Part 4

But, when the opportunity offered for obtaining remunerative practice by the exercise of his scientific skill, Snow showed himself, both in act and industry, competent for success. He soon overcame all difficulties, and managed by his frugality to lay in store for a rainy day for himself, and to help such friends as needed. Many rumours as to the extent of his gains abound which it is right to correct. His income of late years was near £1,000 a year, but it never exceeded that sum. For this, he exhibited chloroform or one or other anæsthetic about four hundred and fifty times annually, taking an average of the ten years preceding his death. In a large number of these cases, however, his services were gratuitously supplied.

In his private relations, Dr. Snow was a man of the strictest integrity and purest honour. The experiences of life, instead of entwining about him the vices of the world, had weaned him from the world. Without any pretence, maintaining no connection with sect or party, living by the rules of the eternal laws which, according to the best of his abilities, he could read from the universe, he carried out a practical religion, independently of any hypothesis or abstruse profession, which few professors could approach. A child of nature, he knew no way of recognizing the Divine influences so purely as in silent and inexpressible admiration of those grand external phenomena which pharisees see not, but which each moment convey to men of his character, the direct impression of a Power all present and revealing itself for ever.

We approach the end. In the midst of his success, when medicine most needed him and his hand was most powerful, he stood one day in his mental strength, and the next day fell. Death found him at his work, and the stern enemy came on him suddenly, though not without forewarnings.

His health had long been indifferent; he had suffered from hæmatemesis several times in the last few years, for which Dr. Budd had attended him, and he had his own forebodings that his life was not of the longest. In the month of December 1857 he was suddenly seized one evening with vertigo and sickness, which compelled him to keep the recumbent position for more than twenty-four hours. At the end of this time he felt better, and went about his usual avocations. He had no convulsions at this time, nor did he lose his consciousness. After this attack, he complained on many different occasions, both to his housekeeper and to several of his medical friends, of numbness in his extremities. Some of these to whom he mentioned this circumstance, do not recollect whether this symptom was greater on one side of the body than on the other; while others distinctly state that it was referred to the left side only. His housekeeper was certain that he never complained of this numbness before the attack in December; and even afterwards, it would appear to have been only an occasional symptom. For six weeks before his final seizure he had made no mention of it. About three weeks before his last attack, he had complained, for some days, of a severe pain in the back of his head, which he himself considered neuralgic, and for which he treated himself. This pain quite left him, and for about a fortnight he had been enjoying excellent health.

On the evening of Tuesday, June the 8th, 1858, he attended a meeting of the Royal Medical and Chirurgical Society. On the following evening there was a meeting of a private society for the study of chest diseases, held at Dr. Quain’s. The subject discussed was the cause of the first sound of the heart. On this, the last occasion of the kind at which he was present, he was in unusual spirits, and looked exceedingly well. He entered into the debate with great earnestness, agreed to form one of a committee to inquire into the cause of the first sound by experiment, and left his friends with enthusiastic expression as to the success of the proposed undertaking. We exchanged our last farewells that night.

He went to bed at half-past eleven o’clock on June 9th, and on the following morning he came down stairs at 8 A.M. When he came down, he complained to his housekeeper of slight giddiness, and she thought he did not walk very steadily. He reclined on the sofa, and said that he should be well again in a few minutes, but that he did not think he could eat any breakfast. Soon after, however, he got up, said he felt very hungry, and ate a very hearty breakfast. When this was done, he proceeded to write a portion of the manuscript of the work on anæsthetics now published. He had written to the last printed sentence, when his housekeeper, who had scarcely left him, heard a great noise, as if some one had fallen. She ran up again and found her master on the floor, making vain endeavours to regain his chair. He does not appear to have had any convulsions, and his consciousness was unimpaired, for he remarked when his housekeeper came into the room, that though he did not quite understand the nature of his complaint, he was very sure he never had had any such symptoms before. His housekeeper observed that he had quite lost all power over his left arm and leg, and that his mouth appeared drawn to the right side. She had him lifted on the sofa; and here he remained for twenty-four hours before any medical assistance was sent for. This was his own wish, as he said he should soon be better, and that he did not wish to trouble any one. During this period he complained much of pain over the lower end of the sternum, which he endeavoured to relieve by frequent inhalations of sulphuric ether, but he neither ate nor slept the whole time. At 6 A.M. on the morning of Friday, June 11th, retching came on, and he vomited a considerable quantity of blood. Upon this his housekeeper sent for Dr. Budd, who, along with Dr. Murchison, continued to attend him to the last. His symptoms, when seen by these gentlemen, were briefly as follows:—Complete paralysis of motion over the whole of the left side of the body, but without loss of sensibility; the left angle of the mouth falling down, and the apex of the tongue deviating to the left; memory and consciousness were unimpaired; there was pain and great tenderness in the epigastrium, with urgent hiccup and hæmatemesis; there were slight indications of albuminuria, but there were no dropsical symptoms.

