The first to use surgical anesthesia was not a dentist, but the physician Crawford Williamson Long

Abstracts

JUSTIFICATIVA E OBJETIVOS: A história da descoberta da anestesia continua incompletamente esclarecida em vários de seus aspectos. Mas é fácil definir que Crawford Williamson Long foi o primeiro a utilizar o éter sulfúrico para operar vários pacientes, sem dor, e realizar analgesias obstétricas. A história é uma ponte que liga o passado ao presente e deve ser estudada e entendida desde os seus primeiros pilares. Assim, justifica-se lembrar ou dar a conhecer quem foi Long, um nome certamente pouco conhecido entre nós, e qual a participação dele na descoberta da anestesia. CONTEÚDO: São discorridos porque e como Crawford Williamson Long foi levado a se tornar o primeiro médico a operar sem dor, quatro anos e meio antes de Morton, e o papel que desempenhou numa das maiores descobertas da Medicina. A biografia de Long é narrada, ressaltando-se o seu caráter, a competência, a dedicação, a modéstia, o desprendimento e um certo desapego com relação à conquista da glória. Descrevem-se as circunstâncias que o levaram a não divulgar de imediato sua descoberta. É analisado o envolvimento de Long na discussão pela primazia da descoberta da anestesia e relatado o seu falecimento. As numerosas homenagens recebidas por Long nos EUA e em outros países são citadas. CONCLUSÕES: W. T. G. Morton costuma ser considerado como o autor da descoberta da anestesia geral, sobretudo por ter sido o primeiro a fazer demonstração pública bem-sucedida, em importante hospital de Boston (EUA). Contudo, provou-se que Long foi o primeiro a utilizar a anestesia cirúrgica e é reconhecido em várias regiões de seu país como o pai da anestesia cirúrgica e "o seu descobridor". É necessário, ainda, reverter o fato de ser Long pouco conhecido entre nós e inseri-lo no lugar a que tem direito na história da anestesia geral.

ANESTESIA, Geral; ANESTESIOLOGIA

MISCELLANEOUS

The first to use surgical anesthesia was not a dentist, but the physician Crawford Williamson Long^*

El primero en utilizar la anestesia en cirugía no fue un dentista, fue el médico Crawford Williamson Long

Almiro dos Reis Júnior, TSA

Anestesiologista do Serviço Médico de Anestesia (SMA) de São Paulo, Hospital Alemão Oswaldo Cruz, São Paulo, SP

^{Correspondence to}

SUMMARY

BACKGROUND AND OBJECTIVES: The history of the discovery of anesthesia is not totally explained, but it is easy to establish that Crawford Williamson Long was the first to use sulfuric ether to operate several patients with no pain and to perform obstetric procedures. History is a bridge connecting the past to the present and should be studied and understood from its first pillars. So, it is justifiable to recall or get to know who was Long, certainly a name almost unknown for many of us, and which has been his participation in the discovery of anesthesia.

CONTENTS: Why and how Crawford Williamson Long became the first physician to operate with no pain four and a half years before Morton are discussed, in addition to the role he played in one of the major Medical discoveries. Long's biography is narrated, stressing his character, competence, dedication, modesty, altruism and a certain unconcern with conquests and glories. Circumstances leading him not to immediately publicize his discovery are described. Long's involvement in the discussion about the discoverer of anesthesia is analyzed and his passing away is reported. Finally, numerous honors to Long by the USA and other countries are described.

CONCLUSIONS: W.T.G. Morton is often considered the discoverer of general anesthesia, especially for being the first to make a successful public demonstration in a major hospital in Boston (USA). However, it has been proven that Long has been the first to use surgical anesthesia and he is acknowledged in several regions of his country as the father of surgical anesthesia and "its discoverer". It is also necessary to revert the fact that Long is almost unknown among us and give him the place he is entitled to in the history of general anesthesia.

Key Words: ANESTHESIA, General: inhalational; ANESTHESIOLOGY: history.

RESUMEN

JUSTIFICATIVA Y OBJETIVOS: La historia del descubrimiento de la anestesia continúa sin ser completamente aclarada en varios de sus aspectos. Pero es fácil definir que Crawford Williamson Long fue el primero a utilizar el éter sulfúrico para operar varios pacientes, sin dolor, y realizar analgesias obstétricas. La historia es un puente que conecta el pasado al presente y que debe ser estudiada y entendida desde sus orígenes. Así se justifica recordar o dar a conocer quien fue Long, un nombre seguramente poco conocido entre nosotros, y cual fue su participación en el descubrimiento de la anestesia.

CONTENIDO: El texto nos cuenta lo que llevó Crawford Williamson Long a convertirse en el primer médico a operar sin dolor cuatro años y medio antes de Morton, por qué y cómo eso se dio, y el papel que desempeñó en uno de los más grandes descubrimientos de la Medicina. La biografía de Long se narra, resaltando su carácter, la competencia, la dedicación, la modestia, el desprendimiento y un cierto desapego con relación a la conquista de la gloria. Las circunstancias que lo llevaron a no divulgar inmediatamente su hallazgo se describen. Analizamos su involucración en la discusión por la primacía del descubrimiento de la anestesia y su fallecimiento. Finalmente, los numerosos homenajes recibidos por Long en los EUA y en otros países.

CONCLUSIONES: W. T. G. Morton es generalmente considerado como el autor del descubrimiento de la anestesia general, principalmente por haber sido el primero a hacer una exitosa demostración pública, en un importante hospital de Boston (EUA). Pero quedó probado que Long fue el primero a utilizar la anestesia quirúrgica y que es reconocido en varias regiones de su país como el padre de la anestesia quirúrgica y "su descubridor". Es necesario, incluso, revertir el hecho de ser Long poco conocido entre nosotros e insertarlo en el lugar a que tiene derecho en la historia de la anestesia general.

INTRODUCTION

Before the discovery of general anesthesia, almost fifty years before loco-regional anesthesia, surgery could seldom be used in minor superficial procedures or limb amputation. Patients were literally restrained and suffering was overwhelming. Surgical rapidity was essential. There was virtually no hope to change such situation. Velpeau used to say: "Excluding pain from surgeries is a chimera which today is no longer possible to pursue". This has dramatically changed as from October 16, 1846, when the world heard about the possibility of operating with no pain. In that date, William Thomas Green Morton, young medical student of the Harvard University and dentist, has publicly shown and in important medical environment, the use, although extremely precarious, of general anesthesia for surgery using sulfuric ether fumes ^1-3.

