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the Edinburgh Monthly, or the Lancet ; others, mere lecturenotes, the dry bones which their author could so readily make live in the fervour of his popular discourses.
In many of the controversial papers, especially those on Hospitalism, we labour under the disadvantage of having one aspect only of the subject presented to us; no opinions could therefore be passed upon the points at issue without such an examination of all the arguments as would be impossible in the present notice. We shall content ourselves by giving a short résumé of the three subjects—anæsthesia, hospitalism, and stamping out disease—from the author's point of view, and referring those who take a more special interest in them to the volume itself, which although made up of chips, as it were, from a great workshop, representing disconnected thoughts rather than mature opinions on some of the great medical and sanitary problems of the day, is undoubtedly of very great interest, and of no mean practical value.
The ancient history of anæsthesia, or nodynia (vwovvia), as Theocritus (* Idyll, 18) perhaps more properly calls it, is vague and unsatisfactory, notwithstanding that allusions are frequent to drugs possessing the power of alleviating pain. Indian hemp was used as early as the third century among the Chinese and in the East generally. The Mandragora officinalis (the basis of the spongia somnifera in the thirteenth century) is extolled in the highest terms by Dioscorides (iv, 76):
“There is prepared also, besides the decoction, a wine from the bark of the root, three minæ being thrown into a cask of sweet wine; and of this three cyathi are given to those who are to be cut or cauterized, as aforesaid; for being thrown into a deep sleep, they do not perceive pain."
With the commencement of the present century we reach the second or modern stage of anæsthetics in the suggestion of Sir Humphry Davy, that,
“As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.”—(* Chemical and Philosophical Experiments,' p. 464.)
Little attention, however, seems to have been paid to these discoveries until nearly half a century later, when the scene is shifted to America, and we there see the earliest operations performed under the influence of sulphuric ether and nitrous oxide gas. The dates and order of sequence in these discoveries, long the subject of dispute, are given by Sir James Simpson as follows:
(1) On December, 11th, 1844, Dr. Wells had at Hertford, Connecticut, one of his molar teeth extracted without pain, after having deeply breathed nitrous oxide gas. The idea had been suggested to him by seeing Mr. (now Colonel) Cooley at a lecture on the previous evening wound his limbs severely against the benches while under the influence of the gas, without feeling any suffering from these injuries.
(2) On the 30th September, 1846, Dr. Morton, a former pupil and partner of Dr. Wells, extracted a tooth without pain whilst the patient was breathing sulphuric ether—this fact making a new era in anæsthetics and in surgery.
(3) On January 19th, 1847, the first case of midwifery in which sulphuric ether was adopted as an anæsthetic occurred at Edinburgh, under Sir James Simpson's care, before any case was tried in Boston or America.
(4) On November 15th, 1847, the anæsthetic effects of chloroform were discovered in Edinburgh, and this drug soon superseded all rivals in Scottish and English practice.
The opposition raised in this country to the use of chloroform, not only in midwifery, but in every form of surgical operation, can only be compared to that which had assailed the introduction of vaccination some forty years before. Childish and absurd as the arguments appear now, they had a real existence at the time, and had to be met vigorously by those who strove for the advance of truth and knowledge. Foremost among these was Sir James Simpson, and more than half of the volume we are reviewing is devoted to the defence of anæsthetics against their persevering and powerful detractors.
The objections raised to the practice of anæsthesia may be conveniently divided into those resting on moral, and those resting on physiological grounds. Some of these, perhaps most of them, have been consigned to the limbo of past experiences, dead faiths, and obsolete superstitions ; others still hold their ground as strongly now as then, and sometimes thwart the physician in his endeavours to mitigate suffering or defeat disease. We suppose there are few mothers even now in the middle classes in England and in the more educated of the lower classes who would not quote the words of the original curse in Genesis (iii. 16, 17) against the exhibition of chloroform during labour. Yet the Hebrew text, if rightly translated, would seem to bear a very different meaning to that offered in our English Bibles:
“16. Unto the woman he said, I will greatly multiply thy sorrow ('itztzabhon) and thy conception; in sorrow ('etzebh) thou shalt bring forth children; and thy desire shall be to thy husband, and he shall rule over thee.
“17. And unto Adam he said, Because thou hast hearkened unto the voice of thy wife and hast eaten of the tree, of which I commanded thee, saying, Thou shalt not eat of it: cursed is the ground for thy sake ; in sorrow ('itztzabhon) shalt thou eat of it all the days of thy life.”
On this Sir James Simpson remarks:
“The state of anæsthesia does not withdraw or abolish that muscular effort, toil or labour; for if so it would then stop and arrest entirely the act of parturition itself. But it removes the physical pain and agony otherwise attendant on these muscular contractions and efforts. It leaves the labour itself ('etzebh) entire. And in relation to the idea that the Hebrew noun in the text truly signifies muscular toil and effort, and not physical pain and maternal agony, it is further highly important to remark that in the very next verse (17), viz., in the first part of the curse on man—the analogous Hebrew noun ('itztzabhon) which we translate by “sorrow," does not in any degree mean or imply mortal suffering or pain, but toil and labour. In sorrow shalt thou eat of it (the ground) all the days of thy life' (p. 47).
If, on religious grounds, your obstetric friends object to relieving a woman entirely of her worst pains, now that they have the means of doing so, they must, on the very sane grounds, refuse to relieve her imperfectly and partially of these or any other pains and sorrows connected with parturition; they must, or, at least, ought to abstain, in fact, from all obstetric practices whatsoever; they should, in short, give up their present profession as a profession of sin-and in the sweat of their face' eat bread” (p. 59).
