The Pain Chronicles (12 page)

A CHIMERA NOT PERMITTED

The puzzle of the history of anesthesia—one on which every medical history speculates to incomplete effect—is why it wasn’t practiced earlier. By the time of Fanny Burney’s operation in 1812, the anesthetic effects of inhaling the gases ether and nitrous oxide had long been known by British chemists. Yet decades of gruesome surgeries would transpire before an American dentist finally brought the gases into the operating room.

In his book
Romance, Poetry, and Surgical Sleep
, the distinguished anesthesiologist E. M. Papper theorizes that anesthesia could only have been invented in America because its development depended on a democratic society in which the pain and suffering of the masses mattered. But many Americans lived in misery, and regardless, the suffering of certain Englishmen certainly counted in the British mind. So why didn’t the elite demand anesthesia?

Part of the answer seems to involve opposition from surgeons. Throughout British medical history, pain and surgery had been linked, and thus, attempts at uncoupling them struck many as impossible, unnatural, or dangerous. The profession required people who were willing to inflict severe pain on others, and who—having done so—were invested in seeing that pain as appropriate. Pain is “necessary to our existence,” argued the Scottish surgeon Sir Charles Bell in 1806. “To imagine the absence of pain is not only to imagine a new state of being, but a change in the earth and all upon it.”

The idea of such a change was viewed with alarm. “To escape pain in surgical operations is a chimera which it is idle to follow up today,” declared the great French surgeon Alfred Velpeau in 1839. “Knife and pain in surgery are two words which are always inseparable in the minds of patients, and this necessary association must be conceded.”

It is worth contemplating what Velpeau means by
chimera.
Is painless surgery a chimera in the sense of a mythical creature that does not exist, even if we wish it did, or a chimera in the sense of a monstrous creature that
should
not exist—a goat with a lion’s head—whose very existence is a subversion of the natural order? After the Fall, aren’t we
supposed
to suffer pain?

Every surgeon was familiar with the moment at which a patient became eerily quiet. Because unconsciousness usually prefigures death (both imitating and presaging it), crying was considered a sign of health, a manifestation of the vital spirit. Moreover, consciousness was considered an emanation of the soul; to extinguish consciousness was to play God and temporarily kill the patient.

Long after the means of anesthesia had become available, many scientists either didn’t understand its potential application or were unsuccessful in convincing others of it, so the story of anesthesia’s development is often told as an allegory of the difficulty of progress, the tenacity of suffering, and the conflict between science and religion. Sir Humphry Davy discovered the anesthetic properties of nitrous oxide (which he termed “laughing gas”) at the turn of the nineteenth century while working at the Pneumatic Institute—a clinic that attempted to treat diseases such as TB and asthma with nitrous oxide and ether gases. One day when Davy was suffering from a terrible toothache, he experimented on himself with the gas. Suddenly, to his surprise, his pain seemed quite amusing. In his book
Nitrous Oxide
, he wrote that as the gas “appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.” His apprentice, Michael Faraday, reached similar conclusions regarding ether. But when pneumatic medicine was discredited and the clinic closed, Davy lost interest in nitrous oxide and went on to be knighted for other discoveries.

The gases became popular among Romantic poets such as Samuel Taylor Coleridge and Robert Southey, who wrote of nitrous oxide as “the air in heaven this wonder working gas of delight.” Ether frolics became the rage; traveling shows would demonstrate the gas’s effects and invite the audience to partake. As in the case of alcohol, the effects of the gases occur in two stages: Initially it creates arousal and exhilaration, which is followed by deep sleep. The first stage seemed inappropriate for surgery: What place could a party trick have in the operating room? The doses administered at shows were usually sufficient to cause giddiness, but not to take subjects into the sleep phase befitting surgery.

