgical evaluation include:
- body mass index (BMI)
- medical history
- current medications
- fasting time
- alcohol or drug intake
- pharmaceutical drug use
- mouth, dental and airway inspection
- observation of neck flexibility and head extension
It is essential that these questions are answered accurately. For instance, if a history of alcohol or drug use is not mentioned, an inadequate amount of anesthesia might be given which could lead to dangerously high blood pressure or unintended intraoperative awareness.
Guedel's classification, designed by Arthur Ernest Guedel in 1937, describes the four stages of anesthesia. Modern anesthetics and updated delivery methods have improved the speed of onset, general safety, and recovery, but the four stages remain essentially the same:
General anesthesia is similar to a comatose state and different from sleep.
Stage 1, or induction: This phase occurs between the administration of the drug and the loss of consciousness. The patient moves from analgesia without amnesia to analgesia with amnesia
Stage 2, or excitement stage: The period following a loss of consciousness, characterized by excited and delirious activity. Breathing and heart rate becomes erratic, and nausea, pupil dilation, and breath-holding might occur.
Because of irregular breathing and a risk of vomiting, there is a danger of choking. Modern, fast-acting drugs aim to limit the time spent in stage 2 of anesthesia
Stage 3, or surgical anesthesia: Muscles relax, vomiting stops and breathing is depressed. Eye movements slow and then cease. The patient is ready to be operated on
Stage 4, or overdose: Too much medication has been administered, leading to brain stem or medullary suppression. This results in respiratory and cardiovascular collapse.
The anesthetist's priority is to take the patient to stage 3 of anesthesia as quickly as possible and keep them there for the duration of the surgery.
How does general anesthetic work?
The exact mechanisms that conspire to produce the state of general anesthesia are not well known. The general theory is that their action is induced by altering the activity of membrane proteins in the neuronal membrane, possibly by making certain proteins expand.
Of all the drugs used in medicine, general anesthetics are an unusual case. Rather than a single molecule acting at a single site to produce a response, there is a huge variety of compounds, all of which generating quite similar but widespread effects, including analgesia, amnesia, and immobility.
General anesthetic drugs range from the simplicity of alcohol (CH3CH2OH) to the complexity of sevoflurane (1,1,1,3,3,3-hexafluoro-2-(fluoromethoxy)propane). It seems unlikely that just one specific receptor could be activated by such different molecules.
General anesthetics are known to act at a number of sites within the central nervous system (CNS). The importance of these sites on the induction of anesthesia is not fully understood but they include:
There are multiple sites that general anesthetics can work at in the brain.
- Cerebral cortex: The brain's outer layer involved in tasks relating to memory, attention, perception among other functions
- Thalamus: Its roles include relaying information from the senses to the cerebral cortex and regulating sleep, wakefulness, and consciousness.
- Reticular activating system: Important in regulating sleep-wake cycles
- Spinal cord: Passes information from the brain to the body and vice versa. It also houses circuitry that controls reflexes and other motor patterns.
A number of different neurotransmitters and receptors are also known to be involved in general anesthesia:
- N-Methyl-D-aspartic acid (NMDA) receptors: some general anesthetics bind to NMDA receptors, including ketamine and nitrous oxide (N2O). They are known to be important in controlling synaptic plasticity and memory functions
- 5-hydroxytryptamine (5-HT) receptors: normally activated by the neurotransmitter serotonin, they play a part in controlling the release of a number of other neurotransmitters and hormones
- Glycine receptor: glycine can act as a neurotransmitter and has a number of roles. It has been shown to improve sleep quality.
Although general anesthetics hold many mysteries, they are hugely important in surgery and the field of medicine at large.