[Sir James Paget was one of the most eminent English surgeons
of the last century: his writings on surgical themes are of
the first authority. The essay, the chief portions of which
follow, appeared in the _Nineteenth Century Magazine_,
December, 1879. The editor's permission to reprint is
thankfully acknowledged. The essay is contained in "Selected
Essays and Addresses," by Sir James Paget, published by
Longmans, Green & Co., 1902. The same firm publishes "Memoirs
and Letters of Sir James Paget," edited by Stephen Paget, one
of his sons.]
The history of the discovery of methods for the prevention of pain in
surgical operations deserves to be considered by all who study either
the means by which knowledge is advanced or the lives of those by whom
beneficial discoveries are made. And this history may best be traced in
the events which led to and followed the use of nitrous oxide gas, of
sulphuric ether, and of chloroform as anæsthetics--that is, as means by
which complete insensibility may be safely produced and so long
maintained that a surgical operation, of whatever severity and however
prolonged, may be absolutely painless.
In 1798, Mr. Humphry Davy, an apprentice to Mr. Borlase, a surgeon at
Bodmin, had so distinguished himself by zeal and power in the study of
chemistry and natural philosophy, that he was invited by Dr. Beddoes, of
Bristol, to become the "superintendent of the Pneumatic Institution
which had been established at Clifton for the purpose of trying the
medicinal effects of different gases." He obtained release from his
apprenticeship, accepted the appointment, and devoted himself to the
study of gases, not only in their medicinal effects, but much more in
all their chemical and physical relations. After two years' work he
published his _Researches, Chemical and Philosophical, chiefly
concerning Nitrous Oxide_, an essay proving a truly marvelous ingenuity,
patience, and courage in experiments, and such a power of observing and
of thinking as has rarely if ever been surpassed by any scientific man
of Davy's age; for he was then only twenty-two.
In his inhalations of the nitrous oxide gas he observed all the
phenomena of mental excitement, of exalted imagination, enthusiasm,
merriment, restlessness, from which it gained its popular name of
"laughing gas"; and he saw people made, at least for some short time and
in some measure, insensible by it. So, among other suggestions or
guesses about probable medicinal uses of inhalation of gases, he wrote,
near the end of his essay: "As nitrous oxide in its extensive operation
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."
It seems strange that no one caught at a suggestion such as this. True,
the evidence on which it was founded was very slight; it was with a rare
scientific power that Davy had thought out so far beyond his facts; but
he had thought clearly, and as clearly told his belief. Yet no one
earnestly regarded it. The nitrous oxide might have been of as little
general interest as the carbonic or any other, had it not been for the
strange and various excitements produced by its inhalation. These made
it a favourite subject with chemical lecturers, and year after year, in
nearly every chemical theatre, it was fun to inhale it after the lecture
on the gaseous compounds of nitrogen; and among those who inhaled it
there must have been many who, in their intoxication, received sharp and
heavy blows, but, at the time, felt no pain. And this went on for more
than forty years, exciting nothing worthy to be called thought or
observation, till, in December, 1844, Mr. Colton, a popular itinerant
lecturer on chemistry, delivered a lecture on "laughing gas" in
Hartford, Connecticut. Among his auditors was Mr. Horace Wells, an
enterprising dentist in that town, a man of some power in mechanical
invention. After the lecture came the usual amusement of inhaling the
gas, and Wells, in whom long wishing had bred a kind of belief that
something might be found to make tooth-drawing painless, observed that
one of the men excited by the gas was not conscious of hurting himself
when he fell on the benches and bruised and cut his knees. Even when he
became calm and clear-headed the man was sure that he did not feel pain
at the time of his fall. Wells was at once convinced--more easily
convinced than a man of more scientific mind would have been--that,
during similar insensibility, in a state of intense nervous excitement,
teeth might be drawn without pain, and he determined that himself and
one of his own largest teeth should be the first for trial. Next morning
Colton gave him the gas, and his friend Dr. Riggs extracted his tooth.
