History of Diphtheria


In 1613, Spain experienced an epidemic of diphtheria. The year is known as El Año de los Garrotillos (The Year of Strangulations) in the history of Spain.

In 1735, a diphtheria epidemic swept through New England.

Before 1826, diphtheria was known by different names across the world. In England, it was known as Boulogne sore throat, as it spread from France. In 1826, Pierre Bretonneau gave the disease the name diphthérite (from Greek diphthera “leather”) describing the appearance of pseudomembrane in the throat.

In 1856, Victor Fourgeaud described an epidemic of diphtheria in California.

In 1878, Queen Victoria’s daughter Princess Alice and her family became infected with diphtheria, causing two deaths, Princess Marie of Hesse and by Rhine and Princess Alice herself.

In 1883, Edwin Klebs identified the bacterium causing diphtheria  and named it Klebs-Loeffler bacterium. The club shape of this bacterium helped Edwin to differentiate it from other bacteria. Over the period of time, it was called Microsporon diphtheriticum, Bacillus diphtheriae, and Mycobacterium diphtheriae. Current nomenclature is Corynebacterium diphtheriae. Friedrich Loeffler was the first person to cultivate C. diphtheriae in 1884. He used Koch’s postulates to prove association between C. diphtheriae and diphtheria. He also showed that the bacillus produces an exotoxin. Joseph P. O’Dwyer introduced the O’Dwyer tube for laryngeal intubation in patients with an obstructed larynx in 1885. It soon replaced tracheostomy as the emergency diphtheric intubation method.

In 1888, Emile Roux and Alexandre Yersin showed that a substance produced by C. diphtheriae caused symptoms of   diphtheria in animals. In 1890, Shibasaburo Kitasato and Emil von Behring immunized guinea pigs with heat-treated diphtheria toxin. They also immunized goats and horses in the same way and showed that an “antitoxin” made from serum of immunized animals could cure the disease in non-immunized animals.

 

Behring used this antitoxin (now known to consist of antibodies that neutralize the toxin produced by C. diphtheriae) for human trials in 1891, but they were unsuccessful. Successful treatment of human patients with horse-derived antitoxin began in 1894, after production and quantification of antitoxin had been optimized.

 Von Behring won the first Nobel Prize in medicine in 1901 for his work on diphtheria.

 

In 1895, H. K. Mulford Company of Philadelphia started production and testing of diphtheria antitoxin in the United States. Park and Biggs described the method for producing serum from horses for use in diphtheria treatment.

In 1897, Paul Ehrlich developed a standardized unit of measure for diphtheria antitoxin. This was the first ever standardization of a biological product, and played an important role in future developmental work on sera and vaccines.

In 1901, 10 of 11 inoculated St. Louis children died from contaminated diphtheria antitoxin. The horse from which the antitoxin was derived died of tetanus. This incident, coupled with a tetanus outbreak in Camden, New Jersey, played an important part in initiating federal regulation of biologic products.

On 7 January 1904, Ruth Cleveland died of diphtheria at the age of 12 years in Princeton, New Jersey. Ruth was the eldest daughter of former President Grover Cleveland and the former first lady Frances Folsom.

In 1905, Franklin Royer, from Philadelphia’s Municipal Hospital, published a paper urging timely treatment for diphtheria and adequate doses of antitoxin.

In 1906, Clemens Pirquet and Béla Schick described serum sickness in children receiving large

quantities of horse-derived antitoxin.

Between 1910 and 1911, Béla Schick developed the Schick test to detect pre-existing immunity to diphtheria in an exposed person.

Only those who were not exposed to diphtheria were preferably vaccinated. A massive, five-year campaign was coordinated by Dr. Schick. As a part of the campaign, 85 million pieces of literature were distributed by the Metropolitan Life Insurance Company with an appeal to parents to “Save your child from diphtheria.” A vaccine was developed in the next decade, and deaths began declining significantly in 1924.

In 1919, in Dallas, Texas, 10 children were killed and 60 others made seriously ill by toxic antitoxin which had passed the tests of the New York State Health Department. Mulford Company of Philadelphia (manufacturers) paid damages in every case.

In the 1920s, an estimated 100,000 to 200,000 cases of diphtheria occurred per year in the

United States, causing 13,000 to 15,000 deaths per year.  Children represented a largemajority of these cases and fatalities. One of the most infamous outbreaks of diphtheria was in Nome, Alaska; the “Great Race of Mercy” to deliver diphtheria antitoxin is now celebrated by the Iditarod Trail Sled Dog Race.

In 1926, Alexander Thomas Glenny increased the effectiveness of diphtheria toxoid (a modified version of the toxin used for vaccination) by treating it with aluminum salts. Vaccination with toxoid was not widely used untli the early 1930s.

In 1943, diphtheria outbreaks accompanied war and disruption in Europe. The 1 million cases in Europe resulted in 50,000 deaths. In 1949, 68 of 606 children died after diphtheria immunization due to improper manufacture of aluminum phosphate toxoid.

In 1974, the World Health Organization included DPT vaccine in their Expanded Programme on Immunization for developing countries.

In 1975, an outbreak of cutaneous diphtheria in Seattle, Washington, was reported.

In 1994, the Russian Federation had 39,703 diphtheria cases. By contrast, in 1990, only 1,211 cases were reported.

Between 1990 and 1998, diphtheria caused 5000 deaths in the countries of the former Soviet Union

In early May 2010, a case of diphtheria was diagnosed in Port-au-Prince, Haiti, after the devastating 2010 Haiti earthquake. The 15- year-old male patient died while workers searched for antitoxin.

