, or
death wine, because of its ability to make victims appear dead when actually still alive.
Although its mode of action is unclear, it was so effective that centurions had orders to
spear the bodies of victims before releasing them. While we do not know whether the Romans
used similar methods to induce surgical anaesthesia, the instructions found at Monte
Cassino, and more detailed ones from the first organised medical school in Europe which
opened two centuries later at nearby Salerno,(8) must at least raise the distinct
possibility that they might have done.
Decline and fall
The sponge was, however, far from being the only method used
to administer anaesthesia, as can be seen from an English account dated 1328. Once again we
find opium and henbane mentioned, with the following instructions: Medle al hem to geder,
and boyle ham a lytal, and do hit in a glasen vessel, well stopped, and do ther of III
spoonful to apotel of good wine....and let hym that shall be coruen, sytte agens a good
fyre, make hym drynke therof til he falle aslepe, and thou moyst savely corye hym.(9)
A similar, but fictional, account appears in a short story by the popular renaissance
writer Giovanni Boccaccio (1313-75): Now the doctor, supposing that the patient would never
be able to endure the pain without an opiate, deferred the operation till the evening; and
in the meantime ordered a water to be distilled from a certain composition, which, being
drunk, would throw a person asleep as long as he judged it necessary.(10)
It was around this time that the use of these primitive techniques seems to have reached
a peak, but the problems that would eventually lead to their abandonment were now becoming
apparent. In his surgical textbook Chirurgia Magna, for example, the French surgeon
Guy de Chauliac (1300-67) describes the soporific sponge, but then gives asphyxia,
congestion, and death as complications of its use.(7)
It is not hard to find reasons why such problems should have arisen. Although the potency
of these extracts varied enormously-depending, for example, on the climatic conditions
under which the plant had been grown and the method used to concentrate its juices-there
was no method of measuring the dose actually administered. Not surprisingly, the results
were highly unpredictable for, as the Italian surgeon Gabriel Fallopius (1523-62) pointed
out: If soporifics are weak, they do not help; if they are strong they are exceedingly
dangerous.(11)
The use of these techniques now began to decline, but at precisely the time that they
were being abandoned by one profession another one was adopting them.
Perchance to
dream
The plays of William Shakespeare contain many references to herbal medicines,
particularly those with sedative powers. In Othello act III, scene iii, for example,
the moor is told that nothing can return to him his once peaceful state of mind:
Not poppy, nor mandragora,
Nor all the drowsy syrups of the world,
Shall ever medicine thee
to that sweet sleep
Which thou owd'st yesterday.
Like countless other writers
since, Shakespeare realised the dramatic potential of substances that could produce
temporary unconsciousness, and when, in act IV, scene i of Romeo and Juliet , Juliet
asks Friar Lawrence for help in finding a way to avoid the marriage arranged for her the
following day to Paris, her fellow Capulet, Shakespeare describes a state not unlike that of
anaesthesia itself. The friar tells Juliet:
Take thou this vial, being then in bed,
and this distilled liquor drink thou off:
When, presently, through all thy veins shall run
A
cold and drowsy humour; for no pulse
Shall keep his native progress,
but surcease:
No warmth, no breath, shall testify thou
liv'st;
The roses in thy lips and cheeks shall fade
To paly ashes; thy eyes' windows fall,
Like death, when he shuts up the day of life;
Each part, depriv'd of supple government,
Shall, stiff and stark and cold, appear like death:
And in this borrow'd likeness of shrunk death
Thou shalt continue two-and-forty hours,
And
then awake as from a pleasant sleep.
Although much of Shakespeare's remarkable knowledge is said to have come from
herbals, it is surely impossible not to find in these words a suggestion of experience more
personal in nature.
