here

History of Anaesthesia VII Proceedings of the 7th International Symposium on the History of Anaesthesia

Chief Editor: Helen Askitopoulou Co-Editors: Kathryn E McGoldrick, Rod N Westhorpe, David J Wilkinson

Crete University Press HERAKLEION 2012

Crete UNIVERSITY PRESS

Foundation for Research & Technology Herakleion: P.O. Box 1385, 711 10. Tel. +30-2810 391097, Fax: +30-2810 391085 Athens: Kleisovis 3, 106 77. Tel. +30-210 3849020-22, Fax: +30-210 3301583 e-mail: [email protected] www.cup.gr



© 2012: First Edition: Printed in:

Crete University Press & Helen Askitopoulou March 2012 Alphabet SA, Greece

ISBN 978-960-524-370-8

E D I T O R ’ S P ro l o g u e

T

he History of Anaesthesia VII is the seventh volume of its kind following a series of very successful publications of the International Symposia on the History of Anaesthesia. These Symposia were organised for the first time in 1982 in Rotterdam by Joseph Rupreht, and since then every four to five years, in London by Tom Boulton (1987), in Atlanta by John E Steinhaus (1992), in Hamburg by Michael Goerig (1997), in Santiago de Compostela by Carlos Diz (2001), in Cambridge, by Neil Adams (2005) and in Heraklion, by Helen Askitopoulou (2009). The present volume contains the Proceedings of the 7th International Symposium on the History of Anaesthesia held in Heraklion. It is a compedium of individual contributions related to the history of anaesthesia, from individual contributors and not a narrative account of the development of anaesthesia as such. The seventh volume of the History of Anaesthesia includes forty seven essays assembled in chronological order in five historical periods, from antiquity to the present: Greek Antiquity, Early Modern Era, Nineteenth century, Twentieth century –first and second halves– and in a separate section on the Pioneers of Anaesthesia. The volume also includes an Introduction on the history of analgesia and anaesthesia and a comprehensive Index of terms and names. The editorial efforts were directed at maintaining a balance between each author’s personal writing style and bringing about a consistent and comprehensible volume with uniformity in style, language and formatting. It was an arduous and time consuming task as English was not the native language of many authors. Besides copy-editing in the British English language –unless the context dictated otherwise– attention was also paid to fact-checking by thoroughly reviewing the content to improve its organisation and quality of communication. We wish to thank all the authors for their patience and eagerness to comply with the editorial efforts and suggestions. We also wish to offer our sincere thanks to Professor Marie-Thérèse J Cousin, Drs Joseph Rupreht and Elsa Astyrakaki for their unreserved support for the completion of this volume. This work could not have been fulfilled without the help of Dionysia Daskalou and the staff of Crete University Press, to whom we also offer our thanks. Chief Editor: Helen Askitopoulou Co-Editors: Kathryn E McGoldrick, Rod N Westhorpe, David J Wilkinson

TABLE OF CONTENT S EDITOR’S Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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LIST OF CONTRIBUTORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

INTRODUCTION

Analgesia and Anaesthesia − From Greek Antiquity to the Twentieth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Helen Askitopoulou

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SECTION I: GREEK ANTIQUITY

Losing the Hippocratic Tradition − A Danger to Our Profession? . . . . . . . . 15 David J Wilkinson

The Hippocratic Approach to Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Elisabeth Astyrakaki, Maria Karatzi, Alexandra Papaioannou, Helen Askitopoulou

Anaesthesia and Analgesia in Ancient Greece and Rome

Louise Cilliers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

A Hippocratic Physician’s Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Georgios Stefanakis , Eleni Konsolaki, Vassilia Nyktari, Helen Askitopoulou

Herbal Pain Medicines in Ancient Egypt and Minoan Crete . . . . . . . . . . . . . . 55 Adelais G Tsiotou, Evangelia K. Kalliardou

Different Concepts of ‘Αnaesthesia’ in Late Greek and Roman Antiquity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Elisabeth Astyrakaki, Vassilia Nyktari, Helen Askitopoulou

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HISTORY OF ANAESTHESIA VII

References to ‘Anaesthesia’ in Galenic Texts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Georgos Giannitopoulos, Elisabeth Astyrakaki, Alexandra Papaioannou, Helen Askitopoulou

Acute Unexpected Deaths of Prominent Men in Ancient Greece . . . . . . . . . 83

Georgios Stefanakis, Eleni Konsolaki, Alexandra Papaioannou, Helen Askitopoulou

S E C T I O N ii : E A R L Y M O D E R N P E R I O D

Hidden ‘Fire Air’, Hidden Letter: Oxygen’s Historic Dilemmas . . . . . . . . . . . . 97 John W Severinghaus

Sedation with Datura Stramonium in Ancient Peru . . . . . . . . . . . . . . . . . . . . . . . 113 César Cortés Román

SE C T ION I I I : N I N E T E E N T H C E N T U RY

The Huxleys & the Rattlesnake: Romance and Australian Anaesthesia in the 1840s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Michael G Cooper, Elizabeth M Todd

Joseph Clover’s Casebook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Christine M Ball

Henry Chambert’s Des Effets Physiologiques et Therapeutiques des Ethers: The Very Rare, Unknown First French Book on Ethers . . . . . . . . . . . . . 151 Jacques Hotton

The History of Early Respirators (Mid 1800s - 1918): A Systematic Re-Assessment of the Main ‘Technology-Transfer’, which led to the Development of Modern Anaesthesia Technology . . . . . . . . . . 159 M Wulf M Strätling, Christian Niggebrügge, Jan Schumacher

Solving the Mystery of ‘Truehead οf Galveston’: ‘The Doctor who Never Was’ - A Detective Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Ronald V Trubuhovich

TA B L E O F C O N T E N T S

‘Sweet’ Methods of Analgesia: Alternatives to Anaesthesia at the End of the Nineteenth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195 Jacques Hotton

S E C T I O N I V: T W E N T I E T H C E N T U RY - F i r s t H a l f

The Draeger Archives: Unveiling one of the Worlds’ Largest Collections on the History of Anaesthesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 M Wulf M Strätling, Jan Schumacher

The Influence of World War One on the Development of American Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Anthony L Kovac

Anaesthesia Aspects of Base Hospital No 28: From Kansas City and the University of Kansas in World War One . . . . . . . . . . . . . . . . . . . 235 Anthony L Kovac

The History of Regional Anaesthesia in Greece in the Twentieth Century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251 Anastasios M Petrou, Georgios St Papadopoulos, Freideriki Steliou

Regional versus General Anaesthesia? What Did Greek Doctors choose in the early Twentieth Century? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Aikaterini Bouzia, Eleni Christopoulou-Aletra

Polarography: A Major Contribution of Jaroslav Heyrovský to Intensive Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 JiřÍ Pokorný

The First Successful Intracardiac Pacing of a Human Heart: Mark Cowley Lidwill – Cardiologist and Anaesthetist . . . . . . . . . . . . . 277 Barry Baker

Endotracheal Intubation in Paediatric Anaesthesia. History and Evolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301 Panagiotis Alexandropoulos, Adelais G Tsiotou, Evangelia K Kalliardou