He remained unconscious for a few moments, and then exclaimed, "A new
era in tooth-pulling! It did not hurt me more than the prick of a pin.
It is the greatest discovery ever made."
In the next three weeks Wells extracted teeth from some twelve or
fifteen persons under the influence of the nitrous oxide, and gave pain
to only two or three. Dr. Riggs, also, used it with the same success,
and the practice was well known and talked of in Hartford.
Encouraged by his success Wells went to Boston, wishing to enlarge the
reputation of his discovery and to have an opportunity of giving the gas
to some one undergoing a surgical operation. Dr. J. C. Warren, the
senior Surgeon of the Massachusetts General Hospital, to whom he applied
for this purpose, asked him to show first its effects on some one from
whom he would draw a tooth. He undertook to do this in the theatre of
the medical college before a large class of students, to whom he had,
on a previous day, explained his plan. Unluckily, the bag of gas from
which the patient was inhaling was taken away too soon; he cried out
when his tooth was drawn; the students hissed and hooted; and the
discovery was denounced as an imposture.
Wells left Boston disappointed and disheartened; he fell ill, and was
for many months unable to practice his profession. Soon afterwards he
gave up dentistry, and neglected the use and study of the nitrous oxide,
till he was recalled to it by a discovery even more important than his
own.
The thread of the history of nitrous oxide may be broken here.
The inhalation of sulphuric ether was often, even in the eighteenth
century, used for the relief of spasmodic asthma, phthisis, and some
other diseases of the chest. Dr. Beddoes and others thus wrote of it:
but its utility was not great, and there is no evidence that this use of
it had any influence on the discovery of its higher value, unless it
were, very indirectly, in its having led to its being found useful for
soothing the irritation produced by inhaling chlorine. Much more was due
to its being used, like nitrous oxide, for the fun of the excitement
which its diluted vapor would produce in those who freely inhaled it.
The beginning of its use for this purpose is not clear. In the _Journal
of Science and the Arts_, published in 1818 at the Royal Institution,
there is a short anonymous statement among the "Miscellanea," in which
it is said, "When the vapor of ether mixed with common air is inhaled,
it produces effects very similar to those occasioned by nitrous oxide."
The method of inhaling and its effects are described, and then "it is
necessary to use caution in making experiments of this kind. By the
imprudent inspiration of ether a gentleman was thrown into a very
lethargic state, which continued with occasional periods of intermission
for more than thirty hours, and a great depression of spirits; for many
days the pulse was so much lowered that considerable fears were
entertained for his life."
The statement of these facts has been ascribed to Faraday, under whose
management the journal was at that time published. But, whoever wrote or
whoever may have read the statement, it was, for all useful purposes, as
much neglected as was Davy's suggestion of the utility of the nitrous
oxide. The last sentence, quoted as it was by Pereira and others writing
on the uses of ether, excited much more fear of death than hope of ease
from ether-inhalation. Such effects as are described in it are of
exceeding rarity; their danger was greatly over-estimated; but the
account of them was enough to discourage all useful research.
But, as the sulphuric ether would "produce effects very similar to those
occasioned by nitrous oxide," and was much the more easy to procure, it
came to be often inhaled, for amusement, by chemists' lads and by
pupils in the dispensaries of surgeons. It was often thus used by young
people in many places of the United States. They had what they called
"ether-frolics," in which they inhaled ether till they became merry, or
in some other way absurdly excited or, sometimes, completely insensible.
Among those who had joined in these ether-frolics was Dr. Wilhite of
Anderson, South Carolina. In one of them, in 1839, when nearly all of
the party had been inhaling and some had been laughing, some crying,
some fighting--just as they might have done if they had had the nitrous
oxide gas--Wilhite, then a lad of seventeen, saw a negro boy at the door
and tried to persuade him to inhale. He refused and resisted all
attempts to make him do it, till they seized him, held him down, and
kept a handkerchief wet with ether close over his mouth. Presently his
struggles ceased; he lay insensible, snoring, past all arousing; he
seemed to be dying. And thus he lay for an hour, till medical help came
and, with shaking, slapping, and cold splashing, he was awakened and
suffered no harm.
