Thursday, November 20, 2008

A History of Medicine, Part 4

The Fjordman Report

The noted blogger Fjordman is filing this report via Gates of Vienna.
For a complete Fjordman blogography, see The Fjordman Files. There is also a multi-index listing here.

This is Part 4 of a series. Parts 1, 2 and 3 are available here, here and here.

One of the oldest medical works in China, the Shen Nung Pen Tsao, contains lists of useful herbs. It is referred to already during the Han Dynasty (206 BC—220 AD) but probably contains older material. Another work, The Yellow Emperor’s Inner Canon of Medicine, was associated with the legendary Yellow Emperor from the mid-third millennium BC. His wife is said to have introduced silk to the Chinese. The book has been of just as great importance to the development of Chinese medicine as the Hippocratic corpus has been to European medicine, but modern historians believe it was actually compiled later than claimed, maybe during Han times. In oracle bones from the historically attested Shang Dynasty of the second millennium BC, disease was often attributed to the gods and relief frequently sought through prayer, as was the case in most civilizations at that time.

According to James E. McClellan and Harold Dorn in their book Science and Technology in World History, second edition, “Hospitals, or at least hospice-like organizations, arose in China out of Buddhist and Taoist philanthropic initiative, but these became state institutions after the suppression of religious foundations in 845 CE. To guide physicians, the central government issued many official textbooks dealing with general medicine, pharmacy, pediatrics, legal medicine, gynecology, and like subjects. One Song pharmaceutical document dating from about 990 CE contained 16,835 different medical recipes. The numerous botanical and zoological encyclopedias also deserve note, in part for their medicinal advice; a government official, Li Shih-Chen, compiled the Pen Tsao Kang Mu, or Classification of Roots and Herbs, which listed 1,892 medicaments in fifty-two volumes. Illustrations graced many of these books.”

There is every reason to believe that some herbs had real effects, in China as elsewhere. For instance, a drug derived from the Chinese joint fir, Ephedra sinica, was recommended for cough and lung ailments. In the 1880s the Japanese scientist Nagai Nagayoshi (1844-1929) extracted ephedrine from this herbal remedy. Ephedrine is used against respiratory diseases even today. Others drugs had beneficial effects but were sometimes overused in traditional Chinese medicine, for instance ginseng. Examination of the pulse was given great weight in diagnosing illness, similar to Roman practice, but this is a technique that, while clearly useful, can also be relied on too much. Chinese published works on natural history took a special interest in insects, especially the silkworm. Silk is one of the oldest inventions associated with Chinese civilization, possibly since prehistoric times.

According to Michael Kennedy, “The earliest hospitals were established by Buddhist monasteries and, in the ninth century, the Tang Dynasty nationalized them and thereafter assumed the responsibility of maintaining them. The Song and Yuan Dynasties continued state interest in medical matters and the compilation of a materia medica and government pharmacies and clinics were developed. Chinese medicine continued virtually unchanged from the Han Dynasty until the nineteenth century.” He believes that Chinese medicine was “marked by a profound conservatism” which lasted until it was confronted with Western science. This does not mean that the Chinese never accepted innovations from other cultures. The concepts of “hot” and “cold” in Chinese medicine may represent transplants from Indian, Ayurvedic theories of disease, and drugs could be imported from other countries. India had a promising start in surgery. Although it did not reach its full potential later, India maintained an edge over China in this discipline. Kennedy again:

“No similar development of surgery occurred and the sophisticated understanding of surgical procedures present in India seems not to have crossed the borders with the Buddhists. The only surgeon found in early Chinese history was Hua To who performed an operation to remove an arrow from the arm of General Kuan Yun. The same surgeon is later described in another incident. A prince named Tsao Tsao was suffering from severe headaches and called upon Hua To for relief. The surgeon recommended trephination of the skull to relieve the headaches. Just as he was about to proceed, his patient, Tsao Tsao, was seized with suspicion and accused the surgeon of conspiring to murder him in league with enemies. The luckless surgeon was arrested and, in 265 CE, executed at the prince’s order. This surgeon, who is unique in Chinese history, had authored many works on medicine and surgery. He requested that they be destroyed before his execution and this was done. The Chinese opposition to the ‘mutilation’ of the body seems to have prevented any development of surgery similar to that in India.”