In 2013, three children died of diphtheria in Hyderabad, India.]

In early June 2015, a case of diphtheria was diagnosed aVt all d’Hebron University Hospita lin Barcelona, Spain. The 6-year-old child who died of the illness had not been previously vaccinated due to parental opposition to vaccination. It was the first case of diphtheria in the country since 1986 as reported by” El Mundo” or from 1998, as reported by WHO.

In March 2016, a 3-year-old girl died of diphtheria in the University Hospital of Antwerp, Belgium.

In June 2016, a 3-year-old, 5-year-old, and 7-year-old girl died of diphtheria in Kedah and Malacca, Sabah Malaysia.

In January 2017, more than 300 cases were recorded in Venezuela.

In November and December 2017, an outbreak of diphtheria occurred in Indonesia with more than 600 cases found and 38 fatalities.

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“Himalayan Viagra” or ‘yarsagumba’ (Ophiocordyceps sinensis)


It’s the time of the year that the mushroom called ‘yarsagumba’ (Ophiocordyceps sinensis), also known locally as ‘keerajari’, appears in the meadows when the snow starts melting.  it is also known as Himalayan Viagra.

The mushroom, which has a long history of use in traditional Chinese medicine (thousands of years), fetches a price of Rs 2 to 5 lakhs per kilogram or much  above locally, depending on quality. It plays a vital role in the local economy, that’s largely pastoral.

It is also called Yart Swa Gun Bu, which in Tibetan means ‘herb in the summer and insect in the winter’. In Nepali it is referred to by the colloquial term Yachagumbu or Yaxagumbu while the Chinese call it Dong cong xia cao.

Usually, as the month of May approaches, villagers from Dasholi, Ghat, Urgam valley, Niti valley, Deval and Joshimath blocks of Chamoli district start start moving into the the higher ranges, armed with essentials and rations. They camp there for at least two months while hunting for the prized mushroom, yarsagumba or Himalayan Viagra.

The heavy snowfall in the higher ranges of Himalayas earlier this week has disrupted the hunt for a prized aphrodisiac fungus popularly referred to as Himalayan viagra. There’s a lot at stake.

Heavy snowfall  has forced villagers to call off the hunt for yarsagumba and climb down from the higher reaches of Chamoli district in Uttarakhand. They will have to wait till the snow melts and that may leave only a handful days left in the Yarsagumba season.

Usually, as the month of May approaches, villagers from Dasholi, Ghat, Urgam valley, Niti valley, Deval and Joshimath blocks of Chamoli district start  moving into the higher ranges, armed with essentials and rations. They camp there for at least two months while hunting for the prized mushroom.

source

Supreme Court judgement on End of Life & Living Will: Partaking moral and ethical dilemma of doctors and relatives


A welcome, long awaited judgement, where law has come to help the doctors and relatives of terminally ill patients. Doctors are often accused of over treatment, without realizing that law does not permit them the termination of treatment as desired by patients or relatives. commonly  doctors come to face these difficult situations, where moral and ethical dilemma  is larger than treatment itself.

The Supreme Court ruled on Friday that individuals have a right to die with dignity, in a verdict that permits the removal of life-support systems for the terminally ill or those in incurable comas.

The court also permitted individuals to decide against artificial life support, should the need arise, by creating a “living will”.

 Living will

A ‘living will’ is a concept where a patient can give consent that allows withdrawal of life support systems if the individual is reduced to a permanent vegetative state with no real chance of survival.

It is a type of advance directive that may be used by a person before incapacitation to outline a full range of treatment preferences or, most often, to reject treatment. A living can detail a person’s preferences for tube-feeding, artificial hydration, and pain medication when an individual cannot communicate his/her choices.

In its verdict on Friday, SC has attached strict conditions for executing “a living will that was made by a person in his normal state of health and mind”.

The US, UK, Germany and Netherlands have advance medical directive laws that allow people to create a ‘living will’.

 Active and passive euthanasia

Active euthanasia, the intentional act of causing the death of a patient in great suffering, is illegal in India. It entails deliberately causing the patient’s death through injections or overdose.

But passive euthanasia, the withdrawal of medical treatment with the deliberate intention to hasten a terminally ill patient’s death was allowed by the Supreme Court in Friday’s landmark verdict.

The court also laid down guidelines on who would execute the will and how a nod for passive euthanasia would be granted by a medical board set up to determine and carry out any “advance directive”.

In cases where there is no “advance directive”, the patient, family, friends and legal guardians can’t take the decision on their own, but can approach a high court for stopping treatment .

 Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill

In 2012, the union health ministry posted a draft of the Terminally Ill Patients (Protection of Patients and Medical Practitioners) Bill on its website and invited public reactions.

The Bill is popularly referred to as the Passive Euthanasia Bill although its draft did not use the emotive word “euthanasia” to skirt complications around the term, a health ministry official told HT in 2016. It says every advance medical directive (also called ‘living will’) or medical power of attorney executed by a person shall be taken into consideration in matter of withholding or withdrawing medical treatment but it shall not be binding on any medical practitioner.

 Misuse of law

A major concern is the misuse of the law. If it is legal to passively allow or hasten death, what’s to say an aged parent won’t be hastened in favor of an inheritance, or a spouse have treatment withdrawn for the sake of a hefty insurance payout? That is why there are legal provisions  in the judgement  by Supreme court, to safe guard the patients.