The fright at having, it was supposed, so nearly killed the boy, put an
end to ether-frolics in that neighbourhood; but in 1842 Wilhite had
become a pupil of Dr. Crauford Long, practising at that time at
Jefferson (Jackson County, Georgia). Here he and Dr. Long and three
fellow-pupils often amused themselves with the ether-inhalation, and
Dr. Long observed that when he became furiously excited, as he often
did, he was unconscious of the blows which he, by chance, received as he
rushed or tumbled about. He observed the same in his pupils; and
thinking over this, and emboldened by what Mr. Wilhite told him of the
negro boy recovering after an hour's insensibility, he determined to try
whether the ether-inhalation would make any one insensible of the pain
of an operation. So, in March, 1842, nearly three years before Wells's
observations with the nitrous oxide, he induced Mr. Venable, who had
been very fond of inhaling ether, to inhale it till he was quite
insensible. Then he dissected a tumour from his neck; no pain was felt,
and no harm followed. Three months later, he similarly removed another
tumour from him; and again, in 1842 and 1845, he operated on three other
patients, and none felt pain. His operations were known and talked of in
his neighbourhood; but the neighbourhood was only that of an obscure
little town; and he did not publish any of his observations. The record
of his first operation was only entered in his ledger:
"James Venable, 1842. Ether and excising tumour, $2.00."
He waited to test the ether more thoroughly in some greater operation
than those in which he had yet tried it; and then he would have
published his account of it. While he was waiting, others began to stir
more actively in busier places, where his work was quite unknown, not
even heard of.
Among those with whom, in his unlucky visit to Boston, Wells talked of
his use of the nitrous oxide, and of the great discovery which he
believed that he had made, were Dr. Morton and Dr. Charles Jackson, men
widely different in character and pursuit, but inseparable in the next
chapter of the history of anæsthetics.
Morton was a restless, energetic dentist, a rough man, resolute to get
practice and make his fortune. Jackson was a quiet, scientific
gentleman, unpractical and unselfish, in good repute as a chemist,
geologist, and mineralogist. At the time of Wells's visit, Morton, who
had been his pupil in 1842, and for a short time in 1843 his partner,
was studying medicine and anatomy at the Massachusetts Medical College,
and was living in Jackson's house. Neither Morton nor Jackson put much
if any faith in Wells's story, and Morton witnessed his failure in the
medical theatre. Still, Morton had it in his head that tooth-drawing
might somehow be made painless, and even after Wells had retired from
practice, he talked with him about it, and made some experiments, but,
having no scientific skill or knowledge, they led to nothing. Still, he
would not rest, and he was guided to success by Jackson, whom Wells
advised him to ask to make some nitrous oxide gas for him.
Jackson had long known, as many others had, of sulphuric ether being
inhaled for amusement, and of its producing effects like those of
nitrous oxide: he knew also of its employment as a remedy for the
irritation caused by inhaling chlorine. He had himself used it for this
purpose, and once, in 1842, while using it, he became completely
insensible. He had thus been led to think that the pure ether might be
used for the prevention of pain in surgical operations; he spoke of it
with some scientific friends, and sometimes advised a trial of it; but
he did not urge it or take any active steps to promote even the trial.
One evening, Morton, who was now in practice as a dentist, called on
him, full of some scheme which he did not divulge, and urgent for
success in painless tooth-drawing. Jackson advised him to use the ether,
and taught him how to use it.
