Doctor's Review: Medicine on the Move

August 16, 2017

© Medicine: An Illustrated History (Harry N. Abrams, 1978)

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A real knockout

Medieval medicine's version of anesthesia was oftenworse than surgery itself

Europe in the Middle Ages was about as bad a time and place to be a patient as there ever was. Murky, religious superstitions superceded reason in virtually every arena of life, from agriculture and education to politics and medicine. Childbirth was often a death sentence, diseases were worsened by the cures, and forget about any sort of trauma: surgery, sutures and broken bones were universally feared and endured. Pain and suffering were a part of life, whether you were a serf or an aristocrat.

From ether to opium

Better almost to have had a baby in Sumeria around 3400 BC when narcotic blessings were already wafting up from the opium fields. Or to have broken a bone in the time of Hippocrates when there was at least decent knowledge of anatomy and splinting. Or to have needed your gallbladder out in the medieval Middle East where doctors were already using narcotics to put patients out by the 11th century. In Europe and North America, millennia later, soldiers were still being offered shots of bourbon and leather straps to bite down on to endure battlefield amputations.

Aside from a few painkilling blips here and there, it wasn’t until the 19th century that true relief from surgery reached the West. Sympathetic Boston dentists Horace Wells (1815-1848) and his student William Morton (1819-1868) paved the way using first nitrous oxide and then ether in the 1840s. Not long after, Scottish obstetrician James Young Simpson (1811-1870) used chloroform to knock patients out during childbirth. Soon after, Queen Victoria somewhat notoriously made it okay to fly in the face of religious tradition and defy the curse of Eve accepting chloroform during the births of her last two kids. Opium came into widespread use in the 19th century, though as much for its recreational effects as for its medicinal qualities.

Recipe for disaster

Yes, up until relatively recently, prayer and potions were all that could be offered to the bleeding, bulging masses. Then, somewhat suddenly in the mid 12th century, a potion called dwale took root throughout Europe and it remained the closest thing to anaesthesia that the continent had for a solid 400 years.

Numerous manuscripts sing the wonders of this thing called “dwale” and the recipe was shared throughout the continent. The name itself, which appears in Chaucer’s Canterbury Tales, is believed to come from the Scandinavian word dool, meaning sleep, or perhaps from the French term for grief, deuil.

In its various forms, the typical recipe calls for a mingling of a few relatively inactive ingredients like local roots, lettuce, bryony (a flowering plant), and the bile or gallbladders of neutered pigs or goats, as well as a hodgepodge of deadlier herbal counterparts like opium, hemlock, belladonna and henbane.

A good recipe became all the rage and physicians had their favourites. More than 50 separate manuscripts exist detailing different ways to concoct the potion, though some made the rounds more than others, such as the following popular version:

“How to make a drink that men call dwale to make a man sleep whilst men cut him: take three spoonfuls of the gall [bile] of a barrow swine [boar] for a man, and for a woman of a gilt [sow], three spoonfuls of hemlock juice, three spoonfuls of wild neep [bryony], three spoonfuls of lettuce, three spoonfuls of pape [opium], three spoonfuls of henbane, and three spoonfuls of eysyl [vinegar], and mix them all together and boil them a little and put them in a glass vessel well stopped and put thereof three spoonfuls into a potel of good wine and mix it well together.”

It was a heady concoction, to be sure. Opium’s qualities were already well known in Europe, though finding it wasn’t always easy since its use had been banned by the Church because they considered anything remotely Eastern taboo. Fortunately, there was wild poppy to fall back on (indigenous to parts of Europe). Hemlock was a good fit too: its fatal paralytic qualities were favoured among poisoners since Ancient Greek times when Socrates was infamously killed himself by drinking it.

Home remedies from hell

Belladonna (aka deadly nightshade, devil’s berries, and naughty-man’s cherries) also had a deadly reputation and deservedly so: its roots, leaves and berries were well-known as a soporific, used to induce hallucinations among witches (who were also rumoured to rub it on their skin to help them fly) and devil-worshippers. The tropane alkaloids within belladonna do indeed have a strong effect on the central nervous system, producing stupor and a variety of mostly unpleasant side effects, and are toxic at certain levels. Two pesky Roman emperors met their ends courtesy of their wives’ familiarity with belladonna, and a Scottish lieutenant by the name of Macbeth, who would later become king, used it to poison Danish troops’ liquor and then slaughtered them in their sleep.

Henbane, similar to belladonna in structure, contains the same pharmaceutically significant alkaloids like hyoscyamine, scopolamine and atropine. And both belladonna and henbane poisoning can be an ugly affair, even at low doses: vomiting, delirium, hallucinations, violence and seizures. Henbane — aka black or stinking nightshade, devil’s eye and Jupiter’s bean — would later rise to literary infamy courtesy of Shakespeare: Hamlet’s father used it to poison his brother by pouring it into his ear as he slept. That literary murder was in fact inspired by a real 1538 event when the Italian Duke of Urbino was done in by his barber.

And what of the medieval surgical patient put out with dwale? Waking him up afterwards was as simple as “dabbing the temples with vinegar and salt,” according to one manuscript. Unfortunately, that was not always the case, for while this creative combination had the desired effect of rendering the patient unconscious, it was all too often a permanent state. Even worse, if the hapless toothache sufferer did indeed wake up and the operation was a success, the after effects of dwale might include memory loss, nervous system impairment, even insanity.

The dwale of choice

The obvious effects of imbibing dwale meant that while it may have begun as a secret passed around by monks and then physicians and then barber surgeons, black-market anaesthetics became highly sought-after. It wasn’t long before housewives were trading dwale recipes and administering homemade concoctions themselves. As such, its use evolved from a surgical anaesthetic to a sort of painkilling panacea used for any complaint, from back pain and muscle spasms to relief from the plagues and poxes. Despite the fact that dwale was so often deadly, it remained a powerful part of medicine cabinet’s until the 15th century.

At that point, some of the finer ideas of the Renaissance began to take hold in Europe, thanks in large part to Paracelsus (1493-1541), the Swiss-German physician, chemist and botanist. He pioneered the use of “sweet vitriol” (ether), which he said “quiets all suffering without any harm and relieves all pain, and quenches all fevers, and prevents complications in all disease." Unfortunately, he only tested it on chickens, though he did develop a little something called laudanum to help his human patients.

Despite the obvious benefits of this “tincture of opium,” it would be a while before it really took off. Though the English doctor Thomas Sydenham (1624-1689) revived its use in the 1660s, opiate use was slow to catch on in surgical applications, being preferred for mental conditions, menstrual cramps and, of course, recreational enjoyment. It really wasn’t until the 1800s that patients were offered any effective substitute for dwale as a general anaesthetic.

While dwale was not without its problems, it was indeed the forerunner of its kind. Dwale’s combination of opiates and tropane alkaloids, such as those found in belladonna, became the basis for one of the first effective surgical anaesthesia known as “twilight sleep,” developed by German physicians towards the end of the 19th century as a replacement for ether and chloroform. But, as Paracelsus himself so famously put it, “The dose makes the poison…” something that in the world of anaesthesia is as true now as it was back then.

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