The bench also stipulated strict conditions for the execution of the living will, which includes the setting up of two medical boards and certification by the judicial magistrate. It also directed high courts to maintain a record of all living will documents prepared within the state.

 Euthanasia in other countries

Euthanasia and physician-assisted suicide have been legal in The Netherlands and Belgium since 2001 and 2002. In the US, Switzerland and Germany, euthanasia is illegal but physician-assisted suicide is legal. Euthanasia remains illegal in the UK, France, Canada and Australia.

Source- Hindustan times

20 interesting facts about the kidneys : World Kidney Day


  1. Kidneys are very important   and   fundamental organs of human body.  They are extremely complex in mechanism and they have two functions  that is blood purification and  waste elimination.
  2. An adult kidney weighs around  142 grams and  is the size of  human fist.
  3. In case of new born human babies, the kidney to body weight ratio is 3 times the kidney to body weight ratio in adults. In case of adults, kidneys form only 0.5% of the entire body weight.
  4. Largest kidney stone recorded was of coconut size and weighed 1.1 kg.
  5. If a child is borne without a kidney, the one kidney will grow and weigh the same as of two kidneys.
  6. The right kidney is below the liver ( largest organ ) and smaller than left kidney.
  7. There are 1.1 million nephrons ( very tiny filters that are capable of filtering blood) in the body. If stretched end to end,  they  will be 8 KM long.
  8. Kidney filter blood around 400 times a day.
  9. If kidney detect fall in Blood pressure, they signal blood vessels to shrink.
  10. A single kidney with only 75 % of its functional capacity can sustain life very well.
  11. They are capable of activating vitamin D in our body. This vitamin is usually produced by special skin cells when they are exposed to sunlight.
  12. Kidneys cleanse 1.3 liters of blood every minute to produce about the same quantity  of urine in a day.
  13. Most common cause of renal stones is not drinking enough water.
  14. About 25 % of the blood from heart, goes to kidneys.
  15. High BP and diabetes can both lead to failure of kidneys.
  16. When the kidney functions are completely lost, it is known as ESRD or End Stage Renal Disease.
  17. People suffering with ESRD can live longer with help of kidney transplant or dialysis.
  18. The first ever kidney transplant was conducted by Yuri Voronoy, a Russian surgeon in year 1933, but was unsuccessful.
  19. The first ever successful kidney transplant was conducted by Dr. Joseph E. Murray in December 1954, in Massachusetts at Peter Bent Brigham Hospital.
  20. A kidney transplant would be normally put in pelvis and  disabled kidney will not be extracted.

 

source

Reversal of medical advancement, reversion of the enemy : ANTIBIOTIC RESISTANCE


Substances with antibiotic properties had been used for various purposes since ancient times.

Before the early 20th century, treatments for infections were based primarily on medicinal folklore. Mixtures with antimicrobial properties that were used in treatments of infections were described over 2000 years ago. Many ancient cultures, including the ancient Egyptians and ancient Greeks, used specially selected mold and plant materials and extracts to treat infections.

For their successful development of penicillin, which Fleming had accidentally discovered but could not develop himself, as a therapeutic drug, Chain and Florey shared the 1945 Nobel Prize in Medicine with Fleming.

Germ theory and discovery of antibiotics has contributed a lot to development of modern medicine. Treatment of advanced multi system diseases, complex surgeries, advanced procedures have become easier to handle because of  advent of antibiotics.  

Over the last several decades, antibacterial drug use has become widespread with their misuse being an ever‑ increasing phenomenon. Consequently, antibacterial drugs have become less effective or even ineffective, resulting in a global health security emergency. These infections will be associated with a high consumption of healthcare resources manifested by a prolonged hospital stay and high mortality. The World Health Organization  has identified antimicrobial resistance as one of the most important problems for human health with significant adverse impacts on clinical outcomes and higher costs due to consumption of healthcare resources.

Antibiotic resistance is a serious problem in all parts of the world including Asia–Pacific, Latin America, Middle East, Europe and North America regions. A particular concern is the misuse or overuse of antibiotics, which has led to the development of resistant or super-resistant bacterial strains.

Reasons for widespread antibiotic resistance:

  1. High burden of infectious diseases
  2. Poor control of infectious diseases and lack of prevention.
  3. Easy availability of antibioics.
  4. Liberal prescription and crosspathy. Common and unrestricted use  by alternative medical system doctors, non doctors and quacks.
  5. Over the counter sale of antibiotics by pharmacists.
  6. Self administration of antibiotics by patients.
  7. Shorter courses and irregular intake of antibiotics by patients.
  8. Inappropriate doses of antibiotics, specially if given by non trained person.
  9. Pressure by patients for early recovery, resulting in over prescription.
  10. Presence of large number of generics of molecules and their quality not ensured.
  11. Poor environmental sanitation, widespread  water contamination, animal waste.
  12. Lack of proper regulation and control of quality of antibiotics
  13. Unregulated  use of antibiotics in animal industry, agriculture, and aquaculture.

 

It is not uncommon to see patients not responding well to treatment. Such scenario increase difficulty for doctors, besides they may be blamed for not doing enough. Reasons may be any of the  above.  Bacteria have been the occupants around us in environment  and also in our body, have acquired deadly weapons  quickly.  Discovery of antibiotics have not lasted even 100 years. Over enthusiasm and euphoria  created by  mass production and use of antibiotics may prove lethal for human race. Antibiotic resistance has potential to undo all the advancement and is a threat of return to pre- antibiotic era .

