The Ancestors of Inhalational Anesthesia: The Soporific Sponges (XIth–XVIIth Centuries)
Philippe Juvin|Jean-Marie Desmonts
THE history of anesthesia is intimately linked to the surgery. The textbooks Hippocratic Collection, which are oldest surviving books Western medicine, describe a number elaborate surgical techniques. 1These procedures must have necessitated that patient remained perfectly still, suggesting restraints were probably used, and some degree analgesia or partial alteration consciousness. Methods available at time obtain adequate operating conditions included application heat cold, jugular vein compression, 2and oral administration alcoholic beverages potions prepared from plants with sedative effects. Sedative substances inhaled time, but only in nonmedical situations, such as Delphic priestess, who uttered her oracles while trance induced result inhalation hallucinogenic vapors. Because these uses inhalation, contemporary authors consider for purposes was first used during XIXth century, 1846 3.However, methods Middle Ages Europe. 4The technique consisted placement sponge soaked juices hypnotic properties under nose patient. current article describes changing composition soporific sponges centuries conflicting opinions about their effectiveness.At councils held by Roman Catholic Church VIth bishops world urged attend diligently duties hospitality assistance. They invited set up hospitalia near residences, offering beds crippled needy. 5Little little, created rural parishes, along roads (most notably those traveled pilgrims), monasteries, or, sometimes, Saint Martin de Tours (France), important shrines. Supported Carolingian kings, became entirely affair Church. therapeutic activity developed form inpatient medical practice until least XIth century. To pass on knowledge comply directives Aix-la-Chapelle Council (ad 817), made reading copying manuscripts mandatory all monastic orders, hospital monks medieval botany, pathology, pharmacology. Monte Cassino Abbey (Italy) particularly active this respect, attested De innumeris morbis remedorium utilitatibus (credited Abbot Bertharius), translations compilations Constantinus Africanus (circa 1015–1087). 5One contains formula known date (see Appendix). sentence leaves no doubt surgery it contained administered inhalation:This preparation be (Id est somnificum…soporati ), appropriate (his qui chirurgia curatur so one can cut without causing pain (aut sectionis dolorem non sentiant ).The word soporati confirms aim procedure actually even if cannot exclude acted through nasal absorption. Opium (opiu thibaicu mandrake (mandracore sucus hemlock (cicute henbane (iusquiami secu ) macerated certain quantity water (cum aqua sufficiente soak (spungie then dried sun (infundis calida ). When perform operation, hot applied still damp nostrils (naris adponis induce loss consciousness (ut ad se ipsum rapiat spiritum, donec dormiat At end another (altera spongia vinegar (aceto calefacto wake 6,7Three arguments suggest Arabs. 8First, many Arab texts translated period. Second, Christians widely an anesthetic wounded. However, Muslims prohibited religion drinking alcohol, fact may prompted them seek alternatives. Last, most important, School Alexandria, dating same period Cassino, contain formulas virtually identical manuscripts. 9Therefore, there strong evidence that, starting century Europe, relief relied taught, monks.Until XIIth however, medicine taught primarily allowing young accompany more experienced brothers they cared patients. Later, manuscripts, captured reliable way allowed reach beyond geographic confines abbey. In Salerno Europe teach laymen, using ideological corpus circulated title Articella (Little Art). 10This structured teaching gave preeminence over offered monasteries. Roger Frugardi, Practica Chirurgiae (1170) Nicolas Prepositus, dean Salerno, Antidotary (1471) 11both described formula. This includes ingredients formula, lettuce seeds (seminis lactuce poppy seed pods (coconidii papaveris climbing ivy (succi edere arborea immature blackberries rubis Fennel roots introduced into patient’s awakening after operation.During XIIIth middle XIVth three universities exercised monopolistic hold Europe: Bologna, Montpellier, Paris. 10Hugh Lucca (1180–1252) famed practitioners Bologna. He his pupil Theodoric (who died 1298) Cyrurgia (1264). 6,12The chapter describing (De somniferis et sublimationibus indicates very clearly intended sleep. Its complex than previous formulas, although exact nature its controversial. addition succi mori sylvestris (bramble berry juice), seminis lapathii , conidium added. terms “seminis ” “conidium illustrate formidable challenges raised translation texts. It has been suggested lapathum lapacium (burdock), polygonaceae (sorrel), chenopodiaceae (spinach), Landolphia Acocanthera, two Somali people poison arrowheads brought crusaders. As (or coconidium spelling cocognidium, vulgar Latin coccum-gnidium. Coccum means “berry” gnidium “daphne,” daphne 13. Gilbertus Anglicus (1180–1250) blackberry should eliminated vinegar-soaked rubbed against teeth. 8The school Bologna attracted students throughout Christendom. Soporific frequently mentioned writings physicians trained slight variations development attributed Guy Chauliac (1300?