Another form of objection was that the use of anæsthetics must be irreligious, for it is so very“ unnatural:”—
“I do not,” writes an esteemed teacher of midwifery from Dublin, “ believe that any one in Dublin has as yet used ether in midwifery; the feeling is very strong against its use in ordinary cases, and merely to avert the ordinary amount of pain which the Almighty has seen fit-and most wisely we cannot doubt-to allot to natural labour; and in this feeling I heartily and entirely concur.
Sir James Simpson playfully applies a like line of argument to the first introduction of carriages into use, and thus shows its absurdity S
“I do not believe that any one in Dublin has as yet used a carriage in locomotion. The feeling here is very strong against its use in ordinary progression, and merely to avert the ordinary amount of fatigue which the Almighty bas seen fit-and most wisely we cannot doubt-to allot to natural walking; and in this feeling I heartily and entirely concur."
In reading Part II, which is concerned with the defence of anæsthesia, it is difficult to realise that we are dealing with arguments used so late as 1847, though it affords another proof how
fast the world is advancing, and how different the thoughts of to-day are from those of even twenty years ago :
"At a meeting of the South London Medical Society held in April last (1847) Dr. Gull read a paper on the injurious effects of ether inhalation, and ended his communication with queries as to the desirability of removing pain,' &c. Mr. Bransby Cooper, Surgeon to Guy's Hospital, afterwards affirmed it as his opinion that pain was a premonitory condition no doubt fitting parts, the subject of lesion, to reparatory action, and therefore he (Mr. Cooper) should feel averse to the prevention of it” (p. 81).
Thanks to the efforts of Sir James Simpson and his fellowworkers, the terrors of operating have almost ceased to exist, and the worst agonies of human suffering have been banished for ever. So little indeed do we of the present generation know of the mental and physical suffering with which our fathers were so familiar, that the eloquent letter from a distinguished surgeon, himself the subject of operation before the days of anæsthetics, will not be without interest at the present time. We have only space for one or two short quotations :
“Suffering so great as I underwent cannot be expressed in words, and thus fortunately cannot be recalled. The particular pangs are now forgotten ; but the black whirlwind of emotion, the horror of great darkness and the sense of desertion by God and man, bordering close upon despair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so.
“ From all this anguish I should of course have been saved had I been rendered insensible by ether or chloroform or otherwise before submitting to the operation.
When I made up my mind to submit to the operation proposed to me, it was with the fullest conviction that the pain it would occasion would far exceed my power of patient tolerance, and I prepared for it simply as for a dreadful necessity from which there was no escape, I awoke each morning from troubled sleep to reconsider the whole reasons for and against submitting to the surgeons, and by a painful effort reached again the determination not to draw back from my first resolution. From all this distracting mental struggle, which reacted very injuriously on my bodily constitution, I should have been exempted had I been able to look forward to the administration of chloroform.
The sum you will perceive of what I have been urging is that the unconsciousness of the patient secured by anæs· thetics is scarcely less important than the painlessness with which they permit injuries to be inflicted on him” (p. 86 et seq.).
To meet objections of a different type, and from a medical point of view, more formidable than those we have already noticed, Sir James Simpson instituted an elaborate inquiry into the result of operations before and after the introduction of anæsthetics—an inquiry which proved, so far as limited figures
could prove, that the risks to life had been reduced; that “the fatality,” for instance, following amputation of the thigh was not greater than one in every four operated upon when the patients were previously anæsthetised. It was as high as one in every two or three operated upon when the patients were not previously anæsthetised” (p. 105). And again, of labour, he says:
“In cancelling the pains of parturition by anæsthesia we also, I believe, to a great extent cancel the perils of the process ; for the mortality accompanying labour is regulated principally by the previous length and degree of the patient's sufferings and struggles. In the Dublin Lying-In Hospital, when under Dr. Collin's able care, out of all the women, 7050 in number, who were delivered within a period of two hours from the commencement of labour, 22 died, or i in every 320; in 452 of his cases the labour was prolonged above twenty hours, and of these 452, 42 died, or 1 in every 11-a difference enormous in its amount, and one surely calculated to force us all to think seriously and dispassionately of the effects of severe suffering upon the maternal constitution" (p. 113).
Of the dangers of chloroform Sir James Simpson thought very lightly. After once beginning its use at an obstetric case, he generally left its exhibition to be continued by the nurse, or by any intelligent friend of the patient who might be in the room. “Some of our midwives,” he says, use it in the cases which they themselves attend” (p. 146). Nor did he think the deaths, attributed to its use, were due so much to the anæsthetic as to the violence or shock of the operation; a position which he fortifies by several interesting examples (p. 151, 152) of deaths under operation where, had the anæsthetic been applied, it would undoubtedly have gained the credit or rather the discredit of the catastrophe.
Part III is occupied with lecture notes and personal experiments on various anæsthetic agents then new and unexplored, but which are too well known at the present day to require special notice at our hands.
The same may be said of much in Part IV, which treats of “the applications of anæsthesia in surgery and medicine.” Directions for the exhibition of chloroform now familiarised by repetition are here found in their original form, and it is no mean proof of Sir James Simpson's accuracy and foresight that they should have undergone changes so slight and insignificant in a practice of twenty years. His summary of rules for the exhibition of chloroform in parturition may be adduced in illustration of what we have advanced :
“Begin the inhalation of chloroform when the patient complains of much pain. This is generally towards the end of the first stage.