1-1619: Jews, Arabs and Latins practice tracheotomies (and mouth to mouth breathing)

Chances are early tracheotomies were performed with no anaesthetics.  I write this not that I know this for sure, although I would imagine the procedure was generally performed as a last ditch effort to try to save a life of a person who was otherwise suffocating and was probably going to die if nothing was done.

There were, however, medicines that could have taken the edge off, such as opium.  Opium is an opiate that is one of the oldest known medicines known to man.  It is described in some of the earliest writings shared among the medical community.  So if the opportunity presented itself, this or some other medicine could have been taken to ease pain and suffering.

The ancient Jews, after the birth of Christ (around the years 1-650 A.D.) were known to perform surgeries when prayer, magic and natural remedies did not work.  When they did resort to surgeries, they did have certain herbs that were perhaps mixed into a drink that was used as a sleeping draught. (1, page 62)

The Jews were nomads, which means they traveled to many places in search of a home.  They spent time among the ancient Mesopotamians and Egyptians, and in the process they picked up a lot of knowledge about medicine.  Perhaps among the medical procedures they learned about from either of these places was the operation later to be called tracheotomy by the Greeks.  As they traveled they may also have educated other civilizations of the procedure.  This was one of the ways medical knowledge traveled through time.

Renouard explains that "the Arabs, and the Latins of the Middle Ages, had so little anatomical knowledge that they very much exaggerated the dangers of the operation, and, without condemning it absolutely in theory, abstained from its practice." (2, page 449)

Although this was not always the case.

Paulus Aegineta (625-690), as was noted earlier, performed the procedure with regularity, and described the procedure pretty much as Antyllus had several hundred years earlier.  (5, page 521) The operation was not regularly practiced until the 16th century, yet most of what was written was a reproduction of what Antyllus wrote on the subject.

Rhazes (865-925), Mesue (777-857), and Avicenna (980-1037) do not mention the methods of the procedure, but recommend it as a last option in cases of "angina strangulans." (3, page 199)  Avecenna did, however, describe "intubating the trachea using 'a cannula of gold or silver.'" (4pages 222-228) 

In the 12th century Arabian physicians Avenzoar and Albacasis were among the few physicians who dared to perform tracheotomies, although prior to them the procedure was rarely performed. Avenzoar (Ibn Zuhr), who was the most renowned physician and surgeon after Avicenna,  noted experiments of the procedure on goats, although he recommended it not be done unless the physician had knowledge of anatomy.  (3, page 198)  (6, pages 70-71)

Of course anatomical knowledge was rarely obtained by physicians mainly because autopsies were rarely performed, and when they were it must have been an unwholesome event.  Historian Fielding Hudson Garrison, in his 1922 history of medicine, explains that bodies were probably stolen, and both the grave robber and the autopsy performer would have risked an untimely death if caught.  There were a few books describing anatomy, although chances were good the descriptions were from animal dissections: pigs, dogs, apes, etc. (1, page 415)

The Surgeon Lanfranchi of Milan (1250-1306), Garrison explains,  was a surgeon at the School of Salerno in Northern Italy who may have been the first physician to mention intubation.  He became involved in the "squabbles of Guelphs and Ghibellines and was exiled.  He arrived in Paris in 1295, where he introduced the French to Italian medicine.  So it's highly likely the French also had knowledge to the technique of intubation.  (1, page 144)

Renouard continues:  "Anthony Benivieni, a physician of Florence, who lived at the end of the fifteenth century, saved the life of a patient by opening the trachea, and giving issue to the pus of an abscess that was formed within it. This is the first account we have of a tracheotomy, after an interruption of twelve hundred years; but its author does not state the manner in which he performed it, and it does not appear that he employed this method in other cases." (2, page 449)

Along with tracheostomies, mouth to mouth breathing also is mentioned in the fifteenth century.  It was documented to have been performed in Italy to revive newborn infants stunned at birth and not breathing on their own. This would have been a major effort on the part of the caregivers to save the life of a newborn infant stunned at birth who otherwise would have had no chance at life.  (5 need reference)

Fabricius d’Aquapendente (1537-1619), Renouard said, "is the first among moderns who gives a detailed description of this operation. He proves that it may be executed without injury to any other important organ; and that by it, we may often save a patient from impending death. The invention of the canula has been attributed to him, which has usually been left for some time in the artificial opening thus made. (2, pages 448-449)

In 1596 Sanatorius became the first to use a trocar to insert a cannula into the stoma, "and left a canula in the opening for three days."  Fabricius ab Aquapendente, in order to prevent the cannula from falling into the airway, added a cannula with wings.  Later later his pupil, Casserius, "made a very important improvement in introducing a canula with a curve corresponding to the arc of the quadrant, and he also tied in position the canula with tape.  The improvement in the shape of the instrument, however, was soon lost sight of, and the straight tube long remained in use." (5, page 521)

So knowledge of how to create an airway made it's way through the dark ages of medicine in the west, and the bright ages of medicine in the east.  Now it would make it's way to the Renaissance, where improved anatomical wisdom would help speed up the advancement of medical wisdom.

