A Botched Job: Surgery and the Politics of Pain

By Michael Brown

In July 1824, an anonymous correspondent wrote to the newly-founded English medical journal, The Lancet, to report on an operation he had witnessed at the United Hospitals of Guy’s and St Thomas’, London. The operation was a lithotomy, the surgical removal of stones (calculi) from the bladder. It was a fairly routine procedure, but one which was nonetheless considerably invasive and which, in the days before anesthesia and antisepsis, was attended with a variety of dangers from shock and blood loss, to internal injury and post-operative infection.

The patient was a young boy of “about eight or ten years of age.” These two factors alone (the risky nature of the procedure and the age of the patient) may have been enough to elicit sympathy, and in this case, something terrible happened which profoundly affected the author. The operation, to put it bluntly, was botched. It was standard practice to ‘sound’ a patient in advance of this surgery. This required the insertion of a metal probe down the urethra and into the bladder in order to verify the presence and location of the stone(s). However, in this case the surgeon chose the “dreadful moment” of the young boy’s entry into a public operating theater, surrounded by surgical pupils and practitioners, to undertake this procedure. “Unfortunately he could not feel the stone, till after trying in all directions, and putting the boy in excruciating pain for several minutes, he, at last, satisfied himself and gave the instrument into the hand of another surgeon, for further testimony.” This surgeon also had great difficulty in locating the calculus and handed the sound to a third colleague. According to the correspondent, “These examinations occupied a full twenty minutes, during the whole of which time the boy continued screaming and was nearly exhausted before the operation commenced.” [1]

It is almost impossible for a modern audience, accustomed to a regime of pain-killers and anesthetics, to comprehend the pain of patients on the early nineteenth-century operating table. Nonetheless, it is difficult not to wince in sympathy at such a description. What is particularly interesting to the historian is the emotive register of the report itself. In witnessing the agonies of this young boy, the author, who was almost certainly a surgeon, effected a profoundly empathic emotional engagement. “The operation itself was tedious, and the effect of the whole upon my mind was distressing,” he claimed. “What must it have been to the young sufferer?”

He used the circumstances of this incident to outline a broader affective framework for operative surgery. Operations, he maintained, should always be undertaken with a mind to the patient’s emotional state. Once a patient had been informed that an operation was necessary, it should be performed as soon as possible, for “whoever is well acquainted with the nature of the animal economy must be convinced how much such anxious expectation, such painful anticipation, must agitate and disturb its functions, and render it more unfit for the operation.”

Likewise, when the patient was brought to the operating theater, any unnecessary delay should be avoided, for:

Feverishly heated, and frequently very much exhausted by his previous sufferings, every additional moment, at this dreadful crisis, becomes to him an hour, and every additional moment that he continues under the torture of the different instruments, diminishes the chances of the success of the operation and, of course, encreases [sic] the danger of his life. [2]

Much historical scholarship in the history of surgery and medicine tends to assume that the development of operative surgery was dependent on the elaboration of a culture of dispassion and emotional detachment, what the celebrated eighteenth-century surgeon, William Hunter, called “a sort of necessary inhumanity.” [3] However, it is evident that the author of this report was far from alone in conceiving of surgery in highly emotive terms. Indeed, the early nineteenth century saw the emergence of a rich discourse of surgical compassion in which surgeons were encouraged to sympathize with their patients and urged to minimize their suffering. Surgery itself was conceptualized as a uniquely affective enterprise, often in contradistinction to medicine.

There are a number of reasons why this period saw emotional expression play an increasingly important role in the shaping of surgical culture and identity. At the most obvious level, this was a period just before the advent of anesthesia, which was introduced to Britain from the United States in the 1840s. [4] As such, patients exerted a more powerful agency in the operating theater than they do now. They were not an unconscious, passive object but a frequently screaming, writhing presence whose state of mind needed to be considered, tamed and mastered. Furthermore, as the correspondent to The Lancet suggests, contemporary ideas about physiology and mind-body interdependence maintained that a patient who was emotionally weak or unprepared might not survive even the most well-performed procedure.

