625-690: Paulus Aegineta describes asthma

2

Paul of Aegineta was a Greek physician who gives us a very early
description of asthma.  He also provided for us one of the first
histories of medicine, thus preserving the thoughts on asthma
of some of the ancient physicians

So how did the ancients define asthma? To get an answer to this question we need look no further than the 7th century A.D., where Paulus Aegineta gave us a summary of how physicians during his day viewed this ailment (1).

He was born in Aegina in 625, was educated at the University of Alexandria, and grew to become a famous Greek physician.  His name was Paul of Aegina, although he is most known by history as Paulus Aegineta. (2)

He became a very skilled surgeon who provided many achievements in the surgical process.  He was among the first to describe a process called bronchotomy, which was an old term for tracheotomy.  Some consider him the originator of plastic surgery.  (3)

He was also a well known expert on diseases of the heart. (4)  Considering heart disease often caused dyspnea, it was generally thrown under the category of asthma.  

He was also a skilled writer, compiling a condensed account of medicine, from surgery to treatment of diseases such as asthma.  His seven books were interpreted into English in 1744 by Francis Adams titled, "The Seven Books of Paulus Aegineta."  The books not only influenced physicians during Aegineta's era, but subsequent eras including Avecena, Rhazes, Haly Abbas, Albucasis, and Fabricius ab Aquapendente.  (5)

While he is most famous for his surgical wisdom, he does provide accounts of various disease processes, such as asthma, and remedies to treat them.  Most of his ideas were borrowed from ancient writers, which makes him an important figure when trying to compile a history of any disease.

The following is how he, and perhaps the ancients in general, defined asthma. This comes from his book "The Seven Books of Paulus Aegineta" translated by Francis Adams.  (6)

1.  Definition:  "Those who break thick without fever, like those who have run fast, are said to be asthmatic, that is to say, to pant for breFath; and from their being obliged, they are called orthopnic. (6)

2.  Causes:  The affection arises from thick and viscid humours becoming infarcted in the bronchial cells of the lungs. (6)

3.  Symptoms:  Dyspnea is a common symptom which accompanies these and many other complaints. (6)

4.  Treatment:  The indications of cure for asthma is to consume the viscid and thick humour by attenuant and detergent medicines.  Wherefore the vinegar of squills will answer well with them, and the oxymel prepared from it; the baked squill itself will answer well triturated with honey; the antidote called heira, continued purging with drastic medicines, and vomiting from radishes.  And, in like manner, the round birthwort may be drunk, the root of the great centaury, the fruit and root of the cow-parsnip,the fruit of calimint, hyssop, iris, and gith.  Put a sextarius of slaters, into the earthen vessel, roast upon the coals; when whitened, pulverize, and, mixing with boiled honey, give a mystrum thereof before and after food.  If there be any urgent necessity, before doing all these things, open a vein and evacuate proportionably to the patient's strength; and stimulate the belly by clysters.  Externally to the chest we may apply cataplasms from figs, the flour of iris, and of barley, containing rosen, wax, and honey; and iris and manna may be sprinkled upon them.  Some benefit may also be derived from raw barley-flour with rosin, wax, iris, and manna.  We may use the more heating ointments, which as those of iris, dill, and rue.  But the following application is particularly proper: Of pumice stone, p.j; of burnt lees of wine, p.iv; of arsenic, p.j; of the schenanth, p. ij; of alcyonium, p.j; of aphronitrom, p.ij; pound, sift, mix with the ointment, and with it rub the parts about the chest, and use emollient ointments for attracting the humours. (6)

So while he is mostly known as being a prolific surgeon, he also gave us some pretty interesting descriptions of diseases, including asthma.

References:

1. Aegineta, Paulus, "The Seven Books of Paulus Aegineta," translated by Francis Adams, volume I, 1844, The Snydenham Society, pages 289-290  (commentary by Adams can be found on pages 407-09)
2. Greeka.com, "Paulus Ageneta: The most important physician of Aegina Greece, Saronic," http://www.greeka.com/saronic/aegina/aegina-history/aegina-paul-of-aegina.htm, accessed June 26, 2012
3. Gurunluoglu R, Gurunluoglu A., "Paulus Aegineta, a seventh century encyclopedist and surgeon: his role in the history of plastic surgery," Dec., 2001, 108 (7), 2072-9, based on a review of mentioned article at Pubmed.gov, http://www.ncbi.nlm.nih.gov/pubmed/11743404, accessed June 26, 2012
4. Virginia.edu, "Paulus Aegineta (625-690)," University of Virginia, Vaulted Treasures, http://exhibits.hsl.virginia.edu/treasures/paulus-aegineta-625-690/
5. Gurunluoglu, op cit, 2072-9
6. Aegineta, Paulus, "The Seven Books of Paulus Aegineta," translated by Francis Adams, volume I, 1744, The Snydenham Society, commentary by Adams can be found on pages 407-09
7. Junior, Democratus,  "Anatomy of Melancholy," translated by Robert Burton, 1827, London, Longman, Rees, Orme, and co., page 90
8. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203
9. Drake, Miriam, "Encycopedia of Library and Information Science," 2nd ed., 2003, New york, page 1840
10. "Rhazes and the first clinically exact description of hay fever (seasonal allergic rhinitis)," Iranian Journal of Medical Science, 2010, September, vol. 35, no. 3, 263

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570-1070: Arabs save medicine

As we study medicine it's essential to understand that one author, one physician, one scientists, cannot make accomplishments in medicine without the accumulated knowledge of all who came before him. Lacking such wisdom, no progress in medicine can be made. Stated another way, it would be impossible to hunt for cures without having prior knowledge of such cures.  

Lacking access to knowledge, every person must start from scratch, and by the time he passes away he'd learn no more than the men before him. Thanks to writings, and schools, one man can be taught all ancient wisdom in a few years. Instead of spending a lifetime relearning old wisdom, he can now study something new. He can think of, invent and discover new things.