News has first reached England, followed by France and then the remaining European countries. In Brazil, the first anesthesia was accomphished by Dr. Roberto Jorge Haddock Lobo, born in Portugal, in a student of the School of Medicine, Francisco d'Assis Paes Leme, Rio de Janeiro, for experimental purposes only, on May 20, 1847 ⁴. Morton then started to be considered among us and in many countries as the author of this change and the discoverer of anesthesia ^1,2, word proposed although not created by Oliver Wendell Holmes, professor of the Harvard School of Medicine, in a letter sent to Morton some days after his first anesthesia ^2-5, which was consolidated and adopted as from that period ^6,7.

However, four and a half years before Morton's breakthrough, a young man from the Southern USA, Crawford Williamson Long (Figure 1), became the first physician to operate with no pain, performing minor surgical and obstetric procedures under anesthesia.

WHO WAS CRAWFORD WILLIAMSON LONG?

Crawfdord W Long was born on November 1, 1815 in Danielsville, Georgia. He was son of James Long e Elizabeth Ware Long ^8-14. His father was a wealthy business leader, active in politics, advocate of progress and intelectual ¹⁰. Long graduated from Franklin College, today University of Georgia, in Athens, at 14 years of age ^13-15. He was part of a class that would be one of the most famous in the American students' history; from there, imminent scientists, generals, senators, secretary of the Treasury and governor have also graduated ⁸. He started to study medicine in 1836, in Lexington, Kentucky and by decision of his father graduated in 1839 from the University of Pennsylvania, Philadelphia, one of the most famous North American medical schools ^8,10,14,15. He was a trainee for 18 months in New York medical centers ^10,11,13 and was invited to become physician of the Marine, which he has not accepted.

Education was important for Long's professional future and he could practice Medicine anywhere; however, some reasons made him choose Jefferson, city with better development opportunities than his home town: filial duties, his bindings to his state, the opportunity to take over the good clinic of Dr. George R. Grant who was moving to Tennessee, and probably Caroline, whom he knew since 14 years of age ¹³. So, in 1841, at 26 years of age, he returned to Georgia and started to practice Clinic, Surgery and Pharmacy in the small Jefferson (500 inhabitants), Jackson County (8500 inhabitants), to the Northeast of Atlanta, 220 km away from the closest railroad, where he acquired many clients ^11-13.

Jefferson, an agricultural region with lots of water and fertile land primarily cultivating cotton, could then count on three physicians ¹³. C.W. Long, tall, blue eyes, gentleman, educated, interested in the English language, dedicated to Medicine, imposing personality, honored, elegant, slim and always well dressed, made many friends and soon became the commander of the male youth and the idol of young ladies of the town ^2,10,14. He married Mary Caroline Swain on August 11, 1842, in Jackson's Methodist church ¹³. Long was so busy that he was late for his own marriage, after which he returned to see his patient and has only re-encountered his wife the next day ⁸; they were married for 36 years and had 12 children, of whom only six have survived their parents ¹³. Notwithstanding being always busy, Long would find time to write articles for the Athens newspaper, always with a certain humor and under a pseudonym ¹⁴.

THE IDEA OF USING SULFURIC ETHER FOR SURGICAL ANESTHESIA

In the early 19^th century, traveling speakers would cross the USA earning money with demonstrations with nitrous oxide, discovered by Priestley ^2,6,10,16, or laughing gas, name created by Humphry Davy ⁸ who, by the way, since 1800 knew very well that such gas could be used for surgical procedures. In the winter of 1841, such demonstrations, known in the USA as laughing gas parties or gas frolics, arrived in Jefferson and caused great excitement ^2,14. Ravished adults and children attended the session.

Immediately after the conference, Long's friends, impressed with what they had seen, went to his place and waited for his return in the hope that, being a physician, he would be able to explain what they had observed. When Long arrived, late at night, his excited friends took him to the living room and stunned him with questions about what they had watched. He listened to them silently and promised to study the subject in his medical library; however, he returned to the room soon after and applied to the nose of each person a handkerchief soaked with sulfuric ether. Reactions were not understood by them; they laughed, sang, moved, talked nonsense and discussed among themselves. Long just smiled.

When the effect of drunkenness was gone, Long, who since his times of student knew the effects of the drug, since during his medical studies he had watched several demos on nitrous oxide and sulfuric ether fumes effects performed by Chemistry and Physics professors with the students, told them: "What a stranger can do a Jefferson physician can also do" ². The scene had major repercussions on the audience, who made him repeat it the following evenings. Winter meetings of the elegant youth of Jefferson at Dr. Long's to talk about literature, play chess or discuss serious subjects, were replaced by ether parties.

Such meetings have grown so much that started to call the attention of local young ladies who one day invaded his office and begged to watch one of those famous meetings; the group was led by a 16-year old girl, considered the most beautiful, Mary Caroline Swain, niece of a former North Carolina governor and his future wife ^2,13. Long, who knew her superficially, was enchanted by the lady and looking at her begging eyes has agreed to prepare an ether party within two days.

Noticing that his ether stock was ending, Long got in touch with his friend Robert G. Goodman, pharmacist in Jefferson and later in Athens, and asked him some bottles of the volatile fluid: "Dear Bob, today I have a minor favor to ask you. I no longer have ether here and would like to have it for tomorrow evening, if it were possible to receive it on time. Some Jefferson girls want to test its effects" ². The next day Long, anticipating the results of his refusal and listening to the insistence of the ladies said: "Well, I shall now inhale the gas to give you pleasure, but you have to promise that you will not be angry with me, whatever it may happen ². The ladies, of course, agreed. Long closed the door to be isolated from his sisters who were Quakers and did not approve such behavior.

Soon after soaking the handkerchief and placing it under the nose, he started walking around and kissing all the ladies. After Long's recovery, the ladies made a queue and started to inhale ether vapors, one after the other. The meeting was a success and triggered Jefferson's ether parties ².

