February 16, 2009. (I plan to revise and polish this a bit yet, but thought I'd get it posted just to get the ball rolling.)
: This is the fourth in a series of presentations given to the February, 2009 session of our local lifelong learning program,
Senior University Georgetown.)
Other lectures in this series include: 1.
Introduction and Germ Theory, plus supplementary webpages on
a brief overview of the history of medicine before 1500,
a brief overview of the history of medicine after 1500, and the
history of microscopy.
2:
Contagion, Infection, Antisepsis
; 3:
The Early
History of Immunology ; 5:
Recognizing Nutritional Deficiencies ;
6:
Hygiene:
Sanitation, Hookworm, Dental Floss, & Summary
The focus of this presentation is mainly
the stories associated with the pains of surgery, dentistry, and
obstetrics, though some later applications to the treatment of chronic
pain may be addressed. Of course, there could be two other tracks, one
dealing with stories associated with the histories of opium and its
compounds, such as laudanum and paregoric, of aspirin and other pain
medicines; and a third track would be the stories of recreational drug
use, using various substances for intoxication and
release—including cannabis, alcohol, and a variety of other
recreational drugs. Of course, there is some overlap, but I'll try to
stay with the subject. Also, the focus is mainly on developments in the
19th century, and though I touch lightly on further developments in the
20th century, I make no claim to offering a thorough treatment, because
ther are so many and their histories are complicated by the
inter-disciplinary complexity of fields that characterize our own
increasingly postmodern world.
The Need for Anesthesia
Many efforts at alleviating pain and discomfort have been a part of
humanity's story since the beginning, and to this end our better-known
responses have been the use of alcoholic beverages and the leaves and
flowers of the cannabis plant (i.e., marijuana). (The psychedelic drugs
derived from plants were strong enough so that where and when they were
used, such substances, such as the peyote cactus buds, generally were
ingested as part of a cultural ritual, a spiritual container of the
visions that would ensue. Such substances were not at all used as
anesthetics.) There were other herbs that were used that might add to a
person's sense of drowsiness, but when the issue was not just pain but
the acute pain of surgery, these anodynes would not suffice.
The pain of surgery was torture! Celsus, a Roman physician, wrote around 100 AD:
"Now a surgeon should be youthful or at any rate
nearer youth than age; with a strong and steady hand which never
trembles, and ready use the left hand as well as the right; with vision
sharp and clear, spirit undaunted; filled with pity, so that he wishes
to cure his patient, yet is not moved by his cries, to go too fast, or
cut less than necessary; but he does everything just as if the cries of
pain cause him no emotion."
Indeed, the necessary brutality of the process---and it also extended
to those who extracted teeth---made this activity less attractive, drew
significantly less status, than the more quiet and dignified work
of the physician. Surgeons were at or below the level of the
apothecary---indeed, they as a profession had only begun to emerge from
the even lower-status "barber-surgeon." But the sciences of anatomy and
pathology, described in previous lectures, as they emerged into
culture, raised the status of the surgeon somewhat. Indeed, when
anesthesia brought quiet instead of screams into the operating theatre,
and antisepsis and then asepsis brought a measure of ritual to the
process, surgeons actually transformed into having more status in the
early 20th century than non-specialist "family practice" doctors!
Another quote, from the satirical play by George Bernard Shaw,
The Doctors' Dilemma, in which a composite successful old codger, Sir Patrick, reminisces:
"He's a clever operator, is Walplole, though he's only one of your chloroform surgeons." [
Walpole
is a young and perhaps overly-self-confident young man whose mission is
to remove some organ--the "nuciform sac"-- that in actually---not in
the play---doesn't exist.] Sir Patrick contines: "In my early days,
you made your man drunk; and the porters and students held him down;
and you had to set your teeth and finish the job fast. Nowadays you
work at your ease; and the pain doesn't come until afterwards, when
you've taken your cheque and rolled up your bag and left the house. I
tell you, Colly, chloroform has done a lot of mischeif. It's enabled
every fool to be a surgeon."