When the last rung of the Roman Empire collapsed in 476 A.D., the west cast aside all such accumulated wisdom in favor of the Bible. This, perhaps with the help of the Black plague, helped send western civilization -- mainly Eastern Europe -- back to a primitive era where the only medicine was religion. All other knowledge, including medical knowledge, was the antithesis of the road to heaven.

During the same time western civilization was turning a blind eye to wisdom, Islamic nations were becoming united by Islamism under the name of Muhammad. By their new religion the Arabs, Muslims, ultimately gained control of Egypt, Syria, Persia, Northern Africa, Islands of Sicily, Rhodes, and Crete. They even gained control of Spain in 720.  (1, page 122)

Similar to Christians, Arabic civilization believed the Koran contained all necessary wisdom, with all other knowledge being "superfluous," proven by the destruction of Alexandrian libraries and schools during the Egyptian conquest. Yet it is believed that the people of this Arabic civilization, even though they had a newly created language, were so poorly educated they couldn't even read their own Koran. (1, page 122, 125)

This changed during the life of Mohamet, of whom, "according to Islam, was the last messenger of Allah." He lived from 570-632, according to dictionary.com. Mohamet wanted to inspire his people to read, and so he told his people he obtained his wisdom after inspiration from heaven. It was this encouragement that inspired the education of the Arabic civilization.  (1, page 124-125)

Mohamet told the story of how Gabriel came down from Heaven and said to him: (1, page 124)

Read -- added the angel -- in the name of God, the Creator.
He formed man by uniting the two sexes.
Read in the name of the adorable God.
He taught man the use of the pen.
He filled the soul with the light of science. (1, page 124)

So by the time Spain was conquered by the Arabs, learning was encouraged by Arabic leaders.  Ancient writings preserved in Egypt and Spain were transcribed to Arabic and studied by anyone eager to learn. 

Among the people driven from Rome in the 5th century were the Nestorians.  They were the followers of Nestorius (386-450) who was chosen to be Patriarch (Archbishop) of Constantinople by Emperor Theodosius II (401-450). He was consecrated in 428 and almost immediately started to make an impression.  In 430 he was condemned for heresy by a majority of his fellow bishops.  The condemnation was ratified by Theodosius and confirmed by Pope Sixtus III (died 440).  He retired to private life, although in 435 he was banished to the Oasis of Upper Egypt.  (3)(6, page 51)

His followers were allowed refuge in Persia. They established a school at Edessa in Mesopotamia, which was, according to historian Thomas Bradford, the "Athens of Syria.  It became the home of many scholars.  Many Greek and Latin works were translated into Syriac... Here on the Euphrates learning once more found a home.  A college and several schools were established." (6, page 51)

Bradford said the "Nestorians were given free exercise of their religion, and they were entrusted with the education of the children of the great Mohammedan families.  He said:

The Nestorians were the depositories of the old Greek medical knowledge. They revered the old names, and collected with great assiduity all the works on medical topics of all the former schools. Pupils hastened to their schools from all directions, and they were able to study practical medicine in a public hospital, probably the first institution of the kind... And this was the commencement of the great school of the future at Bagdhad. (2, page 51)

Speaking of Baghdad, another person who helped advance medicine in Persia was Almanzor (938-1002).  Bradford said Almanzor was responsible for the establishment of Baghdad and the establishment of the first Baghdad college.  He said: (2, page 57)

All the scholars rejoiced, and dreamed of a new Alexandria. Bagdad, the home of the caliphs, the city of the Arabian Nights, city of magnificance, and capital of the Saracens, was situated on the west bank of the Tigris river. In the old days its population was about 2,000,000. It is said that the caliph Almanzor was attacked by a dangerous disease, and sent for a physician who had been of the Nestorian school. Being restored to health by this physician, the caliph learned the value of the healing art, and became a patron of knowledge. Almanzor now made his new and beautiful city the home of the arts and sciences. He invited all the philosophers to visit him, no matter of what religion. It was not long before the cultivators of mathematics, astronomy, medicine and general literature abounded at the court of Almanzor. A medical college was established; there were public hospitals and laboratories for the benefit of students. So great was the culture of the medical faculty that power was given to it to examine all persons who intended to devote themselves to the study of medicine. So great was the number of professors and students who flocked to that centre of learning that at one time it contained six thousand professors and students. Almanzor enriched his new city with a great number of works on medicine, astronomy and philosophy, which he caused to be translated from the Greek. He had the works of Aristotle, Galen and Ptolemy translated, and these labors were continued by his successors.  (2, page 57-58)

Learned scholars banished from Europe in the 6th century were allowed to take refuge in Persia.  They were allowed to continue their studies and even set up schools where they became teachers.  When Arabs conquered Persia in the 7th century, ancient writings were transcribed and taught to Arabic scholars, who absorbed the wisdom eagerly, paying special attention to the works of Aristotle and Galen. To facilitate teaching they even set up hospitals.  (1, page 123)

The importance of education was appreciated so much that a school of medicine was set up in Baghdad. V. J. Fourgeaud said in 1864:

"So Great was the estimation in which their learning and skill were held, that, notwithstanding the intolerant spirit of Mohammedans, they were permitted the free excess of their religion, and were entrusted with the classical instruction of those of the Moslemin whose education was most cared for.  Aristotle, Pliney, Theophrastus, Dioscorides, Galen, and other element authors (were translated to Syriac, Hebrew and Arabic)." (1, page 124)

Before this time the medical profession was open to all who chose to participate in it.  The Arabs passed laws requiring a diploma from a medical school.  Greek and Roman physicians gathered their own herbs and medicinal supplies from grocers and created their own internal remedies.  The Arabs were the first to create a separate profession, the druggist, who was responsible for creating and preparing medicine. (1, page 124)