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HISTORY OF ANAESTHESIA VII

The Australian Society’s Diamond Jubilee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Ross B Holland

S E C T I O N V: T W E N T I E T H C E N T U RY - S e c o n d H a l f

Malignant Hyperthermia − An Australian Story Christine M Ball

. . . . . . . . . . . . . . . . . . . . . . . . . . 321

Air-Cooling to Induce Hypothermia for Cardiac Surgery − Historical Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

Jan Hofland, Karin Leendertse-Verloop, Joseph Rupreht

The World of Veterinary Anaesthesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 Dimitris Raptopoulos

The Origins of the Modern Pain Clinic at the Mayo Clinic . . . . . . . . . . . . . . . 353 Toby N Weingarten, David P Martin, Douglas R Bacon

History of Paediatric Anaesthesiology and Resuscitation in Prague JiřÍ Pokorný

. . . . 361

Sleep Apnoea − A Historical Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373

Eleana E Vlachaki, Irene E Panagiotaki, Stylianos G Velegrakis, George A Velegrakis

Original Development of Anaesthesia Machines Following World War Two in Czechoslovakia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 JiřÍ MÁlek, JiřÍ Pokorný

Interdisciplinary ‘Pain Conferences’ − An Instrument for the Development of Pain Management in the Twentieth Century in Germany . . . . . . 389 Wilfried Witte

The History of Nsaids − From Aspirin to Contemporary COX Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Georgia G Kostopanagiotou, Tatiana F Sidiropoulou

Geoffrey Kaye Museum of Anaesthetic History − Dealing with Hazardous Substances in Museum Collections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Maria Drossos

TA B L E O F C O N T E N T S

SECTION VI: PIONEERS OF ANAESTHESIA

Greek Influence On James Young Simpson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 Alistair G McKenzie

British Pioneers of Regional Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433 J Anthony W Wildsmith

James Moffat’s Tribulations In Paris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 Marguerite Zimmer

Friedrich Von Esmarch − A Pioneer of Emergency Medicine in Germany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449 Heike I Petermann

Benjamin Ward Richardson − His Contribution to Anaesthesia . . . . . . . . . 461 Henry Connor

Samuel J Hayes, Editor of the ‘Dental and Surgical Microcosm’ − The World’s First Anaesthesia Journal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481 George S Bause

Sir Frederic William Hewitt − His Multifaceted Contributions to Anaesthesiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491 Kathryn E McGoldrick

Carl Koller, Cocaine And Local Anaesthesia − Some Less Known and Forgotten Facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501 Michael Goerig, André van Zundert

Rupert Walter Hornabrook −Australia’s First Full-Time Anaesthetist . . . 527 Rod N Westhorpe

René Leriche − The Forgoten Pain Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 539

Marie-Thérèse J Cousin

Pioneers of Greek Anaesthesiology in the Nineteenth and Twentieth Centuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 551 Georgios St Papadopoulos, Anastasios M Petrou

Index of Names . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563 Index of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 575

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l ist of contrib u tors

Panagiotis ALEXANDROPOULOS

Department of Anaesthesia, Anticancer Hospital of Athens ‘Agios Savvas’, Athens, Greece

Helen ASKITOPOULOU

Professor Emeritus of Anaesthesiology, Faculty of Medicine, University of Crete, Heraklion, Greece

Elisabeth ASTYRAKAKI

Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece

Douglas R BACON

Department of Anesthesiology, Mayo Clinic, College of Medicine, Rochester, USA

Barry BAKER

Professor Emeritus, University of Sydney and Dean of Education, Australian and New Zealand College of Anaesthetists, Melbourne, Australia

Christine M BALL

Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University − Honorary Assistant Curator, Geoffrey Kaye Museum of Anaesthetic History, Melbourne, Australia

George S BAUSE

Clinical Associate Professor, Departments of Anesthesiology & Perioperative Medicine and of Oral & Maxillofacial Surgery − Schools of Medicine and of Dental Medicine, Case Western Reserve University, Cleveland, Ohio, USA

Louise CILLIERS

Department of Classical and Near-Eastern Studies, University of the Free State, Bloemfontein, South Africa.

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HISTORY OF ANAESTHESIA VII

Henry CONNOR

Centre for the History of Medicine, University of Birmingham, United Kingdom

Michael G COOPER

Departments of Anaesthesia, The Children’s Hospital at Westmead and St George Hospital, Kogarah, Sydney, Australia

Marie-Thérèse J COUSIN

Professeur & Ex-Chief of Department of Anesthesiologie et Réanimation des Hôpitaux de Paris − Vice-President of the Club d’Histoire de l’Anesthésie et de la Réanimation (CHAR), Buc, France

Maria DROSSOS

Museum Collection Officer, Australian and New Zealand College of Anaesthetists, Melbourne, Australia

Giorgos GIANNITOPOULOS

Trainee, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece

Michael GOERIG

Department of Anaesthesia and Intensive Care, University Hospital Hamburg, Hamburg, Germany

Jan HOFLAND

Divisions of Cardiothoracic and General Anaesthesiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands

Jacques HOTTON

Department of Anesthesia, Centre Hospitalier, Remiremont, France

Evangelia K KALLIARDOU

Consultant Anaesthesiologist, Department of Anaesthesia, Children’s Hospital ‘P. & A. Kyriakou’, Athens, Greece

Maria KARATZI

Trainee, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece

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LIST OF CONTRIBUTORS

Eleni KONSOLAKI

Consultant Oral Surgeon, Department of Oral & Maxillofacial Surgery, University Hospital of Heraklion, Crete, Greece

Georgia G KOSTOPANAGIOTOU

Professor of Anaesthesiology, Second Department of Anaesthesiology, School of Medicine, University of Athens − Attikon University Hospital, Athens, Greece

Karin LEENDERTSE-VERLOOP

Division of General Anaesthesiology, Erasmus MC, Rotterdam, The Netherlands

Jiři MALEK

Associate Professor of Anaesthesiology, Department of Anaesthesiology and Resuscitation, 3rd Medical Faculty, Charles University, Prague and University Hospital Královské Vinohrady, Czech Republic

David P MARTIN

Department of Anesthesiology, Mayo Clinic, College of Medicine, Rochester, USA

Alistair G MCKENZIE

Consultant Anaesthetist, Royal Infirmary of Edinburgh, Hon Clinical Tutor, University of Edinburgh − Department of Anaesthesia, Critical Care & Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Christian NIGGEBRÜGGE

Department of Anaesthesiology, Lübeck University, Lübeck, Germany

Vassilia NYKTARI

Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece

Irene E PANAGIOTAKI

Consultant ENT, Department of ENT, University Hospital of Heraklion, Crete, Greece

Georgios St PAPADOPOULOS

Professor of Anaesthesia, University Hospital of Ioannina, Greece

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HISTORY OF ANAESTHESIA VII

Alexandra PAPAIOANNOU

Lecturer in Anaesthesiology, Faculty of Medicine, University of Crete, Heraklion, Greece

Heike I PETERMANN

Institute for Ethics, History and Theory of Medicine, WWU Muenster, Germany

Anastasios M PETROU

Assistant Professor of Anaesthesia, University Hospital of Ioannina, Greece

Jiři POKORNÝ

Professor of Anaesthesiology, Committee for History of Anaesthesia, Czech Society of Anaesthesiology and Intensive Care Medicine, Praha, Czech Republic