The hæmatemesis ceased after about twenty-four hours, but the vomiting and hiccup continued. By Monday, the 14th, these symptoms also had subsided, but others of a more alarming nature began to show themselves. The pulse and respiration became accelerated, the countenance and extremities became livid, and there was occasional wandering delirium. These symptoms gradually increased in severity; but he retained his consciousness until 11 A.M. of Wednesday, June 16th, when the breathing became stertorous, and deglutition impossible. Throughout his illness, he had been sanguine of recovery, and expressed his belief frequently that he should soon be at his professional work again. On this, the last morning of his life, the fact of the danger in which he was placed was explained. He met the intelligence with calmness, but felt a wish to see Dr. Todd. Soon he sank into a somnolent state approaching to dissolution, and at 3 P.M. death took him.

On the Monday following, Dr. Snow was buried at the Brompton Cemetery. It was the wish of many of his medical friends to follow him to his last home. But his relations, recalling his own unostentatious feelings, laid him in the grave in simple ceremony; and there, ingenuous friend, in the sleep that knows no waking, he sleeps on and takes his rest; the rest he has earned. The old changes of the world live after him, women mourning for their children; youths exulting on the marriage day; the inanimate returning to the elements; the animate returning to the infinite. But in the gaping time shall it chance rarely, for another science-man to come and go, who, taking him all in all, may call him “brother”!

HISTORICAL INTRODUCTION.

The most important discovery that has been made in the practice of medicine since the introduction of vaccination, is, undoubtedly, the power of making persons perfectly insensible to the most painful surgical operations, by the inhalation of the vapours of ether, chloroform, and other agents of the same kind.

In giving a brief outline of this discovery, it is necessary to inquire into the attempts of every kind which had previously been made to prevent severe pain; and also to notice the history of medicinal inhalations, whether undertaken with the view of preventing pain, or of relieving or curing disease.

The practice of taking opium and other vegetable narcotics, to relieve pain or procure sleep, was common in the most remote periods to which history extends; but the earliest notices which remain of any attempts to prevent the pain of surgical operations were written at the period of the Roman Empire. They were alluded to by Dr. Simpson at the Medico-Chirurgical Society of Edinburgh in November, 1847. Dioscorides, speaking of mandragora, says, “Some persons boil the root in wine down to a third part, and preserve the decoction, of which they administer a cyathus (rather more than an ounce and a half) in want of sleep and severe pains of any part, and also before operations with the knife or the actual cautery, that they may not be felt.” (Ante sectiones ustionesve, ut ne sentiantur.) Further on he says: “A wine is prepared from the bark of the root without boiling, and three pounds of it are put into a cadus (about eighteen gallons) of sweet wine, and three cyathi of this are given to those who require to be cut or cauterized: when being thrown into a deep sleep they do not feel any pain.”

The same author also adds, in speaking of a kind of mandragora called morion, “They relate that a drachm of it being taken as a draught, or eaten in a cake or other food, causes infatuation, and takes away the use of the reason. The person sleeps without sense, in the attitude in which he ate it, for three or four hours afterwards. Medical men also use it when they have to resort to cutting or burning.”