 

 

Hammurabi’s medical regulation code (1750 BC): Noble profession has always been regulated cruelly ?


Children are always taught in school that medical profession is a noble one. But they are never told, about the cruelty this profession has faced since ancient times. the ancient rulers always blamed the physician for the poor patient outcome and also made regulations to regulate medical profession, and this was when the medical science was not even developed enough to deal with most diseases.

A great military commander, Hammurabi consolidated small states in the vicinity after ascending to the throne on the death of his father. Sometime around 1780-50 B.C., the Babylonian king Hammurabi promulgated the now famous  Code of Hammurabi, covering both civil and criminal law.

Hammurabi’s Code of Laws was considered the first documented Code ever used by human civilization in Mesopotamia, the cradle of civilization, the land of Assyro-Babylonian culture. This era first saw the interface between medicine and law in the dawn of civilization.

Among the 282 laws in Hammurabi’s Code, nine (215-223) pertain to medical practice:

 

HAMMURABI’S CODE OF LAWS :

  1. If a physician performs eye surgery and saves the eye, he shall receive ten shekels in money.
  2. If the patient be a freed man, he receives five shekels.
  3. If he be the slave of some one, his owner shall give the physician two shekels.
  4. If a physician performs an operation and kills someone or cuts out his eye, the doctor’s hands shall be cut off.
  5. If a physician performs an operation on the slave of a freed man and kills him, the doctor shall replace the slave with another slave.
  6. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.
  7. If a physician heal the broken bone or diseased soft part of a man, the patient shall pay the physician five shekels in money.
  8. If he were a freed man he shall pay three shekels.
  9. If he were a slave his owner shall pay the physician two shekels.

 

As we can see, it did  not take into account  the earlier works or contribution of doctors to society. It also did not take into account the  uncertainty of medical science and uncertainties of the outcome.  The regulatory system was based on  principle of revenge and punishments.

Deselection of providers: Hammurabi’s Codex specified the harshest form of deselection possible. If the physician erred through omission or commission, his fingers or hands were cut off, immediately stopping his practice. This severe punishment for negligence supposedly weeded out physicians incapable of delivering adequate care. In addition, it prevented these physicians from practicing in a different locality. Obviously, such a penalty discouraged a physician surplus.

Since ancient civilization, medical regulation has been always cruel to doctors.   Hammurabi at the start of civilization believed that doctors needed to be punished in case there was poor prognosis. He failed to understand the complexity of human body and the limitations of medical profession.

Today our system  is becoming somewhat  similar, to those ancient regulations in  terms of punishment and revenge. Differential payment system for health care also resembles the Code of Hammurabi in some respects.And this is despite the fact that now we are very well conversant with the workings of the human body and despite cognizance of the poor prognosis in certain disease states.

In an effort to institute managed healthcare, our society is in a way re-entering the realm of an ancient medical care system. Certain aggrieved health care consumers may welcome a move toward harsh penalties in the name of justice and simply for revenge but we need to keep in mind the  poor outcomes in complex diseases, limitation of science and of course the idiosyncrasies of the human body.

 

 

https://en.wikipedia.org/wiki/Code_of_Hammurabi

Code of Hammurabi. (2017, December 18). In Wikipedia, The Free Encyclopedia. Retrieved 16:58, December 23, 2017, from https://en.wikipedia.org/w/index.php?title=Code_of_Hammurabi&oldid=816023447

 

 

Medical Regulation and Medical Community of Ancient Rome


Medical community

Medical services of the late Roman Republic and early Roman Empire were mainly imports from the civilization of Ancient Greece, and then through Greeks enslaved during the Roman conquest of Greece. Greek knowledge imparted to Roman citizens visiting or being educated in Greece.  A perusal of the names of Roman physicians will show that the majority are wholly or partly Greek and that many of the physicians were of servile origin.

The servility stigma came from the accident of a more medically advanced society being conquered by a lesser. One of the cultural ironies of these circumstances is that free men sometimes found themselves in service to the enslaved professional or dignitary, or the power of the state was entrusted to foreigners who had been conquered in battle and were technically slaves. In Greek society, physicians tended to be regarded as noble.

Public medicine

The medical art in early Rome was the responsibility of the pater familias, or patriarch. The importation of the Aesculapium established medicine in the public domain. There is no record of fees being collected for a stay at one of them, at Rome or elsewhere.  individuals vowed to perform certain actions or contribute a certain amount if certain events happened, some of which were healings. Such a system amounts to gradated contributions by income, as the contributor could only vow what he could provide. The building of a temple and its facilities on the other hand was the responsibility of the magistrates. The funds came from the state treasury or from taxes.

Private medicine  A second signal act marked the start of sponsorship of private medicine by the state as well. In the year 219 BCE, a vulnerarius, or surgeon, Archagathus, visited Rome from the Peloponnesus and was asked to stay. The state conferred citizenship on him and purchased him a taberna, or shop, near the compitium Acilii (a crossroads), which became the first officina medica.

The doctor necessarily had many assistants. Some prepared and vended medicines and tended the herb garden. These numbers, of course, are at best proportional to the true populations, which were many times greater.

Roman doctors of any stature combed the population for persons in any social setting who had an interest in and ability for practicing medicine. On the one hand the doctor used their services unremittingly. On the other they were treated like members of the family; i.e., they came to stay with the doctor and when they left they were themselves doctors. The best doctors were the former apprentices of the Aesculapia, who, in effect, served residencies there.

