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A History of Patient Comfort (Part 2) – Passing Gas (1540-1847)

February 1, 2012
by Peter Nkansah, MSc, DDS, Dip. Anaes., Specialist in Dental Anaes. (Ont.)


The story of inhalational anaesthesia leading up to Ether Day is as much about personalities as it is about science. Actually, it’s more about the people than the chemistry. Oxygen, nitrous oxide and ether were each discovered before their use could really be sorted out, not unlike the Internet. The personalities involved included (in alphabetical order) Dr. Gardner Colton, Dr. Crawford Long, Dr. William Morton and Dr. Horace Wells. Their lives often intertwined, sometimes by happenstance, sometimes by design. The end result was the birth of the discipline of anaesthesia, arguably the greatest medical breakthrough ever.

The world of the mid- to late-19th century was a rapidly changing one. The Industrial Revolution was in full swing and civilized life as it was known was changing. Cars, planes, electricity and refrigeration were all yet to come, as were microscopy and chemical analysis. No disease could be cured except for smallpox, a fact which was sadly used to the detriment of Native North Americans in 1763 as part of Pontiac’s Rebellion. The Slavery Abolition Act freed the slaves in most of the British Empire in 1833; the Emancipation Proclamation in the United States followed 30 years later.1 If you were born in North America in 1900, your life expectancy was less than 50 years.2,3 The practice of healthcare was advancing toward the systematic, objective system that we recognize today. Medical schools were established in the University of Pennsylvania in 1765 and in Columbia University in 1767. In Canada, McGill University’s medical school opened in 1824. Slowly, the professions of pharmacy, physician and surgeon were separated, although physicians and surgeons were later reattached. The world’s first dental school was opened at the Baltimore College of Dental Surgery (now the University of Maryland) in 1840, Canada followed suit in 1868 with the establishment of a dental school at the University of Toronto. Before then, dentists were rare in Canada, with extractions being performed by barbers or blacksmiths. Anyone willing to do the work could call themselves a dentist. But the lack of training or standards created barriers to care and trust, as well as hazards to public well-being which pushed Dr. Barnabus Day and some of his colleagues to establish the Ontario Dental Association on July 2, 1867 (kindly not stealing headlines from the Fathers of Confederation). By March 1868, Ontario passed an Act Respecting Dentistry, putting regulatory and licensing powers in the hands of the Royal College of Dental Surgeons of Ontario. It was the first such Act in the world and provided a model for other jurisdictions to follow.4

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Ironically, in the face of the advances of healthcare knowledge and regulation and practices, healthcare practitioners are responsible for a fair amount of the health challenges of the day since the concept of asepsis was only in its infancy. The post-surgical mortality rate after amputations was 40%, leading to the then-common phrase in medical circles, “the operation was a success, but the patient died.” The seminal works on antiseptics and aseptic techniques by Dr. Ignaz Semmelweis (“the saviour of mothers”) in Austria in 1850 and by Dr. Joseph Lister (a friend of Dr. Louis Pasteur and the namesake of Listerine mouthrinse) in Scotland in 1865 were received with open hostility by the rest of the medical community.5,6 So surgeons continued to operate with unwashed hands, unwashed clothes and unwashed instruments for some time. Still, surgeries were the only option for the treatment of many diseases, so they continued with speed as the key element of surgical prowess. It was reported in France that with the right tools (furnished by the Industrial Revolution) bladder stones could be removed through the ureter in under a minute (thankfully). In Paris, a celebrated surgeon named Baron Larrey owed his fame to speed, having performed two hundred amputations in a twenty-four hour period after the Battle of Borodino in 1812.5 Amputations, mastectomies, whatever the surgery, it had to be fast. With no way to achieve comfort through the procedure and the promise of infection afterwards, many patients chose to forego surgery and allowed the disease to run its course.