Dimitris RAPTOPOULOS

Professor and Chairman, Unit of Anaesthesiology & Intensive Care, Faculty of Veterinary Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

César Cortés ROMÁN

Anaesthesiologist, Department of Anaesthesia, 12 de Octubre and Madrid Montepríncipe Hospitals, Madrid, Spain

Joseph RUPREHT

Division of General Anaesthesiology, Erasmus MC, Rotterdam, The Netherlands

Jan SCHUMACHER

Department of Anaesthesia, St Thomas’ Hospital, London, United Kingdom

John W SEVERINGHAUS

Professor Emeritus, Anesthesiology, Cardiovascular Research Institute, University of California, San Francisco, California, USA

Tatiana F SIDIROPOULOU

Lecturer of Anaesthesiology, Second Department of Anaesthesiology, School of Medicine, University of Athens, Attikon University Hospital, Athens, Greece

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LIST OF CONTRIBUTORS

Georgios STEFANAKIS

Trainee, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece

Freideriki STELIOU

Consultant Anaesthesiologist, Department of Anaesthesia, Chatzikosta Hospital of Ioannina, Ioannina, Greece

Meinolfus Wulf M STRÄTLING

Directorate of Anaesthesia, University Hospital of Wales − Llandough University Hospital, Cardiff-Penarth, United Kingdom and Department of Anaesthesiology, Lübeck University, Lübeck, Germany

Elizabeth M TODD

Department of History, University of Sydney, Sydney, Australia

Ronald V TRUBUHOVICH

Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand

Adelais G TSIOTOU

Department of Anaesthesia, Children’s Hospital ‘P. & A. Kyriakou’, Athens, Greece

George A VELEGRAKIS

Professor of ENT, Medical Faculty, University of Crete, Heraklion, Greece

Stylianos G VELEGRAKIS

Trainee, Department of ENT, University Hospital of Heraklion, Crete, Greece

Eleana E VLACHAKI

Trainee, Department of ENT, University Hospital of Heraklion, Crete, Greece

Toby N WEINGARTEN

Department of Anesthesiology, Mayo Clinic, College of Medicine, Rochester, USA

Rod N WESTHORPE

Honorary Curator, Geoffrey Kaye Museum of Anaesthetic History, Australian and New Zealand College of Anaesthetists, “Ulimaroa”, Melbourne,Victoria, Australia

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HISTORY OF ANAESTHESIA VII

David John WILKINSON

Emeritus Consultant, Boyle Department of Anaesthesia, St Bartholomew’s Hospital, London, United Kingdom − Wood Library Museum of Anesthesiology Laureate in the History of Anaesthesia

Marguerite ZIMMER

Dental Surgeon & Doctorate History of Medicine, École Pratique des Hautes Études, in Sorbonne, Strasbourg, France

André van ZUNDERT

Department of Anesthesiology, ICU & Pain Therapy, Catharina Hospital − Brabant Medical School, Eindhoven, The Netherlands

I N TRODU C T ION

Analgesia – Anaesthesia

From Greek Antiquity to the Twentieth Century Helen AskitopoulouI

The Study of the History of Medicine “Life is short, the Art long, opportunity fleeting, experiment treacherous, judgment difficult” Hippocrates, Aphorisms1

The first of the Aphorisms, one of the most renowned of the Hippocratic works, foretells the longevity of the ‘art of medicine’ from the times of empirical knowledge and philosophical speculation, to the era of becoming an ‘art’ and finally a ‘science’. To understand this transition of medicine and the evolution of medical thinking through the ages one needs to delve in to history and specially the history of medicine. This is the linkage to our heritage that helps us understand human struggle and aspirations, societal evolution, and human nature.2 The study of the history of medicine, as Spyros Marketos, Professor of the history of medicine, wrote: “... has two powerful scientific headlights. One is directed towards the past. The other illuminates the future.”3 The history of medicine sheds light on how modern medicine replaced all theocratic dogmas and philosophical speculations with rational scientific thought. It uses primary material to increase understanding of past events and, at the same time, to explore how past events have affected society today. It is salutary for those who entered medicine at a later date to learn the now forgotten difficulties and Helen ASKITOPOULOU, MD, PhD, DA, FRCA, FERC(Hon), FESEM(Hon), Professor Emeritus of Anaesthesiology, Faculty of Medicine, University of Crete, Heraklion, Greece, Organiser of the 7th International Symposium on the History of Anaesthesia.

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HELEN ASKITOPOULOU

problems encountered in the course of history that beset the pioneers. It helps us to understand from where we came, it enriches our minds, our daily practice and often opens the way to new pursuits and the progress of the present.4As Nicholas Green wrote, the history of medicine helps us to “avoid repeating the follies, foibles, and fads of the past.”5 The same transition and transformation is apparent in the historical development of anaesthesia from empiricism and experimentation to an impressive progress, which no other specialty experienced in the same way. The details of the long journey from the beginnings of recorded history, from the first desperate attempts of man to relieve the pain of trauma or disease, back to the roots of contemporary anaesthesia −one and half centuries ago− and to the last decades, are fascinating.  Many of these exploits have become pertinent and made known by the International Symposia on the History of Anaesthesia (ISHA), organised since 1982 every four years and nowadays an established tradition.6 It was therefore singularly appropriate to bring together in the Proceedings of these Symposia, gathered information from the History of Anaesthesia which covers an impressive wealth of facts and practices.7-12 The name of the 7th International Symposium on the History of Anaesthesia was ‘Analgesia – Anaesthesia: From Greek Antiquity to the 20th Century’ (Figure 1) to emphasise the ‘analgesia and anaesthesia journey’ through the ages, particularly

Figure 1. The poster of the 7th International Symposia on the History of Anaesthesia, held in 2009, in Heraklion, Greece.

A nal g esia - A naesthesia : G r eek A nti q uit y to the 2 0 t h C .

as the venue for the 7th ISHA was Crete, a Greek island of such ancient history, that compels us to look back in time. This Mediterranean corner, in the crossroads of many civilisations, has facilitated the transmission, communication and cultural sharing of ideas that have travelled to influence humanity over the years. A transmission of ideas that influenced European development, as well as the emergence of medicine as a scientific phenomenon and of the concept of ‘anaesthesia’ as a philosophical idea, described by Plato, and as a clinical phenomenon conveyed by Hippocrates.