What should be only fun, was for Long a reason for major observations. He described: "I have inhaled ether many times due to its inebriating properties and have observed in my body purple contusions and ecchymosis, caused by involuntary falls during drug inhalation and I have noticed that my friends would thrash about so strongly that they should feel some pain, but when asked they answered that they had felt nothing" ^2,14,17,18.

So, he has imagined that ether fumes inhalation during surgical procedures could lead to similar results, but he lacked the confirmation of his idea, which would come soon ^2,18,19. In fact, before Long, many investigators had observed the anesthetic action of this drug, such as Paracelsus von Hokenhein (1540), Faraday (1818), Goodman (1833), Jackson (1833), Wood and Bache (1834), and others, but incredibly, they did nothing for decades to free mankind from surgical pain and continued to use mesmerism and other palliative means such as hemp plant, alcohol, mandrake, whisky, etc. ^3,6,20,21.

THE FIRST SURGICAL GENERAL ANESTHESIA

It was in Jefferson on March 30, 1842 ^{1,2,12,15-18,22}. James M. Venable, student and Long's friend, suffered from two small tumors on the posterior neck (infected sebaceous cysts) but was scared of the pain he would feel to remove them surgically. Long wrote: "I told him in details that I had had contusions while under the effects of ether without feeling pain, that I was used to inhale the drug and that I would suggest to him the possibility of a painless surgery" ^1,2,15,17,19. After an initial refusal, Venable accepted Long's proposal to extract such tumors with no pain whatsoever.

He was placed in the sitting position (Figure 2), surrounded by some ether-parties participants. Long placed a handkerchief soaked with ether on the nose and mouth of the patient and monitored the pulse with one hand while he administered the anesthetic with the other ¹². Venable went calmly into sleep, at least as reported. Long confirmed skin insensitivity with a needle and then rapidly removed one tumor placing a dressing on the site. He removed the handkerchief and slowly Venable recovered total consciousness and could not believe the fact until he saw the tumor ^11,14,19.

This was the theater of the first known painless surgical procedure, witnessed by at least three people, namely: Andrew Thurmond, William Thurmond and Edmund Rawls. This way, the office of a young physician in the small city of Jefferson was the place where the "major American contribution to medical science" took place ^{1,2,9,12,14,19,23}. Two months later Long removed the second tumor ^1,12,17,19. He charged two dollars for each procedures plus 25 cents for the ether, manipulated by Powers and Weightman and supplied by Reese and Ware's pharmacy, in Athens ^14,23,24.

But, incredibly enough, Long was in doubt; should he attribute anesthesia to ether or to mesmerian forces he had? A new opportunity appeared in July when the son of a slave needed to amputate two toes of one foot, seemingly due to burn ^1,2,14,18. The boy agreed in being submitted to anesthesia. Long put him to sleep and amputated one toe with no patient reaction. Incredibly as it may seem, to prove the action of ether he amputated the second toe without anesthesia. This time the boy has desperately shouted and thrashed about so violently that Long was forced to restrain him to finish the procedure; only then he was convinced that ether was responsible for the lack of sensitivity and not the mesmerian forces he thought he had ^2,14,17. But he did not believe that insensitivity would be long lasting because he wrote: "the result of my experiences made me think that ether action duration was so short that could not be maintained unless the patient inhaled it throughout the procedure" ^2,11,14,17. "His conclusion was right, but lacked the sound faith that by itself transforms observation, knowledge and proof into discovery. He never had the guts to perform such an important experience" ².

Long has operated six ¹ or eight ^2,3,8 patients under ether anesthetic action. The discovery of anesthesia, as many others, is considered by many as one more example of serendipity, that is, unexpected fact, good luck, accurate observation spirit, in addition to knowledge and skills to understand the fact and establish consistent deductions ²⁵. Those who had no opportunity to study in depth Long's role in the discovery of anesthesia think that this was totally accidental or totally or partially derived from social experiences with nitrous oxide or sulfuric ether; however it has been a lot more than this ¹⁰.

WHY DID LONG STOPPED OPERATING WITH NO PAIN?

As it happened with other science pioneers, Long suffered the interference of radical religious and narrow-minded people. Jefferson inhabitants began attacking him and spreading that sooner or later he would kill a patient and should be prohibited of going ahead with his novelty to prevent disgraces. Long made enemies who accused him of having a diabolic drug to insensibilize patients and able to affect their mental power. The whole population started to fear sulfuric ether and Dr. Long himself, which made difficult to him to continue with his anesthetic experience. One day, a committee entered his office asking him to interrupt his audacious practices; the tone of the speech indicated that they liked him very much, but if someone were victim of sulfuric ether, no one would be able to prevent his lynching ^2,13.

It is classic that numerous spectacular scientific discoveries, even those bringing huge progresses to mankind, were almost always followed by absurd reactions from people and even from conservative segments of society. This was also true in Jefferson. Long stopped using ether in his clinic and restarted to operate his patients in the old way, causing them tremendous suffering. From then on, he recovered the trust and esteem of his co-citizens. But Long still believed in the importance of anesthesia and administered ether to his wife during the birth of his second child in 1845 and other subsequent deliveries, thus undoubtedly becoming the pioneer of obstetric analgesia ^8,11.

WHY HAS LONG NOT DISCLOSED HIS DISCOVERY TO MEDICAL CIRCLES

Although disclosing the discovery of anesthesia to Jefferson, Athens and surroundings, and although not hiding it ²², Long has never made anything to make universally known the extraordinary, revolutionary and successful idea of painless surgical procedure, although he was a well trained physician who spoke and wrote very well ^12,23. Not doing so, he deplorably has prevented mankind of the relief of so much suffering for long four and half additional years and if it were not for Wells' attempt and especially the efforts of Jackson and Morton, anesthesia would have possibly died with him ^16,23,24. Long left his explanations recorded ^{1,2,8,12,14,17,19,23,26,27}:

1) Wish that anesthesia would not be mistaken for mesmerism – the major importance of surgical pain relief was not initially obvious to Long who has totally failed in understanding the value of his discovery. On this, many recall that he should have looked for Dr. Paul F. Eve, Professor of Surgery of the Georgia School of Medicine and Editor of the Southern Medical and Surgical Journal, who published an article unmasking and discrediting mesmerism.