For now, let’s go back to the 1770s and the discoveries of oxygen and nitrous oxide. The discoverer of oxygen is a matter of debate, with credit going to Carl Wilheim Scheele in Sweden in 1772 or Joseph Priestly in England in 1774. Both men sent their findings to Antoine Lavoisier (“the father of modern chemistry”) in France, who later named the gas “oxygen” as opposed to “fire air” (Scheele) or “dephlogisticated air” (Priestly). The discovery of nitrous oxide is less contentious, with the credit there going to Joseph Priestly in 1793. At first, Priestly thought it might have a use as a preserving agent, but these experiments failed and nitrous oxide was set aside. Later, in 1799, while at the Medical Pneumatic Institution in Bristol, England, Sir Humphry Davy wrote the book Researches, Chemical and Philosophical Chiefly Concerning Nitrous Oxide or Dephlogisticated Nitrous Air, and Its Respiration. It was an unwieldy title that held little immediate impact in the medical community, even though it noted that nitrous oxide appeared to be “capable of destroying physical pain”. Its future use was even presaged with the statement that “it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.”7-10 Instead, more attention was paid to the amusing effects that it had on people who inhaled it. As such, it became a social drug or “laughing gas”. Nitrous oxide shared the social spotlight with diethyl ether (or just “ether”), which was discovered first by Jabir ibn Hayyam, an Arabian philosopher, in the 8th century and then rediscovered by Raymundus (Raymond) Lully, a European alchemist, in the 13th century.11

In 1540, German botanist and chemist, Valerius Cordus produced a recipe for the production of ether, which he called “sweet oil of vitriol.” (This published record from 1561 is on display in the ASA’s Wood Library-Museum in Park Ridge, Illinois.) Parcelsus, who was a contemporary of Cordus, also produced this sweet vitriol and put it to use as an anaesthetic for animals; it put chickens to sleep when added to their feed.12,13 The name “ether” did not come into use until Froben named the liquid “spiritus æthereus” around 1730. At that time the compound was drunk for its intoxicating (“three times that of whiskey”) and medicinal effects.14 Had Parcelsus’ experiments extended to humans, the history of medicine would certainly be different.

Another near miss for the introduction of surgical anaesthesia came from Dr. Henry Hill Hickman. Dr. Hickman was a doctor practising in Ludlow, Wales, who had an interest in anaesthesia for surgery. Starting in 1823, when the concept of painless surgery was still a far-flung fantasy, he experimented with “suspended animation” using carbon dioxide (“carbonic acid gas”), which was really asphyxiation.15 While the idea of an inhaled anaesthetic was sound, his choice of agent was not. In 1826, The Lancet published an article/letter titled “Surgical Humbug” that was thoroughly critical of Hickman’s work.16 His theory fortunately never gained acceptance and died with him in 1830.

Crawford Williamson Long started his medical training in Jefferson, Georgia as an apprentice. Apprenticeship was the common route to join the medical profession. It was also the most common route to careers in law or the ministry or many industries.17 At a time when many doctors did not have degrees, he was well-trained, receiving an MD degree from the University of Pennsylvania in 1839. Travelling from a small town in Georgia to Philadelphia, as urban a centre as there was in the United States at that time, may also explain his first exposure to sulfuric ether.17 Long returned to Jefferson in 1841 and brought “ether frolics” with him.

“Ether frolics” were the domain of university students and social
ites in the first half of the 19th century. The inhalation of either nitrous oxide or ether was known to be intoxicating and humorous. There were travelling road shows, where either substance would be administered to audience members, who would then do strange and (usually) funny things to the amusement of the audience, but with no memory of the events. Ether and nitrous oxide were also more acceptable than alcohol in higher social circles. Ether was much easier to make and therefore much easier to get than nitrous oxide. Ether had been on the fringe of healthcare since 1760 and by the 1830s was prescribed in cases of respiratory distress or nausea or drunkenness. It could be either inhaled or taken by mouth as a drink. Fun as it was, ether had a darker side too. Vomiting, “stupefaction” and nonrousable unconsciousness (which lead to the expression, “dead to the world”) were included in the list of undesirable effects.9

