|The day pain died by Mike Jay|
June 7, 2009
The day that surgical anaesthesia was first publicly demonstrated, Oct. 16, 1846, ranks among the most iconic in the history of medicine. It was the moment when Boston, and indeed the United States, first emerged as a world-class center of medical innovation.
The room at the heart of Massachusetts General Hospital where the operation took place has been known ever since as the Ether Dome, and the word "anesthesia" itself was coined by the Boston physician and poet Oliver Wendell Holmes to denote the strange new state of suspended consciousness that the city's physicians had witnessed. The news from Boston swept around the world, and it was recognized within weeks as a moment that had changed medicine forever.
But what precisely was invented that day? Not a chemical - the mysterious substance used by William Morton, the local dentist who performed the procedure, turned out to be simply ether, a volatile solvent that had been in common use for decades. And not the idea of anesthesia - ether, and the anesthetic gas nitrous oxide, had both been thoroughly inhaled and explored. As far back as 1525, the Renaissance physician Paracelsus had recorded that it made chickens "fall asleep, but wake up again after some time without any bad effect," and that it "extinguishes pain" for the duration.
What the great moment in the Ether Dome really marked was something less tangible but far more significant: a huge cultural shift in the idea of pain. Operating under anesthetic would transform medicine, dramatically expanding the scope of what doctors were able to accomplish. What needed to change first wasn't the technology - that was long since established - but medicine's readiness to use it.
Before 1846, the vast majority of religious and medical opinion held that pain was inseparable from sensation in general, and thus from life itself. Though the idea of pain as necessary may seem primitive and brutal to us today, it lingers in certain corners of healthcare, such as obstetrics and childbirth, where epidurals and caesarean sections still carry the taint of moral opprobrium. In the early 19th century, doctors interested in the pain-relieving properties of ether and nitrous oxide were characterized as cranks and profiteers. The case against them was not merely practical, but moral: They were seen as seeking to exploit their patients' base and cowardly instincts. Furthermore, by whipping up the fear of operations, they were frightening others away from surgery and damaging public health.
The "eureka moment" of anesthesia, like the seemingly sudden arrival of many new technologies, was not so much a moment of discovery as a moment of recognition: a tipping point when society decided that old attitudes needed to be overthrown. It was a social revolution as much as a medical one: a crucial breakthrough not only for modern medicine, but for modernity itself. It required not simply new science, but a radical change in how we saw ourselves.
The story of anesthesia began in earnest in 1799, in a laboratory in the shabby spa town of Hotwells in the suburbs of Bristol, England.
The laboratory was that of the Pneumatic Institution, the brainchild of Thomas Beddoes, a radical doctor with his eyes fixed firmly on the future, who was convinced that new discoveries in chemistry were poised to transform medicine. Chemical remedies were viewed with suspicion at the time, and prescribed only as a last resort - with good reason, since many were toxic compounds of elements such as lead, mercury, and antimony. Beddoes had been insisting to his fellow doctors for years that chemistry was "daily unfolding the profoundest secrets of nature," and that bold experiments were required to apply its discoveries to medicine.
His scheme was the first example of a medical research institution set up specifically to generate new drug treatments - and, as its name implied, focused on investigating the properties of newly discovered gases. Lung diseases, particularly tuberculosis, were the greatest killers in 18th-century Britain, and Beddoes had spent countless agonizing hours witnessing their terminal stages. Inhaling artificial gases might, he hoped, provide relief and even a possible cure. He engaged an unknown young chemist named Humphry Davy as his assistant, and their freewheeling program of experiment led them, by trial and error, to investigate a gas called nitrous oxide.
This had first been isolated in 1774 by Joseph Priestley, who had christened it "dephlogisticated nitrous air." When Davy and Beddoes tried inhaling it, breathing it from green silk bags custom-designed by the great engineer James Watt, they discovered that it had entirely unexpected mind-altering effects. They struggled to describe the intense euphoria and disorientation that it produced - and to explain how an artificial gas, unknown in nature, could act so powerfully on the human mind. They enlisted their social circle, including the young poets Samuel Taylor Coleridge and Robert Southey, as volunteer subjects, and the experiments devolved into a brilliant but chaotic mix of medical theory and poetry, philosophy and hilarity.
The discovery of nitrous oxide exceeded Beddoes' wildest hopes for the transformation of medicine. A powerful stimulant conjured out of thin air, the gas was the harbinger of a chemical future where, as he put it, "man may, someday, come to rule over the causes of pain and pleasure."
But the experiments, as they unfolded, led the researchers away from any notion they might have had about pain relief. Most of the subjects responded not by losing consciousness, but by leaping around the lab, dancing, shouting, and possessed by poetic epiphanies.
The Pneumatic Institution's curiosity about the mind-altering properties of the gas, and particularly its "sublime" effects on the imagination, were emblematic of the Romantic sensibility of its participants, and their search for a language to map their inner worlds. This sensibility, as it spread, would play an important role in transforming attitudes to pain, but its early adopters still held the social attitudes of their time. Davy believed that "a firm mind might endure in silence any degree of pain," and regarded his frequent cuts, burns, and laboratory misadventures as heroic badges of pride. Coleridge, by contrast, was acutely and often morbidly sensitive to pain, but he perceived this sensitivity as a moral weakness and blamed it for his shameful and agonizing dependency on opium.