In treating of mandragora, Pliny remarks that the juice of the leaves is more powerful than the preparations made from the root. He says, “Some persons even die from a considerable draught. It has the power of causing sleep in those who take it. The dose is half a cyathus (six drachms). It is taken against serpents, and before cuttings and puncturings, lest they be felt. For these purposes it is sufficient for some persons to have sought sleep from the smell (of the medicine).”

Apuleius, under the head mandragora, says, “If any one eat it he will immediately die, unless he be treated with butter and honey, and vomit quickly. Further, if any one is to have a limb mutilated, burnt, or sawn, he may drink half an ounce with wine, and whilst he sleeps the member may be cut off without any pain or sense.”

After reading the above passages from such well-known authors, it may be asked how it was that the practice of preventing the pain of surgical operations was entirely unknown just prior to 1846.

The reason, no doubt, was that the statement these passages contain was looked upon as a vulgar error of the period, which had imposed on the credulity of the authors. Dr. Woodville, speaking of the use of mandragora by the ancients, says, “They employed it principally in continued watchings, and in those more painful and obstinate affections which were found to resist less powerful medicines.” He gives, in a foot note, a reference to the place in Dioscorides from which the passages above quoted are taken, and had he believed in the performance of operations without pain, we may conclude he would not have passed over so important a fact in silence.

With the knowledge we at present possess, however, a different view must be taken of the subject; and it must at least be allowed that the statements of the ancients had some foundation in truth. This is rendered more certain by the circumstance that atropa mandragora belongs to the same genus as belladonna, which has a greater power in annulling the common sensibility than any plant in present use, unless it be aconite. The loss of reason, described by Dioscorides as caused by mandragora, is a striking symptom of poisoning by the class of plants (the solanaceæ) to which it belongs. It appears from some remarks of Aretæus and Cælius Aurelianus that people were in the habit of taking mandragora as an inebriating agent in the time of the ancients, as an allied plant, the datura, is used at present by the natives of India. This practice would lead to a correct knowledge of the quantity which might be taken with impunity.

The mandrake is scarcely used in medicine at present, but its narcotic properties are well established. Hoffberg administered the root in doses of three grains in some cases of gout, with the effect of relieving the pain.

Cases of poisoning by belladonna end, with very few exceptions, in recovery, however large the dose, and however alarming the symptoms may be; and, taking all the above circumstances into account, it is probable, that after ascertaining the right quantity to be administered for the purpose, this medicine or mandragora might be used, with considerable success, and no great danger, to prevent the pain of operations, if chemistry had not supplied us with agents much more convenient.

Not many ages after the Greek and Roman authors above quoted were describing the effects of mandrake in preventing the pain of operations, another plant, the Indian hemp, was employed for the same purpose in a more remote part of the world. M. Stanislas Julien, in an article on Chinese Medicine, gives a notice of a work entitled “Koukin-i-tong, or a General Collection of Ancient and Modern Medicine,” in fifty volumes, 4to., and makes an extract from it respecting Hoa-tho, a practitioner, who flourished under the dynasty of Wei, between 220 and 230 of our era. Respecting Hoa-tho, it is stated that—“When he found that it was necessary to employ acupuncture, he applied it in two or three places; he did the same with the moxa, if it was indicated by the nature of the affection which he had to treat. But if the malady was situated in parts on which the needle, the moxa, or liquid medicines could not act—for example, in the bones, in the medulla of the bones, in the stomach, or the intestines, he gave to the patient a preparation of hemp (Ma-yo), and, at the end of some instants, he became as insensible as if he had been drunk, or deprived of life. Then, according to the case, he made openings and incisions, performed amputations, and removed the cause of mischief; he then brought together the tissues with points of suture, and applied liniments. After a certain number of days (at the end of a month, according to the annals of the later Hân) the patient found himself reestablished, without having experienced the slightest pain during the operation.”