During Long’s frolics, he noted that he sometimes sported bruises that he did not remember earning. He also observed that his friends would sometimes do things that would have hurt them (e.g. fall down, collide with an object), but gave no indication of feeling pain at the time.17 From this came the idea that pain might be abolished during surgery if ether were employed. James Venable was a friend of Long’s who had two cysts on the back of his neck that he refused to have removed because of his fear of pain during the surgery. On March 30, 1842, Venable consented to having one of the cysts removed while under the influence of ether. Venable felt no pain during the procedure, and in fact did not believe that the cyst had been removed until Long showed it to him. In January 1845, Long removed two fingers from Isam Baily, one with ether, and one without. The procedure without anaesthetic, which was the normal practice of the day, was understandably painful. The procedure with anaesthetic was painless. These “etherization” findings were shared with Dr. Charles T. Jackson during a visit to Athens, Georgia, but were not reported in an article until 1849.9,17 Why Long chose to wait seven years before sharing his apparent discovery is a matter of conjecture. It is worthwhile to remember that in the 1840s, pain and surgery were considered to be chimeric. Some of the townspeople of Jefferson even considered Long to be a witch.17 Whatever the reason for the delay, it removed him from common consideration as the founder of anaesthesia.

In fact, Long’s discovery may have been preceded by a few months by William Clarke and Dr. Elijah Pope. Clarke was a chemistry student at the Rochester Collegiate Institute in New York who attended ether frolics along with William Morton. He noticed the diminution of pain while under the influence of the vapour. In January 1842, he used this knowledge to anaesthetize an uncooperative woman who was having a tooth extracted by Pope. Both Clarke and Pope thought that her unconsciousness was the result of her hysteria and not the ether-soaked towel that had been placed over her mouth. Because of this belief, they did not publish a record of this event. Later, Clarke told his colleagues about the appointment, making this the first use of ether as an anaesthetic.12

Dr. Charles Thomas Jackson was born in Plymouth, Massachusetts in 1805 to a family of high standing. He had an early interest in science for science’s sake, which was seen as frivolous. Against his family’s wishes, he pursued careers in medicine, chemistry and geology. He received his MD from Harvard College in 1829. In 1842, after accidentally exposing himself to chlorine gas while preparing a demonstration and lecture on Vesuvius, he inhaled ether as an antidote; ether was believed to have medicinal properties for the lungs. Later that night, with his lungs still irritated, he inhaled ether again, this time putting himself into a state of unconsciousness.18 Jackson still felt that ether’s main application was as a topical anaesthetic.12 He tried to convince dentists to use it to alleviate the pain of dental surgery, but his suggestions were turned down until he developed an association with Dr. William T.G. Morton in Boston.

Dr. William Thomas Green Morton was a dentist in practice if not by degree, as he left the College of Dental Surgery in Baltimore before he completed his studies. He later registered at the medical school in Harvard, but withdrew early from there too. Morton first encountered Jackson as a student attending Professor Jackson’s lectures on chemistry.19 Some knowledge of ether’s ability to render people unconscious was gained there as Jackson would run demonstrations in his classes. Morton knew that ether could provide analgesia if dropped or sprayed onto the skin, he also became aware of its properties as an inhaled anaesthetic.11 It was more convenient than nitrous oxide because it was easier to make and, as a liquid, was easier to transport. Ether was also safer in that surgical anaesthesia could be achieved at a low enough concentration, as a vapour, that hypoxia was not a concern. Nitrous oxide, by contrast, as a weak anaesthetic gas had to be given at 100% in order to induce surgical levels of anaesthesia, therefore depriving the patient of oxygen during the time of administration. This was somewhat reminiscent of Hickman’s “suspended animation” anaesthesia. Again, in accordance with the thinking of the day, the properties of ether were not initially applied to anaesthesia, but rather to analgesia.

By 1844, Morton briefly had entered into a (short-lived) partnership in dentistry in Boston with Dr. Horace Wells after being taught by him in Hartford, Connecticut.9,20 Together, they were developing new materials and processes to make denture teeth; teeth made from porcelain were new and popular.4,12,21 For appointments where teeth had to be removed, Morton and Jackson both wondered how that procedure could be made more acceptable.