BY WHOM PAIN IN SURGERY WAS AVERTED AND ANNULLED

In science the credit goes to the man who convinces the world, not to the man to whom the idea first occurs,” observed the botanist Francis Darwin, son of Charles Darwin. William T. G. Morton’s tombstone reads, “Inventor and Revealer of Anesthetic Inhalation. Before Whom, in All Time, Surgery was Agony. By Whom Pain in Surgery was Averted and Annulled. Since Whom Science has Control of Pain.” Dr. Morton did not discover any new agents, but by persuading the medical establishment of ether’s utility during an operation at Massachusetts General Hospital on October 16, 1846, he bifurcated medical history forever.

During the 1840s at least three Americans were experimenting with ether and nitrous oxide: among them, two New England dentists and a southern country doctor. That one of the two dentists ultimately prevailed has sometimes been attributed to the economics of dentistry; unlike most surgeries, dentistry was usually elective, and the fear of pain kept patients away from it. (But, like the idea that anesthesia could only have been invented in America, this theory seems puzzling. After all, even if the surgical profession as a whole maintained a cultural bias against anesthesia, it would have taken only one surgeon to play Morton’s role.)

The earliest of the three is generally believed to be a doctor from Georgia who, after attending ether parties as a medical student, experimented with using ether during surgery on a patient in 1842. But, concerned that the technique would strike other physicians as improper, to his eternal regret, he did not publish his findings until after Dr. Morton had already claimed credit for ether’s discovery.

At a popular science demonstration three years later, a Connecticut dentist named Horace Wells noticed that one of the volunteers seemed unaware of having accidentally cut his leg while leaping around the room under the influence of laughing gas. The next day, Dr. Wells had a fellow dentist pull out one of his molars while he inhaled nitrous oxide, and he found it didn’t hurt at all. Dr. Wells successfully experimented on other patients (he tried ether on some as well, but decided nitrous oxide was safer, as ether can cause vomiting and is also easily flammable). Finally, Dr. Wells persuaded the eminent surgeon Dr. John Collins Warren, founder of what became
The New England Journal of Medicine
and Massachusetts General Hospital, to permit a demonstration during one of Warren’s surgeries in the hospital’s glass-domed amphitheater (today known as the ether dome).

The demonstration was a failure: the patient hollered at the first cut, and the crowd of surgeons and medical students jeered, “Humbug!” (Dr. Wells might have given the patient insufficient quantities of nitrous oxide, and later the patient said he had felt only a little pain but had been alarmed by the procedure.)

A year later, Dr. Wells’s former colleague Dr. Morton persuaded Dr. Warren to let him demonstrate gas anesthesia, using ether instead of nitrous oxide, on a young man submitting to the removal of a tumor from his jaw. Accounts of the incident are all so vivid: the audience waiting, the tremulous young man strapped down on an operating chair on the stage of the amphitheater, the surgeon impatiently declaring, “As Dr. Morton has not arrived, I presume he is otherwise engaged,” and Dr. Morton finally bursting in, explaining that he had been delayed because the custom-made device for delivering vapors of an ether-soaked sponge had not been ready. The patient inhaled the vapors from the sponge, lost consciousness, and did not awaken until after Dr. Warren had finished washing the blood off his wounds. When questioned about the pain, the patient answered that he had felt only a peculiar scratching at his cheek, like a hoe raking a field.

“Gentlemen, this is no humbug,” Dr. Warren announced to the hushed crowd. Later he wrote, “The student who . . . in distant ages may visit this spot will view it with increased interest, as he remembers that here was first demonstrated one of the most glorious truths of science.” Around the world, word swiftly spread that, as a German surgeon put it, “the wonderful dream that pain has been taken away from us has become reality. Pain . . . must now bow before the power of the human mind, before the power of the ether vapor.”

Anguished with jealousy over Dr. Morton’s success, Dr. Wells suffered a nervous breakdown after trying in vain to petition various boards for recognition of his role in the discovery. In searching for an agent superior to nitrous oxide, he developed an addiction to chloroform. He attacked two prostitutes while under the influence and committed suicide shortly before the arrival of a letter from the Paris Medical Society declaring that he was “due all the honor” for the discovery.