–1368), former student physician popes Avignon 20 yr. His Chirurgia magna Inventarium he completed 1363, occupied place prominence literature Ages. 12,14Treatise VI, doctrine I, VIII provides opium, black nightshade juice, henbane, mandrake, ivy, hemlock, lettuce. A fennel (inserted ears) 15The high quality work Chauliac, relatively wide circulation recent invention printing (more 40 editions printed France), languages (Italian, English, Hebrew, Dutch, French, Spanish, Provençal) Chauliac’s sponges: adopted European surgeons 2 12. During XVIth Ambroise Paré (1509?–1590) it, few changes:He (the patient) will smell flowers, lilies, crushed vinegar, rose water, camphor mixture. Held long enough nose, allow travel brain, sleep.No mention found written late XVIIth afterward. reason unclear. There possible explanations. First, outside field magic. 1589, renowned botanist John Baptista della Porta (1535–1615) wrote Magiae Naturalis apple derived Chauliac. 16However, suspected dabbling occult blamed Pope Paul V 1578. 17This had negative effect reputation sponges. More generally, political climate Inquisition (1542) Index Forbidden Books (1559), contributed disappearance previously accepted techniques, especially when recommended nonconformist minds Porta’s. discarded because recognized ineffective. possibility discussed further on.Toward considerable popularity (of nitrous oxide ether) drew attention Toulouse, Dauriol. Dauriol bold anesthetize several patients use nightshade, stramonium, piece cloth Dauriol’s description experience five published Lancet . 18The amputation finger, removal tumor eyelid, repair anal fistula, breast size hen’s egg, fingers. cases, duration extremely short. explained last case, operation took longer, provided inadequate. After discovery ether, chloroform, rapidly discarded, our never since studied humans. XXth Baur, 1924 19in Switzerland, Infusino, 1989 Californis, 20evaluated effectiveness small rodents. Baur Infusino Neither able sleep study animals.The four earliest henbane. extracted pods, already ancient Greece Rome. therefore not surprising opium consistently 19Hemlock also times: drink carry out death passed Socrates. ingredient conicine cicutine), responsible paralysis sensation. 21,22Henbane alkaloids (hyoscyamine, hyoscine, scopolamine), ability cause parasympathetic system depression produced sedation. Mandrake Egypt, Greece, narcotic effects potentiated superstition surrounded it. 23,24Henbane analgesic Dioscorides 1st century) 21. before sponges, neither nor inhalation.Therefore, true properties. other added, lettuce, blackberry, bramble, daphne, enigmatic lapathum. level essential solutions, increased pods. i.e. hyoscyamine solanine, respectively, depress thus caused 21Blackberry bramble chosen astringent properties, decreased production pharyngeal secretions. We satisfactory explanation ivy. Daphne added simply mask unpleasant ingredients, hemlock. Finally, depresses system. Thus, mixture depressing (potentially sedation), analgesia), paralysis).Several lines effective, including presence sedative, analgesic, perhaps muscle-relaxing effects, previously; accounts own practice; finding nearly 7 centuries. sudden fall disuse failure modern investigators find sleep-inducing seem tell different story. Sponges considered effective initially, favorable impetus needed drive continued centuries, despite gradual finally opinion changed discarded. Four militate favor hypothesis.First, concept centuries: sedation acceptable viewed inadequate later; way, standard postoperative recently reappraised 25Also, early short superficial cito, tuto jucunde (fast, unerringly, harm). Some lasted seconds (e.g. repositioning dislocated joint, realignment fractured bone fragments, amputation) could performed limited relief. worth noting reported underwent unusually long-duration procedure.Second, raises significant difficulties progressive changes grammar vocabulary, widespread abbreviations, frequent errors invented. addition, accurate identification difficult commonly admitted nomenclature XVIIIth inaccuracies factors perpetuated amplified copied again. result, preparations, and, consequently, effectiveness, gradually.Third, old provide little information practical aspects use, season picked, amounts (duration exposure patient, type breathing instructed adopt, expected effects). transmitted orally beginning forgotten distorted.Fourth, scholasticism, fostered ineffective 10Scholasticism emphasized logical argumentation theoretical debate rather experimental science. Teachers often quoted aphorism “experimenting misleading.” philosophy, empiric evaluations would encouraged performed. These practices obviously valid existed. survived lost part effectiveness. Together, considerations first, gradually succumbing dual blow infamous magicians anesthetics predictable effects.Soporific example pharmaceutical capable inducing inhalation. measure any case performance short-duration time. Perhaps imperfect transmission resulted Such prevalent view useless dangerous challenge established practices. Yet, stands testimony compassionate desire relieve ease agents, cornerstone anesthesiology.The author Philippe Juvin thanks Pierre Rézé (teacher Classics, Paris, mark gratitude enriching exceptional humanities, Professor Danielle Gourevitch (Ecole Pratique des Hautes Etudes, France) cultured lectures.Formula 6Id somnificum conveniens curatur, aut nonori soporati. Recipit hec : opiu semis uncia, mandracore ex foliis uncie octo, cicute uiridis sucus, iusquiami tres unum cum sufficiente, ut sucum faciat spungie rude sicca redigis diligenter bis. Et dum uti uoleris ipsa spongia, hora infundis naris facit, dormiat. expergisci uolueris altera aceto infusa naribus apponis sompnum solues.
Anesthesiology|PubMed