In many surgeries, several burly men were needed to hold down patients
and surgeons had to make themselves numb to patients’ pleas for mercy,
coping by seeking to work as rapidly as possible. Alcohol and opium
were used at times, as well as mandragora and some other herbs, which
worked a little, but not terribly well. In large doses they also had
secondary problems and might make the patient throw up and if
sufficiently sedated, possibly inhale some of the vomit, causing a kind
of pneumonia called aspiration pneumonitis. Ether had that problem too
at heavy doses.
Another approach to anaesthsia was what later came to be called
hypnosis, earlier called “animal magnetism” by Anton Mesmer in the late
18th century; but "mesmerism" weas not found to be terribly valid.
Nevertheless, there were a few physicians who found that it worked with
some of their patients in surgery—one fellow,
James Esdaile, used it successfully in India in the 1830s -- but it didn’t work for him in the less suggestible Scotland when he returned to the British Isles.
The Invention of Ether
The small organic molecule of ether was first created in 1275 by
Spanish chemist Raymundus Lullius (shown on the left), as a product of
the action of sulfuric acid on alcohol. (Back then sulfuric acid was
called vitriol—some of you have heard the word “vitriolic” to describe
a very harsh, acidic manner of speaking or a political diatribe.)
Re-distilling the product of vitriol and alcohol generated what Lullius
called "sweet vitriol." Yet no mention was made of its
psychotropic qualities or anesthetic potential.
History is full of this, precursors, someone working with some aspect
of the problem. To say again, though, it’s not really an invention
until—what? When it’s recognized and put to use? Like the joke that the
fellow who invented the wheel was clever, but the guy who invented the
other three and attached them to a wagon—he was a genius! Or
should the credit go to the guy who invented the wheel? Well, we’ll go
into that story later.
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So ether was noted if one read carefully in the literature again in
1540, its synthesis being described by German scientist Valerius Cordus
(shown at the right); and at about the same time, Swiss physician and
alchemist Paracelsus commented briefly on the hypnotic effects of
ether. Later, in 1730, German scientist W.G. Frobenius changed the name
of sweet vitriol to “ether.” And thus it remained until the early 1800s
when gradually people realized that the vapors could generate a
pleasant “high” as a recreational drug. But application as an
anesthetic awaited four more decades.
The Invention of Nitrous Oxide
Now let’s turn to another anesthetic, nitrous oxide, laughing gas. This
simple chemical was first manufactured in 1772 by Joseph Priestly in
England. Priestly was a pioneer of chemistry—drawing away from the less
scientific alchemy a century earlier—and he also discovered the gases
nitrogen and oxygen, though he didn’t really appreciate the
significance of this latter discovery.
A slight digression: Burning and respiration were explained as an
action of phlogiston—which, though never detected, was assumed to be
there. Nowadays we assume several things like this—dark matter and dark
energy, which are said by astronomers to make up 93% of the stuff of
the universe; strings which are unimaginably small but their
configurations in 10 or 11 dimensional space account for the various
sub-atomic particles. Sometimes stuff is theorized and then later the
underlying theory is replaced by another one.
In this case, three years later, the great French chemist Anton
Lavoisier, in 1775, isolated and defined oxygen and re-conceptualized
the nature of oxidation and oxygenation or respiration in living
beings. Lavoisier also described the nature of an acid and the way in
respiration Oxygen was exchanged for carbon dioxide.
The idea that gases might have therapeutic possibilities became
fashionable. A pneumatic medicine institute was started in a spa south
of London.
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Humphrey Davy
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Thomas Beddoes
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In 1799 Humphrey Davy discovered anesthetic properties of
nitrous oxide (N
20)---also
known as "laughing gas." He had recently joined Thomas Beddoes’
Pneumatic Institution (established 1798) for treatment of disease by
inhalation. Beddoes (1760-1808) had picked up on the idea that
inhalation of the different kinds of gasses that were being created
might have a wide variety of therapeutic applications. (A recent
example of a similar fashion was the use of bottles of oxygen that were
fashionable in I think the 1990s at some Japanese and European
bars for refreshment.) Beddoes was an interesting and multi-faceted
character. Because his sympathy for the French revolution made him
politically unappreciated in certain cirlces, it was expedient that he
resign from his faculty position at Oxford even though his classes were
among the most popular.