 

The practice of medicine

The physician

The next step was to secure the cura of a medicus. If the patient was too sick to move one sent for a clinicus, who went to the clinum or couch of the patient.

That the poor paid a minimal fee for the visit of a medicus is indicated by a wisecrack in Plautus. It was less than a nummus. Many anecdotes exist of doctors negotiating fees with wealthy patients and refusing to prescribe a remedy if agreement was not reached. The fees charged were on a sliding scale according to assets. The physicians of the rich were themselves rich. For example, Antonius Musa treated Augustus’ nervous symptoms with cold baths and drugs. He was not only set free but he became Augustus’ physician. He received a salary of 300,000 sesterces. There is no evidence that he was other than a private physician; that is, he was not working for the Roman government.

Legal responsibility Doctors were generally exempt from prosecution for their mistakes. Some writers complain of legal murder. However, holding the powerful up to exorbitant fees ran the risk of retaliation. Pliny reports  that the emperor Claudius fined a physician, Alcon, 180 million sesterces and exiled him to Gaul. By chance a law existed at Rome, the Lex Aquilia  passed about 286 BCE, which allowed the owners of slaves and animals to seek remedies for damage to their property, either malicious or negligent. Litigants used this law to proceed against the negligence of medici, such as the performance of an operation on a slave by an untrained surgeon resulting in death or other damage.

Social position While encouraging and supporting the public and private practice of medicine, the Roman government tended to suppress organizations of medici in society. The constitution provided for the formation of occupational collegia, or guilds. The consuls and the emperors treated these ambivalently. Sometimes they were permitted; more often they were made illegal and were suppressed. The medici formed collegia, which had their own centers, the Scholae Medicorum, but they never amounted to a significant social force. They were regarded as subversive along with all the other collegia.Doctors were nevertheless influential. They liked to write. Compared to the number of books written, not many have survived; for example, Tiberius Claudius Menecrates composed 150 medical works, of which only a few fragments remain. Some that did remain almost in entirety are the works of Galen, Celsus, Hippocrates and the herbal expert, Pedanius Dioscorides who wrote the 5-volume De Materia Medica.

Military medical corps

Republican

 The state of the military medical corps before Augustus is unclear. Corpsmen certainly existed at least for the administration of first aid and were enlisted soldiers rather than civilians. The commander of the legion was held responsible for removing the wounded from the field and insuring that they got sufficient care and time to recover. He could quarter troops in private domiciles if he thought necessary.

Imperial  

The army of the early empire was sharply and qualitatively different. If military careers were now possible, so were careers for military specialists, such as medici. Under Augustus for the first time occupational names of officers and functions began to appear in inscriptions. The term medici ordinarii in the inscriptions must refer to the lowest ranking military physicians. No doctor was in any sense “ordinary”. They were to be feared and respected. During his reign, Augustus finally conferred the dignitas equestris, or social rank of knight, on all physicians, public or private. They were then full citizens and could wear the rings of knights. In the army there was at least one other rank of physician, the medicus duplicarius, “medic at double pay”, and, as the legion had milites sesquiplicarii, “soldiers at 1.5 pay”, perhaps the medics had that pay grade as well.

Practice

Medical corps in battle worked on the battlefield bandaging soldiers. From the aid station the wounded went by horse-drawn ambulance to other locations, ultimately to the camp hospitals in the area. There they were seen by the medici vulnerarii, or surgeons, the main type of military doctor. They were given a bed in the hospital if they needed it and one was available. The larger hospitals could administer 400-500 beds.A base hospital was quadrangular with barracks-like wards surrounding a central courtyard. On the outside of the quadrangle were private rooms for the patients. Although unacquainted with bacteria, Roman medical doctors knew about contagion and did their best to prevent it. Rooms were isolated, running water carried the waste away, and the drinking and washing water was tapped up the slope from the latrines.Within the hospital were operating rooms, kitchens, baths, a dispensary, latrines, a mortuary and herb gardens, as doctors relied heavily on herbs for drugs.. They operated or otherwise treated with scalpels, hooks, levers, drills, probes, forceps, catheters and arrow-extractors on patients anesthetized with morphine. Instruments were boiled before use. Wounds were washed in vinegar and stitched. Broken bones were placed in traction. There is, however, evidence of wider concerns. A vaginal speculum suggests gynecology was practiced, and an anal speculum implies knowledge that the size and condition of internal organs accessible through the orifices was an indication of health. They could extract eye cataracts with a special needle. Operating room amphitheaters indicate that medical education was ongoing. Many have proposed that the knowledge and practices of the medici were not exceeded until the 20th century CE.

Regulation of medicine

By the late empire the state had taken more of a hand in regulating medicine. The law codes of the 4th century CE, such as the Codex Theodosianus, paint a picture of a medical system enforced by the laws and the state apparatus. At the top was the equivalent of a surgeon general of the empire. He was by law a noble, a dux (duke) or a vicarius (vicar) of the emperor. He held the title of comes archiatorum, “count of the chief healers.” The Greek word iatros, “healer”, was higher-status than the Latin medicus.Under the comes were a number of officials called the archiatri, or more popularly the protomedicisupra medicosdomini medicorum or superpositi medicorum. They were paid by the state. It was their function to supervise all the medici in their districts; i.e., they were the chief medical examiners. Their families were exempt from taxes. They could not be prosecuted nor could troops be quartered in their homes.The archiatri were divided into two groups:

Archiatri sancti palatii, who were palace physicians

Archiatri populares. They were required to provide for the poor; presumably, the more prosperous still provided for themselves.

