Plus ca change
PLUS CA CHANGE, PLUS C'EST LA MEME CHOSE
Vivien Stern's delightfully dramatic response to her surgery (1)
reminded me of a similar experience with a patient some thirty years ago.
I am now a retired consultant anaesthetist who in my early days
acquired an enthusiasm for local anaesthesia though I must confess I would
always opt for being totally unaware for any surgical procedure on myself!
As a young consultant I was presented with a very ill man in his
sixties with a gangrenous leg requiring above-knee amputation. The
surgeon and I were agreed that he was a poor candidate for general
anaesthesia and that some form of local anaesthesia would be appropriate.
I had been reading about Refrigeration Analgesia, attributed to Baron
Larrey (2) chief surgeon to Napoleon during his campaign in Russia and
later revived by F. M. Allen in America (3). Today, I imagine few
anaesthetists would consider such a technique which by its very nature
could not be often taught or much practised. In those days before
litigation medicine I decided to give it a go - despite never having seen
or done it before.
For an above-knee amputation many hours refrigeration of the whole
limb were required starting with the patient in his bed in the ward. Red
rubber sheeting was arranged with difficulty to prevent flooding. The
whole supply of ice for the Hospital Group was used up in the process.
Eventually the patient was put on the operating table and I carefully
arranged a small screen to prevent him from seeing what the surgeon was
doing. The operation went well and the patient returned to the ward in
good condition. One beneficial effect of Refrigeration Analgesia was
thought to be a cessation of bacterial activity with resulting reduction
At the end of the list I saw the patient in the ward and asked if he
had found the operation a trying experience. I was surprised when he
said 'Certainly not, I enjoyed every minute. I saw everything that went
on. ' When I recovered my composure he explained that he had seen the
whole operation, including the sawing through his femur, in the small
reflecting mirrors which were a common component arranged around the
inside of the operating theatre light. I was interested to read that
Vivien Stern obtained a similar view of her operation even with today's
modern theatre lighting.
The lesson seems to me that anaesthetists ought sometimes to consider
letting the patient see the surgery but if screening is essential then
they should beware of all reflecting surfaces in the theatre.
1. Vivien Stern BMJ 2000; 321: 1606-7
2. Larrey D.J. Memoires de chirurgie militaire et campagnes. 3.503.
Smith Paris 1812
3. Allen F.M. and Crossman L.W. Curr. Res. Anest. Analg., 1943.22.5
Competing interests: No competing interests