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Chloroform

The Quest for Oblivion

The History Press

Give Me to Drink Mandragora

The escape from pain in surgical operations is a chimera, which it is idle to follow up today. 'Knife' and 'pain' in surgery are words which are always inseparable in the minds of patients, and this necessary association must be conceded.

Velpeau, a leading surgeon of his day, writing in 1839

In 1847 chloroform blazed on to the Victorian scene like a comet, whose muted beginnings were forgotten in scenes of brilliant light and grim shadow. Some regarded it with horror and despair, others predicted its rapid passing, but for many it was a triumph of science over nature, and the harbinger of a bold new age of medicine. To the confident and optimistic, chloroform appeared to be the ideal, the perfect anaesthetic that had been sought by humankind since the dawn of time. This heady excitement was soon to evaporate, but for many years to come, chloroform was widely used, abused and misused in human society.

To understand the reaction of the Victorian medical profession and public to the appearance of chloroform, we must first take a short tour of the history of anaesthesia, which is at least as long as recorded history itself. However, while there is ample information on the subject, it is hard to judge the effectiveness of early attempts at pain relief during surgery since the degree of success reported tends to depend on whether the writer is a surgeon, an academic, or a patient.

From earliest times, the possibility of anaesthesia has thoroughly engaged the minds of commentators on the human physical condition. Early Homo sapiens must surely have noticed that intense pain or a blow on the head would sometimes lead to unconsciousness, a state that mimics natural sleep but during which the patient (or, maybe, the victim) feels no pain. This observation would have stimulated the desire, and later the search, for some artificial means of procuring a pain-free slumber.

Possibly the first depiction of painless surgery in literature is in the Bible, when God causes Adam to fall into a deep sleep while He removes the rib from which He makes Eve. After the couple's fall from grace, God issued a decree, the precise meaning of which is still a matter for lively debate. Henceforth, Adam must toil to bring forth food from the ground, while to Eve God said, 'I will greatly multiply thy sorrow and thy conception; in sorrow thou shalt bring forth children.' The Bible therefore appears to associate painless surgery with the brief period of humankind's innocence, and the travail of childbirth with the decline into sin, a distinction which was not lost on some nineteenth-century obstetricians.

EARLY PAIN RELIEF

The earliest attempts at pain relief probably used soporifics such as opium and alcohol, both of which have been available far longer than written records. Alcohol on its own was known to numb the senses, though its effects were short-lived, especially as pain could lead to rapid sobering of the patient. However, it was often used to carry doses of other drugs.

The unripe seed heads of the opium poppy yield a milky juice rich in alkaloids, of which the most important is morphine. The juice could be dried for storage and later mixed with water and alcohol. Its sedative and sleep-inducing properties made opium a valued aid to medicine, but it had two major drawbacks: it was poisonous; and it was addictive. It was not, of course, an anaesthetic, but for someone about to undergo surgery it was very much better than nothing. Despite the availability of soporifics, however, 'nothing' was what the patient often received. This meant that if a surgeon was to be able to operate effectively, the only thing to do was to tie or hold the patient down and work quickly.

Although the Greeks and Romans knew about opium, their writings make little mention of pain relief. It is not clear, therefore, whether the second-century Greek physician Galen, who advised opium and mandragora for the relief of pain before performing operations, was typical of his time or an enlightened exception. The Greek essayist and biographer Plutarch, describing a first-century operation on the Roman general Caius Marius for tumours in his legs, did not refer to any methods of alleviating pain – rather he praised the patient for his fortitude. Marius elected not to be tied down, but having endured the cutting of one leg without flinching or making a sound, he declined to allow the surgeon to touch the other, commenting, 'I see the cure is not worth the pain'. Celsus, a Roman encyclopaedist writing about surgical practice in AD 30, advised that the ideal surgeon should be among other things 'so far void of pity that while he wishes only to cure his patient yet is not moved by his cries to go too fast or cut less than is necessary'.

Another plant with a long history of use for medicinal and social purposes is Cannabis indica, which grows naturally in Asia and India and produces a resin that has been used from early times to ease pain, induce sleep and soothe nervous disorders. In AD 220 the Chinese physician Hua T'o was said to have performed extremely complex surgical procedures without causing pain after administering a preparation of cannabis in alcohol. Unfortunately, his patients have left no record of their experiences.

Mandragora officinarum, a native of southern Europe whose root and bark have long been known to have soporific properties, is related to the deadly nightshade. It was described in Historia Naturalis, a 37-volume work written in about AD 77 by Pliny the Elder that included the medicinal use of herbs among its many subjects and retained its influence throughout the Middle Ages. According to Pliny, mandragora was 'given for injuries inflicted by serpents and before incisions or punctures are made in the body, in order to insure insensibility to pain. Indeed for this last purpose, for some persons the odour is quite sufficient to induce sleep.' This may be the first recorded reference to pain relief during surgery being produced by inhalation.