The pharmacy profession was established.  They created rules for preparing drugs, which was an advancement to the old system where each physician had his own cook book of medicinal recipes.  The first pharmacopoeia (book of drugs) was created.  (1, page 123)

The Arabs also conquered Spain, and it became the most prosperous county in the world.  Of this, Fourgeaud said:

"Agriculture, commerce, manufacturers, wealth and population are represented to have flourished to such a degree... that, in reading accounts left by historians, as suspicion of oriental exaggeration is often forced upon the  mind.  It is not, therefore, surprising that, in speaking of the Arabs, the Spaniards of that time are represented as saying: 'They have taken our land, but they have covered it with gold.'" (1, page 128)

While other countries in Europe were on the decline, Spain became the "literary and scientific sceptre."  Seventy libraries were opened in Cordova, The medical schools were so great people came from all over the world to be educated.  Even Christian princes in need of medical help traveled there and trusted their lives to the Arabic physicians.  (1, page 128)

With the treasures of the ancient world available to the conquerors of Persia, they were now thrust to the "head of the scientific world."  (1, page 124)

Such was the way for the next 500 years, until this prosperous Arab world came to a halt.  They were driven from Spain by Ferdinand and Isabella, and they then sunk back into the world of ignorance. (1, page 128)

Since the fall of Arabian medicine sometime during the end of the 13th century, "Arabia has been in mental darkness and superstition,"  said historian Thomas Bradford in 1898.  While eastern civilization moved into a dark ages of medicine, western civilization moved out of theirs. (2, page 77)

So we can honestly say that we owe true thanks to the Arabs of the middle ages for saving medical wisdom.  They borrowed medical knowledge from the ancient world, improved upon it, and returned it to the western world of which it came.

References:

1. Fourgeaud, V.J, "Historical Sketches: Medicine among the Arabs: XXI, Intnroduction," Pacific medical and surgical journal, vol. 7, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Francisco, Thompson and Company, pages 122-130
2. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
3. "The Heresiarch," Catholic Encyclopedia, http://www.newadvent.org/cathen/10755a.htm, accessed 10/29/13

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502-575? A.D.: Aetius uses a painful asthma remedy

Teddy Roosevelt once said he'd rather get rid of all his asthma medicines because most seem to make him feel worse.  Perhaps there is no better example of this than a remedy proposed by an ancient physician named Aetius.

He was born a Christian in Amida in Mesopotamia, was educated at the school of Alexandria, and practiced in Constantinople near the end of the 5th century or beginning of the 6th.   He was another of those famous physician who recopied the works of all the ancient physicians who came before him, mainly Hippocrates and Galen. His works voluminous works were published in Tetrabibles. (1, page 65 and 2, page 3)

He believed in many of the ideas of both the Humoralists and Methodists, and he added in some ideas based on his own observations. He described smallpox, fevers, and he attributed "'ringing in the ears' to the oscillations of the pneuma, or vaporous spirits, in the interior of the organ of hearing." (1, page 66)

Of interest of us is to note he "made frequent use of both the actual and potential cautery -- such indeed a few surgeons would advise, and still fewer patients be willing to endure it in our day."  (1, page 66)

So what about his remedies?  Like many of his predecessors he based many of his remedies on "incredulity and superstitious practices."  Some of which include amulets, charms and incantations.

But what is his remedy for asthma?  Yes, and that's what I'm getting to.  Note above that I mentioned he made bold use of the cautery.  Yes, that means, as is noted at the Freedictionary.com : "An agent or instrument used to destroy abnormal tissue by burning, searing, or scarring."

He believed cautery was a good remedy when the disease was "incurable or among the most difficult to treat."  And it's for this reason, perhaps, he believed it was a viable remedy for asthma, pthisis (tuberculosis) and empyema (inflammation of pulmonary sac).  As noted by V.J. Fourgeaud:

"In Chronic asthma, in phthisis pulmonalis and in empyema, he applied two cauteries on the upper part of the chest near the articulation of the clavicle with the sternum, taking care not to injure the trachea; two smaller ones beneath the under jaw, near the carotid arteries, one at each side, being careful to prevent them from penetrating more than skin-deep; two more below the breasts, between the third and fourth ribs; two on the back, near the fifth and sixth ribs; one a little above the xiphoid cartilage; two between the eighth and ninth ribs, and three along the course of the spine, one in the centre and one on each side.  A circular form for the eschars, is recommended by him, as tending to protract their healing, and he makes his prognosis of the recovery or death of the patient depend on the quantity of humors furnished by the suppuration which ensued." (2, page 67)

Um, no thanks!  What do you think?

References:

1. Fourgeaud, V.J, "Historical Sketches:  XL  Medicine from the time of Galen to the Arabic Period," Medical and Surgical Journal, edited by V.J. Fouregaud and J.F. Morse, Volume VII, 1964, San Francisco, pages 60-72
2. Wilkes, John, editor, "Encyclopaedia Londinensis, or, Universal dictionary of arts, sciences, and literature, volume 1,  1810, London

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1774: The birth of the Royal Humane Society

Figure 1 - This is one of two popular engravings
published and sold by the the Royal Humane Society.
This one depicts "a young man taken out of the water
apparently dead, in sight of his disconsolate parents."
(12, page v, xiii)

A primitive mother and her 8-year-old son are walking along the Nile when all of a sudden the child falls into the water.

A bystander pulls the boy out, but the boy appears to be dead: he's cold, pale-blue, and not breathing.  In other words: he is no longer animated.

Using her maternal instincts, the mother kneels over the boy and covers his mouth with her own in a panicked attempt to reanimate him.  As she exhales into his airway she observes her son's chest rise.  She does this for quite a while.  Yet despite her rash efforts her son does not survive.

Similar events must have occurred from time to time since the beginning of mankind. Since people did not understand the physiology of death and dying, their efforts would have been varied and the results mostly futile.

