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Me Ancestors of Inhalational Anesthesia Me Soponic Sponges (Xitb-Xvlltls Centuries) a Universally Recommended Medical Technique Was Abruptly 265 Anesthesiology 2000; 93265-9 0 2000 American Society of Anesthesiologists, Inc. Iippincott Williams & Willcins, Inc. me Ancestors of Inhalational Anesthesia me Soponic Sponges (XItb-xvlltls Centuries) a Universally Recommended Medical Technique Was Abruptly How Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/93/1/265/330537/0000542-200007000-00037.pdf by guest on 30 September 2021 Discarded Philippe Juvin, M.D.,* Jean-Marie Desmonts, M.D. t THE history of anesthesia is intimately linked to the of a sponge soaked in juices of plants with hypnotic history of surgery. The textbooks of the Hippocratic properties under the nose of the patient. The current Collection,which are the oldest surviving books of West- article describes the changing composition of the sopo- ern medicine, describe a number of elaborate surgical rific sponges during the centuries and the conflicting techniques. These procedures must have necessitated opinions about their effectiveness. that the patient remained perfectly still, suggesting that restraints were probably used, and some degree of anal- gesia or partial alteration of consciousness. Methods The Abbeys (VIth-XIth Centuries) available at the time to obtain adequate operating con- At the councils held by the Roman Catholic Church in ditions included application of heat or cold, jugular vein the VIth century, the bishops of the Western world were compression,2and oral administration of alcoholic bev- urged to attend diligently to their duties of hospitality erages or potions prepared from plants with sedative and assistance. They were invited to set up hospitalia effects. Sedative substances inhaled at the time, but only near their residences, offering beds for the crippled and in nonmedical situations, such as that of the Delphic the needy.5 Little by little, hospitalia were created in priestess, who uttered her oracles while in a trance rural parishes, along roads (most notably those traveled induced as a result of the inhalation of hallucinogenic by pilgrims), near monasteries, or, sometimes, as in Saint vapors. Because of these nonmedical uses of inhalation, Martin de Tours (France), near important shrines. Sup- contemporary authors consider that inhalation for surgi- ported by the Carolingian kings, hospitalia became en- cal purposes was first used during the XMth century, in tirely the affair of the Church. The therapeutic activity 18463. that developed in hospitalia remained the only form of However, inhalation methods were used in the Middle inpatient medical practice until at least the XIth century. Ages in Europe.* The technique consisted of placement To pass on their medical knowledge and to comply with the directives of the Aix-la-Chapelle Council (AD 813, which made the reading and copying of manuscripts a * Staff Anesthesiologist. mandatory activity of all monastic orders, hospital t Professor of Anesthesia and Chairman. monks created the first medieval textbooks of medical Received from the Department of Anesthesiology and Intensive botany, pathology, and pharmacology. The Monte Care, Bichat-Claude Bernard Hospital, Paris, France. Submitted for Cassino Abbey (Italy) was particularIy active in this re- publication September 7, 1999. Accepted for publication March 3, spect, as attested to by the De innumeris morbis and De 2000. Support was provided solely from institutional and/or depart- innumeris remedorium utilitatibus (credited to Abbot mental sources. Presented in part at the 1998 Annual meeting of the Bertharius), and by the translations and compilations by American Society of Anesthesiologists, Orlando, Florida, October 17-21. Constantinus Africanus (circa 1015-1087).5 One of these Address reprint requests to Dr. Juvin:Department of Anesthesiology compilations contains the oldest soporific sponge for- and Intensive Care, Bichat Claude Bernard Hospital, 46 Rue Henri Huchard, 75018 Paris, France. Address electronic mail to: mula known to date (see Appendix). The first sentence [email protected] of this formula leaves no doubt that the sponge was used Key words: Anesthesiology; history; history of medicine; Middle for surgery and that the substances it contained were Ages; surgery. administered by inhalation: Anesthesiology,V 93, No 1, Jul 2000 266 JUVIN ET AL. This is a soporific preparation to be inhaled (Id est somnijicum- ositus, the dean of the School of Salerno, in the Antidot- . soporatz), appropriate for those who are to have surgery (his aty (1471)l’ both described a soporific sponge formula. qui cbirurgia curatur),so that one can cut without causing pain (aut sectionis dolorem non sentiant). This formula includes the ingredients used in the Monte Cassino formula, and