Dr. Horace Wells was born in 1815 in Hartford, Vermont. He had descended from good stock with his ancestors among the first settlers of Vermont. His parents were cultured, wealthy land owners who were willing and able to provide amply for their three sons. Wells began to study dentistry as an apprentice in 1834. In 1836, he moved to Hartford, Connecticut and quickly established a successful practice.20 By all accounts, Wells was a conscientious, skilled dentist. He was an early advocate of preventive and restorative dentistry and got along well with children. Still, this was the mid-1800s, so much of his practice involved the extraction of teeth. His compassionate and religious ways led to great unease with the suffering that he inflicted on some of his patients.

Gardner Quincy Colton was born in Georgia, Vermont in 1814, the youngest of twelve children. His family was poor and deeply religious. In a book about his recollections, he noted that he often “would wake up in the morning and find a snow drift on my bed, the snow having blown through the leaky roof. I think I did not have an overcoat till I was near twenty years of age.” Colton married in 1839, but his wife died only fifteen months later. At that time, Colton’s siblings offered to help him through medical school, an offer that he did not refuse. He entered the Crosby Street College of Physicians and Surgeons in New York City in 1842, but left after two years to lecture on chemistry and “natural philosophy” (sort of physics with reasonings). Nitrous oxide, of course, was known to medical students, and Colton could lecture on it and demonstrate it since he had the knowledge and ability to make it. Laughing gas exhibitions had been popularized by “the Celebrated Dr. Coult of New York, London and Calcutta”. It was, in fact, Samuel Colt, the creator of the Colt revolver gun, but the entrepreneurial die had been cast. The financial success of his first exhibition in 1844 led him to present more exhibitions throughout New England.22 Figure 1 shows an example of an advertising poster from 1845.

Colton’s “Grand Exhibition of the Effects Produced by Inhaling Nitrous Oxide” tour brought him t
o Union Hall in Hartford, Connecticut on December 10, 1844. Encouraged by his wife to attend, Horace Wells and a friend, Sam Cooley, attended and were in the first group of ten to try the gas. During his recovery from his dose of nitrous oxide, Wells noticed that Cooley, who was sitting beside him, had blood on his pants. This was the result of Cooley plowing into a wooden settee onstage during his own nitrous oxide-induced antics. When asked about what had happened, Cooley did not remember the incident at all as the pain began to set it.9 At the end of the show, Wells approached Colton and asked, “Why cannot a man have a tooth extracted and not feel it under the effects of the gas?”20 The exact events of the next day vary according to the source, but what appears to be certain is that Horace Wells himself, had a tooth extracted by John Riggs, a former Wells student and neighbouring dentist. After the extraction, Wells reportedly said, “I didn’t feel it so much as the prick of a pin!” after he awoke. After more successful dental and medical trials in Hartford, Dr. Wells took his discovery to Boston and contacted Dr. John Collins Warren, head of surgery at Massachusetts General Hospital and the preeminent surgeon in the United States at the time. His aim was to present this finding to “those who were best qualified to investigate and decide upon its merits”.20

On January 10, 1845, in Warren’s operating theatre, Wells used nitrous oxide in the extraction of a tooth. The intended surgery was the removal of a tumour, but that patient backed out of the surgery for fear of the anticipated pain. The replacement patient ended up being a medical student who was in the audience. Here too, the exact details of the nitrous oxide administration and the patient’s response to the surgery are unclear, as reports vary slightly; what is not unclear is that the patient responded to the extraction. Whether the specific response was a yell or a “hallo” or a whimper did not matter. The gas was probably not administered correctly because of an equipment malfunction or maybe even nervousness on the part of Wells. In any case, the damage had been done; the patient had not been rendered insensible to surgery. Wells immediately left the theatre in shame. Afterward the patient claimed to have felt nothing, but the audience did not accept this. The demonstration was deemed an utter failure. Actually, it was deemed a “humbug,” and that was about the worst insult that could be directed at a clinician or scientist (see: Hickman’s undoing in 1826). And with that, nitrous oxide was sent back to the students and socialites.