The most common response to such a situation would probably have been to idly stand by in a state of shock. This was described by the authors of a 1920 booklet by the Lungmotor company:

That drowning was probably a most frequent cause of accidental death in the primitive days of man, when like other animals he sought the drinking place and the swimming hole, is most probable, and is supported by Ethnological observations. That the awe and horror, which caused the early man to stand inactive beside his drowned dead is in a great measure still existent in the heart of modern man, is proven by every day observation; because where they are not definitely instructed, those measures of resuscitation which are taught by the experience of Life Saving Crews, are neglected by the general public. (1, page 3)

Figure 2 -- This engraving shows
the "subsequent resuscitation"
of the boy in figure 1.
Such engravings as these
show the 'great benevolence"
created by the efforts
of the Royal Humane Society
12, pages viii,xiii)

Indeed, there must have been a few precious moments when such a child was pulled from the water, awkward versions of mouth to mouth breathing performed, and the child survived. Perhaps a rescuer thumped on a child's chest or abdomen and the child survived. Or, perhaps he tickled the child's nose with a feather, and the child survived.

Such successes, although rare, would have brought great joy and celebration, thus encouraging the rescuers to share these stories. As later generations experienced similar situations, their response may have been similar to that of the characters in the stories.

There were random, almost vague, descriptions of artificial breathing in ancient writings, although these were generally hints of it being done, as opposed to descriptions of a specific life saving procedure.  A perfect example is the hint to mouth to mouth breathing in the Second Book of Kings where Elisha is depicted as resuscitating the child of a Shunamite woman.

When Elisha came into the house, he saw the child lying dead on his bed. 33 So he went in and shut the door behind the two of them and prayed to the Lord. 34 Then he went up and lay on the child, putting his mouth on his mouth, his eyes on his eyes, and his hands on his hands. And as he stretched himself upon him, the flesh of the child became warm.35 Then he got up again and walked once back and forth in the house, and went up and stretched himself upon him. The child sneezed seven times, and the child opened his eyes. (2 Kings 4: 33-36

However, according to an 1823 Annual Report of the Royal Humane Society:

"The art of resuscitating the apparently dead does not appear to have been known to the ancients." (12, page v)

Chances are the report is correct, and the procedure, or efforts to reannimate, were rarely performed in the ancient world.  When they were, they were rarely successful.  When they were successful, chances are the child would have lived irregardless of the technique used.

When a child who had been submerged in water survived, chances are he was breathing shallow, and had skin of a purplish color, and was cool to the touch, similar to a cadaver. He was alive, but not conscious. Eventually, whether efforts were made or not, he would take in a deep breath, open his eyes, and spit out water from his mouth.

He was, as Dr James Curry explained in 1792, in a state of "Apparent Death" but not yet in a state of "Absolute Death." Curry said: (14, page 1)

The important difference between the two states is this,—that in absolute death, the Vital Principle is completely extinguished, whilst in apparent death, it only lies dormant, and may again be roused into action, and the person thereby completely restored to life and health. (14, page 1)

By the 18th century the state of "apparent death" was often referred to as "suspended animation." Attempts at reviving, or at resuscitation, were referred to as "reanimation attempts." A person who was "brought back to life" was thought to have been "reanimated."

And regardless of the truth, credit was always given to the rescuer, or more likely God.  Her brave efforts were the reason the child was brought back to life, but her actions were guided by the almighty God.  This was the case of the Shunamite child, where the works of Elisha were proof that God existed.

The 1823 report suggested that the first official report of "recovery from drowning and hanging" did not occur until 1650. The report further notes that "it does not seem, however, that these instances did not excite any public interest, or that any serious investigation of the subject of SUSPENDED ANIMATION took place until the middle of the last century (about 1750)." (12, page v)

The first official report of artificial respiration was made in 1773, and this ultimately lead to a group of men gathering together to discuss how they might be able to help save the lives of those in need.  They would ultimately form an organization, the Royal Humane Society.

Men victims on the mind of these men were those who were pulled from water. However, there were other reasons a person might might suddenly lack animation, such as hangings or other such methods of suicide attempts.  A medical reason might be appoplexy, which is an old term used to describe what we would now refer to as a stroke.  (12, page 32)

Yet the most common reason for an unexpected death was drowning.  There were simply too many young men and children who were falling into unprotected waters only to meet their maker.

The first known evidence of mouth to mouth breathing was

Such was noted by the Lungmotor Company:

The first reliable history of a resuscitation from drowning was that performed by M. Reamer in Switzerland. This was reported to the French Academy of Sciences and translated into English by Dr. Crogan in 1773. About this time Dr. J. Fothergill published his "Physical Dissertation on Drowning," which was read before the Royal Society in England. In 1773, the first society for the rescue of those apparently drowned was instituted at Amsterdam, Holland (in 1767). In 1774, Dr. Crogan's translation of Reamer's paper, together with Crogan's success in resuscitating those apparently drowned, enlisted the sympathy of Dr. Hawes and these two gentlemen, with thirty-two of their friends, organized the Royal Humane Society which appointed Dr. John Mullwood as their first physician, and proceeded to establish stations throughout the empire to save the lives of those in a state of suspended animation due to apparent drowning. (1, page 3)(also see 12, pages v-vii)(the date 1767 comes from reference 14, page iii and 15, page 1)

Now it is well documented that the first time mouth to mouth resuscitation was recommended was by the Paris Academy of Sciences in 1740. It was essentially recommended for the reanimation of a near drowning victims.

Dr. J. Fothergill noted a variety of methods used in saving drowned victims, and in his report to the Royal Society noted "the possibility of saving many lives without risking anything." (12, page vi)

While his report went relatively ignored initially, it did ultimately lead, as noted above, to the formation of a society in Amsterdam called The Life Saving Society of Amsterdam, or The Life Saving Society of the Apparently Drowned.