Possibly, this particular surgeon was not of Chinese origins; he may have been an Indian who came with Buddhist scholars. Chinese accounts of anatomy were often mired with stylized and inaccurate descriptions which did not always correspond to reality. Dissection of human bodies is described only very sporadically and anatomy was largely ignored until recent times. It is possible that ancestor worship prohibited violation of the corpse of dead patients. The absence of dissection or any experimental analysis allowed theoretical speculations to become more and more convoluted “until the original grains of real knowledge in Chinese medicine were submerged by traditions that had no basis in science.”

The growing influence of European medicine in late imperial and early republican China (the 1800s and early 1900s) posed considerable challenges to traditional Chinese doctors. Some of them rejected it entirely; others wanted to adopt certain aspects of it or rejected traditional Chinese medicine. Some scholars tried to argue that the differences between the two traditions were minor or that Western learning had Chinese origins and that traditional Chinese medicine had also stressed the brain. The sinicization of Western pharmacy was made easier by the rich tradition of pharmacopoeia in China. Chinese doctors during the 1800s gradually integrated the Western anatomy of blood vessels and the nervous system and focused on advances in modern chemistry vs. ancient and medieval alchemy. However, there was some skepticism towards the invasive surgical techniques employed by Western physicians.
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Acupuncture, the idea of inserting needles into the body, predates imperial times but was developed further in imperial China. The practice was linked to the Taoist doctrine of qi and its circulation. The insertion points are located on invisible lines or meridians running through the length of the human body, which control certain physical conditions. Acupuncture, too, became updated following the encounter with Western medicine. As scholar Benjamin A Elman puts it in A Cultural History of Modern Science in China:

“In this cultural encounter, Chinese practitioners such as Cheng Dan’an (1899-1957) modernized techniques such as acupuncture. Cheng’s research enabled him to follow Japanese reforms by using Western anatomy to redefine the location of the needle entry points. His redefinitions of acupuncture thus revived what had become from his perspective a moribund field that was rarely practiced in China and, when used, also served as a procedure for bloodletting. Indeed, some have argued that acupuncture may have originally evolved from bloodletting. This Western reform of acupuncture, which included replacing traditional coarse needles with the filiform metal needles in use today, ensured that the body points for inserting needles were no longer placed near major blood vessels. Instead, Cheng Dan’an associated the points with the Western mapping of the nervous system. A new scientific acupuncture influenced by Japan and sponsored by Chinese research societies thus emerged alongside traditional acupuncture, providing with its better map of the human body an enhanced diagnosis of its vital and dynamic aspects. Similarly, Chinese doctors assimilated the discourse of nerves and the theory of germ contamination from Western medicine.”

Daniel Jerome Macgowan (1814-1893) and Benjamin Hobson (1816-1873), both physicians, were key pioneers in the late 1840s and early 1850s in introducing Western medical and other sciences to China. Macgowan was an American, initially serving as a medical missionary, who later became a freelance lecturer and writer. Translations were made of Western scientific works on electricity and the nervous system and of Chinese classics to European languages. The English medical missionary Hobson in Hong Kong prepared a series of scientific translations co-authored with Chinese scholars. The introduction of Western medicine began first in the treaty ports, particularly Guangzhou, Ningbo and Shanghai.

However, as Elman says, “Meanwhile, outside the missionary hospitals and clinics in the treaty ports, Hobson’s translations were not popular due to the Chinese distaste for surgery. Minor surgical procedures such as cutting warts, lancing boils, cauterizing wounds, removing cataracts, and castration for eunuchs were relegated to the nonliterati majority of physicians. Hobson’s Treatise on Physiology and his Treatise on Midwifery introduced invasive surgery for childbirth, drawn from the anatomical sciences that had evolved in Europe since the sixteenth century. But although anatomy could pinpoint childbirth dysfunctions as happening in the uterus, interventions were dangerous even by Western standards until modern surgery integrated sterilization techniques with anesthetization procedures.. Rather than invasive surgery for childbirth problems, Chinese physicians preferred practical therapies for women based on their holistic, interactive model of the human body.”

