Special feature: You must expect to suffer: Mme d’Arblay and surgery before the advent of anesthesia

Issue: BCMJ, vol. 55 , No. 5 , June 2013 , Pages 240-242 News&Notes

Surgery without anesthesia—now unthinkable—was once the only option for curing a number of operable conditions, including the advanced breast cancer of Madame Frances d’Arblay (née Burney), who underwent a harrowing mastectomy without an anesthetic in 1811.


Stories of patients awakening from anesthesia during surgery are frequently related with macabre fascination, highlighting gory details and eliciting shudders from listeners. As horrified as we now feel about the thought of undergoing surgery with no anesthesia or pain medi­cation, it was once the only option to cure a number of ailments and conditions. Such was the case for novelist Frances Burney, whose advanced breast cancer required a lifesaving mastectomy in 1811. 

Dr Antoine Dubois: A frightening diagnosis 
Frances (Fanny) Burney (1752–1840) was an English novelist, diarist, and playwright, whose work was recognized for its sardonic humor about eighteenth-century life.[1] She married Aléxandre-Jean-Baptiste Piochard d’Arblay, an impoverished monarchist and refugee artillery officer from re­publican France, at the age of 40, and the couple had a son, Alexander. 

In 1810, when Mme d’Arblay was 58, she noticed a heaviness in her right breast. She ignored her husband’s advice to see a doctor until two frightened confidantes also voiced their concerns. Mme d’Arblay then saw a local doctor, but there was no change in her condition. M d’Arblay then ask­ed Dr Antoine Dubois (1756–1837), the most celebrated physician in France, to see his wife, as he had once treated her for an abscess. 

Dr Dubois, who at the time was serving as the attending physician for the pregnancy of Napoleon’s second wife, Empress Marie-Louise, examined Mme d’Arblay and made the frightening diagnosis of cancer. He secretly thought that her cancer was too advanced for surgical treatment, and was of the opinion that surgery would only aggravate the disease and hasten her death. He wrote her a prescription and made hearty attempts to soothe her anxiety, but his reassurances merely stoked her fears. M d’Arblay’s haggard, doleful expression betrayed his own anxieties, and Mme d’Arblay wrote that her husband’s sorrowful demeanor left her “confounded and stupefied.”[2]

Dr Dominique-Jean Larrey: A reluctant recommendation to operate
Dr Dubois had taken up residence in the Tuileries Palace in order to closely supervise the pregnancy of Empress Marie-Louise, and his duties in this capacity prevented him from seeing Mme d’Arblay for a month after the diagnosis. Desperate to find immediate assistance for his wife, M d’Arblay asked Dr Dominique-Jean Larrey (1776–1842), chief of surgery to Napoleon’s Imperial Guard, to see Mme d’Arblay. Dr Larrey agreed, and Mme d’Arblay gave her written permission for him to take over her case from Dr Dubois. 

Dr Larrey admired his witty pa­tient, and she briefly blossomed under his attention. He considered the option of surgery to remove the cancer, but knowing the pain and suffering Mme d’Arblay would experience, he hesitated. Mme d’Arblay’s condition be­gan to worsen. Wondering whether his wish to avoid causing Mme d’Arblay unnecessary harm was clouding his clinical judgment, Dr Larrey asked Dr Ribe, the foremost anatomist in France, for his opinion. He also called in another physician, Dr Moreau, to see Mme d’Arblay. After examining Mme d’Arblay and reviewing the case, Drs Ribe and Moreau concurred that an operation was necessary. Dr Larrey relayed the decision to Mme d’Arblay with tears in his eyes.

The surgery
There was no anesthesia. Dr Dubois, who briefly took leave of his duties at the palace to confer on the surgery, did not have a soothing bedside manner. He told Mme d’Arblay, “You must expect to suffer, I do not want to deceive you—you will suffer—you will suffer very much!”[2

Dr Ribe, equally grim, followed suit by in­structing Mme d’Arblay to cry out during the operation. He seemed glad to hear how she had screamed when her son, Alexander, was born. Dr Larrey sighed, and wished he had never met Mme d’Arblay—the thought of her suffering dismayed him so much that he half considered asking for a commission to a far part of the Empire in order to avoid participating in the surgery. He championed Dr Dubois to perform the operation, but Mme d’Arblay demurred—Dr Larrey enjoyed her full confidence, and she wanted him to be the one to operate.

Three weeks passed. Mme d’Arblay spent the days leading up to her surgery frightened and full of dismal fantasies. She was aghast at the very large pile of charpie (shredded linens), bandages, and compresses thought necessary for the surgery, dutifully gathered by M d’Arblay and a friend.