Horace Wells never really recovered from this public failure, and by April 1845 had given up his dental practice. In 1846, Wells had to suffer through Ether Day and the subsequent claims by Morton (his former student) and Jackson (his former teacher), that they should each exclusively be recognized as the discoverer of anesthesia. Wells’ wife called it, appropriately, “the gas war.”20 In 1847, Wells travelled to Paris, France to present his claim at the leading centre of medical knowledge of the day. His request was refused. On his return to the United States, Wells moved to New York City because physicians in Connecticut were more interested in using letheonTM (Morton’s mix of ether and an aromatic agent) than nitrous oxide.19 At this time, Wells had also begun to experiment with and abuse chloroform. In January, 1848, likely under the influence of chloroform, he threw sulfuric acid at two women that he deemed to be prostitutes (“abandoned females”) and was arrested. In an interesting piece of prisoner supervision, Wells was allowed to go home to collect some personal effects before returning to jail. Among these effects were a bottle of chloroform and a razor. Once in the jail cell, Wells inhaled chloroform, severed his femoral artery and on January 24, 1848, died at the age of 33.9,20 Three days later, unaware of Wells’ death, the Societé Médicale Française, which had refused to evaluate nitrous oxide as an anaesthetic in 1847, voted to acknowledge Wells as the discoverer of anaesthesia.19 Today, he is generally recognized as the discoverer of anaesthesia.7,23

Morton had been in the audience in Massachusetts General Hospital for Wells’ ill-fated nitrous oxide demonstration in 1844, in fact, the instruments used for the extraction were his. By the summer of 1846, Morton and Wells were no longer partners; Morton’s search for an anaesthetic had been rekindled by reports of people at ether frolics hurting themselves but having no recollection of whatever trauma they had experienced. Jackson reportedly suggested trying ether as an inhalant as opposed to a topical or ingested anaesthetic. Morton first practiced “etherization” on animals at his farm. By September, he was using ether on patients in his office.11 He then contacted the same Dr. Warren from Wells’ failed demonstration to arrange a new demonstration.

On October 16, 1846, the only operation scheduled at Massachusetts General Hospital for the day was the removal of a neck tumour by Warren himself. Scheduled for 10:00 a.m. Morton was late, as he was frantically putting the finishing touches on his new ether inhaler that had been constructed only the night before. Upon Morton’s arrival, Warren sarcastically stated, “Well sir, your patient is ready.” After setting up and administering ether for 3 or 4 minutes rendering the patient unconscious, Morton stepped back, bowed to Warren and said, “Your patient is ready, sir.” The tumour was removed; the patient, Gilbert Abbott, did not flinch or “hallo”. Dr. Warren stepped back and announced, “Gentlemen, this is no humbug.”9,21 This was Ether Day. The operating theatre in the hospital’s Bullfinch building is now a designated historical site commonly known as the Ether Dome.

What followed in the next few years was a bitter and protracted legal and personal tripartite battle between Wells, Morton and Jackson for recognition as the founder of anaesthesia. At different levels, this battle killed each of them. As previously noted, Wells committed suicide in 1848. Morton died on July 15, 1868 in Central Park in New York of “brain congestion” or possibly a stroke. By that time he had applied to the U.S. Congress four times looking for financial recognition for “his” discovery.9 Jackson died in 1880 in a Boston asylum after living comfortably for a time, then not so comfortably when a cousin gained control over the inheritance that had provided him with income. Long was not involved in this battle and died on June 16, 1878 at the age of 62 from a cerebral haemorrhage.17 Nearly fifty years later, in 1926, a statue of Long was erected in Statuary Hall in the U.S. Capitol recognizing him as the discoverer of sulphuric ether as an anaesthetic. On its base is the Long quotation, “My profession is to me a ministry from God”.17,19

Both medicine and society were slow to accept this new, mysterious and fantastic approach to healthcare. Some of the strongest societal opposition came from the Church, which called the use of ether a “decoy of Satan” among other things. This changed when Dr. John Snow used chloroform in England during the deliveries of Queen Victoria’s eighth and ninth children (Leopold in 1850 and Beatrice in 1853). Since Queen Victoria was the head of the Church, the religious debate over the appropriateness of anaesthesia was effectively ended.11 And so began the age of discovery for anaesthesia.
The story continues… OH

(Part 1 appeared in the 100th anniversary issue, Fall 2011 Oral Health).

