In praise of anesthesia: Two case studies of pain and suffering during major surgical procedures with and without anesthesia in the United States Civil War-1861-65.

Background The United States Civil War (1861-1865) pitted the more populous industrialized North (Union) against the mainly agricultural slaveholding South (Confederacy). This conflict cost an enormous number of lives, with recent estimates mentioning a total mortality greater than 700,000 combatants [1]. Although sulfuric ether (ETH) and chloroform (CHL) were available since Morton's use of the former in 1846 and the employment of the latter in 1847, and even though inhalational agents were used in Crimean war (1853-1856) and the Mexican-American War (1846-1848), the United States Civil War gave military surgeons on both sides the opportunity to experience the use of these two agents because of the large number of casualties. Methods Research of historic archives illustrates the dramatic control of surgical pain made possible with introduction of two general anesthetic and analgesic drugs in 1846 and 1847. Results An appreciation of the importance of anesthesia during surgical procedures can be noted in the poignant and at times hair raising cases of two left arm amputations carried out under appalling circumstances during the United States Civil War. In the first-case the amputation was delayed for nearly five days after the wounding of Private Winchell who served in an elite sharpshooter brigade and was captured by the Confederate Army during battle. The amputation was performed without anesthesia and the voice of the Private himself narrates his dreadful experience. The postoperative course was incredible as he received no analgesia and survived a delirious comatose state lying on the ground in the intense summer heat. Thomas Jonathan "Stonewall" Jackson was a famous ascetic Confederate General who helped defeat the Union forces at the Battle of Chancellorsville on May 2, 1863. In the ensuing near-darkness, Jackson was fired upon by his own friendly troops where he suffered multiple gunshot wounds on his right hand as well as a ball in the upper humerus of the left arm similar to that of Private Winchell. Transported to a field hospital about thirty miles away, the evacuation was carried out under artillery fire and the General dropped from the stretcher at least twice before arriving at the field hospital. There, a team of surgeons operated on "Stonewall", using open drop chloroform, the surgery taking 50 min, anesthesia times of one hour with General Jackson awake and speaking with clarity shortly after the termination of the anesthesia. A brief explanation of the use of anesthetics in the military environment during the Crimean, Mexican American and the United States Civil War is also presented. Conclusion and implications Two case stories illustrate the profound improvement in surgical pain made possible with ether and chloroform only 160 years ago. Surgeons and patients nowadays have no ideas what these most important improvements in modern medicine means, unless "reliving" the true hell of pain surgery was before ether and chloroform.

Venous air embolism: a warning not to be complacent--we should listen to the drumbeat of history.

Clinical Considerations Concerning Detection of Venous Air Embolism. By Maurice S. Albin, Robert G. Carroll, Joseph C. Maroon. Neurosurgery 1978; 3:380-84. Abstract used with permission from the Congress of Neurological Surgeons, copyright 1978. Venous air embolism during neurosurgical procedures (detected by Doppler ultrasound and aspiration via a right atrial catheter) was noted in 100 of 400 patients in the sitting position, 5 of 60 patients in the lateral position, 7 of 48 patients in the supine position, and 1 of 10 patients in the monitored prone position. We confirmed venous air embolism in many of these patients by using serial technetium-microaggregated albumin lung scans. Gravitational gradients from the venous portal of entrance to the right side of the heart were as small as 5.0 cm, with aspiration of 200 ml of air occurring. Doppler ultrasonic air bubble detection and aspiration through a previously inserted right atrial catheter are critical factors in the diagnosis and treatment of this condition.

Intraoperative visible bubbling of air may be the first sign of venous air embolism during posterior surgery for scoliosis.

STUDY DESIGN: Case report of two children sustaining venous air embolism (VAE) during posterior surgery for scoliosis. OBJECTIVES: To report 2 cases where visible bubbling at the operative site was the first clinical indication of VAE-induced cardiovascular collapse and to raise the level of consciousness that VAE in the prone position can occur, often with serious consequences. SUMMARY OF BACKGROUND DATA: Twenty-two cases of VAE during surgery for scoliosis in the prone position have been reported. Ten were fatal and ten were in children. Visible bubbling at the operative site was noted in two published cases. METHODS: Retrospective study of 2 cases of VAE at one institution. Clinical, anesthetic, and radiographic features are presented. Details of previously published cases are reviewed and discussed. RESULTS: Both patients were girls with adolescent scoliosis who underwent prone positioned posterior spinal fusion with instrumentation. Visible bubbling of air at the thoracic aspect of the surgical site was noted near the completion of instrumentation and was the first indication of VAE. In both cases, this was clinically recognized and promptly treated. One patient survived normally and the other died. CONCLUSIONS: Visible air bubbling at the operative site may herald the onset of massive VAE during multilevel posterior spinal fusion and instrumentation. A prospective multicenter study using precordial Doppler, central venous catheter, and end-tidal CO2 is recommended to determine the true incidence of VAE in spinal deformity surgery and to evaluate monitoring and treatment methods.