Inventing Anesthesia for fun and profit

Nitrous Oxide, Ether, and Chloroform Anesthesia in the 19th Century

I think it’s fair to say that medical science and medical treatment made very little progress for many centuries in the Common Era.  In fact, patients very often saw the appearance of the physician at their bedside as an occasion for outright fear and despair; a certain sign that the end was near.  Then, in the 19th and 20th centuries, three stunning advances were made, in antisepsis and anesthesia (in the 19th century) and antibiotics (in the 20th).  Patients were not slow to recognize the tremendous benefit of these advances.  One needs only read the personal reports on surgery without anesthesia to be sure of that.

However, of these three, the early development of anesthesia was particularly unpromising.  As is caricatured in the image, anesthetics had their beginning in private and then public entertainment.

In the 18th century, scientist Joseph Priestly and others discovered biologically active gases, oxygen and nitrous oxide among them, and so the existence of such things was well known.  The anesthetic and entertainment effects of nitrous oxide, however, were not known until 1795 when scientist Humphrey Davy (pictured with the bellows in the image) tried inhaling it.  Its effects struck everyone as a really good party stunt and public entertainments such as that depicted on the right quickly followed.

Still, it was not considered for medical use until an American dentist, Horace Wells, had it administered to himself for extraction of a molar.  This happened to work well enough, but when he and a colleague, the dentist and Harvard medical student William T. Morton tried to demonstrate its use for the extraction of a neck mass from a large, bull-necked individual, the demonstration failed for technical reasons and Wells was disgraced.  He later became addicted to the anesthetic gas chloroform and committed suicide.  Morton went on to work successfully with ether anesthesia, but fell into disgrace when he tried to profit personally from the use of the agent.

James Simpson, a professor in Edinburgh, was working with chemicals for anesthesia with some colleagues when, according to a possibly apocryphal report, one of them tipped over a bottle of chloroform.  Simpson’s wife came into the room to find them all asleep, as in the image.  This picture is entitled the “Chloroform Party”, but except for the period clothing is reminiscent of a typical spring semester weekend party at UMD using, perhaps, alternative intoxicants.

Of these three gases, ether was the most successful, but was replaced by better agents in later years.  Nitrous oxide is still used in dental applications with good success.

Inventing Antisepsis: “Nazi” Semmelweis Gets/Goes Mad

Ignác (nickname: “Nazi”) Fülöp Semmelweis (1818-1865), German-Hungarian physician who discovered the cause of puerperal (“childbed”) fever and introduced antisepsis into medical practice.

Some people with dementia become “pleasantly confused”.  They may even find their memory lapses amusing.  These people are more likely to endear themselves to their caregivers than annoy them.  Dr. Ignac Semmelweis, medical genius and a victim of presenile, or early-onset, Alzheimer’s Disease, was not one of these.  He publicly and literally raged against his medical skeptics and when it was finally clear that he was demented and was confined to a private asylum in Vienna,  he was so agitated and belligerent that his attendants, in an attempt to subdue him, beat him so severely that he died of his injuries within two weeks.  This was the ignominious end of a frustrating, tragic,  Cassandra-like life.

The image on the right shows red-stained bacteria called streptococcus pyogenes.  S. pyogenes can cause  Puerperal Fever and other diseases like the aggressive Flesh Eating Bacterium infection which has attracted attention in more recent times (see Necrotizing Fasciitis (Flesh Eating Bacterium) Image).  The other, darker cells in the image on the right are white blood cells, part of the body’s defense against infection.

In the 19th century, these germs, carried on the hands of doctors, commonly led to a fatal pelvic infection in women following childbirth.  Now, there are antiseptic techniques and highly effective antibiotics available to prevent and treat this kind of infection.  It has become a cause for concern if even one case of streptococcal pelvic infection occurs in the delivery room of any Minnesota hospital.  It is a tribute to Dr. Semmelweis’s powers of observation and his intellectual openness that he recognized, at a time when such things as “germs” and “bacteria” were barely known, that physicians were transmitting this disease to their patients .  The term “antisepsis” had been known and written of since the 18th century.  The concept of antisepsis had been at least vaguely realized since ancient Egypt (see Egyptian copper-containing antiseptics in online Royal Society of Chemistry article), but its effective, informed, clinical use had to await the career, or, more correctly, the aftermath of the career of Dr. Semmelweis.