Note:  Spelling within quotes is that of the original author

References:

1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
2. Renouard, Pierre-Vincent, "History of medicine: from its origin to the nineteenth century,"
3. 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  (referenced to page 198-9)
4. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
5. Mackenzie, Morrell, "Diseases of the throat and nose, Volume I, 1880, Philadelphia, Presley Blakiston
6. 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

1550 B.C.: Moses preaches good hygiene

Moses (12th and 13th century B.C.)
He is the father of hygiene therapy,
or prophylactic medicine.

While most people don't think of Moses in this light, he had a significant impact on health and healing. In fact, many medical historians give Moses credit as the father of preventative medicine.

Moses (sometimes referred to as Mesu, Mouses and Mosheh) was a Hebrew liberator, leader, lawgiver, profit and historian. He lived at the end of the 13th and early part of the 12th centuries before the birth of Christ.  (2)

The Bible records that his cradle was set into the Nile river by his Hebrew mother Jochebed when the Pharaoh ordered that all first born Hebrew sons be killed. Moses was rescued by the Pharoah's daughter, and adapted by the family of the Pharaoh.  He was then educated "in all the knowledge of the Egyptian priesthood, in which he became proficient," said medical historian Pierre Victor Renouard in 1856. (1, page 32)

Of interest here is that Egyptian priests were educated in all the wisdom of the Egyptian gods, as their studies included all the wisdom of the Sacred books, or the Hermetic books. This knowledge would have include mathematics, weights and measures, law, cosmology, religion, and medicine. So it is very likely that Moses was as adept at health and healing as he was at being a leader.

The Bible says that "One day, after Moses had grown up, he went out to where his own people were and watched them at their hard labor. He saw an Egyptian beating a Hebrew, one of his own people. Looking this way and that and seeing no one, he killed the Egyptian and hid him in the sand."

When Pharaoh learned of this, he tried to kill Moses, but Moses escaped to Midian.

Concerned about the Israelites, God sent Moses back to Egypt to free the Israelites. He allowed Moses to perform miracles before the Pharaoh to convince the king that Moses was sent by the Israelite God, and the Pharaoh sent for "wise men and sorcerers."

These wise men and sorcerers were the high priests, the Chief Priests of Egypt, who were learned in all the greatest magic of the gods. Pharaoh was convinced the power of the gods was more powerful than the god of the Israelites.

The Bible then says:

"So Moses and Aaron went to Pharaoh and did just as the Lord commanded. Aaron threw his staff down in front of Pharaoh and his officials, and it became a snake. Pharaoh then summoned his wise men and sorcerers, and the Egyptian magicians also did the same thing by their secret arts. Each one threw down his staff and it became a snake. But Aaron's staff swallowed up their staffs. Yet Pharaoh's heart became hard and he would not listen to them, just as the Lord had said."

Moses lead the Israelites out of Egypt in what became known as the Exodus. He helped them escape the Pharaoh's army to Midian by creating an opening in the Red Sea.

God appeared to Moses once again in a burning brush on Mount Sinai. Thus, it was through Moses that God said:

"I will put none of these diseases upon thee, which I have brought upon the Egyptians: for I am the Lord that healeth thee." (Exodus 15:26)

And then God provided Moses with laws for the people of Israel to follow, including the ten commandments. The Catholic translation is as follows (translations may vary, although the basic idea is always the same):

1. I, the Lord, am your god.  You shall not have other gods besides me.
2. You shall not take the name of the Lord God in vain
3. Remember to keep holy the Lord's Day
4. Honor your father and your mother
5. You shall not kill
6. You shall not commit adultery
7. You shall not steal
8. You shall not bear false witness
9. You shall not covet your neighbor's wife
10. You shall not covet your neighbor's goods

Renouard explained that wisdom obtained while living among the Egyptians, along with wisdom learned from the Isrealite God, allowed Moses to lead the Hebrews to the promised land. He would have had knowledge of the Egyptian Pharmacopoeia, and known that their recipes would be hard to put together while traveling to the promised land.

So god appeared to him and encouraged him to educate the people in how to prevent disease, as opposed to treating it. In order to accomplish this, Moses, through the Lord, preached good hygiene. He encouraged the Hebrews to only eat the purest foods, such as the rabbit and hog, even though these animals were considered impure in Egypt. Perhaps, Renouard proclaims, this is evidence that Moses held "his own views other than those ascribed to him."