A report noted:

Finding that a strong and general prejudice existed against the practicability of Resuscitation, and that the idea was even ridiculed as hopeless and chimerical, he determined to demonstrate it. With this view he publicly offered rewards to persons who, between London and Westminster Bridges, should, within a certain period from the occurrence of an accident, rescue drowned persons, and bring them to places appointed on shore for their reception. At these places he and his friends restored several lives. During a whole year Dr. (William) Hawes continued to pay these rewards himself. At the end of this period Dr. Cogan represented to him the injury his private fortune must sustain by such continued expenses, and kindly offered to unite with him for the formation of the HUMANE SOCIETY, which at first consisted of 32 individuals, their respective private friends. (12, vi-vii)

Perhaps responsible for the formation of the Royal Humane Society, and its success, was due to the fact there were physicians in England at that time (many of them of notable fame).  Dr. Hawes is responsible for forming the Humane Society, and Dr. John Hunter was the first director.  His brother Dr. William Hunter, along with Dr. Cullen, Dr. Monro Secundus, and Fothergill were also members. (15, page 1)

Another reason for the success of the organization is that...

...from the start start kept records of all cases of attempted resuscitation which came to its knowledge. At various intervals it formulated and published rules, in conformity with the views which prevailed, at the time, and stimulated individuals to and formed committees for special investigations with the object of discovering reliable methods to be employed. (15, page 1)

The keeping of data made it possible to review cases, and determine what methods worked and what methods did not work. Methods that worked would continue to be recommended as the rules and recommendations were updated. Methods that did not work, or that caused excessive trauma to the body that made caring for the reanimated patient difficult, were noted as high risk or no longer recommended.

The committees made it possible to research for better wisdom and newer methods of resuscitation. The committees also made it possible for the Humane Society to adjust to changes in society, as when new emergent situations emerged, new safety and rescue recommendations were made.

For example, along with rescuing drowned victims, the society ultimately learned how to save people from hangings, electrocutions, intoxication, gas poisoning, drug overdoses, fainting, exposure to cold, suffocation, still born births, etc.

In other words, the members of the Royal Humane Society did the best they could with the data they presently had, and as they learned better they did better.

*For example, in 1786 the Humane Society of Massachusettes was formed. (13, page 3) In 1824 the Royal National Lifeboat Association was formed.  (9, page 171), 

References: 

1. "Drowning: Historical-Statistical Methods of Resuscitation," no author nor editor listed, Published by Lungmotor Company, Boston, Massachusetts, 1920
2. "Pulmotor advertises gas company," Gas Age, volume 29, 1922, New York, Robbins Publishing Company Inc. 
3. Cannon, Walter Bradford, George Washington Crile, Joseph Erlanger, Yandell Henderson, "Report of the Committee on Resuscitation from Mine Gases," Technical paper number 77, Department of Interior, Bureau of Mines, Joseph A. Holmes, Director, 1914, Washington, Government Printing Office
4. "Schaefer Method of Resuscitation," The Colliery Engineer, August, 1913, Volume XXXIV, August 1913 to July 1914, Scranton, PA, International Textbook Co., page 53 (no author or editor listed)
5. Hughes, Martin, Roland Black, "Advanced Respiratory Critical Care,"  2011, New York, Oxford University Press; material from section 3.1: "Invasive Ventilation Basics: Development of Invasive Ventilation (history)."
6. Agasti, T.K. "Textbook of Anesthesia for Postgraduates," 2011, New Delhi, Jaypee Brothers Medical Publishers, page 590
7. Safar, Peter, "Exhaled air ventilation and cardiopulmonary resuscitation," published in the following: Gordon, Archer S, "Cardiopulmonary Resuscitation: Conference Proceedings," May 23, 1966, Washington D.C., National Research Council
8. Donahue, Mary, "History of Lifesaving," DeAnza Collegge, http://faculty.deanza.edu/donahuemary/Historyoflifesaving, accessed 8/10/13
9. "Resuscitation of the apparently drowned," The Dominion Illustrated Monthly, February, 1893, Montreal and Toronto, Vol. II, NO. 1, pages 171- 175
10. Eisenberg, Mickey S., "Life in the Balance: Emergency Methods and the Quest to Reverse Sudden Death," 1997, New York, Oxford University Press
11. Knott, Arthur Reynolds, "Lie Saving and Artificial Respiration," 2nd edition, 1915, no city or publisher noted in book
12. "The Forty Ninth Annual Report of the Royal Humane Society, For the Recovery of  Persons Apparently Drowned or Dead," 1823, London, 
13. "History of the Humane Society of Massachusetts," 1845, Boston, Samuel N. Dickinson, Printer
14. Curry, James, "Observations on Apparent Death from drowning, hanging, suffocation by noxious vapours, fainting-fits, intoxication, lightning, exposure to cold, & etc., and an account of the means to be employed for recovery. To which are added the treatment proper in cases of poison, with caution and suggestions respecting various circumstances of sudden danger," 2nd edition, 1815, London (the 1st edition was published in 1792)
15. Meltzer, S. J., "History and analysis of the methods of resuscitation," Medical Record: A Weekly Journal of Medicine and Surgery, July 7, 1917, Volume 92, Number 1, New York, 
16. Meltzer, ibid, page2; the reference alluded here is to an article by Arthur Keith, Lancet, 1909, 1, page 745, 825, 895,
17. Rush, Benjamin, "Medical inquiries and observations," volume 1, 2nd edition, 1805, Philadelphia, chapter one: "An inquiry into the natural history of medicine among the Indians of North America, and a comparative view of their diseases and remedies with those of civilized nations, read before the American Philosophical Society, held at Philadelphia, on the 4th of February, 1774," pages 1-68

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1774-1829: Humane Society used intubation, bellows

Figure 3 -This is an 1823 version of an airway box.
 It was often referred to simply
as a Case of Resuscitating Instruments.
 Contained inside was all the equipment
necessary to breathe for a victim.
  Such cases were stored at Receiving Houses.
Rarely were they at the scene when needed,
so other means of inflating lungs were attempted.
(12, page liii) (14, page46)

One of the recommendations by the Royal Humane Society was to breathe for victims by using fireside bellows.