We are not informed of the way in which the hemp was administered. If insensibility was caused so quickly, as is stated, it must have been by inhaling the fumes of the hemp when exposed to heat, and not by taking it into the stomach. This view of the matter is rendered more probable by the circumstance that the ancient Scythians were in the habit of inhaling the fumes of hemp, several centuries before the time of Hoa-tho, and also by the practice of the Hindoos at present, who inhale the fumes of hemp from a pipe. The remark that the patient became reestablished at the end of a certain number of days, must refer to his recovery from the wound caused by the operation, and we are not informed how long the state of insensibility continued.

The next notice of any attempt to prevent the pain of operations, that I am aware of, occurs in the work on Surgery of Theodoric, an author who lived in Italy in the latter half of the thirteenth century. He writes as follows: “The making of a flavour for performing surgical operations according to Dominus Hugo. It is thus made:—take of opium, of the juice of the unripe mulberry, of hyoscyamus, of the juice of hemlock, of the juice of the leaves of mandragora, of the juice of the woody ivy, of the juice of the forest mulberry, of the seeds of lettuce, of the seeds of the dock, which has large round apples, and of the water hemlock [cicuta]—each an ounce; mix all these in a brazen vessel, and then place in it a new sponge; let the whole boil, as long as the sun lasts on the dog days, until the sponge consumes it all, and it is boiled away in it (the sponge). As oft as there shall be need of it, place this sponge in hot water for an hour, and let it be applied to the nostrils of him who is to be operated on, until he has fallen asleep; and so let the surgery be performed. This being finished, in order to awaken him, apply another sponge, dipped in vinegar, frequently to the nose, or throw the juice of the root of fenugrek into the nostrils; shortly he awakes.”

I altogether disbelieve that a sponge, prepared as above, would, after being placed in hot water, give off any odour or vapour which would cause insensibility. The active ingredients, as they exist in the various plants, are not sufficiently volatile to be given off at a heat below that of boiling water. Hemlock, indeed, contains a volatile principle, which can be liberated by an alkali; but, even if it were set free by any chance during the preparation of the sponge, it would all be dissipated by the long boiling.

If sleep were really caused in this way, it must have been by some of the moisture from the sponge reaching the mouth or throat, and being swallowed; and it may be remarked that the author speaks of the preparation of a taste or flavour (confectio saporis), rather than an odour, although the sponge is certainly directed to be applied to the nostrils. It must be remarked, also, that if the patient were made so insensible, as not to feel the surgeon’s knife, he would be little affected by vinegar, or the juice of fenugrek, in his nostrils.

Immediately after the prescription quoted above, and in the same paragraph with it, Theodoric gives another recipe from Master Hugo, directing antimony, quicksilver, soap, quick lime, and a little arsenic, to be sublimed together. A portion of the resulting compound, the size of a nut, is directed to be placed over a hernia, or whatever else is to be operated on. Then follows a rather lengthy direction for subliming arsenic, also from Dominus Hugo. The arsenic so sublimed is described as rendering surgical operations extremely pleasant. The words are—“hæc acus fiat mitis et suavis: sicut sudor beatæ virginis quum peperit Christum.”

I have applied arsenic to the skin for twenty-four hours, with no other effect than irritation, and an eruption of pimples, the sensibility of the part being increased; and in my opinion, arsenic would not cause insensibility, unless it were applied so long that the inflammation caused by it should end in gangrene. I consider that the statement of Theodoric, respecting arsenic, strengthens the doubts I have expressed concerning his spongia somnifera. There is another reason for disputing the efficiency of the above mentioned recipes. Theodoric directs the patients about to undergo operations to be tied, or held by strong men. In the operation for hernia, for instance, he directs the patient to be tied to the bench, or table, with three bands, one round the ankles, another round the thighs, and a third across the chest, holding the arms and hands. This circumstance is the more significant, since Theodoric had lived some time with Hugo, and seen his practice, as he states in the dedication to his work.

It is reasonable also to conclude that if any successful plan of preventing the pain of surgical operations had been introduced after the revival of literature, it would not have fallen into disuse and been forgotten.