This does not mean that all Chinese resisted the new advances: “On the basis of his own examination of human corpses, Wang Qingren (1768-1831), one of the few Chinese physicians to take anatomy seriously, contended that all of the bodily depictions in the Chinese medical classics were inaccurate. His Corrections of Errors in the Forest of Medicine (1830, 1853) also maintained that the brain was the central organ of the body, a view that became more prominent after Protestant medical texts such as Hobson’s were translated into Chinese. Hobson’s work represented the first sustained introduction of the modern European sciences and medicine in the first half of the nineteenth century.”

Hobson introduced new knowledge in physics, chemistry, astronomy, geography and other disciplines, but this was always presented as God’s creation, and this did not always go down well with Chinese scholars. In the early seventeenth century, European Christian missionaries were Catholics Jesuits. They did bring new knowledge in mathematics and astronomy to China and a renewed interest in China back to Europe, but eventually they lagged behind in the sciences, were suppressed by the Catholic Church and lost out in competition with other Westerners. In the nineteenth century most of the Christian missionaries were Protestants, who were soon supplemented by other groups. As Benjamin Elman writes:

“Patrick Manson (1844-1922), a port surgeon and medical officer in the Imperial Chinese Customs Office since 1866, helped establish the London School of Tropical Medicine in 1898. Assigned for over two decades to Chinese treaty ports, Manson studied tinea, Calabar swelling, and blackwater fever before he developed a focus on tropical hygiene. He distinguished himself with his research on filariasis, a disease endemic in South China for which neither Chinese nor European medicine had a remedy. In particular, he observed in 1878 that the filariae worms causing elephantiasis passed part of their natural life cycle in the Culex mosquito, thus demonstrating transmission by parasites and explaining their natural history. Until the idea was unseated by the germ-parasite theory of disease in the late 1890s, Europeans regarded malaria as a miasma defined by human fever; Hobson himself associated malaria with putrid air. In the latter half of the nineteenth century, Western physicians tried to explain such extreme fevers by using a chill theory that described tropical illnesses according to the degree of change in an individual’s physiology. Hot days and cold nights produced such fevers, most thought. Such views overlapped with Chinese notions of cold- and heat-factor illnesses.”

Unlike Chinese astronomy, which was completely reworked in the seventeenth and eighteenth centuries by the introduction of European techniques, traditional Chinese medicine did not face a serious challenge until the mid-nineteenth century. Except for quinine therapy for malaria and a number of herbal medicines unknown in China, the medicine brought by European physicians did not achieve superior therapeutic results until a relatively safe procedure for surgery combining anesthesia and asepsis was developed towards the end of the nineteenth century. But as we have seen before, Europeans did have a superior understanding of human anatomy, based on centuries of systematic dissection since the Late Middle Ages.

According to the eminent British historian of medicine Roy Porter in The Greatest Benefit to Mankind: A Medical History of Humanity, “The idea of probing into bodies, living and dead (and especially human bodies) with a view to improving medicine is more or less distinctive to the European medical tradition. For reasons technical, cultural, religious and personal, it was not done in China or India, Mesopotamia or pharaonic Egypt.”

It is wrong to assume that human dissection was never practiced in traditional civilizations. I have seen evidence of isolated cases of dissection in Hellenistic Egypt, India and elsewhere. Dissection was apparently used in a limited way in forensic medicine in the Chinese justice system. The medical expert Song Tz’u or Song Ci (1186 — 1249) combined historical cases of forensic science with his own experiences and wrote the influential book Collected Cases of Injustice Rectified to avoid miscarriages of justice. However, in China there was no medical profession as we know it, and religious healers remained prominent until modern times. The state exploited useful knowledge across a wide range of applications, but the centralized bureaucracy could and sometimes did hamper advances in science. According to Toby E. Huff in The Rise of Early Modern Science: Islam, China and the West, second edition:

“It stands in striking contrast to the local and community-based inquest held before an elected or appointed jury in the English and continental traditions. That is, in both of those European cases, citizens from local communities were elected or appointed to serve as a jury, with the coroner acting as much as an agent of the community as the national or federation officials. Moreover, unlike the Chinese case, physicians were often brought in to examine the body. Examples of Italian physicians performing an autopsy in cases of suspicious deaths go back to the thirteenth century. Furthermore, physicians and surgeons in Europe already at this time — the thirteenth century when the Chinese manual of instruction to the magistrate was being written — belonged to legally autonomous guilds as well as to university faculties. Hence, they were already launched on a path to specialization in medical inquests (and especially the performance of autopsies and dissections) as well as the autonomous teaching of medicine, when Chinese authorities were centralizing medical examinations in the hands of non-specialists, namely magistrates and Judicial Commissioners who were not trained in medicine.”