This culture of compassion was also shaped by broader social and intellectual trends. Firstly, the later eighteenth century had seen the full-flowering of the concept of sensibility, epitomized by the writings of David Hume and Adam Smith, which viewed our capacity to perceive the emotions of others as forming the very bedrock of moral philosophy. [5]  Though not without its critics, this idea continued to resonate into the new century, as the title of Jane Austen’s celebrated 1811 novel, Sense and Sensibility, suggests. Secondly, this was a period in which surgeons were asserting their status as respectable men of science as opposed to ‘mere’ tradesmen, a process signaled by the transition from the Company of Surgeons in 1745 to the Royal College of Surgeons in 1800. Such claims to respectability entailed a forceful rejection of the established stereotype of the surgeon as unthinking brute, and the articulation of more resonant ideals of the surgeon as restrained and considerate, an ideal which placed sensibility at its heart.

L0034242 Five surgeons participating in the amputation

A classic image of old-fashioned surgical indifference, by Thomas Rowlandson (1793)

What is evident from the report to The Lancet is that it was also a profoundly political process. This was, after all, a botched operation, one performed in a highly incompetent manner. To be sure, pain was an inevitable consequence of surgery, but as the correspondent made clear, this level of suffering was something else:

A great part of this painful process might be, or ought to be avoided. It is woeful to the patient, it is disgraceful to the surgeon. [6]

V0006116 Thomas Wakley. Stipple engraving by W. H. Egleton after K. M

Thomas Wakley (1795 -1862)

In this regard, the author’s choice of journal for publication was critical. The Lancet was founded in 1823 by the surgeon Thomas Wakley, and was consciously established as a radical and reforming mouthpiece for the disadvantaged medical class known as general practitioners. [7] These were men who, as far as they saw it, had studied hard and demonstrated their abilities but who, due to a lack of financial resources and/or familial and professional connections, were denied access to the best practices and the best positions, notably surgical appointments at the London teaching hospitals. In this political context, then, the pain and suffering endured by patients at hospitals like Guy’s and St Thomas’ was rendered a function of incompetence, nepotism and corruption: the inevitable result of a system which granted preferment not through merit but through patronage.

In fact, this correspondent’s report was only one of many similar accounts of bungled operations to appear in The Lancet in the first three decades of its existence. The author was clearly aware of this precedent and began by stating that:

As the principal object of the LANCET is to improve the medical and chirurgical practice, and, of course, to ameliorate the condition, and to diminish the distress of the subjects of its operation; you may not, perhaps, think the following observations unworthy of insertion. [8]

Needless to say, Wakley’s decision to publish these cases excited the anger of established surgeons who resented such scrutiny and felt their reputations endangered by it. However, Wakley was unrepentant:

A young surgeon’s professional prospects may be ruined, it is said, if his failures are blazoned forth to the public. All we have to say in answer to this objection is, that if a young man is elected to fill the office of surgeon to a public hospital, the public have a right to know in what manner he performs his duty.

He continued:

If it be taken as an appeal to our compassion, then we reply that there is a compassion due to patients as well as to surgeons, and that if the reputation or finances of the latter plead for suppression, the safety of the former calls imperiously for publicity.

For Wakley, objections to journalistic exposure were merely indicative of the callous indifference of elite practitioners:

The suffering and destruction of the patient go for nothing, and it is only the mortification endured by the Surgeon, from the consciousness of his own ignorance which excites their sympathy and commiseration.[9]

V0001258 Bransby Blake Cooper. Coloured etching by

A satire on The Lancet’s attacks upon elite surgeons by William Heath (c.1828)

In the context of early nineteenth-century English surgery compassion became a powerful political rhetoric, one which positioned honest, hardworking and humane general practitioners against a cruel and incompetent surgical establishment. This was a campaign which had broader cultural and political resonances, for the values of meritocracy and democracy espoused by The Lancet were very much those of an inchoate middle class who, in the wider political realm, were challenging what they saw as the corruption and callous indifference of the aristocratic political order. In this sense, compassion and sympathy were integral to the very foundation of modern surgical practice. In what way these values were transformed or undermined by the advent of anesthesia and antisepsis is the subject for further research, but their historical significance nonetheless raises interesting and challenging questions about the place of empathy and affect in the cultures of modern surgery.