lettuce seeds (seminis lactuce), The word soporati confirms that the aim of the pro- poppy seed pods (coconidii papaveris), and juices of cedure was actually inhalation, even if one cannot ex- climbing ivy (succi edere arborea) and immature black- clude that sponges acted through nasal absorption. berries (succi more immature rubis). Fennel roots were Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/93/1/265/330537/0000542-200007000-00037.pdf by guest on 30 September 2021 Opium (opiu thibaicu), mandrake (mandracore sucus), introduced into the patient’s nose to induce awakening hemlock (cicute), and henbane (iusquiami secu) were after the operation. macerated in a certain quantity of water (cum aqua sufficiente) and used to soak a sponge (spungie), which was then dried in the sun (infundis in calida). When it Bologna (XIIIth-xIvth Centuries) was time to perform the operation, the sponge was soaked in hot water and applied while still damp to the During the XIIIth century and until the middle of the nostrils of the patient (naris adponis) to induce loss of XIVth century, three universities exercised a virtually monopolistic hold over the teaching of medicine in Eu- consciousness (ut ad se @sum rapiat spiritum, donec dormiat). At the end of the operation, another sponge rope: Bologna, Montpellier, and Paris.” Hugh of Lucca (1180-1252) was one of the famed practitioners from soaked (altera spongia) in hot vinegar (aceto calefacto) was used to wake the the School of Bologna. He used a soporific sponge for- mula, which was described by his pupil Theodoric (who Three arguments suggest that these soporific sponges died in 1298) Cyrurgia (1264).63’2The title of the were first developed by the Arabs.’ First, many Arab in medical texts were translated at Monte Cassino during chapter describing the sponge (De somniferik et subli- this period. Second, Christians used alcoholic beverages mationibus) indicates very clearly that the sponge was widely as an anesthetic for the wounded. However, intended to induce sleep. Its formula was more complex Muslims were prohibited by religion from drinking alco- than previous formulas, although the exact nature of some of its ingredients is controversial. In addition to the hol, a fact that may have prompted them to seek alter- plants used by the School of Salerno, succi mori sylves- natives. Last, and most important, manuscripts from the School of Alexandria, dating from the same period as tris (bramble berry juice), seminis lapathii, and conid- that of Monte Cassino, contain soporific sponge formulas ium were added. The terms “seminis lapathii” and that are virtually identical to those in the Monte Cassino “conidium” illustrate the formidable challenges raised by the translation of medieval medical texts. It has been manuscripts.’ Therefore, there is strong evidence that, starting in the XIth century in Europe, a technique for suggested that lapathum may be lapacium (burdock), surgical pain relief that relied on inhalation was used, polygonaceae (sorrel), chenopodiaceae (spinach), or taught, and made known by monks. even Landolphia or Acocanthera, two plants used by the Somali people to poison arrowheads and brought to Europe by the crusaders. As for conidium (or co- The School of Salerno (XrIth Century) conidium), another spelling may be cocognidium, a vulgar Latin word for coccum-gnidium. Coccum means Until the XIth or XIIth century, however, medicine “berry” and gnidium means “daphne,” suggesting that was taught only in monasteries, primarily by allowing conidium may be the daphne berry13. Fennel roots and young monks to accompany more experienced brothers vinegar were used to wake the patient. At the same time, as they cared for their patients. Later, by copying manu- Gilbertus Anglicus ( 1180 - 1250) suggested that black- scripts, they captured this knowledge in a more reliable berry and lapathum should be eliminated from the for- way and allowed it to reach beyond the geographic mula and that the vinegar-soaked sponge used to induce confines of their abbey. In the XIIth century, the School awakening should be rubbed against the patient’s teeth.8 of Salerno was the first in Europe to teach medicine to laymen, using an ideological corpus that was circulated From Guy de Chauliac to Ambroise Pare under the title Articella (Little Art).” This structured (xIvth-XVIth Centuries) teaching gave the School of Salerno preeminence over the medical teaching offered by monasteries. Roger Fru- The school of Bologna attracted students throughout gardi, in Practica Chirurgiae (1 170) and Nicolas Prep- Western Christendom. Soporific sponges are frequently Anesthesiology, V 93, No 1, Jul 2000 267 THE SOPORIFIC SPONGES: ANESTHESIA IN THE MIDDLE AGES mentioned in the writings of physicians trained in Bolo- may have been discarded because they were recognized
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