Davy himself was an
exuberant young man who later looked back on this phase of his life
with a bit of chagrin; he became a noted scientist who discovered the
elments potassium and sodium, invented a miner's lamp, and so forth.
Around 1799, though he first experimented with nitrous oxide on
animals, then himself, and was most taken with the experience, writing
about it with enthusiasm.
There ensued in America and England a bit of a fashion, the idea of enjoying intoxication
with nitrous oxide or ether. In the cartoon to the right, the
caricaturist Gillray shows a demonstration, dated around 1802,
featuring probably Davy as an assistant. The cartoonist is stretching
the truth to weave in a bit of broad humor: Breathing a gas may make
you high, but it won’t make you fart. Still, it was a topic for satire.
Anyway, people enjoyed getting high, as seen below in another 1808 cartoon of a nitrous oxide gathering:
A wide variety of reactions would come with the breathing of laughing
gas---a suffusion of insight, occasional grandiosity, sometimes
belligerence, quasi-mystical experiences, but the problem is that
attempts to write down these experienced insights didn't work: the idea
or feeling slips away like a dream
The point to make here is that the two gasses that were to become
important anesthetic were first viewed as merely recreational in
nature, and in some places made illegal, the way marijuana or MDMA
("Ecstasy") has been more recently treated.
Here are some other pictures of ether parties in the 1830s:
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In the 1820s, a newspaper suggested a way to have one's wife become more tractable and mellow.
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Let's get stoned: Young men trying ether in the 1830s.
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But it hadn't yet mad inroads to the medical profession. Rather, there
was a pride in operating quickly. For example, Robert Liston in London
was a “hot shot” surgeon who was strong and well practiced, and enjoyed
high status because of his skill. He could be charitable and kind to
the poor, or gentle in the sick-room, but tended to be contentious with
peers. A number of anecdotes attend the rapidity of his surgeries—we’re
talking about finishing the main part of a procedure in less than 2
minutes!
The Discoverer(s) of Anesthesia.
Four professionals later claimed to have been the main one who
discovered anesthesia! Their fight went all the way to Washington DC
and to the French Academy, and various public figures and later
historians tended to support this or that figute.
The first one---who, alas, held back his publication until later!---was
Crawford Williamson Long (1815-1878), an established small-town
(Danielsville) Georgia physician who
claimed to have used ether for surgery in 1842. He had
apprentices---four young gentlemen---Long being around 29 and they
around 20. As was common, all held occasional nitrous oxide parties,
and one time they had run out of nitrous and Long reminded them that
ether might also serve as an intoxicant. This led to his noticing that
high spirits during such frolics might result in injury without the
person seeming to feel pain. So finally he tried it on a patient, and
then several.
His later excuse was that he felt that he needed more of a peer-group
consensus and felt intimidated by his small-town status. After
anesthesia was publicized, he made his claim that he had tried if four
years earlier.
The next candidate was Horace Wells (1815-1848) . He was also a
young man who had contact and dealings with the next two people
to be mentioned. He was a dentist who, at an exhibition of the use of
nitrous oxide, also witnessed analgesia under the influence.
Wells went
home and tried it on himself: he had an impacted molar and asked a colleague to extract it, Wells first having inhaled
deeply of nitrous oxide. This was successful, so he tried it first on a
patient, then several more. Emboldened, he spoke to Jackson, who
pooh-poohed the idea, but nevertheless proposed to the nearby medical
school that this substance could be a possible anesthetic.
The appointment was set up in 1844, the experiment engaged, but nitrous
is too short-acting, and one must also inhale it for quite a while.
Even then, possibly breaths need to be taken fairly frequently to
maintain analgesia---it wears of fairly rapidly, too. For whatever
reason, this demonstration failed: The patient groaned and grimaced as
the surgery neared completiong, and the observers jeered. Wells was
humiliated and left. What was more galling is that Wells thereupon
obtained a great deal of documentation that his approach worked---he
used nitrous oxide with many patients who were profoundly grateful. But
the opportunity to demonstrate the potential for anesthetic passed to
another--William Thomas Green Morton (1819-1868):
Morton was another dentist---and a one-time partner with Wells!---also
living in the greater Boston region. He had studied with a man named
Charles Jackson (about whom we'll hear more) and who suggested that
Morton try using ether.