In fact, he needn’t have been too jealous of his old friend. Although Dr. Morton would receive credit for the discovery of the “greatest gift ever made to suffering humanity,” the alleviation of mankind’s pain came at a personal price. Dr. Morton wasted the rest of his life in a futile attempt to patent ether in order to profit from it (he was unable to patent it, because he hadn’t invented it). He had hoped to disguise ether’s well-known reek by mixing it with orange-scented oils and other fragrances and calling it Letheon, after the Greek river of forgetfulness, but the ingredient was evident. He died bitter and impoverished.

THE SLAVERY OF ETHERIZATION

In a corner of the Public Garden in Boston stands an unusual monument, one that is neither to a hero nor a battle, but rather to a medical achievement: “The discovery that the inhaling of ether causes insensibility to pain. First proved to the World at the Mass General Hospital in Boston.” The 1868 forty-foot rose-speckled marble and granite obelisk is the only such statue in the world. The invention of other revolutionary medications, such as the discovery of antibiotics, does not seem to call for the visual tribute of a monument—they are celebrated, one might say, by every life they save.

The commissioning of the ether memorial was controversial in its time, and its intricate surfaces make clear its real purpose: not merely to mark an achievement but also to address the source of the controversy that surrounded it by attempting to reconcile science’s and religion’s competing perspectives on anesthesia. The monument did so by interpreting the discovery not as a triumph of the former over the latter, but rather as a
fulfillment
of the prophecy from the book of Revelation inscribed on its east relief: “Neither Shall There Be Any More Pain.” Above those words an angel of mercy descends upon a sufferer, while the south and north faces of the monument depict operations performed with anesthesia. On the west side of the monument, a female allegorical embodiment of Science perches on a throne of lab equipment, and an inscription from Isaiah insists, “This also commeth forth / from the Lord of hosts . . .”

Yet, critics of anesthesia pointed out that Revelation prophesizes that
God
—not science—“shall wipe away all tears from their eyes.” And they considered anesthesia “of the devil,” a deliberate flouting of Adam’s curse. The benefit of anesthesia is so absurdly obvious now that it’s hard for us to believe it was ever controversial, yet at the time some physicians saw only “evil” in anesthesia. It was “a questionable attempt to abrogate one of the general conditions of man,” one causing “the destruction of consciousness.” (Advocates countered that ordinary sleep is a nightly destruction of consciousness.)

Ether, in the view of many, was a party drug that was now being brought into the most serious of arenas, inducing a state that, in its exhilaration stage, suspiciously resembled drunkenness. “Even were the reports of persons who felt no pain during an operation credible, this would not be worth the consideration of a serious-minded doctor,” a prominent surgeon declared. A full seventeen years after the discovery, New York surgeon Valentine Mott wrote a passionate defense of anesthesia, arguing that “
the insensibility
of the patient is a
great convenience to the surgeon
” (Mott’s emphasis).

But some surgeons saw only inconvenience in having to share their operating rooms with a new medical specialist—an anesthesiologist—who might make them “a mere operator, a subordinate instead of a chief, who under all circumstances retains the supreme command,” as one Edinburgh surgeon grumbled. Anesthesia went so far as to represent “the degradation of surgery against which all surgeons should guard with all their might.”

Moreover, many surgeons considered ether “a remedy of doubtful safety,” a poison that caused unnecessary bleeding, suffocation, TB, depression, insanity, or sometimes death. The experience of pain was thought to be somehow conducive to healing. “Pain during operations is, in the majority of cases, even desirable; its prevention or annihilation is, for the most part, hazardous to the patient,” wrote a British physician. Unsurprisingly, military surgeons were among the most reluctant. “The shock of the knife is a powerful stimulant,” a military surgeon wrote; “it is better to hear a man bawl lustily” from pain than “sink silently into the grave.”

By anesthetizing patients, the physician was seen as temporarily “killing” them and imposing a “slavery of etherization.” Perhaps he might even commit a crime such as rape against them. Like drunkenness, anesthesia was thought to induce lascivious dreams in female subjects. After hailing its discovery, the Boston surgeon Henry Bigelow himself soberly warned in his address to the Boston Society for Medical Improvement on November 9, 1846, “It is capable of abuse, and can readily be applied to nefarious ends.” Alarmed by the depiction of such dangers, even patients themselves sometimes refused anesthesia.