Although it is possible to find examples of sporadic cases of human dissection in other civilizations, the sustained practice of human dissection by a trained body of medical practitioners with the stated objective of understanding the workings of the human body was an achievement of Renaissance Europe in the Late Middle Ages.

According to Roy Porter, “In the short run, the anatomically based scientific medicine which emerged from Renaissance universities and the Scientific Revolution contributed more to knowledge than to health. Drugs from both the Old and New Worlds, notably opium and Peruvian bark (quinine) became more widely available, and mineral and metal-based pharmaceutical preparations enjoyed a great if dubious vogue (e.g., mercury for syphilis). But the true pharmacological revolution began with the introduction of sulfa drugs and antibiotics in the twentieth century, and surgical success was limited before the introduction of anaesthetics and antiseptic operating-room conditions in the mid nineteenth century. Biomedical understanding long outstripped breakthroughs in curative medicine, and the retreat of the great lethal diseases (diphtheria, typhoid, tuberculosis and so forth) was due, in the first instance, more to urban improvements, superior nutrition and public health than to curative medicine. The one early striking instance of the conquest of disease — the introduction first of smallpox inoculation and then of vaccination — came not through ‘science’ but through embracing popular medical folklore.”

Although the Chinese had a flawed theoretical understanding of the human body, they still managed to develop effective therapies for some conditions. Following a series of epidemics in seventeenth century, new theories of disease gained adherents which postulated that some diseases entered through the nose or mouth and in some cases such as smallpox and tuberculosis could be communicated by contact. Though rudimentary, this hypothesis was at least as close to a realistic understanding of infectious diseases as was European medicine of the day, still wedded to the idea that diseases were caused by bad air (“malaria” means “bad air”). However, as we know, the later breakthroughs in understanding did take place in Europe and couldn’t have happened without the European invention of the microscope.

Smallpox was present in China from an early age and the disease almost certainly originated somewhere in Asia. Several Asian countries used some form of induced immunity through limited exposure to smallpox since it had been recognized for centuries that some diseases never reinfect a person after recovery. However, there was no proper theoretical understanding of why this procedure worked and it was apparently not applied to other infectious diseases. This crucial step was taken in Europe after the concept of inoculation had been imported to the continent from Asia via the Middle East.

The alchemist/chemist and physician Philippus Theophrastus Aureolus Bombastus von Hohenheim is better known as Paracelsus (1493—1541). The name means “equal to or greater than Celsus,” a Roman encyclopedist from the first century AD known for his medical work De Medicina. His mother was Swiss and his father was a physician who taught metallurgy and chemistry (alchemy) at a mining college in Austria. Paracelsus travelled widely across the European continent. He started his medical studies at the University of Basel, Switzerland, later moved to Vienna and eventually got his medical degree from the University of Ferrara in Italy. He was highly unorthodox and gifted, but also a practicing astrologer and “had something of the charlatan in him.” According to Michael Kennedy, Paracelsus on his travels learned of a peasant remedy known among the subjects of the Ottoman Empire to prevent smallpox. He thus became the first in Europe to recommend inoculation, two centuries before Jenner and Lady Montague:

“He was a contemporary of Martin Luther and met him, but remained a Catholic. His revolutionary interest was to place chemistry at the center of medicine. He insisted on mixing chemical compounds from pure ingredients with standard formulas, a truism now, but unknown at that time of patent remedies with exotic ingredients. In 1527, he accomplished a spectacular cure of a prominent citizen of Basel — no one seems to know how — and this act brought him into contact with the famous scholar Erasmus. Paracelsus succeeded in curing Erasmus of gout and, through the influence of both his parents, was awarded the position of town medical officer of Basel. Paracelsus characteristically created problems for himself, when he declared that his lectures in Basel would be in German, not in Latin, and that barber-surgeons and midwives were welcome to attend. Luther had adopted German for religious writing and now Paracelsus followed the example. He rejected the four humours theory of disease and added that fermentation and putrefaction were at the center of biological functions. He advocated the use of chemistry in treatment of disease although he continued to hold some primitive beliefs similar to those of other cultures.”