The archiatri settled all medical disputes. Rome had 14 of them; the number in other communities varied from 5 to 10 depending on the population.

 

 

 

History & Evolution of Anesthesia: 18th and 19th century advancement in science of anesthesia


Discovery of Anesthesia is one of the most important advancement of modern medicine. The Renaissance saw significant advances in anatomy and surgical technique. However, despite all this progress, surgery remained a treatment of last resort. Largely because of the associated pain, many patients with surgical disorders chose certain death rather than undergo surgery. Although there has been a great deal of debate as to who deserves the most credit for the discovery of general anesthesia, it is generally agreed that certain scientific discoveries in the late 18th and early 19th centuries were critical to the eventual introduction and development of modern anesthetic techniques.

Although anesthesia is known since ancient times,  major advances occurred in the late 19th century, which together allowed the transition to modern surgery. An appreciation of the germ theory of disease led rapidly to the development and application of antiseptic techniques in surgery.

18th century

Joseph Priestley (1733–1804) was an English polymath who discovered nitrous oxide, nitric oxide, ammonia, hydrogen chloride and  oxygen. Beginning in 1775, Priestley published his research in Experiments and Observations on Different Kinds of Air. The recent discoveries about these and other gases stimulated a great deal of interest in the European scientific community. Thomas Beddoes (1760–1808) was an physician and teacher of medicine. With an eye toward making further advances in this new science as well as offering treatment for diseases previously thought to be untreatable (such as asthma and tuberculosis), Beddoes founded the Pneumatic Institution for inhalation gas therapy in 1798 at Dowry Square in Clifton, Bristol.  Beddoes employed chemist and physicist Humphry Davy (1778–1829) as superintendent of the institute, and engineer James Watt (1736–1819) to help manufacture the gases.

During the course of his research at the Pneumatic Institution, Davy discovered the anesthetic properties of nitrous oxide. Davy, who coined the term “laughing gas” for nitrous oxide, published his findings the following year.  Davy was not a physician, and he never administered nitrous oxide during a surgical procedure. He was however the first to document the analgesic effects of nitrous oxide, as well as its potential benefits in relieving pain during surgery.

 

19th century

 Eastern hemisphere

Hanaoka Seishu (1760–1835) of  Osaka  was a Japanese surgeon of the  Edo period  with a knowledge of  Chinese herbal medicine, as well as Western surgical techniques. Beginning in about 1785, Hanaoka embarked on a quest to re-create a compound that would have pharmacologic properties similar to Hua Tuo’s mafeisan. After years of research and experimentation, he finally developed a formula which he named tsūsensan . Like that of Hua Tuo, this compound was composed of extracts of several different plants.

The  five of these seven ingredients were thought to be elements of Hua Tuo’s anesthetic potion, used 1600 years earlier.

The active ingredients in tsūsensan are    scopolamine , hyoscyamine ,  atropine , aconitine , angelicotoxin.  In sufficient quantity, tsūsensan produces a state of general anesthesia and  skeletal muscle paralysis. Shutei nakagawa (1773–1850), a close friend of Hanaoka, wrote a small pamphlet titled “Mayaku-ko” (“narcotic powder”) in 1796. Although the original manuscript was lost in a fire in 1867, this brochure described the current state of Hanaoka’s research on general anesthesia.

On 13 October 1804, Hanaoka performed a partial mastectomy for breast cancer on a 60-year-old woman named Kan Aiya, using tsūsensan as a general anesthetic. This is generally regarded today as the first reliable documentation of an operation to be performed under general anesthesia. Hanaoka went on to perform many operations using tsūsensan, including resection of malignant masses,  extraction of bladder stones, and extremity amputations. Before his death in 1835, Hanaoka performed more than 150 operations for breast cancer.

Western hemisphere

Friedrich Sertürner (1783–1841) first isolated morphine from opium in 1804,  he named it morphine after Morpheus, the Greek god of dreams.

Henry Hill Hickman (1800–1830) experimented with the use of carbon dioxide as an anesthetic in the 1820s. He would make the animal insensible, effectively via almost suffocating it with carbon dioxide, then determine the effects of the gas by amputating one of its limbs. In 1824, Hickman submitted the results of his research to the Royal Society in a short treatise titled Letter on suspended animation: with the view of ascertaining its probable utility in surgical operations on human subjects. The response was an 1826 article in The Lancet titled ‘Surgical Humbug’ that ruthlessly criticised his work. Hickman died four years later at age  of 30. Though he was unappreciated at the time of his death, his work has since been positively reappraised and he is now recognised as one of the fathers of anesthesia.

By the late 1830s, Humphry Davy’s experiments had become widely publicized within academic circles in the north eastern United States. Wandering lecturers would hold public gatherings, referred to as “ether frolics”, where members of the audience were encouraged to inhale diethyl ether or nitrous oxide to demonstrate the mind-altering properties of these agents while providing much entertainment to onlookers. Four notable men participated in these events and witnessed the use of ether in this manner. They were William Edward Clarke (1819–1898), Crawford W. Long (1815–1878), Horace Wells (1815–1848), and William T. G. Morton (1819–1868).