Twilight sleep
Dauriol's attempt
in 1847 to reintroduce, as an alternative to ether, a technique that had been by then long
abandoned, was rightly greeted with a dignified silence. It did not, however, take long
after the discovery of ether and chloroform for it to become apparent that the use of these
agents was also not without risk. The search for a safe anaesthetic went on, and in 1888 the
physician Benjamin Ward Richardson decided to investigate the anaesthetic power of the
mandrake. Richardson obtained a mandrake root and prepared from it a tincture in exactly the
manner described by Dioscorides, which he tested both on animals and on himself. He
concluded:
The wine of mandragora is a general anaesthetic of the most potent quality. The action no
doubt depends on the presence of an alkaloid which is like, if not identical with, atropine
and which would, I have no doubt, be one of the most active anaesthetics we have yet
discovered.(12)
Unknown to Richardson, however, the alkaloid had already been isolated from another
solanaceous plant, Scopolia carniolica, which grows naturally in the Slovenian
province of Carniola. In the same way that atropine, its near relative, had previously been
named after Atropa belladonna, the deadly nightshade, so this new alkaloid was now
given the name scopolamine.(13)
Right: Scopolia carniolica - the source of scopolamine (Royal Horticultural
Society, Lindley Library)
In 1900, stimulated by continuing concerns about
the safety of chloroform, doctors in Germany began to experiment with the use of morphine
and scopolamine as an alternative to mask anaesthesia.(11) The technique, which
involved giving one or two hourly injections until anaesthesia was considered adequate,
never gained popularity in British operating theatres, but in 1910 the anaesthetist D W
Buxton wrote:
A terrified patient after a sleepless night is in the worst condition for an anaesthetic and
an operation. In such patients I am convinced that the use of scopolamine and morphine
injections before a general anaesthetic is valuable.(11)
Right: A form of Scopolia carniolica (Blooms of Bressingham)
Many examples are known of medical techniques that have been abandoned, only to be
rediscovered by a new generation. There is, however, surely no finer one than that of this
ancient partnership, known to the Romans and perhaps to Shakespeare, and now reborn as the
20th century anaesthetic technique of premedication.
In somno
securitas
Although less frequently prescribed today, morphine (or omnopon) and
scopolamine still remain in certain situations a pharmacological partnership without equal.
Furthermore, like the mandrake roots and poppy heads on the arms of the Association of
Anaesthetists, the combination serves as a reminder, in this the quintacentenary year of
ether anaesthesia, that the desire to alleviate the fear and pain of surgery, if not always
the ability to do so in safety, has been with us since time
immemorial.
Today, when we think of plant based medicines, we
tend to think of substances that are weak or homoeopathic, but in Shakespeare's day they
would have known better. When Friar Lawrence chooses the plant from which he will make
Juliet's sleeping potion, he tells us: Within the infant rind of this small flower, Poison
hath residence, and medicine power.
I thank Dr Arthur Hollman, medical adviser to
the Chelsea Physic Garden, for his invaluable advice and encouragement in the writing of
this paper.
The physic garden is open to the public on Wednesday and Sunday afternoons
from April to October.
North Staffordshire
Hospital,
Stoke on Trent ST4 6QG
Anthony John Carter,
consultant anaesthetist
Correspondence to: 21 Church Road,
Alsager,
Stoke on Trent ST7 2HB.
References:
1 Dauriol M. Nouveau procede pour plonger dans la stupeur
les malades qui doivent subir une opeeration. Journal de Meedecine et Chirurgie de
Toulouse 1847;10 :178.
2 Dauriol M. A substitute for ether to annul sensation
during operations. Lancet 1847;i:540.
3 Grieve M. A modern herbal.
London: Jonathan Cape, 1931:397-404.
4 Guthrie D. A history of medicine. London:
Thomas Nelson, 1945:116.
5 Bowes J B. In: Atkinson RS, Boulton TB, eds. The history
of anaesthesia . London: Royal Society of Medicine, 1989:43.
6 Thompson C J S. The
mystic mandrake. London: Rider, 1934:100-1.
7 Keys T E. The history of surgical
anaesthesia . New York: Schuman, 1945:104.
8 Ellis E S. Ancient anodynes .
London: Heinemann, 1946:137.
9 Husemann T. Weitere Beitrage zur chirurgischen
Anasthesie im Mittelalter. Deutsch Zeit F Chir 1900;57 :516.
10
Boccaccio G. Quoted in: Gordon R. The literary companion to medicine . London:
Sinclair Stevenson, 1993:295-301.
11 Duncum B. The development of inhalation
anaesthesia. London: Geoffrey Cumberlege, 1947:375.
12 Richardson B W.
Asclepiad 1888;5 :174-83.
13 Atkinson R S, Rushman G B, Davies N J H. Lee's
synopsis of anaesthesia . London: Butterworth, 1993:92.
Materia botanica
It was this ability of henbane to induce prolonged unconsciousness that particularly
impressed the 18th century physician (and benefactor of the Chelsea Physic Garden) Sir Hans
Sloane, who recorded the case of four children who accidentally ate henbane seeds. They
slept for two days and two nights.(3)
Mandragora officinarium
Right: Christ's tribulations in a 13th century manuscript from Salerno.
Traditionally this sponge contained vinegar (Sloane manuscript 1977, by permission of the
British Library)