Greek Antiquity: Rational Explanations The Mythical Origin of Europe The origins of Europe can be traced back to the island of Crete, a corner of the Mediterranean basin where, historically and geographically, East meets the West. According to Greek mythology, Europa, the legendary Phoenician princess, after whom the whole continent is named, arrived in the shores of Crete on the back of the god Zeus disguised as a beautiful white bull. In Crete, Europa gave birth by Zeus to three sons. One of them, Minos, was the founder of the first civilisation in Europe, the Minoan civilisation. In the following years myth, religion and territorial identity went together in harmony. Even Hippocrates differentiates culturally and politically Europeans (not necessarily Greeks) from Asians. In his treatise On Airs, Waters, and Places he mentions: “I wish to show, respecting Asia and Europe, how, in all respects, they differ from one another, ... I say, then, that Asia differs very much from Europe as to the nature of all things, ...”13 Medicine as a Secular Science This Mediterranean basin also witnessed the emergence of Medicine as a secular science in the fifth century BCE, in the face of the Greek physician Hippocrates. Little is known about him, but a strong tradition surrounds his name and the Hippocratic School at the Aegean island of Kos. Hippocrates was the first to reject the theories that implied that only god is responsible for illness. He separated philosophy from medicine and expelled the gods in one incisive stroke. Thus he freed medicine from magic, superstition and at last religion. Diseases were given a logical interpretation and were no longer considered a punishment resulting from divine wrath. His works, Sacred Disease, Art and Ancient Medicine, attack respectively the ‘divine’ origin of diseases and the intrusion into medicine of the hypothetical speculation of philosophers.14 The Hippocratic writer of Sacred Disease (sacred means epilepsy) asserts:

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“It is not [the disease called sacred], in my opinion, any more divine or more sacred ..., but has a natural cause, and its supposed divine origin is due to men’s inexperience”.15 And in the Art Hippocrates argues that: “... if really it be possible to see the non-existent, as it is to see the existent, I do not know how a man could regard as non-existent what he can both see with his eyes and with his mind think that it exists”16 Hippocrates, besides the actual practice of medicine, also tried to promote the progress of medicine. His forethoughts about medicine are impressive, when in Ancient Medicine he writes that medicine as always existed. “But medicine has long had all its means to hand, and has discovered both a principle and a method, through which the discoveries made during a long period are many and excellent, … But anyone who, casting aside and rejecting all these means, attempts to conduct research in any other way or after another fashion, and asserts that he has found out anything, is and has been the victim of deception.”17a The merits of Hippocratic medicine and its messages were emphasised in the opening Hippocrates Lecture ‘Loοsing the Hippocratic tradition: a danger to our profession?’ by Dr David John Wilkinson.18 Anaesthesia as a Philosophical and Clinical Concept It is in the Hippocratic Corpus, that the word ‘anaesthesia’ was used for the first time in a medical context as loss of sensation and unconsciousness.19 In the treatise Breaths the adjective ‘anaesthetos(a)’ acquires the medical meaning of loss of sensation, when Hippocrates writes: “For when they [breaths] pass through the flesh and puff it up, the parts of body affected lose the power of feeling [‘anaestheta’]”.20a Again, ancient Greeks were the first to seek rational explanations for the phenomena they observed. Plato, one of the most creative thinkers of the ancient world, the founder of the famous Academy, used the word in a philosophical context.19 In his work Philebus the word has the philosophical meaning of “... the oblivion of the soul from the movements of the body” or “want of perception”.21 In the Hippocratic treatise Breaths ‘anaesthesia’ is related to ‘analgesia’, when the writer affirms that the patient who is unconscious, is also insensitive to pain, ‘analgetos(i)’:

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Figure 2. Roman bronze head of the god of sleep ‘Hypnos’, found in Perugia, Italy. British Museum, London.

“At this time the patients are unconscious [‘anaesthetoi’] of everything, deaf to what is spoken, blind to what is happening and insensible to pain [‘analgetoi’]”.20b Once again, both Greek words express loss of feeling and insensitivity to pain caused by a disease process rather than as a result of a pharmacological action.19 Although Hippocrates does not refer to pharmacological anaesthesia and its different aspects, he knew that some herbal substances could induce sleep. Hippocratic physicians used the word ‘hypnikon’, bringing sleep, to describe soporific substances applied to patients with toothache.19 The word is derived from the word ‘hypnos’, sleep, still used in modern Greek, from which the terms ‘hypnosis’ and ‘hypnotikon’, hypnotic, are derived.19,22 In Greek mythology, Hypnos was a singularly ancient deity closely associated with other deities, like oblivion, Lethe, pain, Ponos, and most of all with death, Thanatos, his twin brother. Hippocratic physicians separated the mythical god Hypnos from the natural phenomenon, when they observed in the work Dreams that: “For the body when asleep has no perception [aesthanetai], but the soul when awake has cognizance of all things – sees what is visible, hears what is audible, walks, touches, feels pain, ponders.”23 It was in the twentieth century that John W Severinghouse made the connection of anaesthesia with the mythical god Hypnos, when he wrote in his introduction to John Nunn’s Applied Respiratory Physiology, referring to the Roman bronze head of Hypnos (Figure 2) with a burning candle in front of it: “And what of the god of sleep, patron of anaesthesia? Now before Hypnos, the artisan has set the respiring flame that he may, by knowing the process, better the art.”24

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No wonder that the god Hypnos was chosen as the emblem of the 7th ISHA, a meeting held in Greece.

Nineteenth Century − A Major Breakthrough During the middle ages the treatment of pain was featured with pessimism and fatalism. Doctors were still influenced by Galen’s medicine, and applied peculiar therapies based on bleeding, laxatives and vomiting. Rational scientific thinking during Romanticism brings a critical change. Pain and disease were no longer considered a result of supernatural phenomena but rather an expression of nature. Their study and cure could be modified accordingly. By the early 1840s successive cultural and medical changes based on newer humanistic standards had resulted in the view that physical pain is purposeless.25 This new concept regarding pain prevention and its relief is the social scenery for the discovery of modern ‘anaesthesia’ during the middle of the 19th century. Pain had not prevented surgery in the past, but it had made it almost an unbearable, excruciating agony. This is how, in January 1843, George Wilson, a medical student who underwent surgery to amputate an infected leg, described his experience of surgery without anaesthesia and analgesia: “Of the agony it occasioned, I will say nothing. Suffering so great as I underwent cannot be expressed in words. ... The particular pangs are now forgotten; but the black whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close upon despair, which swept through my mind and overwhelmed my heart, I can never forget ...” 26 Although, in the decade 1835-1845 there were attempts to suspend consciousness by anaesthetic agents, these gained little recognition, as breathing of gas carried the danger of asphyxia and, ultimately, death. The world-famous October 16th, 1846 successful ether demonstration by Thomas Green Morton received much attention, partly due to serendipity, as the ether worked and did not cause asphyxia.25 To lend credit to the Hippocratic axiom: “And that physician who makes only small mistakes would win my hearty praise. Perfectly exact truth is but rarely seen.”17b By the end of the 19th century, anaesthesia, as a method to alleviate pain during operations, had become a landmark in the history of medicine and a symbol for the wider humanitarian movement.25 It was proclaimed as one of the civilising factors of the Western world and remains the most vivid example of medicine’s capacity to diminish human suffering. The new discovery was given the name ‘anaesthesia’ by Oliver Wendell Holmes (1809-1894), the renowned Harvard profes-