Michael Brown is Senior Lecturer in History at the University of Roehampton, London. His book, Performing Medicine: Medical Culture and Identity in Provincial England, c.1760-1850 is now out in paperback and his most recent article on The Lancet and radical medical reform in the journal Social History is available for free via Open Access.

[1] The Lancet, 2:42 (17 July 1824), 92.

[2] The Lancet, 2:42 (17 July 1824), 91-2.

[3] For example, Lynda Payne, With Words and Knives: Learning Medical Dispassion in Early Modern England (Ashgate, 2007).

[4] Stephanie Snow, Blessed Days of Anaesthesia: How Anaesthetics Changed the World (Oxford University Press, 2008).

[5] G. J. Barker-Benfield, The Culture of Sensibility: Sex and Society in Eighteenth-Century Britain (University of Chicago Press, 1992); John Mullan, Sentiment and Sociability: The Language of Feeling in the Eighteenth Century (Clarendon Press, 1988).

[6] The Lancet, 2:42 (17 July 1824), 92.

[7] See my ‘“Bats, Rats and Barristers”: The Lancet, libel and the radical stylistics of early nineteenth-century English medicine’, Social History, 39:2 (2014), 189-209.

[8] The Lancet, 2:42 (17 July 1824), 91.

[9] The Lancet, 2:39 (26 June 1824), 397.

4 comments

  1. You seem to have missed a crucial link. Sensibility wasn’t just an aesthetic basis for non-credal morality, as in Smith and Herder. It was a mind-body theory of the nerves and personality, from the work of Willis and Cheyne, which was popularized throughout Europe in the novels of Richardson.

    Genteel Whigs and ladies saw themselves in terms of their elevated sensibilities. Patients related their experiences to their doctors in terms of sensibility, as did the soldiers of the Revolutionary War, writing to Benjamin Rush.

    Thus, the nervous sensibility of the agonized patient was resonating with the refined sensibility of the doctors, like the sympathetic strings of a viola d’amore.

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  2. Pingback: Whewell’s Gazette: Vol. 3 | Whewell's Ghost

  3. Michael Brown

    Of course sensibility was a physiological theory as well as a cultural phenomenon. This is a blog post, not an academic article, and as such does not permit one to go into as much depth as one might like. However, what I would suggest is that there is a politics to sensibility, particularly by the end of the eighteenth century and another aspect of my research explores the dispute between John Bell and James Gregory in turn-of-the-century Edinburgh in which Bell, the surgeon, articulates a vision of plain, honest and unadorned sensibility which he contrasts with the affected, polite and ‘fashionable’ sensibility of elite physicians such as Gregory (à la Mackenzie). So, in other words, surgical sensibility is, in certain cases, being deliberately positioned in opposition to that of physicians as part of a political critique of privilege and entitlement. What this post is designed to highlight is the ways in which this discourse is shaped by the radical medical reform movement of the 1820s and 30s.

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    • Sensibility was political almost from the outset, within medicine and outside it. Both Whig vs Tory, and gender. Few Tories would admit to mourning a pet, as Stukeley did. Women were more moral because of their greater sensibility. Burke opposed representation for the colonials because slaveowning had coarsened their sensibilities to the point where they could not be trusted with English liberties. Robust Tory surgeons wielded the obstetric forceps whereas effete Whig physicians such as William Hunter waited on Nature. [very simplistic contrast]

      I didn’t mean to criticize, but rather to point to longterm political issues embedded within the rhetorical development of the fashionable concept, quite apart from specific uses of it as a tool. I expect I could have expressed myself better, but I was just writing a blog comment.

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