The Greek pharmacologist Dioscorides, who lived in the first century AD, prepared the first systematic pharmacopoeia, De Materia Medica. It was translated and preserved by the Arabs, and finally translated back into Latin by the tenth century. This suggested that the root of the mandragora plant be steeped in wine and given 'before operations with the knife or actual cautery that they may not be felt'. Mandragora had its dangers, however, which may have led to some caution in its use. Aetius, a Greek physician writing at the end of the fifth century, remarked on the effects of an overdose of mandragora, stating that a patient given too much would gasp for breath, became convulsed, and, if assistance was not given, die. This description has the ring of personal observation.

Mandragora continued to be used with caution for many hundreds of years. Bartholomeus Anglicus, who compiled an encyclopaedia of natural history in 1235, stated: 'the rind thereof medled with wine ... gene to them to drink that shall be cut in their body, for they shall slepe and not fele the sore knitting'. The thirteenth-century Spanish chemist, Arnold of Villanova, gave the following recipe:

To produce sleep so profound that the patient may be cut and will feel nothing as though he were dead, take of opium, mandragora bark and henbane root equal parts, pound them together and mix with water. When you want to sew or cut a man dip a rag in this and put it to his forehead and nostrils. He will soon sleep so deep that you may do what you will. To wake him up, dip the rag in strong vinegar.

A contemporary surgeon, Hugo of Lucca, refined this method. He added the juice of lettuce, ivy, mulberry, sorrel and hemlock to the above and boiled it with a new sponge. This was dried and when wanted dipped in hot water and applied to the patient's nostrils.

The properties of mandragora were still well known in the early seventeenth century. Shakespeare mentioned it in Antony and Cleopatra, when the Egyptian Queen demands:

Give me to drink mandragora! ... That I might sleep out this great gap of time My Antony is away.

Hyoscyamus niger, commonly known as henbane, is found throughout central and southern Europe, western Asia and India, and was well known by the first century AD for its action in pain relief and inducing sleep. The main constituents are the alkaloid hyoscyamine with small amounts of hyoscine and atropine. The plant was recommended by Dioscorides, though Pliny declared it to be 'of the nature of wine and therefore offensive to the understanding'.

It is also mentioned in medical works of the tenth and eleventh centuries, and by Elizabethan herbalists such as Nicholas Culpepper, an apothecary who in 1652 wrote his famous herbal The English Physician, and John Gerard, who in 1597 published his Historie of Plants, a compendium of the properties and folklore of plants.

Later it seems to have fallen into disuse, and is omitted from eighteenth-century pharmacopoeias. Gerard wrote that the juice caused 'an unquiet sleep, like unto the sleep of drunkenness, which continueth long and is deadly to the patient', and Culpepper advised that it should never be taken internally at all. In the Middle Ages the fumes obtained from heating the seeds were a popular treatment for toothache, though it was observed that there was considerable risk in its use, as its actions were uncertain and could lead to dangerous side-effects.

THE ABANDONMENT OF OLD KNOWLEDGE

The works of Galen, the Arab physician Avicenna, and the Greek 'father of medicine' Hippocrates were the basis of medical knowledge until the Middle Ages. Universities studied the old texts but added nothing to them. Since medieval philosophers held that the forms of nature were determined by God, it was not felt necessary to explain how things worked. Medicine was based on superstition, folk remedies, herbs, astrology and prayer.

While there were no real advances in pain relief up to the mid-nineteenth century, one might imagine that the old tried and tested herbal soporifics would continue to be employed in the absence of something better. The evidence of those who actually experienced or observed surgery tells a different and remarkable tale. Surgery after the Middle Ages was a terrifying and bloody agony, and the early methods of pain relief were largely abandoned.

Why did this happen? Some historians admit that they don't know the answer. Others skate so carefully around the gap that one has to look carefully to find it. Still others say, in the face of considerable evidence to the contrary, that since the old soporifics were available they 'must' have been given. A few offer explanations, that there was a Renaissance backlash against the practices of the ancients, that opium, henbane and mandragora were not as effective as had been claimed and were dangerous in use, or that medical and religious tracts suggested that pain was in some way essential to the proceedings. All of these suggestions have some element of truth.

In the fifteenth century, improved translations of the classic texts created a renewed interest in Greek and Roman medicine, and this eventually spawned a counter-movement, whose most influential voice was the Swiss physician who called himself Paracelsus. He certainly believed in sweeping away the old beliefs, for in 1527 he publicly burned the revered works of Avicenna and Galen in front of the University of Basel. He believed in personal observation rather than books, and, importantly, he ushered in the study of the chemistry of the body and medicine. After his death his followers continued his work and, ignored by the universities, obtained private funding for their laboratories. Science and religion were still linked, and God was still the creator, but man could use science to explain the nature of the universe.