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sor of anatomy and physiology, who had attended this first historical demonstration. In a letter to Morton, Holmes wrote: “The state should, I think, be called ‘anaesthesia’. This signifies insensibility, more particularly (as used by Linnaus and Cullen) to objects of touch”.27 So, about 2300 years after the introduction of the word ‘anaesthesia’ in a medical context by Hippocrates, Oliver Wendell Holmes proposed the term for a mostly momentous discovery, for a newly born medical practice. Οne more medical term of Greek origin enriched the international medical vocabulary. However, William Thomas Green Morton (1819-1868) was not the first in history to use ether as an anesthetic. In March 30th, 1842, Crawford Williamson Long (1815-1878) a doctor from Georgia, applied his social observations from ‘ether frolics’ to remove under ether a cyst from the neck of a young man, who did not feel any pain. Long did not publish his findings as he wanted to be sure of his discovery, until an editorial appeared in the December 1846 issue of Medical Examiner about Morton’s ether demonstration. Therefore, although Long was the first, Morton was given credit for using ether for surgical anaesthesia. Another such example is the case of Joseph Priestley (1733-1804) and Carl William Scheele (1742-1786) for the discovery of oxygen. John W Severinghouse, in a lecture on Hidden ‘Fire Air’, Hidden Letter: Oxygen’s Historic Dilemmas during the 7th ISHA, unravelled the truth why the credit of such a significant discovery did not go to Scheele.28 The next significant innovations were the use of chloroform in obstetrics by James Young Simpson in 1847, and of local anaesthesia by cocaine by Carl Koller in 1884, unknown details about the life of whom are portrayed in this volume. Less recognised aspects of the work of pioneers of anaesthesia, and related fields, are also presented, as for instance of James Moffat, Friedrich Von Esmarch, Benjamin Ward Richardson, Thomas Henry Huxley, Joseph Clover, Frederic William Hewitt, Samuel J Hayes, Carl Koller, Rupert Walter Hornabrook, Renè Leriche, Henry Chambert, Jaroslav Heyvroskỳ, Mark Cowley Lidwill, as well as of other pioneers. The history of technical innovations such as the early respirators in the second half of the 19th century was unfolded by Wulf Strätling and colleagues, in a presentation that got the award of the best 7th ISHA paper.29

Twentieth Century − Key Advances The ether and chloroform era and the significant advances in everyday anaesthesia that highlighted the 19th century extended until the end of World War One. Afterwards, the significant boost in medicine led to the development of the specialty of Anaesthesiology at both sides of the Atlantic and Australia and the transition of anaesthesia from a craft into a specialty discipline. However, for the

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progress of general anaesthesia into the 20th century, according to Sir Keith Sykes, the decisive steps were: “...to develop an apparatus that could add ether or chloroform to a mixture of oxygen and nitrous oxide, ... to devise a way in which an airtight connection could be made with the lungs, ... to learn how to maintain ventilation of the lungs, to devise a method of preventing collapse of the lungs...”30 The introduction of intravenous agents, in the 1930s, of muscle relaxants in the 1940s and of halothane in the mid-1950s brought about a revolution in the practice of anaesthesia. At the same time, significant, and less significant, advances in new techniques, drugs, equipment and the expansion of Anaesthesiology far beyond the operating theatres all contributed to this evolution. Such examples presented in this volume are the first successful human intracardiac pacing, the introduction of hypothermia for cardiac surgery by air-cooling, the use of resuscitation devices, the first successful management of malignant hyperthermia and also the development of pain clinics and veterinary anaesthesia. Anaesthesia continued to develop in the 20th century and its safety and efficacy was considerably improved. The scientific foundations of anaesthesia and the pioneering work of many anaesthetists reconfigured surgical practice. Anaesthesia, by releasing surgery from the barriers of pain and trauma, and allowing an impressive variety of lifesaving procedures to be developed, proved to be overwhelmingly greater than initially anticipated, a great gift to humankind.

Conclusions “The farther backward you can look, the farther foreword you can see”31

This famous quote of Sir Winston Churchill stresses the fact that the knowledge of the past helps to organise in a better way the future for the next generations. No doubt, ‘anaesthesia’ of today is the culmination of many earlier discoveries and events which have opened the way to present day progress. The goal of the International Symposia on the History of Anaesthesia is to present and relate past initiatives with evidence and to encourage research about how earlier scientists thought and worked. This diachronic dimension of history, which facilitated Anaesthesiology to reach its current scientific significance was also expressed by the 7th ISHA. This volume is a demonstration of the evolutionary journey of anaesthesia and analgesia from antiquity to the twentieth century.

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References 1.

Hippocrates. Aphorisms. Vol IV. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 2005: Ι.I.2.

2.

Desai SP, Buterbaugh J, Desai MS. The Making of an Anesthesia Historian: Lessons from a Worldwide Biographical Survey. Anesth Analg 2011; 113: 383-6.

3.

Μαρκέτος ΣΓ. Ιστορία της Ιατρικής του 20ού αιώνα. Αθήνα: Ζήτα Ιατρικές Εκδόσεις, 2000.II

4.

Ασκητοπούλου Ε. Η Ιστορία της Αναισθησίας. Άρθρο Σύνταξης,III Acta Hellen Anaesthesiol 2010; 43(3-4): 91-94.

5.

Greene N. Dr Gwenifer Wilson: First Laureate of the History of Anesthesia. Anessthesiology 1996; 85: 703-705.

6.

Rupreht J, Erdmann W. International Symposia on the History of Anaesthesia (19821992); With particular emphasis on the first one. In: The History of Anesthesia. Proceedings, the Fourth International Symposium on the History of Anaesthesia. Schulte am Esch J, Goerig M, eds. Lubeck, Verlag DragerDruck GmbH & Co, 1997: 21-34.

7.

Rupreht J, van Lieburg MJ, Lee JA, Erdmann W, eds. Anaesthesia: Essays on Its History. Heidelberg, Berlin, New York, Tokyo: Springer–Verlag, 1985.

8.

Atkinson RS, Boulton TB, eds. The History of Anaesthesia. Proceedings of the Second International Symposium on the History of Anaesthesia. London, New York: Royal Society of Medicine Services Ltd, 1989.

9.

Fink RA, Morris LE, Stephen CR, eds. The History of Anaesthesia. Proceedings, Third International Symposium. Park Ridge, Illinois: Wood Library–Museum of Anesthesiology, 1992.

10. Schulte am Esch J, Goerig M, eds. The History of Anesthesia. Proceedings, the Fourth International Symposium on the History of Anaesthesia. Lubeck, Germany: Verlag DragerDruck GmbH & Co, 1997. 11. Diz JC, Franco A, Bacon DR, Rupreht J, Alvarez J, eds. The History of Anesthesia. Proceedings of the Fifth International Symposium, Santiago, Spain, 2002. Amsterdam, The Netherlands: Elsevier Health Sciences, 2002. 12. Drury PME, Armitage EN, Bacon DR, Barr AM, Bennetts FE, Horton JM, Kuipers AJ, Mckenzie AG, Morris P, Padfield A, Rucklidge MA, Wilkinson DJ, Zuck D, eds. The History of Anaesthesia. Proceedings of the Sixth International Symposium on the History of Anaesthesia, Cambridge, UK, 2005. Reading, Berkshire, UK: Conservatree, 2007.

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Marketos S. History of Medicine of the 20th Century. Athens: Zeta Publ, 2000. Askitopoulou H. History of Anaesthesia. Editorial.