Morton tried this on some animals and finally approached the cheif
surgeon at the Massachussets General Hospital where earlier Wells had
failed. On October 16, 1846 the demonstration again was held---Morton
actually came in late, delayed by last-minute adjustments to the ether
inhaler in the picture to the right:
The scene that ensued has been painted and shown by a number of artists:
The same surgeon who had given Wells a chance finally was able to
operate without a screaming patient. At the end, Dr. Warren said,
"Gentlemen, this is no humbug." Many who witnessed it said that they
were profoundly moved!
The third fellow, Charles T. Jackson, is an interesting character, a man
not afraid of claiming to have influenced matters—he claimed to have
given the idea of morse code to Morse of the telegraph fame. In this
case, he may have been somewhat active in suggesting to both
Wells and Morton the potential for anesthesia in these gases—Jackson
was in a role to do this; and he claimed to have done it; but didn’t
demonstrate it or write it up early. Historians are mixed about his
priority. A few give him credit, others consider him a scoundrel and
probable a bit of a sociopath
The fourth man is Thomas Morton, who has been given the main credit by
many medical historians because he stuck with it and demonstrated the
effectiveness of ether—that was what he used—at the Massachusetts
Hospital— and the one who brings the method to the public gets the real
credit. But there are several catches and circumstances.
Oliver Wendell Holmes, Senior—the pioneer against unwashed hands in the prevention of childbed fever mentioned in the
second lecture—also
lived in Boston area, heard about the demonstration, and wrote Morton,
commending him and suggesting the use of the term “anesthesia.”
Subsequently, all four of them or their surviving family members and
associates battled in congress and up to the Supreme Court as to who
deserves official recogniton! Wells appealed to the French
Academy. Money was a hoped-for side benefit, the claimants
wishing they could get something additional along with that recogniton.
It went on for years and various notables took sides.
A few side issues: Morton was not entirely forthcoming about the
formula: He had added a bit of artificial fragrance to a fairly widely
known and common substance, and re-named it Letheon. He hoped to patent
it and profit from it, but the chief of the hospital held out until he
admitted it was simple ether. Now there’s another historical note here:
Ever since there was a bit of a scandal about some docs in the previous
century who kept back as a secret gimmick only they could use—the word
for that is “proprietary”— the use of a more effective design for
obstetrical forceps—which could have saved thousands of lives—the ethos
was reinforced that this kind of patenting of what everyone should be
able to use is unethical.
At any rate, this indeed was a true breakthrough of the first order,
and it rightly swept the civilized world within a year or two. In
contrast to the slower and more contested growth ofvaccination or germ
theory, I guess the squeeky –or perhaps, a more appropriate word is
screaming—wheel gets the grease. Nevertheless there was wariness among
medical men and clergy, some of whom thought that pain was good, right,
just, natural, and should not be interfered with.
So, then, who is to get the credit?
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C. Long
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H. Wells
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Wm T. Morton
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Chas T. Jackson
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It's really a rather sad story. Wells sought justification, but
interestingly, a few years later, discovered chloroform, which is a
rather seductive substance, and became habituated. He went downhill,
also using alcohol, and finlly killed himself in jail! Morton and
Jackson also struggled and also had unhappy ends. Long died of
natural causes.
England and James Simpson
Within a year people had been incorporating ether into their surgical
practice in England and Western Europe. The aforementioned Robert
Liston had amputated a leg with the patient anesthetized and announced,
"This Yankee dodge, gentlemen, beats Mesmerism hollow!"
In January, 1847, James Young Simpson (1811-1870) used ether as
an aid to reduce pain in a difficult childbirth in Edinburgh, Scotland,
which, at the time, had one of the top medical schools in the world.
Ether, however, was by no means an ideal anesthetic. It tended to make
people cough, could feel stifling and generate struggling in those who
didn't trust the method, and sometimes made people throw up. It took a
while to get them to sleep and smelled funny. It wasn't easy to use.