2) Fear of being considered charlatan for his revolutionary ideas – the introduction of radically different ideas from those in place is always difficult and in Georgia of that time it was even more difficult. Long knew that if he failed or was considered a charlatan, he certainly would no longer have the positive medical concept and the same comfortable life. In 1912, North-American professor of surgery J. Chalmers Da Costa, wrote: "Morton and Warren informed the world, Long discovered and could have made the world understand its importance if he would have looked for a major medical center as the forum to present his discovery and a for famous surgeon to advocate it". In 1913, the electors of the Pantheon of Fame of the New York University have thoroughly studied the subject and concluded that Long had only published his experience in 1849, being unconceivable, however less probable, that he did not know the importance of the immediate disclosure of the possibility of eliminating surgical pain. In fact, it seems unbelievable that after anesthetizing a second patient and using analgesia in his own wife during the birth of his second child, Long still did not understand the beneficial consequences of his discovery.

3) Duty of having further experience with the method – Long wrote: "The issue was undoubtedly raised because I have not published the results of my ether experiments immediately after they were made. I was anxious to publish, but before it I had to accumulate a number of cases to totally satisfy my concept that anesthesia was produced by ether and not by the effect of my imagination or any other peculiar insusceptibility for pain of people I treated". In this aspect, Long has strictly followed the teachings of Dr. George B. Wood, his professor in the University of Pennsylvania, who condemned premature publications based on observation of isolated cases and with inadequate methods. But, faced to this difficulties, Long should have asked physicians with further surgical practice to perform more serious investigations, even in the less evolved South of the USA from the first half of the 19^th century.

4) Expectation that someone could have used anesthesia before him – this is clearly inferred after reading Long's notes: "I decided to wait some months before publishing a report on my discovery and wait to see whether some surgeon would report having used inhalational sulfuric ether for surgical procedures before me". Long was a good physician, gentle, delicate, distinct, loyal, gentleman, introverted, shy and resisted to impose himself by force. It is clear that he could not believe that a physician from the countryside, moreover from the South, could compete with medical authorities from the whole world or even from the North of the USA. In fact, he was almost pathologically modest, or had no imagination.

5) Need to perform major surgeries under general anesthesia – Long wanted to prove the efficacy of ether in major surgeries, but he knew that this would be impossible in his clinic. He recorded: "After being totally satisfied with the power of ether to induce anesthesia, I wanted to administer it in a difficult surgical procedure which I had never performed. In my practice, before publishing about ether as anesthetic agent, I never had the opportunity of testing it in a major surgery, because my cases were limited to extirpation of small tumors or amputations of fingers or toes".

6) Very busy life – according to Long "I started writing to the Medical Examiner editor to ask that journal to spread the use of sulfuric ether, which, when inhaled, could make surgeries painless and which had already been used by me with that aim for more than four years. I was interrupted when I had written some lines and was could not summarize my publication due to a cumbersome rural practice, when I received the January 1847 edition. A considerable period of time has also elapsed before I could determine the exact period in which my first procedures were performed. Evaluating this fact, and probably due to negligence, I have once more allowed a longer period to go by " So, having been exposed to a predominantly conservative medical environment while studying in Philadelphia and New York, Long should not have been surprised with the initial reaction of a Medical Examiner publication in 1846 by Morton defenders, among them famous physicians H. J. Bigellow and J. C. Warren, from Boston.

HOW BOSTON'S ANESTHETIC EXPERIENCE HAS BECOME KNOWN

In a December 1846 evening, Long found a report on the success of the first painless surgical procedure, described by H. J. Bigelow ^1,2,16,17,24, where he reports that "the preparation used by Morton (Letheon) smells like ether and, we have almost no doubts, is an ethereal solution of some narcotic substance". Morton, helped by Jackson, used a secret product and tried to cheat physicians to patent the "discovery" and transform it in source of money. Long has never though of that or made anything hidden, but rather, as we have already reported, disclosed his discovery among the physicians of Jefferson, Athens and surroundings ^18,22.

There should have been a dialog between him and his wife ²: "Look at this, Caroline, the first! They describe it as a sensational event; a surgery performed last October in the Massachusetts General Hospital which they state having been the first painless procedure! And those performed by me in Jefferson in 1842? Moreover, the medical journal states that the inventor of anesthesia, a Bostonian dentist, tried to hide the name of the anesthetic to use it for patent purposes". Caroline: "You should have published immediately a report on those facts. I told you that". Long: "You know perfectly well how things were by that time. Jefferson people though I was a wizard doctor, what made me almost loose my patients. It was better not to mention the subject. Now someone has left me behind". "How come", asked Caroline, "it is not too late. It is enough for you to write today to the Medical Examiner to tell them that four years ago you performed some painless procedures".

Long started believing that it would be easy to confirm the truth of his primacy with the testimonial of Venable and of other patients and witnesses, with which he had never before been concerned. He thought that if he sent to the journal a statement that he had used ether for surgical procedures it would be easy to prove the primacy of his invention. He tried to be fast and started to gather papers and to write the intended statement. However he was called for a labor in the rural zone of Athens, city where he had moved to, and left the office and the pharmacy full of patients only returning the next morning; the same happened the next day. Due to lack of time, he decided to publish his documents in the next Medical Examiner edition. But before doing so, he received the January 1847 edition of this journal in which Morton, under pressure of the North-American Medical Association, explained that the anesthetic he used was sulfuric ether. With this, Long lost his hopes of defending himself, especially after reading in the next edition of the same journal the announcement that Wells, also a dentist, had also tried to use an inhalational method (nitrous oxide) to insensibilize patients, before Morton.

THE STRIVE FOR ANESTHESIA DISCOVERY PRIMACY

In 1847, the competition for the primacy of the discovery of anesthesia, especially among Horace Wells, Charles Thomas Jackson and William Thomas Green Morton, became so fierce that the American Congress decided to arbitrate the issue, known as "the ether controversy" ⁸.