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13. Hippocrates. On Airs, Waters, and Places. Vol I. Jones WHS, trans. Loeb Classical Library. Cambridge, Massachusetts: Harvard University Press, 2004: XII. 14. Jones WHS. General Introduction. In: Hippocrates. Vol. I. Ancient medicine. Airs, Waters, Places. Epidemics I & III. The Oath. Precepts. Nutriment. Loeb Classical Library. Cambridge: Harvard University Press, 1923. 15. Hippocrates. The Sacred Disease. Jones WHS, trans. Vol. II. Loeb Classical Library. Cambridge: Harvard University Press, 1923: I.2-10. 16. Hippocrates. The Art. Jones WHS, trans. Vol. II. Loeb Classical Library. Cambridge: Harvard University Press, 1923: II.5-8. 17. Hippocrates. Ancient Medicine. Vol I. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 2004: (a) II.1-9, (b) IX.21-22. 18. Wilkinson DJ. Loοsing the Hippocratic tradition: a danger to our profession? In: History of Anaesthesia VII. Proceedings of the 7th International Symposium on the History of Anaesthesia. Askitopoulou H, McGoldrick KE, Westhorpe RN, Wilkinson DJ, eds. Herakleion: Crete University Press, 2012: 15-22 19. Astyrakaki E, Papaioannou A, Askitopoulou H. References to Anesthesia, Analgesia, and Pain in the Hippocratic Collection. Anesth Analg 2010; 110:188-94. 20. Hippocrates. Breaths. Vol II. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 1998: (a) XIII.2-4, (b) XIV.44-46. 21. Plato. Philebus. Vol VIII. Goold GP, ed. Fowler HN, trans. Cambridge, Massachusetts: Harvard University Press, 1975: Stephanus 34.a. 22. Askitopoulou H, Ramoutsaki IA, Konsolaki E. Analgesia and anesthesia: etymology and literary history of related Greek words. Anesth Analg 2000; 91:486-91. 23. Hippocrates. Regimen IV or Dreams. Vol IV. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 2005: LXXXVI.12-16. 24. Severinghouse JW. Introduction. In: Applied Respiratory Physiology. J Nunn, ed. Oxford: Butterworth-Heinemann, 1969. 25. Snow SJ. Medical milestones: Anaesthesia, symbol of humanitarianism. BMJ  2007; 334: Suppl 1: s5. 26. Adler RE. Such Stuff as Dreams are made on: The Discovery of Anesthesia. In: Medical Firsts. From Hippocrates to the Human Genome. Adler RE, ed. Hoboken, New Jersey: John Wiley & Sons, Inc, 2004: 83-94. 27. The American Heritage Dictionary of the English Language, 3rd edition. Boston: Houghton Mifflin Company, 1992. 28. Severinghouse JW. Hidden ‘Fire Air’, Hidden Letter: Oxygen’s Historic Dilemmas. In: History of Anaesthesia VII. Proceedings of the 7th International Symposium on the History of Anaesthesia. Askitopoulou H, McGoldrick KE, Westhorpe RN, Wilkinson DJ, eds. Herakleion: Crete University Press, 2012: 97-111.

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29. Strätling MWM, Niggebrügge C, Schumacher J. The history of early respirators (mid1800s-1918): A Systematic Re-Assessment of the Main ‘Technology-Transfer’, which led to the Development of Modern Anaesthesia Technology. In: History of Anaesthesia VII. Proceedings of the 7th International Symposium on the History of Anaesthesia. Askitopoulou H, McGoldrick KE, Westhorpe RN, Wilkinson DJ, eds. Herakleion: Crete University Press, 2012: 159-180. 30. Sykes K, Bunker JP. Anaesthesia and the Practice of Medicine: Historical Perspectives. London: Royal Society of Medicine Press Ltd, 2007: 33-46. 31. Churchill by Himself. Langworth RM, ed. UK: Ebury Press, 2008: 576.

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SECTION I

GR E E K A N TIQUIT Y

Losing the Hippocratic tradition

A Danger to our Profession?I David J WilkinsonII

A bstract

Hippocrates, often referred to as ‘the father of medicine’ was born on the island of Kos around 460 BC into a medical family. Hippocrates’ legacy to medicine is seen in the Hippocratic Corpus a collection of books, manuscripts and essays probably originally collated in the Alexandrian library which outline the current state of medicine at that time. Hippocrates based his medical teachings on observation of the individual patient and moved away from associating illness with supernatural or divine forces placing them firmly in the natural world. If they had natural causes then it was evident that there must be natural remedies. His other major contribution was the establishment of an ethical framework for practice which was brought together in the Oath. Hippocrates was to die in Larissa in Thessaly around 370 BCE after a life full of travel and practice. His importance in the medical world was cemented by the writings of Galen of Pergamum some 400-500 years later. Galenic medicine was based on the Hippocratic tradition and remained unchallenged for a further 1000 years. Modern medicine looks back at this ‘ancient time’ with little interest. The assumption that all that is modern must be best is not based on fact. Individuals are subsumed into groups of ‘like’ patients and detailed histories and examination are becoming secondary to the results of blood tests and image reports. In anaesthesia too, modern development seems to move towards treatment by protocol rather than by carefully considered patient focussed care. Individuals

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‘Hippocrates Lecture’, delivered during the Opening Ceremony of the 7th International Symposium on the History of Anaesthesia, on October 1st, 2009, in Heraklion, Crete. David J WILKINSON, MB BS, FRCA, Emeritus Consultant, Boyle Department of Anaesthesia, St. Bartholomew’s Hospital, London, UK, Wood Library Museum of Anesthesiology Laureate in the History of Anaesthesia.

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are hampered in their desire to investigate simple matters by stringent ethical committee paperwork and the need for everything to be costed. In the first Aphorism are the words “Life is short, the Art is long, opportunity fleating, experiment treacherous, judgement difficult”. Good anaesthesia remains an ‘art’ and in turning away from some of our Hippocratic legacy we are in danger of doing harm to both our profession and more importantly to our patients.

Introduction Hippocrates could well be considered to be the most well known physician of all time. Often referred to by medical historians as the ‘father of medicine’, the truth about his life and work are now clouded by centuries of well meaning embellishment which now make the facts hard to elucidate. Although many of the details about his life remain unclear the principles of professional medical practice as delineated in his (or his followers’) written works remain clear and relevant to today’s practice. Modern medicine which is often highly technically based is moving away from a profession to a speciality that is more of a trade. This is a retrograde step and is a potentially catastrophic one for medicine as a whole and anaesthesia in particular.