Therefore, Simpson undertook to explore the range of other possible
anesthetic agents. Finally he came upon chloroform, which he tried a
few times not only on himself, but also on some friends.
He hit upon chloroform, which knocked him out, made his friends act
weird, but it was a pleasant type of unconsciousness and it smelled
better than ether.
Simpson tried it on some patients and then on some obstetric patients.
It became accepted in many circles because Simpson was associated with
high status faculty and there didn't seem to be much problem. Again
clergy and some doctors objected, but Simpson responded with reason and
good arguments.
The use of chloroform became even more mainstream when Queen Victoria
used it in 1853 to help with the birth of her son Leopold. John Snow
(1813-1858) had become better known for his work on a cholera
epidemic---we'll talk about that more in the
last lecture. Her Majesty recorded in her journal, "The effect was soothing, quieting & delightful beyond measure."
Even some doctors objected, such as the old codger described jokingly
in Bernard Shaw’s “The Doctors’ Dilemma,” noting the old days when you
had to be fast, and now with chloroform anyone can do it and take their
time.
An interesting thing about chloroform, though: It is good, but not as
safe as some originally thought. If there’s any adrenaline in the
system, people tend to get cardiac arrest and die. Also, there are
occasional late complications of severe and fatal toxicity to the
liver, which leads to a distinctly uncomfortable death. Happens a bit
more in kids.
It took 30 years to really run the numbers but it became ever-more
clear that ether was safer, with something like 3 per 1000 occasions of
mortality versus 14 or so for chloroform.
Technological Developments
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Codman ether inhaler
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Codman nitrous oxide inhaler
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Ormsby Inhaler
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Allis Inhaler 1880s
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Drip inhaler
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Junker's inhaler
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In the wake of the new technology of the gaseous anesthetics, a variety
of inhalant systems were invented and revised in an attempt to promote
the easiest, smoothest, most comfortable, most convenient, and in other
ways a better way to use these substances.
Some of the questions asked might include the following: What can
ensure adequate air or oxygen supply while breathing nitrous? How about
compressing the gas so that it need not fill large bags? That requires
the building of metal bottles and compressing equipment, and also
valves so all doesn’t go into mouth or lungs and blow them up with
compressed air. (That’s one of the functions of that little side
non-inflatable bag you see.)
Further Developments: Endo-Tracheal Anaesthesia
This is where they put the patient to sleep with an intravenous
anaesthesia, then put in a topical spray on his vocal cords so
they don't go into spasm, and slip a tube down his windpipe a bit.
There's an inflatable cuff so no fluid (saliva, vomit) can get down
into the lungs. It's needed so they can breathe for you.
The first problem was that going into the chest broke a kind of vacuum
that's needed for effective breathing. They needed this technology so
they could "bag" the patient, breathe for him, even if the diaprhagm
muscle can't expand the lungs. This allows the surgeon to operate on
the lungs, esophagus, heart or anything else within the chest cavity.
Another need for this
kind of breathing is that if they do deep abdominal surgery, they
need to counteract the tendency of the abdominal muscles to contract.
It's more than difficult to retract and keep it open with this spasm.
Either they must increase the depth of the anesthesia to dangerous
levels or pharmacologically relax the muscles.
In the 1940s they discovered the active ingredient in South American
Amazon Indian arrow poison: It's Curare. They synthesized it. The only
problem with using this stuff is that you are so relaxed you can't
breathe or swallow---but you're fully awake. So what needs to happen is
to put you out deeply, then relax your muscles, and then time it so
that the relaxant wears off before the anesthesia---which is one reason
why you need a specialist! (I suspect they don't need to do this
with the more recent laparoscopy procedures.)
Topical, Local, and Regional "Block" Anaesthetic
Almost everyone has experienced their dentist putting an injection of
novocaine or something like that into their gum area before working on
a tooth.That process requires a number of developments that emerged in
the mid-late 1800s. First, they needed the invention of the hypodermic
syringe, which with improvement became possible to go intravenously and
even into the spinal canal.