For years, Jackson was violently disputing the primacy of the discovery of inhalational anesthesia with Morton, trying to obtain the glory for him, or at least, for both. It is known that Morton has initially denied, but then confirmed that he did not know sulfuric ether and that he had used it exclusively by suggestion of Jackson, internationally known physician and chemist. Jackson, to beat Morton, has even supported Wells; when he felt that his cause was lost, he turned his eyes to Long ². History made clear that Jackson, in addition to brilliant, was highly competitive and smart, but also dissimulated and manipulator ⁸. Once he was asked if he would have asked for himself the merit of the discovery or even the credit of the suggestion if during Morton's demo the patient had died. Jackson has not answered ^1,8.

Jackson had a prodigious memory and kept clippings of the several Medicine, Geology and Chemistry journals which interested him the most. One day he asked his assistant, James, to look in his file for an article of a Southern physician who said he had been the first to use ether to operate patients. "It must be a report from the Georgia Medical Association", he remembered ².

In fact, in 1848, Long decided to talk in this Society about his role in the discovery of anesthesia; having been welcomed and encouraged to publish it, he did it in 1849 in the Southern Medical and Surgical Journal, where he stated having administered ether to some patients in 1842, thus four and a half years before the issue known today in the USA as the "Ether Day" ^1,2,7,15,28. In this report, Long humbly stated: "I know I took long to make my discovery known to be entitled to the primacy of this invention and I leave to the School of Medicine the task of solving the issue" ^2,17. But Long's discovery had true repercussion only after the publication in 1877 of an article by J. M. Sims, notorious New York physician ^3,14,18.

Jackson promptly decided to benefit from the fact and adopted the argument that, due to the low scientific concept of the South by that time, the world had not looked into this important discovery ². Of course, on his own interest, he wanted the whole America to know the name of Crawford W. Long, physician who had for the first time applied Jackson's idea and who should be the only one to divide with him the primacy of discovering anesthesia ². Jackson got off the train in Athens, where Long lived with his family after spending one year in Atlanta (1850), and whose clinic had increased a lot allowing him to become partner of the largest pharmacy of the region and to purchase a large farm ^2,8.

Jackson went to Athens claiming that he had been asked to inspect Dahlonega gold mines ², but according to other version, he went to see Long at request of the Congress for a final decision on the true discoverer of anesthesia ⁸. By the way, some believe that Jackson has visited the small city of Jefferson in the Spring of 1842, in the exact moment when Long was applying ether to his first patient and, if this is true, it seems unlikely that Jackson had not heard from local citizens about the greatest news in town ⁸; moreover, it is possible that Jackson has in fact been in Jefferson because when returning to the Harvard University he reported having inhaled ether to treat a sore throat, what has left him sat down and unconscious ⁸. In fact, it seems that Jackson has been to Athens to convince Long to support him against Morton's intentions ^18,22.

Jackson entered the pharmacy where Long was a partner in the morning of March 8, 1854 and was received by C.H. Andrews, pharmacy employee who informed that Long would arrive soon and invited him to sit next to the fireplace ¹. Andrews described him as tanned skin, approximately 180 cm height, black hair, brilliant eyes and aged approximately 40 years; it seems that he was tanned for having worked on the field as geologist ¹. Jackson waited restlessly for Long. Listening to the noise of a galloping horse, Jackson left the pharmacy in a hurry and went to meet Long who, even before dismounting, received a card from the foreigner with the following words: Dr. Charles Thomas Jackson, physician, knight of the Legion of Honor, government geologist, chemist and minter ².

Admired, Long heard from Jackson that he had come to Athens to talk to the man who, for the first time, had used sulfuric ether for surgical procedures ². Long received Jackson and called Andrews to witness the conversation, In 1900, 46 years after that meeting, Andrews reported: "They were frank, correct, however careful; it was a tiresome workday" ^17,22. Andrews has also reported that al those who knew Long felt for him reverence and affection ¹.

Jackson spent two days in Athens, most of the time at Long's office studying his notes, and two more days in Jefferson, where he talked to physicians and witnesses of Long's anesthesias ²². He returned to Athens to see Long once again. "It is my duty to help you protecting your rights", said Jackson, after thoroughly analyzing Long's files once more, and added: "Everything is very convincing, dear doctor. The only thing I do not understand is why you have not demanded your rights" ².

Long explained his reasons and Jackson understood that he needed to convey assurance to the modest and unknown physician from Athens. "It was a pity you have not written to me by that time. Thanks to my relationships, I would have asserted your rights before the Academy of Science of Paris and, together we would have obtained the recognition of the scientific world. Because you might not ignore my major participation in this discovery" ².

Then he reported that he had performed theoretical and practical investigations with sulfuric ether, which, according to him, were done prior 1842. In fact, it seems that Jackson has discovered in his lab, by chance, the analgesic action of ether fumes which gave him the idea of using them against surgical pain, but he has never done it. "Certainly I have not performed surgical procedures; here, I admit you primacy. Of course, I am talking in practical terms because undoubtedly the idea you have firstly applied, my dear colleague, I already nurtured since 1838. This is why our two causes are closely connected.

But tell me, dear doctor, isn't it an injustice that the reward owed to us goes to an insignificant dentist of Boston? Wouldn't it be worth gathering our efforts to put an end to the insolence of that impostor?" ². Jackson had already had a similar conversation in Hartford with the widow of Wells who, in 1844, performed that failed general anesthesia demonstration with a few liters of nitrous oxide not associated to oxygen ².

Long was not sure of his primacy, but was smart and would not be easily fooled. After listening to Jackson, notorious physician well posted on everything that was known about anesthesia, and if he, Long, was in fact the inventor of anesthesia, he concluded that he did not need any partnership to support his cause and that he would strive alone, even without his support ¹⁷. Courageously and respectfully he conveyed his opinion to Jackson. For him, renouncing for good to any participation in the discovery of anesthesia and admitting that its primacy belonged solely to a physician from the South of the USA was almost unbearable.

But the hatred he devoted to Morton was huge and stronger than anything else, even morbid; he stepped back and agreed with Long's arguments, although having to abandon his intentions. With great pain and difficulty, Jackson said that he was convinced of Long's rights, that he only wanted the truth and that he could count on his total and uninterested cooperation ². What mattered most to Jackson now was to kill Morton's pretensions. "Dr. Jackson will state to the whole world that you are the sole inventor of anesthesia" ².