On that same evening, the 30th of September, 1846, Morton inhaled the
ether, put himself to sleep, and, when he awoke, found that he had been
asleep for eight minutes. Instantly, as he tells, he looked for an
opportunity of giving it to a patient; and one just then coming in, a
stout, healthy man, he induced him to inhale, made him quite insensible,
and drew his tooth without his having the least consciousness of what
was done.
But the great step had yet to be made--the step which Wells would have
tried to make if his test experiment had not failed. Clearly,
operations as swift as that of tooth-drawing might be rendered painless,
but could it be right to incur the risk of insensibility long enough and
deep enough for a large surgical operation? It was generally believed
that in such insensibility there was serious danger to life. Was it
really so? Jackson advised Morton to ask Dr. J. C. Warren to let him
try, and Warren dared to let him. It is hard now to think how bold the
enterprise must have seemed to those who were capable of thinking
accurately on the facts then known.
The first trial was made on the 16th of October, 1846. Morton gave the
ether to a patient in the Massachusetts General Hospital, and Dr. Warren
removed a tumour from his neck. The result was not complete success; the
patient hardly felt the pain of cutting, but he was aware that the
operation was being performed. On the next day, in a severer operation
by Dr. Hayward, the success was perfect; the patient felt nothing, and
in long insensibility there was no appearance of danger to life.
The discovery might already be deemed complete, for the trials of the
next following days had the same success, and thence onwards the use of
the ether extended over constantly widening fields. A coarse but feeble
opposition was raised by some American dentists; a few surgeons were
over-cautious in their warnings against suspected dangers; a few
maintained that pain was very useful, necessary perhaps to sound
healing; some were hindered by their dislike of the patent which Morton
and Jackson took out; but as fast as the news could be carried from one
continent to another, and from town to town, so fast did the use of
ether spread. It might almost be said that in every place, at least in
Europe, where the discovery was promoted more quickly than in America,
the month might be named before which all operative surgery was
agonizing, and after which it was painless.
But there were other great pains yet to be prevented, the pains of
childbirth. For escape from these the honour and deep gratitude are due
to Sir James Simpson. No energy, or knowledge, or power of language less
than his could have overcome the fears that the insensibility, which was
proved to be harmless in surgical operations and their consequences,
should be often fatal or very mischievous in parturition. And to these
fears were added a crowd of pious protests (raised, for the most part,
by men) against so gross an interference as this seemed with the
ordained course of human nature. Simpson, with equal force of words and
work, beat all down; and by his adoption of chloroform as a substitute
for ether promoted the whole use of anæsthetics.
Ether and chloroform seemed to supply all that could be wished from
anæsthetics. The range of their utility extended; the only question was
as to their respective advantages, a question still unsettled. Their
potency was found absolute, their safety very nearly complete, and,
after the death of Wells in 1848, nitrous oxide was soon neglected and
almost forgotten. Thus it remained till 1862, nearly seventeen years,
when Mr. Colton, who still continued lecturing and giving the gas "for
fun," was at New Haven, Connecticut. He had often told what Wells had
done with nitrous oxide at Hartford, and he wanted other dentists to use
it, but none seemed to care for it till, at New Britain, Dr. Dunham
asked him to give it to a patient to whom it was thought the ether might
be dangerous. The result was excellent, and in 1863 Dr. Smith of New
Haven substituted the nitrous oxide for ether in his practice and used
it very frequently. In the nine months following his first use of it, he
extracted without pain nearly 4,000 teeth. Colton, in the following
year, associated himself with a dentist in New York and established the
Colton Dental Association, where the gas was given to many thousands
more. Still, its use was very slowly admitted. Some called it dangerous,
others were content with chloroform and ether, others said that the
short pangs of tooth-drawing had better be endured. But in 1867 Mr.
Colton came to Paris and Dr. Evans at once promoted his plan. In 1868 he
came to London and, after careful study of it at the Dental Hospital,
the nitrous oxide was speedily adopted, both by dentists and by the
administrators of anæsthetics. By this time it has saved hundreds of
thousands of people from the sharp pains of all kinds of operations on
the teeth and of a great number of the surgical operations that can be
quickly done.