Second, you need a liquid anesthetic to inject. In the early 1800s some
chemists had brought back the leaves of the coca plant from South
America and began to extract and identify the active ingredient that
they named "cocaine." Gradually its properties became a little more
known, and one physician who was especially interested in its
energizing properties was a general practitioner with some background
in neurology, named Sigmund Freud. Age 29, Freud tried drinking a fluid
extract of cocaine and was very pleased---enough to encourage his
fiancee at the time, Martha Bernays, to, well, warm up a bit.
Freud also turned his friends on to cocaine, and was dismayed to
discover that some of them became addicted. This he hadn't anticipated.
Indeed, for a while cocaine was actually used as a treatment for
morphine addiction, which had become not uncommon by that time in
Europe and America.
Freud shared his enthusiasm for the potential of this new medicine with
a friend, the eminent (in Vienna, anyway) ophthalmologist, Carl Koller.
Dr. Koller also noticed the way cocaine numbs the skin and mucous
membranes, and from there Koller experimented and found cocaine to be a
good local anesthetic for the eyes. Others discovered that it was also
good for surgery or other procedures on the nose, inserting catheters
into the urethra, and other procedures for which a topical anesthetic
is indicated.
In the United States, the idea of local anesthesia appealed to
up-and-coming surgeon William Stewart Halstead (1852-1922) who also
experimented on himself and with some friends and found that it could
work. Alas, he also became addicted!
Hypodermic needles had been invented in the 1850s and improved
thereafter. Halstead tried not only topical anesthesia, but putting
this numbing agent around nerves, and found again that it worked in
depth. He is the pioneer then of what is called “conduction” anesthesia.
An interesting side problem: It turned out cocaine was addictive, and a
few years later, Halstead went into a hospital and was treated with
morphine to counter the withdrawal symptoms from cocaine, whereupon he
became addicted to morphine instead of cocaine, and in spirt of a few
efforts to conquer this addiction, relapsed several times. An
interesting point is that except for Halstead not being terribly
social, he was for the most part able to function, be maintained on his
morphine, and adjusted to that maintenance dose, was quite alert—enough
to function as perhaps the most outstanding surgeon in the United
States at the time! This went on for at least a decade or
more! This story has implications for our views of
what are the necessary consequences of addiction and how much is due
not to the substance or addiction so much as the illegality of the
whole process, and when is something to be called a disease?
Back to anesthesia: So now we have two types of anesthesia, inhalation
of certain gases and hypodermic. A third route, intravenous, came with
the continuing development of better needles, finer and more flexible,
less likely to break off— and also the invention of the chemical,
barbituate, and its derivatives. Old phenobarbital was developed in the
early 1900s, but it was too long-lasting. Around 1915 someone invented
some shorter-acting meds.
Another thing about cocaine and morphine, for your interest. They had
invented another type of opiate that would be helpful in countering
morphine addiction: In 1895 Heinrich Dreser working for The Bayer
Company of Elberfeld, Germany, finds that diluting morphine with
acetyls produces a drug without the common morphine side effects. Bayer
begins production of diacetylmorphine and coins the name "heroin." In
1898 the Bayer Company introduced heroin as a substitute for morphine.
In the early 1900's the philanthropic Saint James Society in the U.S.
mounts a campaign to supply free samples of heroin through the mail to
morphine addicts who are trying give up their habits. In 1902 in
various medical journals, physicians discuss the side effects of using
heroin as a morphine step-down cure. However, several physicians would
argue that their patients suffered from heroin withdrawal symptoms
equal to morphine addiction! And by 1903 heroin addiction rises to
alarming rates. (Interestingly, around 1946 Demerol
(meperidine or pethidine) was introduced with a similar claim of being
less addicting, but by the 1980s it became clear that this medicine was
no better than morphine in its effectiveness and no better than
morphine also in its addictive potential— and in some ways worse in its
side-effect profile.
Summary
For a while several served mainly as recreational drugs—which leads me
to state right now that there are several drugs developed more in the
last fifty years that have been made almost impossible to explore
regarding serious medical applications, psychiatric applications—LSD
being one, MDMA also known as ecstasy another—although they may offer
correspondingly significant benefits. So what is considered
recreational and naughty and worthy of suppression may need to be
re-thought—that’s one of the first morals to this story.
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