The use of mouth to mouth breathing was initially on the list of recommended methods.  However, due to epidisodes of disease, people developed a fear of this method, and it was ultimately scratched from the list of recommendations.

Surely there was other equipment that could have been used to provide breaths, although since fireside bellows were readily available in nearly every household, they became the preferred equipment.

In the case a drowning victim was pulled from the water, a rescuer was supposed to carry the victim to a warm shelter.  Perhaps in most instances, this shelter would be a home or business.  The victim was stripped of his wet clothing, dried with warm towels, and placed on a warm bed.  The fire should be stoked to warm the victim, and the fireside bellows should be used to provide artificial breaths.

An old depiction of bellows being used to breathe for a victim.
The more recommended recommendation was to insert the bellows
into one nostril, and then to block the nose and mouth.
Another recommendation was to also apply cricoid pressure,
a method of pressing in on the trachea to occlude the esophagus.
All these techniques were required to prevent air from insufflation
from leaking out so that more air could get into the lungs.
However, lacking a 2nd or 3rd rescuer, the above technique
would probably be the only recourse left. 

The use of fireside bellows to provide artificial breaths was not new.  Galen described using them to provide breaths to animals, and most certainly he was not the only one. Yet considering it was considered sacrosanct to interfere with the process of death in the ancient world, most who made such efforts would most certainly keep it to himself.

In 1530 Paracelsus, and again in 1665 Robert Hooke, used double chambered fireside bellows to breathe for animals through a tracheostomy. Back then, when breaths were given by mechanical means, it was referred to as insuflation.

Dr. Monro secundus played on this idea and constructed double chambered fireside bellows to insuflate vicitms, but his bellows were too big and were rejected by the society. (15, page 2)

In 1776 British anatomist John Hunter used his own double chambered fireside bellows to insuflate lungs. His work made bellows the preferred method of artificial respiration. (5, page 102) (15, page 2)

The creators of the Amsterdam Life Saving Society recognized the significance of bellows, as these were among the apparatus included at rescue stations at "intervals along Amsterdam's canal." (8)

Figure 4 - Photo of the apparatus

used by the society in 1823,

and contained in the cases

like the one in figure 3.

Can you guess what the above

instruments are? The answers

can be found at the end of the

post.   (12, page lii)

The Humane Society was based on a similar model, likewise endorsing the use of bellows:

"Receiving Houses, which are established in the most convenient and appropriate situations along the shores of the Thames, near the banks of canals, in the immediate neighborhood of dangerous pieces of water, and in various parts of the metropolis and its vicinity. And to ensure the due and prompt application of the processes and means of the Society, respectable Professional Gentlemen residing near the Receiving Houses are appointed Medical Assistants." (12, page xi)

In this House (which may be considered as the Society’s model) every thing necessary for the application of the resuscitating process is provided, and kept in constant readiness. A bed is fitted up—a warm bath and electrifying machine, in case it should be found necessary, are in a state of preparation for instant use—apparatus and medicine, of every kind, necessary in a case of Suspended Animation, are deposited there, and during the bathing season in summer, and the frosts in winter, a medical gentleman attends for the purpose of rendering immediate and effectual assistance on the occurrence of accidents. (12, page xii)

On the outside of the other Receiving-Houses of the Society are placed large and conspicuous boards, announcing their object. These Houses are furnished with drags, poles, and other necessary apparatus, all of which are under the constant superintendance of the Society’s Surveyor, and are thus kept in a state of repair and readiness for immediate use in case of accident. (12, page xii)

This is an engraving of the Receiving House in Hyde Park. (12, page xiv)

However, while Hunter proved the significance of bellows, and even though he was the director of the Humane Society, the bellows adapted by the Society were those made by Charles Kite (Kyte), which had a capacity of 500 cubic centimeters. "

From 1782 onward bellows were recommended by the Royal Humane Society as the best means for artificial respiration." (15, page 2)

The bellows, if they were available, were used in one of a variety of ways. One method (the preferred method) was to insert the bellow into one nostril, while the other nostril and mouth were occluded by a second rescuer in order to prevent insuflated air from entering the stomach and to prevent air from leaking out. (12, page 6)

Figure 5 -  A. This is a flexible tube that is inserted beyond the windpipe and gullet.
 An ivory sliding piece can be pushed with the hand as far as possible
in order to plug up the opening of the gullet, and thereby preventing
any air from getting into the stomach. The tube is inserted by the rescuer
inserting the forefinger of his left hand as far as he can into the victim's airway,
and then guides the tube along his finger into place.
B. This is a silver cannula inserted beyond the windpipe into the trachea.
 This cannula is inserted in the same way as inserting the flexible tube.
Bellows are connected to this cannula.  While an assistant holds the
tubes in place, and occludes the nostrils, the bellows are used to
provide artificial breaths to the victim. If this method did not work,
then the rescuers would use the scalpel in the kit to perform a tracheosomy.
A tube would be inserted into the trachea that the bellows were connected to.

(14, plates between pages 204 and 205)(14, page 50-52)

The bellows could also be inserted into the mouth, although a problem that ensued here was that the tongue sometimes blocked the airway. So this may have lead to the recommendation to use the nose. It also lead to the recommendation by Goodwin to insert a catheter into the esophagus to keep the tongue out of the way and keep the airway open. The catheter also came with an ivory sliding piece that could be pushed down into the gullet (the esophagus) to prevent air from entering the stomach. (15, page 2) (14, page 50-52)

The bellows generally came in a case with a variety of other apparatus and gadgets, which could be rigged in a variety of ways depending on the needs of the victim. A blade was usually among the kid if the need to arose to perform the operation of tracheostomy (what was then called bronchotomy). A tube could be inserted into the stoma, and the bellows could be attached to this tube. (12, page vii)

However, the recommendation to use bellows changed in "1829 when Leroy d'Etiolles stated in a memoir that it was possible to kill an animal by suddenly inflating its lungs."