The movement gained ground, fuelled by advances in scientific method and inventions such as the microscope. The works of Galen and Hippocrates were no longer regarded with un-questioning veneration, and their remedies could be tested. While the old drugs were still used, it was no longer claimed that they produced anaesthesia, and it was realised that complete pain relief was only possible at great risk to the patient.

Nineteenth-century surgeons were extremely sceptical of the efficacy of such measures as Hugo of Lucca's anaesthetic sponge. Dr John Snow, the leading London anaesthetist of his day, examined the prescription and announced his utter disbelief that such a sponge as prepared would, after being placed in hot water, give off any odour or vapour that would cause insensibility. He thought that if sleep were really caused by it, some of the moisture on the sponge might have reached the mouth or throat and been swallowed, his reason being that that the main ingredient was hemlock, which is not volatile enough for inhalation.

Snow also referred to a description written by Theodoric, the son and student of Hugo of Lucca, of patients about to undergo an operation being tied down or held by strong men. In operations for hernia Hugo directed that the patient be tied to a bench or table with three bands; one round the ankles, one round the thighs and one across the chest holding down the arms and hands. This hardly suggests a confidence in the anaesthetic.

Henry J. Bigelow, professor of surgery at Harvard University, declared in 1876 that the essentials of a modern anaesthetic were that insensibility should be always attainable, complete, and safe. By contrast, he described stupefaction with poppy, henbane, mandragora and hemp, as partial, occasional and dangerous. Certainly, prior to the development of instruments for the sensitive measurement of drugs and the establishment of dosages, the amount of active principle in a herbal preparation must have varied enormously, with highly unpredictable results.

It is tempting to conclude with the nineteenth-century doctors that if their predecessors had had, as they claimed, a safe and successful method of preventing pain, it would not have fallen into disuse. The patient might well have felt that some pain relief was much better than none at all, but many doctors were chary of using strong soporifics, and while there were a few who were willing to make their patients drunk to the point of stupor before an operation, this practice was generally condemned.

A great deal of progress would be needed before anaesthesia could become possible, particularly in the development of the science of chemistry and the evolution of sensitive measuring apparatus. Meanwhile, just as doctors unable to prevent infection assumed that suppuration was normal and desirable, and welcomed the appearance of 'laudable pus', so they also declared that pain was a necessary and beneficial part of surgery, and deplored attempts to relieve it as not merely wrong, but dangerous. Medically, pain was a stimulant – it was good for you – while morally it was a punishment for sin, or a test of faith for the holy. If this was true of surgical pain, it was doubly true of the pain of childbirth, which was a perfectly natural thing with which it was unnecessary to interfere.

SURGERY AND PAIN

Descriptions and illustrations of surgery in the seventeenth to mid-nineteenth centuries are mainly a catalogue of unrelieved agonies. An account of an amputation by John Woodall of St Bartholomew's Hospital, written in 1639, makes no mention of pain relief, but refers to the surgeon requiring five helpers, two of whom were to assist the surgeon with his instruments and needles, and the other three to restrain the patient. It was normal practice to locate the operating theatre of a hospital as far as possible from the main wards, often in a tower room, so the shrieks of the unfortunate patient could not be heard by those destined to suffer the same fate.

Despite Celsus's recommendation that a surgeon be without pity, it is clear that many felt acute distress at the sufferings they were about to inflict. William Chesleden, one of the most distinguished surgeons of his day, was said to have suffered great mental anguish on operating days. His method of sparing the patient agony was speed, and he was able to complete a lithotomy (extraction of stones from the bladder) in less than one minute. In 1731 he recommended a draught of opium for the pain, but that was after the operation, not before. John Hennen, a deputy inspector of military hospitals, suggested in 1820 that 'many of the primary operations would be rendered much more favourable in their results by the administration of a single glass of wine', which does rather suggest that in some cases the patient was not even receiving that much.

A few doctors were eager to experiment with various means of reducing pain during surgery. Quite apart from humanitarian considerations, there was a great advantage to the surgeon. The cries and struggles of the unfortunate patient were distracting and distressing. The surgeon was obliged to hurry to complete his work and had little or no time to consult with colleagues when difficulties were encountered. Muscle spasms made treatment of fractures and dislocations especially difficult, and many delicate or lengthy operations, while technically possible, could not be performed on a conscious patient.

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Excerpted from Chloroform by Linda Stratmann. Copyright © 2013 Linda Stratmann. Excerpted by permission of The History Press.
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