Paracelsus burned the works of Galen and Avicenna, then still the authorities in the medical education in Europe, sprinkling sulphur and nitre on the flames with spectacular results, proclaiming that “All the universities and all the ancient writers put together have less talent than my arse.” Needless to say, his lectures became public events, but he made enemies with his unorthodox views and behavior. He continued to be a difficult figure but his work remained outstanding. In one case, he is alleged to have cured several cases of syphilis, then a new disease probably introduced by the returning sailors of Columbus from the Americas and much more virulent than the modern disease, although no-one knows exactly why. Nevertheless, despite the colorful history of Paracelsus, the real breakthrough for the concept of inoculation in the Western world came in the eighteenth century.

In 1718 Lady Mary Wortley Montague reported that the subjects of the Ottoman Empire deliberately inoculated themselves with fluid taken from mild cases of smallpox. Since the European medical profession was relatively organized, new methods of variolation could be made known quickly. Several people were engaged with this idea in Europe in the late eighteenth century to combat the greatly feared and often lethal disease, but credit for popularizing the concept goes to the Englishman Edward Jenner (1749-1823).

According to scholar Stefan Riedel, “During the great epidemic of 1721, approximately half of Boston’s 12,000 citizens contracted smallpox. The fatality rate for the naturally contracted disease was 14%, whereas Boylston and Mather reported a mortality rate of only 2% among variolated individuals. This may have been the first time that comparative analysis was used to evaluate a medical procedure. During the decades following the 1721 epidemic in Boston, variolation became more widespread in the colonies of New England. In 1766, American soldiers under George Washington were unable to take Quebec from the British troops, apparently because of a smallpox epidemic that significantly reduced the number of healthy troops. The British soldiers were all variolated. By 1777, Washington had learned his lesson: all his soldiers were variolated before beginning new military operations.”

Jenner had heard tales that dairymaids were protected from smallpox naturally after having suffered from cowpox, a related but less dangerous disease. He tested this and found that the tales were true. The Latin word for cow is vacca, cowpox is vaccinia; Jenner therefore called the procedure vaccination and reported his findings to the Royal Society of London. The use of vaccination against smallpox spread rapidly in Europe during the early 1800s.

According to Riedel, “Jenner’s work represented the first scientific attempt to control an infectious disease by the deliberate use of vaccination. Strictly speaking, he did not discover vaccination but was the first person to confer scientific status on the procedure and to pursue its scientific investigation. During the past years, there has been a growing recognition of Benjamin Jesty (1737—1816) as the first to vaccinate against smallpox.” It was nevertheless Jenner’s relentless promotion and devoted research that changed the way medicine was practiced.

By the early 1800s, surgery in the Western world was still just as painful and dangerous as everywhere else, and the causes of diseases were not better understood by Europeans than by others. This situation would change dramatically in the course of the nineteenth century, ushering in the greatest medical revolution in human history. As Roy Porter says:

“I devote most attention to what is called ‘western’ medicine, because western medicine has developed in ways which have made it uniquely powerful and led it to become uniquely global. Its ceaseless spread throughout the world owes much, doubtless, to western political and economic domination. But its dominance has increased because it is perceived, by societies and the sick, to ‘work’ uniquely well, at least for many major classes of disorders. (Parenthetically, it can be argued that western political and economic domination owes something to the path-breaking powers of quinine, antibiotics and the like.) To the world historian, western medicine is special. It is conceivable that in a hundred years time traditional Chinese medicine, shamanistic medicine or Ayurvedic medicine will have swept the globe; if that happens, my analysis will look peculiarly dated and daft.. But there is no real indication of that happening, while there is every reason to expect the medicine of the future to be an outgrowth of present western medicine — or at least a reaction against it. What began as the medicine of Europe is becoming the medicine of humanity. For that reason its history deserves particular attention.”