This alarmed the members of the Royal Humane Society, and bellows quickly fell out of favor, no longer being listed as a recommendation for artificial respiration. During the "abeyance" of bellows, the chief methods of reanimation was warming the patient, "with treatment commencing with the immersion of a patient in a bath of about 100° F." (15, page 2)


However, in review of the date, the following was learned:

The following data, taken from one of Kieth's tables, present us with a bewildering illustration.  From 1795-1811, when warmth and insuflation (bellows) were used, there were as many as 54.8 per cent. unsuccessful cases; from 1832-1851, when warmth and friction were used, there were only 10 per cent. unsuccessful cases. Is this striking contrast merely an outcome of the familiar unreliableness of information derived from statistical data, or is it due to the fact that inflation of the lungs by bellows is indeed a very dangerous procedure. (16, page 2)

This was the first ever study that confirmed the fact that inflating too much air into a person to fast could cause damage to the victim's lungs.  The idea that better training, and gentler breaths, must not have occurred to the gentlemen of the society, because as of 1829 bellows were no longer recommended, and fell into rapid disuse.  They would make a comeback, but that wouldn't occur until later in the century.

Figure 3.  Here is a brief description of the apparatus shown in this photo:  1,2 & 3 are fireside bellows;4 is a flexible tube to convey air into the lungs, and 5-9 are pieces that go to this tube;10 is a tube to be inserted into the trachea which the bellows could be connected to; 11 is an elastic bottle for injecting fluid into the stomach; 12 is a flexible tube to inserted into esophagus to convey spirits into the stomach; 13 & 14 are clyster pipes for administering enemas;15 is a scalpel for administering the surgery of tracheotomy. The rest of the objects simply gadgets for joining one part to another.  So, did you guess right? (12, page lii)

References:

 References:  See post "1774:  The birth of the Royal Humane Society"

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500 A.D. Asthma in Ancient Japan

Fuiwara no teika ( (1162-1241)

If you lived with asthma in ancient Korea and Japan your asthma may have been recognized, yet treatment would have been mainly supportive.  It wasn't until the 6th century A.D. that Chinese medical ideals -- mainly in the form of the Nei Ching -- spread to these nations.

Chinese medicine was referred to as canpo in Japan, and asthma-like symptoms were referred to as zensoku as early as 700 A.D.  (1)

The most famous asthmatic in Ancient Japan was Fujiwara no Teika who was considered one of the most famous poets in Japanese history.  Legend has it that his poems became well read due to his cordial relationship with the Emporor Go-Toba (1180-1239).

Japanese children learned early that there were 404 different kinds of illnesses, and they learned of the various herbal formulas used as remedies, most of them indigenous to the region.  One interesting remedy for asthma was by eating a potion containing earthworms dried under the sun, cooled and then boiled.

Most asthma remedies were similar to what was recommended by Traditional Chinese Medicine.  So prior to the 6th century Japanese asthmatics would have been recognized although there wasn't much anyone could do other than offer support.

Yet if you were afflicted with breathing difficulties in the 6th century you would have had available to you many of the same treatments available to Chinese asthmatics, including Ma Huang, a very efficient bronchodilator.

References:

1. Jackson, Mark, "Asthma: A biography," 2006, New York, page...

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476-1543.: Medicine survives the dark ages of medicine

Between 476 and 1543 A.D., medicine in western civilizations entered a dark age. Except for a few random collections, the knowledge of Hippocrates and Galen was lost and forgotten. People resorted to primitive methods of using superstition and religion to explain health and disease. However, thanks to Arabic physicians, medicine survived these dark ages by a thin thread.

While the Greeks and Romans were concerned with cleanliness, with the Romans connecting cleanliness with good health, peasants of the middle ages had no use for such nonsense.  The lack of the peasants ability to take baths was noted by the Bible as acceptable:    (2, page 85)

"Does your skin roughen without baths?  Who is once washed in the blood of Christ needs not wash again."  And St. Paul noted: "All things were 'counted dung but to win Christ.'" (2, page 85)

European peasants had no use for performing autopsies, and no time to do it either. They saw even touching a human corpse as morbid, disgusting and counterproductive. (2, pages 84-6)

Again, this was inculcated by the Bible, which preached that the only knowledge that was useful was Biblical knowledge that lead you on your way to heaven. (2, pages 84-6)

During this period Greek knowledge, and even the ancient Greek language, was unknown in western Europe.  This was unfortunate because, as medical historian Edward Withington said:

At this time Greek was still the key to all higher knowledge, especially in medicine.  Latin versions of some Galenic treaties, indeed, existed, yet they were so little known that Constantine the African could boast in the eleventh century that he was the first to translate that author.  Celsus, whose work might have formed an excellent text-book, was almost entirely forgotten." (1, page 176)

With a few exceptions, most people didn't need natural remedies and physicians to treat diseases, and they didn't seek to know the diagnosis nor the prognosis of diseases.  Instead, they lived the hard life, and prayed to God for health and for healing. All they needed, as Osler noted, was the Bible and the Church.

Yet not all was lost of the ancient way of life.  In the old world there were basically two groups of people, the: (4, page 2)

1. Elite or aristocrats:  They controlled wealth, religious institutions, government, bureaucracy. 
2. Peasantry: They did all the work.  They were the farmers, herders, builders and merchants.  They consisted of about 80 percent of the populace. (4, page 2)

In the middle ages this same system was maintained, although it was adjusted slightly.  The elite were called kings and queens, and the peasants were called serfs.  The system was called feudalism.