Immediately, encouraged and coordinated by Jackson himself, Long, Caroline, the assistant James, friends and patients started preparing the documentation needed to prove the achievement of whom had become the idol of Jefferson, Athens and Georgia; they also made contact with senator W.C. Dawson, representative of the state, and asked him to present the case before the North-American Congress. All Athens citizens commented: "Who knows for how long would Long maintain this major discovery in secret; so modest he is that it was necessary a notorious scholar to came from the North to disclose such a well kept secret; what a glory for our city, and what an honor for the Union!" ².

When the decision about the discoverer of anesthesia was getting to an end and tended to indicate Morton as deserving the award, senator W.C. Dawson, representative of Georgia was against it, stating that undoubtedly the glory belonged not to the Northern states but rather to his state. He showed a huge dossier to prove his arguments but has not used it; he just read two small sheets of paper without changing his voice, which has impressed the Congress. One of them, a two-dollar invoice, dated 1842, paid to Dr. Crawford W. Long by the student Venable, from Jefferson, for the extraction of a tumor under sulfuric ether anesthesia ^2,16,23. He circulated the invoice by the room and waited for the emotion created by this unexpected document to reach its peak.

Then, calmly, he continued with his moderate and laconic speech and read a message from Jackson confessing that he had already pled, before the Senate, the primacy and the reward for the discovery of anesthesia, since he had been the first to explore this medical field and the one recommending Morton to test sulfuric ether; then, continued Jackson, he had claimed for him and Morton the same advantages and had maintained his decision until that moment when he confirmed that Crawford W. Long had successfully performed several painless procedures in patients anesthetized with sulfuric ether; moreover, he now would like to apologize and renounce the paternity of the discovery in behalf of Long ^2,29.

Senator Dawson asked his peers to pay attention to Jackson's objective, elegant and uninterested statement ². Senator Truman Smith, reminding previous statements supporting Wells and Morton, and extremely irritated, asked explanations to Jackson, who answered: "I totally ignored that this unknown physician from the state of Georgia had preceded us, but the sense of justice made me accept the truth" ². Morton's request was once more postponed. As before with regard to Wells and Morton, the Congress could not ignore new evidences and was forced to study the issue raised by senator Dawson to decide about the 100 thousand dollars owned to the discoverer of anesthesia ².

But several other claims appeared. North-American Congress discussions were extended for years and all documents and proofs submitted by most claimers were examined, ruling out almost all requests. Finally, the unofficial conclusion was that Morton was the true inventor of anesthesia ². No one thought of denying that others before him had the same idea, but he was the only one to translate the idea into act, and only the act counted.

It was from the theater of Boston General Hospital that ether anesthesia took off to conquer the world. He would receive alone the donation of 100 thousand dollars ². The resolution about Morton's merit reached the table of President Franklin Pierce but was not concretized due to some questions he raised about the merit of the issue ^2,19. Regardless of the USA Congress conclusion, which remained open, several governments, entities and US and international medical associations approved different resolutions and started to praise one of the four major participants in the discovery of anesthesia: Long, Jackson, Wells and Morton ^2,8,22. In 1852, the Medical Association of Georgia officially considered Long the first to use sulfuric ether for surgical anesthesia and referred the discussion about this primacy to the American Medical Association ¹⁴.

It is interesting to remind that during the controversy about the primacy of the discovery of anesthesia, in which Long was almost not involved, Oliver Wendell Holmes has answered when asked about the issue, with a pun: "The credit might well be given to e(i)ther" ³.

LONG AND THE NORTH-AMERICAN CIVIL WAR (1861-1865)

Some years later, during the American Civil War, Long was serving the Southern army sanitation service; Morton was fighting on the other side, the North ^2,14. The war was coming to an end and before it was too late, Long in a certain evening, rode a horse to his home, awakened his daughter France (there are reports that she and a brother were already escaping) and recommended her to promptly gather her personal things and, before dawn, escape to the home of his assistant's sister, who had already been warned.

He went to his office and took from a secret drawer a small carefully closed glass coffer he maintained for a long time, gave it to his daughter and asked her to keep it very carefully because it had all the proofs of his discovery of anesthesia, and added: "Will you promise me that you will hide these papers as soon as you get to your destination so that no one will find them?" ². And continued: "If you are surprised on your way by the enemy then everything will be ended for me; you may give them the papers if they ask you to" ². And he returned immediately to his post. Frances knew the importance of those papers and only when she was safely in the lieutenant's sister home she revealed her secret. At night, both ladies went to the forest and buried the coffer by a tree that was marked ².

After the war, Long, old, prostrate, grieved and poor, returned to his clinic and pharmacy. Some days after, Frances happily returned to her father the important documents she had hidden and tried to encourage him: "Don't give up, Dad, one day you will be famous, thanks to your discovery of anesthesia" ². Irritated, Long said: "Don't talk to me about that, I don't want to hear the word anesthesia. That's it!" ². Frances wrote: "I was still young and unconcerned by that time, however I noticed the silent courage with which my father has hidden for years the sorrow for the non recognition of his discovery" ². But he continued to scrutinize the documents about the first surgical anesthetic procedures ².

Such papers were the documental proofs of Long's primacy in the discovery of anesthesia (letters, certificates, written and sworn statements, memorandums, records, notes, etc.), the originals of which remained with Long's daughters, kept in a safe place ²⁹. His daughters loved him a lot and Emma, one of them, dedicated to him a beautiful and long poem which ends: "Some day the heart of your Nation will proudly applaud its talented son" ¹⁴.

LONG'S DEATH

In a winter evening of 1878, Long went to see a parturient whose husband, desperate with her pains, insistently asked the physician to use a certain drug he had heard of ². Long resisted a lot but finally decided: "Well, wait a minute, I will bring something to relieve your wife's pain" ². He went to the pharmacy, picked a small bottle and returned to the farm where the woman's shouts were heard from the distance. At bedside he said: "In a few seconds you won't feel anything, my daughter" ². The woman smiled. However, when applying a sponge to the nose of the patient to start anesthesia his hands shook, he dropped the ether bottle and fell to the ground; some relatives tried to help him, but he insisted: "Take care of the mother and the baby first" ^2,8,11,14. He passed away some hours later ^11,14, supposedly from violent brain hemorrhage ⁸, before the news of his discovery had crossed the limits of his city ³⁰.