Yet even if they had focused single-mindedly on the painkilling properties of nitrous oxide, it's hard to imagine that Beddoes and Davy could have succeeded in selling the medical world of 1799 on the idea of surgical anesthesia. It didn't occur to the surgeon among the volunteers, Stephen Hammick of the Plymouth naval hospital, who was so gripped by euphoria that he fought off anyone who attempted to take the silk bag away from him. In the wider world, doctors were still resistant to medical experiments of any kind, and even Beddoes' modest trials of gases on tubercular patients were heavily criticized on ethical grounds. The crucial elements in an operation were thought to be the surgeon's skill and the patient's fortitude, and the awkward trappings of gas anesthesia - chemical reactions, red-hot retorts, and cumbersome air bags - would have been viewed as life-threatening obstacles to critical procedures.
As a result, it was the power of nitrous oxide to produce pleasure rather than suppress pain that caught the public imagination. Dismissed by the medical profession as a curiosity with no therapeutic application, it found a twilight existence in music-hall entertainments and variety shows. In a precursor of the stage hypnotism shows of today, a master of ceremonies would offer air bags to members of the audience; the chosen volunteers would mount the stage and be encouraged to act out their moment of intoxication in song, dance, poetry, or bursts of infectious laughter.
By the 1820s, these entertainments had earned nitrous oxide its enduring nickname of "laughing gas," and it had become a staple of American carnivals. Samuel Colt, before he invented the mass-produced revolver, toured the States with a laughing-gas show that advertised itself with Robert Southey's poetic epithet: "the atmosphere of the highest of all possible heavens must be composed of this gas."
It was in this seamy milieu that visiting doctors and dentists first noticed something remarkable about those people who thrashed and stumbled around under the influence: they could injure themselves without feeling pain. William Morton and his competitors began to consider the practicalities of introducing it into the operating theater.
The idea that gases might banish pain had, in fact, been mooted before Beddoes' and Davy's gas experiments had even begun: In 1795, Beddoes' friend Davies Giddy had asked whether, if the gases turned out to have sedative properties, they "might not be used before painful operations?"
But a half-century after the original experiments, there was still determined resistance, both medical and religious, to the idea of pain-free surgery. Since time immemorial, pain had been seen in religious terms as a concomitant of original sin and, as such, an irreducible part of the human condition. Indeed, it was often explained as part of God's mercy, "the voice of nature" that kept us from harm by alerting us to physical dangers.
This view was echoed by the medical opinion of the day. Most doctors still believed it was only pain that kept patients alive through the trauma of operations. System failure due to shock was a frequent cause of death during surgery, and the loss of sensation was believed to make it more likely. A screaming patient, however tormented, had a better prognosis than a limp and lifeless one.
But new sensibilities were ushering in a more genteel and compassionate society, and they were slowly changing medicine as well. Cruelty to animals was widely disapproved and prohibited, corporal punishment of children and public hangings were increasingly criticized as inhumane, and pain in general was coming to be seen as a traumatic experience to be ameliorated wherever possible.
At the same time, medical professionals were coming to recognize that pain control wasn't just a gimmick for luring weak-willed patients into the chair, but might be key to the future of surgery. Technical advances had led to more sophisticated and extended operations, and the patient's ability to endure them had become the limiting factor in their progress. It was the evolving requirements of surgeons, as much as the feelings of their patients, that eventually tipped the balance.
The motivation for William Morton's pioneering Boston experiment, as for those of his competitors, combined the interests of the dentist with those of his patients: the pain of tooth extraction and removing cysts was bad for business. By the 1840s, dental techniques had improved markedly, but potential customers were deterred by the painful and lengthy procedures they required. There were plenty of potential customers for the new natural-looking and snug-fitting dentures, but few who were prepared to have all their rotten stumps removed to fit them.
Once Morton had successfully demonstrated his technique of ether anesthesia, it was quickly seen that its implications reached considerably beyond the dental business. Before 1846 was out, it had been successfully tried by the most celebrated surgeon in Britain, Robert Liston, who pronounced that the new "Yankee dodge" had "the most perfect and satisfactory results" and was "a fine thing for operating surgeons." It was enthusiastically championed by an emerging generation of medical humanitarians, and the new buzzword "anesthesia" crystallized the sense of novelty and medical miracle. Chemistry had, as Thomas Beddoes had prophesied, come to rule over pain.
Despite its successes, resistance to the idea didn't vanish overnight. Until the end of the century, some doctors would maintain that pain had a necessary role in the preservation of life, but from 1846 onward they were outnumbered by those who insisted that it was the job of a physician to inflict as little of it as possible. Some religious voices would hold out for a good deal longer: Pope Pius XII would confirm that "the Christian's duty of renunciation and of interior purification is not an obstacle to the use of anaesthetics" only in February 1957.
Despite the long resistance, that demonstration in the Ether Dome marked a transition that was as irreversible as it was historic. The practice of medicine finally achieved a goal that it had, until that moment, never truly been able to imagine: loosening pain's age-old stranglehold on humanity. And in a sense, the invention was the least of it. The real milestone witnessed in Boston that day was the moment when culture had finally caught up with chemistry.
Mike Jay is the author of "The Atmosphere of Heaven," published last month by Yale University Press. "The Day Pain Died" was published earlier today in the Boston Globe and is published on Planetary by the kind permission of the author.