Ether required patience—surgeons had to wait for it to take effect. It did not work on all patients, and even when it did, in lighter doses it created a state of semiconsciousness where patients, alarmingly, talked or sang. It could cause vomiting, and—most perilously—it was highly flammable. How to dose the drug to avoid exhilaration and induce sleep was poorly understood. Different kinds of inhalers produced different results. As an 1847 article in
The Lancet
noted, “In some cases there is perfect insensibility to pain,” but “there are cases in which ether does not act at all or appears to act as a violent stimulus.”

That same year, Sir James Young Simpson pioneered the use of chloroform, which caused unconsciousness without exhilaration. It swiftly replaced ether; indeed, its use became so universal that opponents of anesthesia in general were dubbed the Anti-Chloroformers. Hospital records of the era show us that many surgeons worked without any anesthesia, while others used chloroform for their initial cuts, but did without it during the rest of an operation, or limited their use of it to major operations. James Syme—the Scottish surgeon who had amputated poor George Wilson’s foot—said he would use anesthesia only “if the patient has a very great dread of pain”! Factors such as sex, age, and ethnicity were considered in decisions regarding who merited anesthesia and when.

Many Christian churches strongly opposed using anesthesia during childbirth, on the grounds that it contradicted God’s direct commandment to Eve. The entire city of Zurich banned anesthetics on these grounds. “Pain is the mother’s safety, its absence her destruction,” wrote an obstetrician. “Yet are there those bold enough to administer the vapour of ether even at this critical juncture, forgetting it has been ordered that ‘in sorrow shall she bring forth.’ ”

Sir James Young Simpson argued that the Genesis commandment was actually to bring forth children not in “pain” but in “toil” (the Hebrew words for Eve’s pain actually carry both meanings). And, Dr. Simpson argued, labor under anesthesia certainly involved toil. In 1853, chloroform received the ultimate imprimatur when Queen Victoria chose to use it to ease the birth of her eighth child, causing masses of women to demand “anesthesia
à la Reine.
”

By the close of the nineteenth century—almost one hundred years after Michael Faraday suggested that nitrous oxide could ease pain in surgery—the acceptance of anesthesia was virtually universal, and with its acceptance, the meaning of pain in Western culture was forever altered. For if anesthesia had robbed the craft of surgery of its terrors, as Henry Bigelow put it, it also stole from pain some of its store of ancient meanings.

Tensions between secular and sacred conceptions of medicine had long existed, but efforts had always been made to reconcile the two. Ambroise Paré, for example, famously ended his case histories with the sentence, “I dressed him, God healed him.” Since ancient times, sufferers had slept in the temples of the gods of healing
and
taken opium and willow bark, and for the most part, such actions were not considered inconsistent. In the nineteenth century, as Darwin’s theory provided a biological framework for understanding pain and the discovery of anesthesia allowed for its control, the medical alliance between scientific and religious perspectives finally splintered.

In 1887, H. Cameron Gillies wrote a series of articles in
The Lancet
claiming that “Pain never comes where it can serve no good purpose,” because pain is God’s way of protecting the body. In reply, W. J. Collins argued that not all pain is protective: “Is this the grim comfort he [Gillies] would bring to a suffering woman, tortured slowly to death by a sloughing scirrhus of the breast, or to a man, made almost inhuman and killed by inches by the slow yet sure ravages of a rodent ulcer?”

The medical establishment dismissed Gillies. By the end of the Victorian era, the underlying debate was conclusively settled: there was no meaning to pain. Pain was not a metaphor; it was a biological by-product of disease. The body had been claimed as the province of science, the patient dispossessed. Pain was not passion, alchemy, ordeal; in the cosmological contest between demons and deities, it was man who had won. Thousands of years of thinking about pain were swept aside as the biological paradigm of pain displaced the religious one. The telegram went out: just as the consumptives came down the mountain, acute surgical pain could be controlled by anesthesia. Medical science could now turn to chronic pain, and surely it, too, would soon be mastered.

Surely.