Hippocratic Era Hippocrates became a young man at the time of the great Periclean golden age for Athens. At this time architecture, philosophy, sculpture, literature and politics were all at a spectacular peak which was only to be ended by the Peloponnese War c. 404 BCE. Socrates was propounding his philosophy, Protagoras and the sophists were initiating a new rhetoric, the Parthenon and Propylaia were built, the Assembly was demonstrating the power of democracy and Sophocles and Euripedes were writing their great theatrical works. It was a great time for new thoughts and innovation and Hippocrates certainly added his share. Early Life Hippocrates was born on Kos around 460 BCE and lived probably in Astypalaia, the then capital, as Kos Town was not built until c. 365 BCE. This town was situated on the south western coast of the island. Tradition has it that he was born into a medical family that could show a direct lineage (through 17, 18 or 19 generations) back to Apollo and his son Asclepios. It is certainly likely that he was part of a long medical family as at that time medical knowledge was closely guarded within families. His father was Heraclides and his mother was Praxitela, daughter of Phainarete. Hippocrates had at least two sons Thessalus and Draco and at least

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one daughter as his son in law, Polybus, studied under Hippocrates and became a physician too. Early Medical Training Hippocrates was taught by his father and grandfather on Kos initially. He then is said to have travelled widely to enhance his medical knowledge and it is suggested that he studied in Athens, Thrace, Macedonia, Thessaly and even perhaps Egypt before returning to Kos. Herodicus of Selymbria, who developed a system of treatment based on massage and exercise was one of his teachers, as were Georgias of Leontina and Democritos of Abdera who taught rhetoric and philosophy respectively. The Asclepian tradition of medicine, into which Hippocrates had been born, was said to have had three main schools; on Kos, at Cnidus (just across the sea in what is now Turkey) and in nearby Rhodes. It was said that the Kos school based teaching on the whole patient while the Cnidus school was more focused on diagnosis. The link with Rhodes was described by Galen. It is unlikely that these divisions existed, all three schools were relatively close to one another and there would have been a ready exchange of thoughts and beliefs. Contemporary Accounts There are few references to Hippocrates in currently known contemporary accounts. Plato (428 - 348 BCE) wrote a dialogue Protagoras that refers to an important physician from Kos called Hippocrates. Soranus, the Greek physician from Ephesus, wrote a biography of Hippocrates but this was in ca 100 CE some 300 years after his death and it probably was augmented by fictional accounts. It was Galen, the Roman physician born in Pergamum (139-199 CE), who developed the myths and legends that surround Hippocrates life now even further. Galen wrote a huge number of books many of which described what he believed the works of Hippocrates really meant and he constantly showed how these conclusions were supported by his own research. Galenic medicine was to dominate the Western World until the Renaissance and he expanded and augmented the theories found in Hippocrates’s writings using observation, experimentation and deductive reasoning. Many of his attributions to Hippocrates cannot be substantiated and his legacy stifled further development in medicine for over 1000 years, a concept that would have had his hero, Hippocrates, probably turning in his grave! School on Kos The Asclepeiion in Kos is situated a few kilometers outside of Kos Town and it was here that Hippocrates taught medicine to anyone who would pay for that tuition. This too was a new concept as before medicine had been protected within families. Excavation of the huge site by Zaraftis and Hertsok in 1902 showed a

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huge expanse of four linked levels from different ages. The first is Roman from the time of Vespassian (c. 100 CE), the second is the old medical school of Kos (3rd century BCE), the third is the Temple of Apollo (probably 4th century BCE) and the final is a Doric temple and patient accommodation (c. 2nd century BCE). As well as teaching here, Hippocrates was said to teach under the plane tree now in the square in front of the Castle of the Knights in Kos Town. Two thousand years old trees are not unknown but this too may be legend rather than fact. Later Life Hippocrates left Kos at an unknown time and travelled widely round Greece and Macedonia, eventually settling in Larissa in Thessaly where he died c. 370 BCE. His grave was discovered in 1928 after a major flood and a large mausoleum and statue now stands on the site. At some point his papers were put together and transported to the Alexandrian Library. Here they were bundled together with similar texts from his students and this whole mass of books and papers became known as the Hippocratic Corpus. It is from this body of work that our knowledge of Hippocratic medicine has been discovered and the challenge remains that much of the Corpus may not have been written by Hippocrates and there is probably much outside of the Corpus that was written by him!

Hippocratic Corpus There are over 60 texts written in Ionic Greek that comprise this Corpus. In 1526, the Aldine Press in Venice published the complete works of Hippocrates in Greek and this is our current earliest text. There are many other works that contain portions of the Corpus but it seems likely that the complete works was in existence from 300 BCE and attributed to Hippocrates at that time. Many anomalies still remain e.g. Testament is in many Greek texts but is not in the Corpus and Sevens is only in Latin text having been 'lost' until 1837. It is now believed that Generation and The nature of the child were originally one book and it is apparent that Epidemics was written by several authors at different times. In addition The Heart and Precepts are probably from the 3rd or 2nd centuries BCE while Decorum may well be from 100 CE.1

Changes Propounded by Hippocrates Asclepian medicine as taught to Hippocrates was based on the principle of an all powerful set of Gods like Apollo and Asclepios who ‘punished’ the sick by creating injury and illness because of 'bad’ or ‘inappropriate’ behavior. However, together with this mystical cause, and therefore treatment by offerings and prayers, there

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was knowledge of herbs and other treatments from Egyptian and Babylonian cultures. Hippocrates moved towards a treatment of the person as a whole; he would take a careful history from the patient, discuss exercise and cleanliness, he would then make careful observation of the patient, contemplate and consider the case and then offer some treatment regimes. He tried to develop a corpus of knowledge about illnesses and then offer ‘rational’ treatments based on that understanding. This was a radical change from random treatments which might or might not work. This assumption that illness can be cured by specific treatments, which did not depend on some ‘whim of the gods,’ permitted a differentiation between good doctors and those who were mere charlatans. The Hippocratic physician tried to separate important from unimportant symptoms so that the underlying reason for the disease in that individual might be determined. In this it is the individual disposition of the patient rather than some generic cause that was held to be important. Severity of illness was determined by a comparison between past wellness and current illness. Treatments were based on dietetics and drugs using a knowledge base of previous effective treatments. Careful bandaging and manipulation of fractures was undertaken together with regimes of exercise and cleanliness. Surgery was rarely advocated. A fundamental principle here is that of medical autonomism. This can be considered to be the ability, and indeed the right of the doctor, to look after the patient and for there to be an informed debate between them over treatment options. In this, there is an acceptance that the fully trained doctor is in a unique position to guide and advise the patient in a manner in which no other nonqualified person can do. In addition Hippocrates advocated an ethical basis within which medicine should be practiced. This was formulated into the Hippocratic Oath that doctors were asked to swear.