In the 1840s, Semmelweis was working at the Allegemeine Krankenhaus in Vienna (read: “Vienna General”).  The hospital was experiencing an epidemic of Chidbed Fever and prevailing medical opinion said that this sort of thing was inevitable; could not be prevented.  However, he noticed that pregnant women who were delivered in Ward One (where they were attended by medical students) had a mortality rate of 29%, while women in Ward Two (where they were attended by midwifery pupils who did not attend autopsies like medical students did) had a mortality rate of 3%.  The accepted practice, then, was that doctors and medical students would walk between the morgue and the delivery room without changing their presumably bloodstained clothes (neither autopsies nor deliveries are exactly elegant procedures) or washing their hands.

Semmelweis experimented by switching the the two wards, medical students now working in ward two.  The mortality rate followed the medical students.  Then, a professor and colleague of Semmelweis’s, Jacob Kolletschka, cut his finger in the autopsy room and soon died of the same septicemia that was the fate of so many women suffering from Childbed Fever.    (See Michael Kennedy, “A Brief History of Disease, Science and Medicine”, Mission Viejo, California: Asklepiad Press, 2004, pp 138-39)

Semmelweis wrote, “Day and night, the image of Kolletschka’s illness pursued me.”  He began to require that medical people simply wash their hands in a solution of chlorinated water  between the wards and the autopsy room (chlorine being an effective antiseptic).  Infection rates fell dramatically.  Being repudiated, he resigned in disgust from the Allegemeine Krankenhaus and moved to Budapest where he repeated his experiments at St. Rochus Hospital with the same results.  In 1861, he published his results in his “The Cause, Concept, and Prophylaxis of Childbed Fever”.  The publication was greeted with skepticism and his simple recommendations were not carried out in a general way in his lifetime.  Kennedy states accurately that he was reported to have died, ironically, of streptococcal septicemia contracted while doing an autopsy.  That was reported, but it was not true.  Dr. Sherwin B. Nuland, physician and historian, investigated and discovered the true cause of Semmelweis’s death at the hands of his attendants at the asylum.

The tragic (for him and his patients), frustrating story of Semmelweis’s life is also a cautionary tale against allowing scientific opinion to ossify to the point where it rejects new data.  This phenomenon has in fact been called the “Semmelweis Reflex”, the rejecting out of hand any information automatically, without thought, inspection, or experiment.  I feel I have experienced this to a degree.  I recently read in Newsweek Magazine an article written by Sharon Begley, respected science writer for the Wall Street Journal and Newsweek.  Her thesis was that antidepressants are of no benefit to the majority of patients suffering from depression.  She writes specifically of the class of antidepressant known as SSRI, or Selective Serotonin Re-uptake Inhibitors.  I have personally prescribed these medications for at least dozens of my patients and I believe I have seen beneficial effects, even some which were unexpected by the patient and, at first, by me.  For example, the meds seem to be almost a specific antidote to “irritability”.  Viz, the crabby, negative behavior seen so often by one or the other marital partner, that has its root in depression.  To the amazement of the patient and even more often to the spouse, this irritability goes away after starting an SSRI.

I have seen this and other improvements occur too many times to doubt the effectiveness of SSRIs…and, yet, the old Hippocratic saying is true: “Experience is fallacious and judgment difficult.”  I stand uncomfortably close to Semmelweis’s critics if I reject Begley’s thesis out of hand and do not investigate it or suspend judgment until others investigate it further.  Almost every “fiber of my being” calls out that Begley is wrong (just as it likely did with Semmelweis’s detractors), but part of the discipline of science is to suspend disbelief and investigate.