While attending undergraduate school in Rochester, New York, in 1839, classmates Clarke and Morton apparently participated in ether frolics with some regularity. In January 1842, by now a medical student at Berkshire Medical College, Clarke administered ether to a Miss Hobbie, while Elijah Pope performed a dental extraction. In so doing, he became the first to administer an inhaled anesthetic to facilitate the performance of a surgical procedure. Clarke apparently thought little of his accomplishment, and chose neither to publish nor to pursue this technique any further. Indeed, this event is not even mentioned in Clarke’s biography.

Crawford W. Long was a physician and pharmacist practicing in Jefferson, Georgia in the mid-19th century. During his time as a student at the University of Pennsylvania School of Medicine in the late 1830s, he had observed and probably participated in the ether frolics that had become popular at that time. At these gatherings, Long observed that some participants experienced bumps and bruises, but afterward had no recall of what had happened. He postulated that that diethyl ether produced pharmacologic effects similar to those of nitrous oxide. On 30 March 1842, he administered diethyl ether by inhalation to a man named James Venable, in order to remove a tumor from the man’s neck. Long later removed a second tumor from Venable, again under ether anesthesia. He went on to employ ether as a general anesthetic for limb amputations and parturition. Long however did not publish his experience until 1849, thereby denying himself much of the credit he deserved.

On 10 December 1844, Gardner Quincy Colton held a public demonstration of nitrous oxide in Hartford, Connecticut. One of the participants, Samuel A. Cooley, sustained a significant injury to his leg while under the influence of nitrous oxide without noticing the injury. Horace Wells, a Connecticut dentist present in the audience that day, immediately seized upon the significance of this apparent analgesic effect of nitrous oxide. The following day, Wells underwent a painless dental extraction while under the influence of nitrous oxide administered by Colton. Wells then began to administer nitrous oxide to his patients, successfully performing several dental extractions over the next couple of weeks.

William T. G. Morton, another New England dentist, was a former student and then-current business partner of Wells. He was also a former acquaintance and classmate of William Edward Clarke (the two had attended undergraduate school together in Rochester, New York). Morton arranged for Wells to demonstrate his technique for dental extraction under nitrous oxide general anesthesia at Massachusetts General Hospital, in conjunction with the prominent surgeon John Collins Warren. This demonstration, which took place on 20 January 1845, ended in failure when the patient cried out in pain in the middle of the operation.

On 30 September 1846, Morton administered diethyl ether to Eben Frost, a music teacher from Boston, for a dental extraction. Two weeks later, Morton became the first to publicly demonstrate the use of diethyl ether as a general anesthetic at Massachusetts General Hospital, in what is known today as the Ether Dome. On 16 October 1846, John Collins Warren removed a tumor from the neck of a local printer, Edward Gilbert Abbott. Upon completion of the procedure, Warren reportedly quipped, “Gentlemen, this is no humbug.” News of this event rapidly traveled around the world. Robert Liston performed the first amputation in December of that year. Morton published his experience soon after  Harvard University professor Charles Thomas Jackson (1805–1880) later claimed that Morton stole his idea. Morton disagreed and a lifelong dispute began. For many years, Morton was credited as being the pioneer of general anesthesia in the Western hemisphere, despite the fact that his demonstration occurred four years after Long’s initial experience.

In 1847, Scottish obstetrician James Young Simpson (1811–1870) of Edinburgh was the first to use chloroform as a general anesthetic on a human (Robert Mortimer Glover had written on this possibility in 1842 but only used it on dogs). The use of chloroform anesthesia expanded rapidly thereafter in Europe. Chloroform began to replace ether as an anesthetic in the United States at the beginning of the 20th century. It was soon abandoned in favor of ether when its hepatic and cardiac toxicity, especially its tendency to cause potentially fatal cardiac dysrhythmias, became apparent.

In 1871, the German surgeon Friedrich Trendelenburg (1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia.

In 1880, the Scottish surgeon William Macewen (1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform.  All previous observations of the glottis and larynx (including those of Manuel García,  Wilhelm Hack and Macewen) had been performed under indirect vision (using mirrors) until 23 April 1895, when Alfred Kirstein (1863–1922) of Germany first described direct visualization of the vocal cords. Kirstein performed the first direct laryngoscopy in Berlin, using an esophagoscope he had modified for this purpose, he called this device an autoscope.

 

https://en.wikipedia.org/wiki/History_of_general_anesthesia

Permanent link: https://en.wikipedia.org/w/index.php?title=History_of_general_anesthesia&oldid=805843  182

History & Evolution of Anesthesia: ancient, Middle Ages and Renaissance Anesthetics


Discovery of Anesthesia is one of the most important advancement of modern medicine. Attempts at producing a state of general   anesthesia can be traced throughout recorded history in the writings of the ancient Sumerians, Babylonians, Assyrians, Egyptians, Greeks, Romans, Indians, and Chinese. During the Middle Ages, which correspond roughly to what is sometimes referred to as the Islamic Golden Age, scientists and other scholars made significant advances in science and medicine in the Muslim world and Eastern world.

The Renaissance saw significant advances in anatomy and surgical technique. However, despite all this progress, surgery remained a treatment of last resort. Largely because of the associated pain, many patients with surgical disorders chose certain death rather than undergo surgery. Although there has been a great deal of debate as to who deserves the most credit for the discovery of general anesthesia, it is generally agreed that certain scientific discoveries in the late 18th and early 19th centuries were critical to the eventual introduction and development of modern anesthetic techniques.