René Théophile Hyacinthe Laennec (1781-1826), a French physician working at the Necker Hospital in Paris, invented the stethoscope in 1816. It gave access to the internal organs and was one of the most important advances for diagnosis prior to the discovery of X-rays by the German physicist Wilhelm Conrad Röntgen (1845—1923) in 1895. Laennec in 1819 published a treatise and described a wooden instrument, which was applied to one ear with the other end placed on the chest. In 1852 the American George Cammann invented the familiar instrument with rubber tubing and two earpieces.

Some medical improvements were made by more rigorous application of the experimental method, for instance by the French physiologist Claude Bernard (1813 —1878), widely regarded as one of the founders of experimental medicine. Many advances, however, were dependent upon advances in other scientific disciplines, for instance chemistry and microscopy. Countless instruments which we take for granted today followed on the heels of studies of electricity and electromagnetism during the nineteenth century.

The Italian physicist Luigi Galvani’s (1737—1798) work on bioelectricity in the late eighteenth century paved the way. Static electricity had been known since ancient times, but no known instruments for generating an electric current existed before nineteenth century Europe, and no civilization had ever made the connection between electricity and physiology. Alessandro Volta (1745—1827) invented the battery in 1800. The French physicist André-Marie Ampère (1775—1836) was one of the contributors to the development of the galvanometer, used for detecting and measuring electric current, as was the German physicist Georg Ohm (1789—1854) and others. The Italian Carlo Mateucci (1811-1868) in 1843 was able to measure the electrical current of muscle contraction using a galvanometer. In 1856 the German anatomist Heinrich Müller (1820-1864) and the Swiss anatomist Rudolph Albert von Kölliker (1817—1905) identified an electrical current generated by frog heartbeat.

The Scottish electrical engineer Alexander Muirhead (1848-1920), a specialist in wireless telegraphy, while working at St Bartholomew’s Hospital in London 1869-1872 recorded the first human electrocardiogram. Gabriel Lippmann (1845—1921), born in Luxemburg but raised in Paris, in 1891 developed a method for reproducing colors photographically and an instrument called capillary electrometer in 1872 to measure changes in the heart. The French scientist Étienne-Jules Marey (1830—1904), a pioneer of photography and cinema, in 1881 devised a photographic technique to record these measurements. The British physiologist Walter H. Gaskell (1847-1914) demonstrated the sinus node and the atrio-ventricular node in the turtle heart, and in 1887 the British scientist Augustus Desiré Waller (1856-1922) created the first real ECG (electrocardiogram) machine and succeeded in measuring cardiac electrical activity from the surface of the body.

The greatest breakthrough came with the Dutch doctor Willem Einthoven (1860—1927). He began to improve the capillary electrometer in 1893 while being a professor of physiology at Utrecht, described the waves of electrical recording and discovered that people with heart disease had different electrocardiogram tracings. He then began to develop a new machine which he called a “string galvanometer.” The first one was large and heavy and occupied two rooms, but also very accurate. The reports he released, starting in 1901, changed cardiology forever, and made recordings of many cardiac diseases and their effects on ECG. Visitors came from all over Europe and North America to see the innovation. Einthoven was later astonished during a visit to the USA in 1924 to see that an ECG technician could make a diagnosis of heart conditions just by looking at the ECG diagram. In 1928 the Cambridge Scientific Instrument Company of London built the first portable string electrocardiograph.

Other improvements were related to advances in chemistry. Surgery before modern anesthesia was obviously extremely painful and was conducted quickly and only when absolutely necessary. For hundreds of years people suffered unspeakably during operations. Physicians and healers did have some forms of pain relief prior to modern times and sometimes employed opium, cannabis incense, coca, tobacco or other forms of herbal anesthesia locally available. Alternatively, the patient prior to surgery might drink vast amounts of alcohol. Yet they did not practice general anesthesia as we think of it today.

According to Michael Kennedy, “In 1800, surgery was conducted exactly as [French surgeon Ambroise] Paré had practiced in 1537. Operations were limited to amputations and drainage of abscesses with anal fistula surgery the most sophisticated and closest to modern physiological concepts. Fractures were set, but open fractures were fraught with danger from infection and amputation was often the safest course.” Moreover, “Speed was essential when pain could not be relieved. Baron Larrey, Napoleon’s chief surgeon, reported performing 200 amputations at the battle of Borodino in twenty-four hours: one amputation every seven minutes. No mention was made of how many survived, but in good conditions, the mortality rate was about forty percent. Great advances were being made in spite of the limitations early in the century.”