Studying the lives of the participants in this marvelous discovery, it is possible to observe that Long was the only one whose life was not spoiled by fights and disputes. Long's focus was not to try to receive the material award for discovering anesthesia, but many times he said that he would like to be remembered as benefactor of mankind ^9,14,22. Wells became addicted to chloroform and committed suicide in the Tombs Prison on January 23, 1848 ^2,27. Jackson died at 75 years of age, in 1880, in a Sommerville's asylum, where he lived for seven years ^2,18. Morton, stressed by the fight against Jackson, died in the Saint Lucas Hospital, New York, after suffering a heart attack when crossing Central Park in a hot summer day, on July 15, 1868, leaving wife and five children left to abandon ^2,18.

ACKNOWLEDGMENTS TO CRAWFORD W. LONG

Long received honors from England, México, France and other European countries ¹⁴. But part of the world seems to have forgotten Long. Unfortunately, in Brazil he is almost totally unknown. However, in the USA and especially the cities where he lived, Jefferson and Athens, and his home state Georgia, have never forgotten him and consider him one of the 32 most important Georgeans ¹¹. One of Jefferson's squares has a monument to Long. The Georgia University acknowledges him as discoverer of anesthesia, benefactor of mankind and pays homage to him with a monument. New Orleans has built a monument to one of the greatest benefactors America has given to the world ¹⁴.

In 1921, the American College of Surgeons of Atlanta decided to consider Long the discoverer of anesthesia and founded the Crawford Long Association ⁸. Long was depicted by several painters, in general with a thick beard; there is a picture painted by one of his daughters in the Crawford W. Long Hospital in Atlanta (Emory University) ¹¹. The State Palace of Atlanta has in its lobby an oil painting of this great North-American ¹⁴. The School of Medicine, University of Pennsylvania has a picture of Long painted by the famous artist R. Lahey ¹¹. The same university, to keep alive its brilliant student, has created a bronze medallion projected by Dr. R.T. McKenzie on March 30, 1912, where he is depicted very young administering ether to a patient, where it is written: "To Crawford W. Long, First to Use Ether for Surgical Anesthesia, March 30, 1842, From His Alma Mater", in the center "1815-1878" and below "Class from 39 – Pennsylvania" ^3,10,14.

One of the greatest acts of gratitude of the US to Long was a marble statue placed in the Statue Room of the Capitol, Washington, D.C., on March 30, 1926, where it is written: "Crawford W. Long (1815-1878) – who discovered the anesthetic value of sulfuric ether for surgery on March 30, 1842, in Jefferson, Jackson County, Georgia" ^3,14.

The Crawford W. Long museum – opened since 1957 on 28^th College Street, Jefferson, in a building probably next to the office Long had in 1842 ¹³ – is another great monument in memory of this pioneer; it is currently maintained by the Georgia Society of Anesthesiology and by Friends of the Museum, volunteers and different societies of Anesthesiology, with the mission of "preserving, interpreting and promoting achievements, life and age of Long, Georgian physician and discoverer of anesthesia" ⁹.

The association includes heads of Anesthesiology Departments of the School of Medicine, Emory University and of other medical centers ⁹. In 1986, the museum was enhanced with the acquisition of two neighbor buildings. The configuration of the 1842 garden is basically the same, with Cherokee roses, typical of Georgia, in addition to ornamental plants common in the 19^th century.

The museum has a library with controlled temperature and humidity and exhibits anesthesia machines, collections of records and videos on the history of anesthesiology and keeps Long's personal objects and medical tools, in addition to a Shakespeare volume with his favorite texts and numerous memorandums, letters written or received by Long, statements of witnesses or patients of the first and other painless interventions, including Venable and his mother, from Andrew about his meeting with Jackson and Jackson's letter written in April 1861, where he states having examined the documents, having listened to Long's patients and witnesses and mentions other facts and arguments already described herein ^9,29.

There is also a painting showing Long operating one of Venable's cysts and three witnesses, and another depicting Long, wife and children. The Jackson County History Society has its headquarter in this museum which is visited every year by thousands of people ⁹. Currently, the museum is developing cultural programs especially focused on Long's age and every year the last week of March is always dedicated to the discovery of anesthesia. March 30 is dedicated to "Doctors Day" ^"9.

The Crawford W. Long Museum was used in 1940 for the launching ceremony of the stamp celebrating the series of famous North-Americans, with the picture of Long when he was 55 to 60 years old (Figure 3) and which became his most used and circulated image ^9,11,31,32; the only other initiative of this kind was a stamp in honor of Dr. Virginia Apgar, launched on October 24, 1994 ^9,11. In 1992, a Symposium on the History of Anesthesia was held from March 27 to 31 during which the 150 years of Long's discovery were celebrated ^9,11. A curiosity: the Coca-Cola company has paid homage to the event by stamping on its bottles the picture of Long with the words: Crawford W. Long – Discoverer of Anesthesia – 1842, Jefferson, Georgia.

Last but not least, a rare ferrotic picture (Figure 4) was found a some 20 years ago in a book fair in Austin, Texas, and was acquired by Dr. Scott Smith, resident in Anesthesiology of the Medical Center Hospital, who donated it to P. I. Nixon Medical Historical Library – University of Texas Health Science Center at San Antonio, in honor of Dr. Maurice S. Albin, professor of Anesthesiology of the Health Science Center and director of neuroanesthesiology of the Medical Center Hospital and of the V A Medical Center ^32-34. Made between 1854, when such photographic process was created, and 1861, when the American Civil War exploded, possibly in 1855, the picture simulates a surgical procedure under the effect of ether.