Such is the history of the discovery of the use of anæsthetics.
Probably, none has ever added so largely to that part of happiness which
consists in the escape from pain. Past all counting is the sum of
happiness enjoyed by the millions who, in the last three-and-thirty
years, have escaped the pains that were inevitable in surgical
operations; pains made more terrible by apprehension, more keen by close
attention; sometimes awful in a swift agony, sometimes prolonged beyond
even the most patient endurance, and then renewed in memory and terrible
in dreams. These will never be felt again. But the value of the
discovery is not limited by the abolition of these pains or the pains of
childbirth. It would need a long essay to tell how it has enlarged the
field of useful surgery, making many things easy that were difficult,
many safe that were too perilous, many practicable that were nearly
impossible. And, yet more variously, the discovery has brought happiness
in the relief of some of the intensest pains of sickness, in quieting
convulsion, in helping to the discrimination of obscure diseases. The
tale of its utility would not end here; another essay might tell its
multiform uses in the study of physiology, reaching even to that of the
elemental processes in plants, for these, as Claude Bernard has shown,
may be completely for a time suspended in the sleep produced by
chloroform or ether.
And now, what of the discoverers?[1] What did time bring to those who
brought so great happiness to mankind?
* * * * *
Probably most people would agree that Long, Wells, Morton and Jackson
deserved rewards, which none of the four received. But that which the
controversy and the patent and the employment of legal advisers made it
necessary to determine was, whether more than one deserved reward, and,
if more than one, the proportion to be assigned to each. Here was the
difficulty. The French Academy of Sciences in 1850 granted equal shares
in the Monthyon Prize to Jackson and to Morton; but Long was unknown to
them, and, at the time of the award, the value of nitrous oxide was so
hidden by the greater value of ether that Wells's claim was set aside. A
memorial column was erected at Boston, soon after Morton's death in
1868, and here the difficulty was shirked by dedicating the column to
the discovery of ether, and not naming the discoverers. The difficulty
could not be thus settled; and, in all probability, our supposed council
of four or five would not solve it. One would prefer the claims of
absolute priority; another those of suggestive science; another the
courage of bold adventure; sentiment and sympathy would variously affect
their judgments. And if we suppose that they, like the American
Congress, had to discuss their differences within sound of such
controversies as followed Morton's first use of ether, or during a war
of pamphlets, or under burdens of parliamentary papers, we should expect
that their clearest decision would be that a just decision could not be
given, and that gratitude must die if it had to wait till distributive
justice could be satisfied. The gloomy fate of the American discoverers
makes one wish that gratitude could have been let flow of its own
impulse; it would have done less wrong than the desire for justice did.
A lesson of the whole story is that gratitude and justice are often
incompatible; and that when they conflict, then, usually, "the more
right the more hurt."
Another lesson, which has been taught in the history of many other
discoveries, is clear in this--the lesson that great truths may be very
near us and yet be not discerned. Of course, the way to the discovery of
anæsthetics was much more difficult than it now seems. It was very
difficult to produce complete insensibility with nitrous oxide till it
could be given undiluted and unmixed; this required much better
apparatus than Davy or Wells had; and it was hardly possible to make
such apparatus till india-rubber manufactures were improved. It was very
difficult to believe that profound and long insensibility could be safe,
or that the appearances of impending death were altogether fallacious.