Scholar Joel Mokyr (pdf format) wonders why the discovery of general anesthesia happened so late in Europe, and not at all in China:

“Could anesthesia have been invented in China? Unlike optics, in this case there was no need here for some breakthrough in the underlying knowledge base, since little of that existed in the West either. Nobody in the mid nineteenth century had any idea how precisely ether, chloroform, or other substances knocked out the patient. The Chinese embarked on another route toward pain relief: instead of chemical intervention, their path led to physical means through acupuncture.. Yet much of Chinese medicine was based on the use of herbal medicine and the prevalence of opium in the nineteenth century indicates that chemical intervention in sensatory bodily processes was by no means alien to them. Perhaps more plausible is the explanation that surgery itself was rare in China. Conditional on that premise, perhaps the Chinese should not have been interested in anesthesia. But this argument does not seem wholly satisfactory. Childbirth suffering presumably was not wholly culturally-determined. We need to ask what it was, if anything, in Chinese culture that made surgery unacceptable….There was not one but many types of Chinese medicine…Yet none of them resulted in the adoption of surgery as a widely practice form of medicine outside cataract surgery.”

Mokyr concludes that Western science itself was not “inevitable.” One early development of anesthesia has been claimed in East Asia, but in Japan, not in China. The Japanese physician Seishu Hanaoka (1760-1835) has been credited with performing the first known surgery using general anesthesia in the form of an oral compound composed of a number of traditional plant-based drugs, among them mandragora (mandrake root), on a breast cancer patient in 1804. He had learnt traditional Chinese medicine as well as Dutch-imported European surgery, which inspired him to conduct experiments not previously performed in East Asia. However, due to the isolationist policies of the Tokugawa Shogunate his achievements were not known abroad. The development of general anesthesia in the Western world, which was later exported to other continents, happened along very different lines.

The discovery that a number of substances can knock a patient unconscious without long-term damage happened surprisingly late. In the late eighteenth century, great advances were being made in chemistry, especially regarding the nature of various gases. Nitrous oxide was discovered by Englishman Joseph Priestley (1733—1804), but he did not understand its anesthetic properties. The investigation of multiple gases in the atmosphere led to a faddish enthusiasm for “pneumatic medicine,” the inhalation of the various gases. The young English scientist Humphrey Davy (1778-1829) tried inhaling nitrous oxide and stumbled upon the idea of using it for anesthesia, but still failed to see its full potential.. Previous attempts at pain relief had used opium, mandrake root or mandragora (which produced Juliet’s death-like coma in Shakespeare’s play Romeo and Juliet) or atropine, all with inadequate effect. Hyoscyamine (called henbane or poor man’s opium) had been known since ancient Egypt and may have been used by the Greeks at the Oracle at Delphi to induce hallucinations.

In the United States, nitrous oxide (often called laughing gas) was popular at parties and fairs, but no medical application was considered until 1844 when the dentist Horace Wells (1815—1848) attended a fair and watched a demonstration. The idea of using it for tooth extraction occurred to him and he offered himself as a candidate. While under its effect, his molar was extracted by fellow dentist John Riggs. Although it could be useful for dentistry, his apparatus was not capable of producing enough depth of anesthesia for major surgical operations.

Morphine, a purified alkaloid named after the Greek god of dreams, Morpheus, was discovered by the German apothecary Friedrich Sertürner (1783-1841) in 1803-1805. It was enthusiastically received and aided the development of the modern pharmaceutical industry. The invention of the first practical hypodermic syringe in 1853 independently by the French surgeon Charles Gabriel Pravaz (1791-1853) and the Scottish physician Alexander Wood (1817-1884) led to increased use of morphine as a painkiller. However, although morphine is very useful in many cases, it was gradually understood that it is also highly addictive.