Two major advances occurred in the late 19th century, which together allowed the transition to modern surgery. An appreciation of the germ theory of disease led rapidly to the development and application of antiseptic techniques in surgery. Antisepsis, which soon gave way to asepsis, reduced the overall morbidity and mortality of surgery to a far more acceptable rate than in previous eras. Concurrent with these developments were the significant advances in pharmacology and physiology which led to the development of general anesthesia and the control of pain.

In the 20th century, the safety and efficacy of general anesthesia was improved by the routine use of tracheal intubation and other advanced airway management techniques. Significant advances in monitoring and new anesthetic agents with improved pharmacokinetic and pharmacodynamics characteristics also contributed to this trend. Standardized training programs for anesthesiologists and nurse anesthetists emerged during this period. The increased application of economic and business administration principles to health care in the late 20th and early 21st centuries led to the introduction of management practices.

Ancient anesthesia

The first attempts at general anesthesia were probably herbal remedies administered in prehistory. Alcohol is the oldest known sedative; it was used in ancient Mesopotamia  thousands of years ago.

Opium

The Sumerians are said to have cultivated and harvested the opium poppy  in lower Mesopotamia as early as 3400 BCE, though this has been disputed. A small white clay tablet at the end of the third millennium BCE discovered in 1954 during excavations at Nippur.  Currently  it is considered to be the most ancient pharmacopoeia in existence.  About 2225 BCE, the Sumerian territory became a part of the Babylonian empire. Knowledge and use of the opium poppy and its euphoric effects thus passed to the Babylonians, who expanded their empire eastwards to Persia and westwards to Egypt, thereby extending its range to these civilizations. Opium was known to the Assyrians in the 7th century BCE.

  The ancient Egyptians had some surgical instruments, as well as crude analgesics and sedatives, including possibly an extract prepared from the mandrake fruit. The use of preparations similar to opium in surgery is recorded in the Ebers Papyrus, an Egyptian medical papyrus.

   Prior to the introduction of opium to ancient India and China, these civilizations pioneered the use of cannabis incense and aconitum. c. 400 BCE, the Sushruta Samhita (a text from the Indian subcontinent on ayurvedic medicine and surgery) advocates the use of wine with incense of cannabis for anesthesia. By the 8th century CE, Arab traders had brought opium to India  and China.

Classical antiquity

In Classical antiquity, anaesthetics were described by:

·         Dioscorides (De Materia Medica)

·         Galen

·         Hippocrates

Theophrastus (Historia Plantarum)–

China

Hua Tuo, Chinese surgeon, c. CE 200

Bian Que. 300 BCE was a legendary Chinese internist and surgeon who reportedly used general anesthesia for surgical procedures

Hua Tuo   CE 145-220  was a Chinese surgeon of the 2nd century CE. Before the surgery, he administered an oral anesthetic potion, probably dissolved in wine, in order to induce a state of unconsciousness and partial neuromuscular blockade.

The exact composition of mafeisan, similar to all of Hua Tuo’s clinical knowledge, was lost when he burned his manuscripts, just before his death. Because Confucian teachings regarded the body as sacred and surgery was considered a form of body mutilation, surgery was strongly discouraged in ancient China. Because of this, despite Hua Tuo’s reported success with general anesthesia, the practice of surgery in ancient China ended with his death.

 

Other substances used from antiquity for anesthetic purposes include extracts of juniper and coca.

Middle Ages and Renaissance

Arabic and Persian physicians may have been among the first to utilize oral as well as inhaled anesthetics.

In 1000, Abu al-Qasim al-Zahrawi (936-1013), an Arab physician described as the father of surgery. who lived in Al-Andalus, published the 30-volume Kitab al-Tasrif, the first illustrated work on surgery. In this book, he wrote about the use of general anesthesia for surgery. c. 1020, Ibn Sīnā (980–1037) described the use of inhaled anesthesia. The Canon described the “soporific sponge”, a sponge imbued with aromatics and narcotics, which was to be placed under a patient’s nose during surgical operations. Ibn Zuhr (1091–1161) was another Arab physician from Al-Andalus. In his 12th century medical textbook Al-Taisir, Ibn Zuhr describes the use of general anesthesia.These three physicians were among many who performed operations under inhaled anesthesia with the use of narcotic-soaked sponges. Opium made its way from Asia Minor to all parts of Europe between the 10th and 13th centuries.

 

Throughout 1200 – 1500 A.D. in England, a potion called dwale was used as an anesthetic. This mixture contained bile, opium, lettuce, bryony, and hemlock. Surgeons roused them by rubbing vinegar and salt on their cheekbones. One can find records of dwale in numerous literary sources, including Shakespeare’s Hamlet, and the John Keats poem “Ode to a Nightingale”. In the 13th century, we have the first prescription of the “spongia soporifica”—a sponge soaked in the juices of unripe mulberry, flax, mandragora leaves, ivy, lettuce seeds, lapathum, and hemlock with hyoscyamus. After treatment and/or storage, the sponge could be heated and the vapors inhaled with anasthetic effect.

Alchemist Ramon Llull has been credited with discovering diethyl ether in 1275. Aureolus Theophrastus Bombastus von Hohenheim (1493–1541), better known as Paracelsus, discovered the analgesic properties of diethyl ether around 1525.  August Sigmund Frobenius gave the name Spiritus Vini Æthereus to the substance in 1730.

 

https://en.wikipedia.org/wiki/History_of_general_anesthesia

 https://en.wikipedia.org/w/index.php?title=History_of_general_anesthesia&oldid=805843182

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