Bold as Davy was, bold even to recklessness in his experiments on
himself, he would not have ventured to produce deliberately in any one a
state so like a final suffocation as we now look at unmoved. It was a
boldness not of knowledge that first made light of such signs of dying,
and found that what looked like a sleep of death was as safe as the
beginning of a night's rest. Still, with all fair allowance for these
and other difficulties, we cannot but see and wonder that for more than
forty years of the nineteenth century a great truth lay unobserved,
though it was covered with only so thin a veil that a careful
physiological research must have discovered it. The discovery ought to
have been made by following the suggestion of Davy. The book in which he
wrote that "nitrous oxide--capable of destroying physical pain--may
probably be used with advantage during surgical operations," was widely
read, and it would be hard to name a man of science more widely known
and talked of than he was. Within two years of the publication of his
_Researches_ he was appointed to a professorship in the Royal
Institution; and in the next year he was a favourite in the fashionable
as well as in the scientific world; and all his life through he was
intimately associated with those among whom all the various motives for
desiring to find some means "capable of destroying physical pain" would
be most strongly felt. Curiosity, the love of truth, the love of
marvels, the desire of ease, self-interest, benevolence,--all were alert
in the minds of men and women who knew and trusted whatever Davy said or
wrote, but not one mind was earnestly directed to the rare promise which
his words contained. His own mind was turned with its full force to
other studies; the interest in surgery which he may have felt during his
apprenticeship at Bodmin was lost in his devotion to poetry,
philosophy, and natural science, and there is no evidence that he urged
others to undertake the study which he left. Even his biographers, his
brother, Dr. John Davy, and his intimate friend, Dr. Paris, both of whom
were very capable physicians and men of active intellect, say nothing of
his suggestion of the use of nitrous oxide. It was overlooked and
utterly forgotten till the prophecy was fulfilled by those who had never
heard of it. The same may be said of what Faraday, if it were he, wrote
of the influence of sulphuric ether. All was soon forgotten, and the
clue to the discovery, which would have been far easier with ether than
with nitrous oxide, for it needed no apparatus and even required mixture
with air, was again lost. One could have wished that the honour of
bringing so great a boon to men, and so great a help in the pursuit of
knowledge, had been won by some of those who were giving themselves with
careful cultivation to the search for truth as for its own sake. But it
was not so: science was utterly at fault; and it was shown that in the
search for truth there are contingencies in which men of ready belief
and rough enterprise, seeking for mere utility even with selfish
purposes, can achieve more than those who restrain themselves within the
range of what seems reasonable.
Such instances of delay in the discovery of truth are always wondered
at, but they are not uncommon. Long before Jenner demonstrated the
utility of vaccination it was known in Gloucestershire that they who had
had cow-pox could not catch the small-pox. For some years before the
invention of electric telegraphy, Professor Cumming of Cambridge, when
describing to his class the then recent discovery by Oersted of the
power of an electric current to deflect a magnet, used to say, "Here,
then, are the elements which would excellently serve for a system of
telegraphy." Yet none of his hearers, active and cultivated as they
were, were moved from the routine of study. Laennec quotes a sentence
from Hippocrates which, if it had been worthily studied, might have led
to the full discovery of auscultation [trained listening to sounds].
Thus it often has been; and few prophecies can be safer than that our
successors will wonder at us as we do at those before us; will wonder
that we did not discern the great truths which they will say were all
around us, within reach of any clear, earnest mind.
They will wonder, too, as we may, when we study the history of the
discovery of anæsthetics, at the quietude with which habitual miseries
are borne; at the very faint impulse to action which is given by even
great necessities when they are habitual. Thinking of the pain of
surgical operations, one would think that men would have rushed after
the barest chance of putting an end to it as they would have rushed to
escape from starving. But it was not so; the misery was so frequent, so
nearly customary, deemed so inevitable, that, though it excited horror
when it was talked of, it did not excite to strenuous action. Remedies
were wished for and sometimes tried, but all was done vaguely and
faintly; there was neither hope enough to excite intense desire, nor
desire enough to encourage hope; the misery was "put up with" just as we
now put up with typhoid fever and sea-sickness, with local floods and
droughts, with the waste of health and wealth in the pollution of
rivers, with hideous noises and foul smells, and many other miseries.
Our successors, when they have remedied or prevented them, will look
back on them with horror, and on us with wonder and contempt for what
they will call our idleness or blindness or indifference to suffering.