Ether had been manufactured since the eighteenth century for use as a solvent, but was never applied to surgery until 1842. In fact, ether was synthesized in 1540 and known as “sweet vitriol.” As Kennedy states: “Raymundus Lullius, a Spanish alchemist, first produced ether in 1275. He found that, if vitriol (sulphuric acid) was mixed with alcohol and distilled, a sweet white fluid resulted. Valerius Cordus rediscovered ether in 1540 and named it ‘sweet oil of vitriol.’ Paracelsus used the same chemical to relieve pain about the same time, but the concept of surgical anesthesia did not occur to him. It was renamed ether (or sulphuric ether) in 1730 and was used as an expectorant to bring up phlegm in respiratory illnesses. In 1815, Michael Faraday, Davy’s assistant, noted that ether could produce an effect similar to laughing gas and ‘ether frolics’ soon became popular.”

The American physician Crawford Long (1815—1878) became the first person to have performed a surgical operation using general anesthesia induced by ether. Long, a doctor in Jefferson, Georgia, had attended ether parties (ether was popular entertainment before its surgical use) and noted that pain was absent under its effects. He later used it to remove a cyst in the neck of a boy, James Venable, in March 1842. Venable was unconscious and did not suffer pain. Long’s practice became successful, but he did not publish his results until 1849 and has therefore often been ignored in historical accounts. William Clarke, a physician from New York, suggested the use of ether for extracting teeth to his dentist Elijah Pope, who performed the first successful use of ether in dentistry in January 1842. Like Long, however, Pope did not publish his results at the time.

The so-called ether controversy regarding who should be credited with the application of ether as general anesthesia involved several Americans, among them William T. Morton (1819-1868) and Charles Jackson (1805—1880). Long may not have been personally responsible for the worldwide dissemination of the idea and did not become involved in the controversy, but Morton had visited Georgia in 1842 when Long performed his first anesthesia and was probably aware of this since it caused a sensation in that state at the time. Morton arranged a famous public demonstration of diethyl ether (then called sulfuric ether) as an anesthetic agent in October 1846 at the Massachusetts General Hospital. After this, the use of ether spread rapidly throughout the Western world.

According to Kennedy, “Ether, stronger and more effective than nitrous oxide, was tried in Europe with equal success and a new age dawned. Robert Liston, an English surgeon known for speed, who held his knife in his teeth when not using it for cutting, performed an amputation of the thigh under ether anesthesia in December 1846, only two months after Morton’s demonstration. Present in the audience was medical student Joseph Lister who would conquer the next hurdle in surgery. After completing the pain-free operation Liston declared, ‘This Yankee dodge, gentlemen, beats mesmerism (hypnotism) hollow.’ World acceptance was rapid and ether was used in the Crimean War on battle casualties.”

Chloroform was discovered by the American physician Samuel Guthrie (1782-1848) in 1831, and independently at almost the same time by French pharmacist Eugène Soubeiran (1797—1859) and the great German chemist Justus von Liebig (1803—1873). Clearly, it was an invention whose time had come. It was named and classified in 1834 by the French chemist Jean-Baptiste Dumas (1800-1884), but he did not understand its medical usefulness. Its anesthetic properties were noted in 1847 by another Frenchman, Marie Jean Pierre Flourens (1794-1867). Because it caused less lung irritation and vomiting, chloroform tended to replace ether once its potential was grasped. In 1847, the Scottish obstetrician James Young Simpson (1811—1870) became the first to use chloroform for general anesthesia during childbirth.. After this, its use expanded rapidly in Europe. In 1853 Britain’s Queen Victoria (1819—1901) took chloroform during the birth of Prince Leopold, administered by the English physician John Snow (1813 — 1858). Snow published a book on chloroform describing its use in anesthesia.

There were a few protests against these developments. Some were on religious grounds (was not pain ordained by God?) and some on medical grounds. There were, and still are, risks associated with the use of general anesthesia. Ether would eventually prove to be safer, ironically partly because of the lung irritation it causes, which stimulates breathing. Chloroform carries a risk of liver damage and the mortality rate of surgery under chloroform was eventually shown to be higher than that using ether.


Afonso Henriques said...

Thank you Fjordman for this great essay. And thank you Baron for publishing it.

Melissa said...

I visited an acupuncturist once and loved my experience. Truthfully, I am impressed with the detail that went into this article. I enjoy Chinese history and so I will dive back into my Chinese historical novel, Return to the Middle Kingdom by Yuan-tsung Chen. An insider’s account of the Cultural Revolution.

Findalis said...

And when all else fails, Chicken Soup. Millions of Jewish mothers can't all be wrong.