This picture was discovered by an antiques tradesman in Gainsville, Georgia, who has bought it from a Long's descendant and sold it to another rare books tradesman in Athens. It is an important document for the history of Medicine because it seems to be the only picture of Long; his other images are all oil paintings. Strong hints, since there are no conclusive evidences, indicate that is really Crawford W. Long, between 39 and 45 years of age, who appears getting ready to amputate the leg of a barefoot patient, with tourniquet applied above the knee and on the mid region of the leg and, imagine, placed on a wooden crate or box; Long is with an assistant who takes care of surgical instruments and with someone who administers ether and monitor patient's pulse. For his professional medical posture and high physical resemblance with his family, the young "anesthetist" seems to be Robert, also physician and Long's brother. Moreover, the wooden box acting as operating table contains the following words, probably related to Long's name and address: Williamson, GA and Temperane, which in fact should be Temperance, city close to Athens, to a railroad terminal, Union Point, and to Crawfordsville.

FINAL REMARKS

Long's history reinforces two essential issues for the understanding of the "ether controversy", that is, to determine whether the primary merit belongs to the discoverer (Long) or to whom has introduced it de facto to medicine and has publicized general anesthesia (Morton), and to position the merit of two other major participants in the discovery: Jackson for the suggestion and orientation given to Morton, and Wells, for having tried to show the possibility of using nitrous oxide, widely used today. In fact, history is not always totally correct; it often suffers cultural, religious, ethnic, economic and politic influences which distort real facts. The solution lies on the definition of discovery and discoverer, very clear in most modern dictionaries. However, it has happened before: someone discovers something e does not disclose it until another one also discovers the same thing, capturing the idea of a third party and making it widely known. Certainly, all major participants have their merits.

Although there are criticisms about Morton's behavior, his high value and importance are undeniable; undoubtedly he was a major benefactor of mankind. His demonstration, and especially the prompt notice of the possibility of operating with no pain, made feasible a huge development of surgery, which before this was very limited. On the other hand, there is no doubt that Long has induced the first surgical anesthesia. As result, he could have easily obtained a higher place in the international history of anesthesia, but the reasons already exposed greatly explain why he has not reached it, what does not invalidate his well-deserved value. A stereotyped image of Long has been created long time ago and has passed from generation to generation: a simple countryside physician believing that his knowledge and experience were incompatible with the grandeur of the discovery of anesthesia; such are preconceived, inadequate and false notions. Long has the right of being among the two out of four major North-Americans who made possible one of the most fantastic discoveries of Medicine and his work cannot be forgotten and should be nurtured by Brazilian and international Anesthesiologists, in addition to being remembered and celebrated every March 30.

ACKNOWLEDGMENTS

To Crawford W. Long Museum and to P.I. Nixon Medical Historical Library - University of Texas Health Science Center at San Antonio, for valuable references and images of Dr. Long. To Dr. Carlos P. Parsloe, for intermediating such materials and for supplying us with data from his huge personal library. To my daughter, Márcia N. R. Carvalho, for locating and obtaining the original photograph.

REFERENCES

Submitted for publication 31 de outubro de 2005

Accepted for publication 15 de março de 2006

• 01. Fenster JM Ether Day: The Strange Tale of American's Greatest Medical Discovery and the Haunted Men Who Made It, 1Ş Ed, New York, Harper Collins Publishers, 2001.
• 02. Fülop-Miller R O Triunfo sobre a Dor: História da Anestesia, 2Ş Ed, Rio de Janeiro, José Olympio, 1951.
• 03. Castiglioni A História da Medicina, 2ş Volume, 1Ş Ed, São Paulo, Editora Nacional, 1947;263.
• 04. Meira DG Contribuição à História da Anestesia no Brasil Crônicas, 1Ş Ed, Rio de Janeiro, Guanabara, 1968;92-94.
• 05. Shane SM Anesthesia: Thief of Pain, 1Ş Ed, New York, Vantage, 1956;73-87.
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• 15. Faulconer Jr A, Keys TE Fundations of Anesthesiology, Springfield, Charles C Thomas, 1965;310-316.
• 16. Toski JA, Bacon DR, Calverley RK The History of Anesthesiology, em: Barash PG, Cullen BF, Stoelting RK Clinical Anesthesia, 4^th Ed, Philadelphia, Lippincott Williams & Wilkins, 2001; 3-24.
• 17. Long CW An account of the first use of sulphuric ether by inhalation as an anaesthetic in surgical operations. South Med Surg J, 1849;5:705-713. Em Wood Library Museum of Anesthesiology History of Anesthesia, 1^st Ed, Park Ridge, Number One, 1992;5-13.
• 18. Sims JM The Discovery of Anaesthesia. Virginia Med Monthy, 1877;4:81-100. Em History of Anesthesia, Wood Library Museum of Anesthesiology, First printing by Wood Library Museum in 1971. Reprint Series Number One, Park Ridge, 1992;18-41.
• 19. Duncum BM The Development of Inhalation Anaesthesia: with Special Reference to the Years 1846-1900, 1^st Ed, London, Oxford University, 1947.
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• 24. Bobbio A História Sinóptica da Anestesia, 1Ş Ed, São Paulo, Nobel, 1969;62-65.
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• 28. Young HH Crawford W. Long: the pioneer in ether anesthesia. Bull Hist Med, 1942;12:200-201.
• 29. Jacobs J Documentary Evidence In Proof of the Prior and Original Discovery of Surgical Anaesthesia by the Use of Sulphuric Ether by Crawford Williamson Long of Jackson County, Georgia, and of His Use of the Same in Surgery Prior to the Dates of Its Use by Other Claimants, em: Jacobs J Dr. Crawford W. Long The Distinguished Physician-Pharmacist, University of Pennsylvania, 1992;35-47.
• 30. Medrado VC Os Pioneiros da Anestesiologia: Horace Wells (1815-1848) e Crawford W. Long (1815-1878), Simpósio Médico, 1975.
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• 33. Albin M, Ray J, Smith S The Discovery of the Only Know Photo of Crawford Long Staging a Demonstration of an Amputation Under Ether Anesthesia (Circa 1855). Department of Anesthesiology and the Briscol Library The University of Texas Heath Science Center at San Antonio.
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*

Received from Hospital Alemão Oswaldo Cruz, São Paulo, SP.

Publication Dates

• Publication in this collection
  29 May 2006
• Date of issue
  June 2006

History

• Accepted
  15 Mar 2006
• Received
  31 Oct 2005