Medical historian Fielding Hudson Garrison said that the ultimate goal here was to prevent the people from getting sick. He inculcated the idea that it was especially important to wear clean clothing, and to wash and bathe, especially while traveling to foreign lands, and when touching strangers. He inculcated good hygiene when surrounded by sick people, and handling dead bodies or other unclean objects. He encouraged good hygiene during menstrual periods. He discouraged sexual perversion because sexual perversion was linked with illness. These were techniques of keeping people "pure" in order to avoid sickness. (4, page 60)

For an example Renouard refers us readers to the Bible, Numbers Chapter 15, which starts like this: And the Lord spake unto Moses, saying: (1, pages 32-33)

Speak unto the children of Israel, and say unto them, When ye be come into the land of your habitations, which I give unto you. And will make an offering by fire unto the Lord, a burnt offering, or a sacrifice in performing a vow, or in a freewill offering, or in your solemn feasts, to make a sweet savour unto the Lord, of the herd, or of the flock. (Numbers 15: 2-3)

Renouard also refers to Levaticus 11 and 12, which show God telling Moses what to teach the Israelites about what they should and should not do in order to maintain their health. Here is a small sample of what Moses said: 

The Lord said to Moses and Aaron, "say to the Israelites: 'Of all the animals that live on land, These are the ones you mayt eat: You may eat any animal that has a divided hoof and that chews the cud. "There are some that only chew the cud or only have a divided hoof, but you must not eat them. The camel, though it chews the cud, does not have a divided hoof; it is ceremonially unclean for you. The hyrax, though it chews the cud, does not have a divided hoof; it is unclean for you. The rabbit, though it chews the cud, does not have a divided hoof; it is unclean for you. And the pig, though it has a divided hoof, does not chew the cud; it is unclean for you. You must not eat their meat or touch their carcasses; they are unclean for you. Of all the creatures living in the water of the seas and the streams you may eat any that have fins and scales. But all creatures in the seas or streams that do not have fins and scales—whether among all the swarming things or among all the other living creatures in the water—you are to regard as unclean. And since you are to regard them as unclean, you must not eat their meat; you must regard their carcasses as unclean. Anything living in the water that does not have fins and scales is to be regarded as unclean by you. (Levaticus 11: 1-10)

The Lord said to Moses:

"You will make yourselves unclean by these; whoever touches their carcasses will be unclean till evening. Whoever picks up one of their carcasses must wash their clothes, and they will be unclean till evening." (Levaticus 11: 24)

He said:

"And if any beast, of which ye may eat, die; he that toucheth the carcase thereof shall be unclean until the even. And he that eateth of the carcase of it shall wash his clothes, and be unclean until the even: he also that beareth the carcase of it shall wash his clothes, and be unclean until the even. And every creeping thing that creepeth upon the earth shall be an abomination; it shall not be eaten." (Levaticus 11: 39-41)

And the Lord spake unto Moses, saying, Speak unto the children of Israel, saying, If a woman have conceived seed, and born a man child: then she shall be unclean seven days; according to the days of the separation for her infirmity shall she be unclean. And in the eighth day the flesh of his foreskin shall be circumcised. And she shall then continue in the blood of her purifying three and thirty days; she shall touch no hallowed thing, nor come into the sanctuary, until the days of her purifying be fulfilled. (Levaticus 12: 1-4)

Moses also makes a reference to healing:

The one who struck the blow will not be held liable if the other can get up and walk around outside with a staff; however, the guilty party must pay the injured person for any loss of time and see that the victim is completely healed.

“Anyone who beats their male or female slave with a rod must be punished if the slave dies as a direct result, but they are not to be punished if the slave recovers after a day or two, since the slave is their property. (Exodus 21: 19-21)

Thanks to Moses, the Hebrews were freed from the bonds and prejudices of Egyptian laws and tradition, said medical historian Theodor Puschmann in 1891. (3, page 28)

It was also thanks to Moses that the Jewish (and later the Christian) community was introduced to the method of good hygiene as a method of preventing disease.

Perhaps, said Puschman, it was this new found freedom that allowed Moses to encourage the Hebrews to eat some of the foods Egyptian gods forbade, such as rabbit and hog. Yet this may also have been a byproduct of the necessity of eating the foods that were available in the lands the Hebrews happened to be in at the time, for Moses surely wouldn't want his followers to starve on the way to the promised land due to Egyptian laws. (3, page 28)

Puschmann said this newfound freedom also allowed the Hebrews to be influenced by the people they came into contact with, such as the Assyrians, Babylonians, Chaldees, and Persians. This exposure further increased their medical knowledge as well. (3, page 28)

The Hebrews were able to adapt these new cultures and incorporate them into their own. For example, you no longer had to be a priest in order to be a physician. For the first time ever, anyone interested in learning could learn, and this meant anyone could become a doctor. (3, page 28)

This was perhaps a gift of the God of Israel.

1. Renouard, Pierce Victor, "History of Medicine: From it's origin to the 19th century," 1856, Cincinnati, Moore, Wistach, Keys and Co., page 26, chapter 1, "Medicine of the Antique Nation."
2. "Moses," Catholic Encyclopedia, http://www.newadvent.org/cathen/10596a.htm, accessed 3/21/13
3. Puschmann, Theodor, translated by Evan H. Hare, "A history of medical education from the most remote to the most recdent times," 1891, London, H.K. Lewis
4. Garrison, Fielding Hudson, "An introduction to the history of medicine, with medical chronology, suggestions for study, and bibliographic data," 3rd edition, 1922, Philadelphia and London, W.B. Saunders Company