An interesting facet of this is that, despite their overwhelming majority, the peasants or serfs accepted this form of government perhaps because it was all they knew.  And while other forms of government may have been tried from time to time, such as the democracies and republics of Greece and Rome, none succeeded at motivating the populace better than the monarchy. (4, pages 6-7)

Another reason why this "elitist" system was so generally accepted may have been due to the Bible, which encouraged human beings to accept peasantry as your role in life, your part in the scheme of life that God intended for you.  (4, page 2-5)

The feudal system was such that those who obtained the most land, or control of the most resources, obtained the most power.  These are the folks who formed the Aristocracy.  They formed the family of kings and queens who made the laws to organize and motivate the peasants to farm and herd the land, build structures, and sell the merchandise.  The aristocracy represented God, and you were therefore obliged to honor and respect them.  (4, page 6)

Under this system the peasants had no identity. They worked 12 hour shifts every day year round, and even their kids were trained at an early age to do the work. There was little time for recreation, and little time to to sit around and wonder of a possible better way of life. It may best be explained by Norman Cantor: (4, page 7)

Some historians describe the ancient structure as a one-class system because other than in fifth-century B.C. Athens (always a significant exception) only one group -- the ruling elite -- had such a sense of identity.  Only the aristocracy had a distinct life-style, justified its own existence, loved itself as a class.  Not until much later did the bourgeoisie begin to develop class consciousness.  In the ancient world, only the elite knew things, knew how to do things, the ruling class was the only literate, conscious group in society.

So one can only imagine how easy it was for this aristocracy to shape the opinions of such a naive and ignorant populace. And one can also only imagine how difficult it would have been for any knowledge of the old world to have made its way through this era. Although, thankfully, some ancient works were so voluminous, copied so many times, and saved by some few groups of people, and some few schools, that some ancient works managed to survive.

A thin thread of medicine survived by the following means:

1.  School of Salernum in Northern Italy:  Osler explains that the better educated in Southern Italy continued to speak Greek and understand Latin, and "the cathedral and monastic schools served to keep alive the ancient learning."  Among the most significant was the School of Salernum "which for centuries kept alight the lamp of old learning, and became the centre of medical studies in the Middle Ages; well deserving it's name 'Civitas Hippocratica.'" (2, pages 86-7)

2.  Conquer of Spain allows for the rise of Arabian Medicine:  Ancient Greek and Roman medicine continued to be studied in Spain.  Mohamet was, according to Islam, was the last messenger of Allah, and it was he who encouraged Muslims to learn as much as they could.  So by the conquer of Spain in 720 A.D., the environment in the east had already been created that was conducive to learning.

The Arabs now had access to the wisdom of the ancient sages of Greece and Rome, although they were all in Latin.  Osler explains that by the end of the 9th century the Arabs translated much of the Ancient Greek and Roman writings, and were able to use this knowledge to further advance science and medicine.  A perfect example here is Rhazes who defind smallpox,  Maimonides who wrote a treaties on asthma, and Avicenna who was known as the Prince of Physicians.

Thomas Bradford said medicine started its transfer from the west to the east as early as the time of Charlemagne (742-814), "though it became more marked in the following centuries." (7, pages 74-75)

Beginning with the crusades knowledge started to make it's way back to Europe.  Men like Constantinus Africanus translated the works such as Hippocrates and Galen  from Arabic back into Latin at Salernum.  The works of Rhazes, Maimonides, Avicenna and others were likewise translated for Western Europe.

The Muslims added little knowledge to anatomy considering the Muslim religion also prohibited autopsies, but they did add quite a bit to knowledge of diseases, and provided the Europeans with quite a few additional herbal remedies. (2, page 91- 104)

To learn more about how the Arabs saved medicine click here. 

3.  The rise of universities in the 13th century:  Around the 14th century associations of persons with particular skills started to form during the Middle ages, otherwise known as universities.  These were places where people could share ideas and study.  Universities in northern Italy were mainly controlled by students from various nations.  The students arranged lectures and hired teachers.  Yet those of Paris were controlled by the teachers.

Knowledge of ancient writers, especially Aristotle and Galen, were preserved by such schools in Italy and Spain.  The Arabs gained access to this resource.  Books of Avicenna, Albucasis and Rhazes were also studied.  Study of human anatomy was encouraged for the first time since Galen's day, and a book of anatomy (or at least a book on how to perform autopsies) was published by Mundinus in 1316, "a book that served as a text book for the next 200 years."  It was difficult to get a body for autopsy, and permission was often required, although it was accomplished.  Usually the bodies were those of condemned criminals.  (2, page 106)

Science and medicine were not advanced in the west until around 1543 when a man named Andreas Vesalias published a book called De Humani Corporis Fabrica in 1543.  For the first time in over a thousand years medicine was once again moving forward. Yet that would be a fear years down the road.  For now, the most amazing development during the Dark Ages of Medicine was Arabic Medicine, which will be discussed in an upcoming post.

Read about AndreasVesalias by clicking (to be published 3/28/13).
Read how medicine survived the dark ages by clicking (to be published 1/15/13).
Read the end of the Dark Ages of Medicine (to be published  10/1/13)

References:

1. Withington, Edward Theodore, "Medical History from the Earliest Times: A Popular History of the Art of Healing," 1894, London, The Scientific Press. 
2. Osler, William Henry, "The Evolution of Modern Medicine: A series of lectures delivered at Yale..." page 85
3. Meryon, "
4. Cantor, Norman F, "The Civilization of the Middle Ages: A Completely Revised and Expanded Edition of Medieval History," 1993, first edition, Harper Collins Publishers
5. Cantor, Norman, "The Civilization of the Middle Ages: A Completely Revised and expanded Edition of Medieval history: The Life and Deal of a Civilization," 1993, Harper Collins Publishers, New York
6. Johnston, Harold Whetstone, "The Private Life of Romans," 1908, Chicago, Atlanta, New York, Scott, Foresman and company
7. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey

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