On the day of the surgery Mme d’Arblay forced down a crust of bread for breakfast. She sent Alexander to take a note to her husband’s superior saying that “the moment was come” and requesting that he summon M d’Arblay out of the house on some pretext. Alexander sobbed, but obey­ed. Mme d’Arblay forced her painful right arm to write farewell letters to her husband and Alexander, and eventually Dr Moreau appeared and gave her a wine-cordial to prepare her for the surgery.

Mme d’Arblay’s maid and a nurse both fled in terror as seven men in black silently entered the room. They were her doctors: Drs Dubois, Larrey, Ribe, and Moreau, a Dr Aument, and two medical students. Dr Larrey was as “pale as ashes.”[2] Dr Dubois seemed agitated, but gave orders like a sergeant major, au militarie. 

They laid her, shaking, on a mattress and put a cambric handkerchief over her face. Mme d’Arblay saw the glint of steel through the handkerchief and watched her silent doctors wordlessly signalling what sort of incision should be made.

Then Dr Larrey asked, “Who will hold this breast for me?” “I will, sir,” quavered brave Mme d’Arblay. Mme d’Arblay later wrote, “ …when the dreadful steel was plunged into the breast—cutting through veins, arteries, flesh, nerves—I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly the whole time of the incision… so excruciating was the agony… the air felt like a mass of minute but sharp and forked poniards that were tearing the edges of the wound.”[2]

It was hard to cut away the base of the breast, and Dr Larrey had to change hands. The torture continued, and Mme d’Arblay was aware of the knife scraping the breast-bone (probably a rib) as Dr Dubois told Dr Larrey to continue scraping, again and again, until all the peccant attoms (diseased fragments) were removed.

Mme d’Arblay had refused to be held down. She did not writhe or wrestle, and made no complaint. She felt sorry for her doctors, exclaiming “Ah, Sirs! How I pity you.” The operation and dressing took 20 minutes. Then, wrote Mme d’Arblay, “I saw my good Dr Larrey, pale nearly as myself, his face streaked with blood, its expression depicting grief, apprehension, and almost horror.”[2]

The operation was a success. Mme d’Arblay recovered and lived for another 29 years. Her husband was promoted to lieutenant-general and they eventually relocated to England.

The legacies of Drs Dubois and Larrey
After Mme d’Arblay’s operation, Dr Dubois hurried back to the Tuileries to supervise Marie-Louise’s delivery. The birth was difficult, but mother and baby survived and Napoleon rewarded Dr Dubois with 100 000 francs and the Legion of Honour. He kept his position at court and later became chief of surgery at the Academy of Medicine.

Dr Larrey is regarded as the first modern military surgeon. He went on to invent “flying ambulances”—horse-drawn wagons containing a doctor, two assistants, and a nurse, that galloped to the front to treat wounded soldiers on the spot and avoid the risks and delays of transporting them to the rear. He continued to take part in Napoleon’s campaigns, performing 300 amputations in 24 hours at the Battle of Borodino. 

At the Battle of Waterloo the Duke of Wellington or­der­ed his troops not to fire in Dr Larrey’s direction, “to give the brave man time to gather up the wounded.” Wellington said, “He has the courage and devotion of an age that is no longer ours.” Dr Larrey was later captured by the Prussians and ordered to be shot. A Prussian surgeon recognized him from a lecture and spoke up on his behalf, and he was subsequently re­leased by Field Marshal Blücher, a man whose son’s life he had once saved.

When Napoleon was in exile on St. Helena he described Dr Larrey as a truly good man who combined all the virtues of philanthropy and science to the highest degree, and who treated every wounded soldier like a member of his family. He added that Dr Larrey was the most virtuous man he had ever met. Mme d’Arblay also extolled the character of Dr Larrey, describing him as “The worthiest… singularly excellent of men.”[2]
Dr Larrey’s name is engraved on the Arc de Triomphe in Paris.

Suggested reading
Enright DJ (ed). The Faber Book of Fevers and Frets. London: Faber and Faber; 1989.
Schom A. Napoleon Bonaparte: A life. New York, NY: Harper Collins; 1997.


References

1.    Wikipedia. Frances Burney. Accessed 2 May 2013. http://en.wikipedia.org/wiki/Mme d’Arblay_Burney.
2.    Burney F. Account from Paris of a terrible operation—1812 [letter to Esther Burney]. Henry W. and Albert A. Berg Collection. 22 March 1812. New York Public Library, New York. Online at the New Jacksonian Blog. Accessed 9 May 2013. http://newjacksonianblog.blogspot.ca/2010/12/breast-cancer-in-1811-Mme d’Arblay-burneys.html.

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Dr Morrant is a psychotherapist in Richmond with an interest in literature, history, and gardening.

J.C.A. Morrant, MBBS, DObst, RCOG, DPM, FRCPC,. Special feature: You must expect to suffer: Mme d’Arblay and surgery before the advent of anesthesia . BCMJ, Vol. 55, No. 5, June, 2013, Page(s) 240-242 - News&Notes.



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