Dr. Peter Nkansah is a dentist-anaesthesiologist with a private practice in Toronto. He is also Past President of the Canadian Academy of Dental Anaesthesia, an international lecturer, and a member of the teaching staff in the Discipline of Anaesthesia at the Faculty of Dentistry, University of Toronto.

REFERENCES
1. Canadian Broadcasting Corporation. http://www.cbc.ca/news/interactives/slavery-canada/. Accesse
d November 26, 2011.
2. Norris, S and T. Williams (Government of Canada, Science and Technology Division). http://dsp-psd.pwgsc.gc.ca/Collection-R/LoPBdP/BP/prb0023-e.htm#HISTORICAL TRENDS IN LIFE EXPECTANCY(txt). Accessed November 20, 2011.
3. Kinsella, K. Changes in life expectancy 1900-1990. The American Journal of Clinical Nutrition, 55: 1196S-1202S. 1992.
4. Crawford, R. http://www.cda-adc.ca/en/cda/about_cda/history/ 2002. Accessed November 12, 2011.
5. Bryson, B. At Home: A Short History of Private Life. 2010.
6. Science Museum. http://www.sciencemuseum.org.uk/broughttolife/people/ignazsemmelweis.aspx. Accessed November 12, 2011.
7. Archer, WH. The History of Anesthesia. Proceedings of the Dental Centenary Celebration pp.334-363. 1940.
8. Chemical Heritage Foundation. http://www.chemheritage.org/discover/chemistry-in-history/themes/electrochemistry/davy.aspx Accessed Nov­ember 20, 2011.
9. Fenster, JM. Ether Day: The Strange Tale of America’s Greatest Medical Discovery and the Haunted Men Who Made It. 2001.
10. Yagiela, J. Personal communication. 2011.
11. Whalen, FX, DR Bacon and HM Smith. Inhaled anesthetics: an historical overview. Best Practice & Research Clinical Anaesthesiology, 19(3): 323-330. 2005.
12. Gallucci, JM. Who deserves the credit for discovering ether’s use as a surgical anesthetic? Journal of the History of Dentistry, 56(1): 38-43. Spring 2008.
13. Medical Discoveries. http://www.discoveriesinmedicine.com/Enz-Ho/Ether.html. Accessed November 12, 2011.
14. The Encyclopedia Brittanica (1890). http://books.google.ca/books?id=6SaalkfxgkAC&pg=PA568&lpg=PA568&dq=froben+ether&source=bl&ots=tRDnYfAwJg&sig=OURojnKLh_t1pCwcCO9qBH9wFKs&hl=en&ei=fyrLTsXDCYjv0gHD1KxF&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCsQ6AEwAg#v=onepage&q=froben%20ether&f=false. Accessed November 21, 2011.
15. Keller, J. An exploration of anaesthesia through antiquity. UWO Medical Journal, 78(1): 49-52. 2008.
16. The Lancet, letter to the editor. The Lancet, 5(127): 646-647. 1826.
17. Hammonds, WD and JE Steinhaus. Crawford W. Long: Pioneer physician in anesthesia. Journal of Clinical Anesthesia, 5: 163-167. 1993.
18. Wolfe, RJ and RW Patterson. Charles Thomas Jackson, “The Head Behind The Hands”. 2007.
19. López-Valverde, A, J Montero, A Albaladejo and R Gómez de Diego. The discovery of surgical anesthesia : discrepancies regarding its authorship. Journal of Dental Research, 90(1): 31-34. 2011.
20. Jacobsohn, PH. Horace Wells: discoverer of anesthesia. Anesthesia Progress, 42: 73-75. 1995.
21. Woodward, GS. The Man Who Conquered Pain: A Biography of William Thomas Green Morton. 1962.
22. Smith, GB and NP Hirsch. Gardner Quincy Colton: pioneer of nitrous oxide anesthesia. Anesthesia and Analgesia, 72: 382-391. 1991.
23. Orr, D. Dear Aetna… (Editor’s Message). NDA Journal 11(1): 5-9. Spring 2009.


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