Ethical Basis Hippocrates suggested that every doctor should know the limits of their own expertise and be willing to hand over care to those who were more skilled. They should offer treatments that were effective rather than those which 'looked good' and they should be aware when to treat and when not to offer treatment. At all times they should talk to the patient and their relatives in a tactful and understandable manner. The Hippocratic Oath contains some of these concepts but also has many confusing aspects. There is a requirement not to use a knife to treat and yet surgery was well known for many ailments, there is the requirement not to cause an abortion despite such processes being clearly described in

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Hippocratic writings; it advises that it is forbidden to hasten death through medical treatment and yet clear descriptions of such events also occur in his writings and there is an overall mystical/religious overlay which was the exact opposite of what Hippocratic medicine espoused. Perhaps the most confusing aspect is the fact that the Oath does not appear to have been used for many centuries and may not even have been written by Hippocrates at all. It is interesting to note that many University Medical Schools in the UK still use a form of this Oath at their granting of Diploma ceremonies. What Followed after Hippocrates? Western medicine became, for the most part, frozen in Galenic thinking until the renaissance. Only Arabic and Eastern medicine seems to have developed in this interim period and much of this failed to reach the western world. The huge strides that followed in the understanding of anatomy, physiology, pharmacology, chemistry and physics have meant that ‘ancient medicine’ became of interest only to historians and the relevance of Hippocrates and his ‘tradition’ seemed non-existent except for the oath and a few eponyms such as Hippocratic faces which denote approaching death, Hippocratic fingers which show clubbing and the Hippocratic smile which shows facial spasms. What of Anaesthesia? With the first public demonstration of ether anaesthesia in October of 1846 in Boston, Massachusetts a new speciality was formed (although it took many decades for that to become a reality). At first there was an empiric approach to the subject with no understanding of the principles of pharmacology, physics and physiology which underpin today’s practice. This then was anaesthesia’s pre-Hippocratic period; try the same for everyone, try any new drug to see what happens and there is little need for any training. John Snow, Joseph Clover, Dudley Buxton and Frederic Hewitt changed this and started to apply systematic analysis to the subject with a huge improvement in outcome. Science and teaching moved the speciality foreword to its current lofty position, but all is not well. Modernity is the absolute byword in today’s practice. The latest drug, the latest monitor, the latest equipment are all important but the patient is still the patient. There is no place for history within the current examination structure of anaesthesia and medicine itself is losing that dialogue that it used to have with philosophy, drama, music and debate. Careful history taking, observation examination and then provisional diagnosis with investigation leading to final diagnosis are being turned around. Modern imaging techniques allow three dimensional representation of all areas of the body while specific markers of disease processes and the unraveling of genomics often mean that any history and examination are taking place after diagnosis has been made. Patients are ceasing to be individuals and are becoming

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diseases or anatomical descriptions e.g. another hernia, another gall bladder! This focus on a specific disease often means that the overall patient is forgotten so that the 120 kg patient with severe diabetes and ischaemic heart disease is still only a gall bladder that needs to be removed and the overall benefit of a knee replacement in the 150 kg person who has not taken any exercise for 30 years is not considered. Holistic medicine is grouped with pyramids and auras and dream catchers and regarded as a fringe subject yet each individual is crucially important. In anaesthesia, trainees learn how to pass exams as a first priority, they are losing practical experience by legislation that controls their working time, they are encouraged to work to fixed protocols and rarely think ‘outside-the box’, they work with smaller and smaller diversity of agents and are constrained from personal research by lack of time and bureaucratic ethical committees. While in the medical schools there is great stress placed on the importance of ethics within medicine and professionalism is taught at undergraduate and post graduate levels it does not seem to be applied within anaesthesia (and surgery). There are increasing professional tensions moving into hospital practice. Patient interests versus the doctors employers in terms of limited resources; the constraints of health economy with government initiatives and targets which supervene medical imperatives; consultant autonomy against public accountability; medical autonomy within the multidisciplinary team; doctors as managers versus their medical obligations, these are just some of the potential dilemmas that surround modern anaesthetic practice.

Figure 1. Statue of the 1st century CE, found in the Odeion of Kos in 1929, suggested to represent Hippocrates in a young age. Archaeological Museum of Kos, Greece.

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Aphorism and Summation Hippocrates wrote in the first Aphorism: “Life is short, the Art is long, opportunity fleating, experiment treacherous, judgement difficult. The physician must be ready, not only to do his duty himself, but aso to secure the co-operation of the patient, of the attendants and of external .”2 It is my belief that there still remains an art to good anaesthesia and part of that art is the recognition that in the clinical situation there should be an equal weighting placed on the triad composed of the doctor, the patient and the patient’s state of health. It is also my belief that we are losing this sense of art and proportion within our speciality and that Hippocrates would not be pleased! I believe that there is a place for many aspects of the Hippocratic tradition and that its loss will be to our detriment as doctors and anaesthetists. I also believe that within the modernity in which we live and practice there is a very important place for history. It is up to all medical historians to ensure that this place and these traditions are not lost but are taught and thus transferred on to future generations of doctors. The Hippocratic legacy is worth preserving. Bibliography 1.

Nutton V. Ancient medicine. London: Routledge, 2004.

2.

Hippocrates. Aphorisms. Vol IV. Henderson J, ed. Jones WHS, trans. Cambridge, Massachusetts: Loeb Classical Library, Harvard University Press, 1959: I.I.

The Hippocratic Approach to Pain management Elisabeth Astyrakaki, Maria Karatzi, Alexandra Papaioannou, Helen AskitopoulouI

A bstract

The Hippocratic Corpus is a valuable source of information regarding medicine in ancient Greece. Among the numerous medical issues described in these treatises, pain and its treatment has a dominant role. Hippocratic physicians used a diverse number of cures for painful ailments, such as ‘phlebotomy’ (also known as venesection or bloodletting), application of plasters, clysters, poultices or sponges, cauterisation, purging, diet and many others. In addition, different medications against pain are also described, either herbal, such as white opium poppy, black hellebore, hyoscyamus, peplium or others, or animal substances like ‘castorium’ an extract derived from beaver’s sac. A remarkable finding is that the Hippocratic physicians named an unknown soporific substance used for toothache as ‘hypnikon’. This word, as well as the term ‘hypnosis’, are derived from the ancient Greek word ‘hypnos’ which means sleep. This is a significant association between the state of sleep and the properties of an herb that probably reflects knowledge gained by observation of medicinal sleep. Elisabeth ASTYRAKAKI, MD, PhD, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece. Maria KARATZI, MD, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece Alexandra PAPAIOANNOU, MD, PhD, EDA, Lecturer in Anaesthesiology, Faculty of Medicine, University of Crete, Heraklion, Greece. Helen ASKITOPOULOU, MD, PhD, DA, FRCA, FERC(Hon), FESEM(Hon), Professor Emeritus of Anaesthesiology, Faculty of Medicine, University of Crete, Heraklion, Greece.

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Introduction Hippocrates (460-377 BCE), the Greek physician from the island of Cos, did set the grounds for the development of medicine as a rational and systematic science. Hippocratic medicine is based on observation and the study of the human body as well as the relation of health and environmental factors. Hippocrates founded and taught at the medical school of Kos, which most probably included a library. The collection of medical texts of this library comprises the Hippocratic Corpus. Probably not all of these works were written by Hippocrates himself, but what is significant is that these texts reflect the Hippocratic ideas and the medical practice of the school of Kos.1 Pain was among a variety of medical problems the Hippocratic physicians studied meticulously and systematically. They used its features to define diagnosis or prognosis, as well as to describe the course of an illness. To distinguish between the various types of pain they developed a broad terminology and to relieve painful conditions they applied many diverse cures.2 The purpose of this study was to identify and interpret the analgesic cures described throughout the Hippocratic Corpus. All the texts of the Hippocratic Corpus were reviewed and examined for descriptions of analgesic therapies using the electronic program Thesaurus Lingua Graeca (TLG).3 This program is an electronic database of the entire ancient Greek literature, including search options for combined search. This database was searched for references to the words, which the Hippocratic physicians used to describe all types of pain, such as ‘algos’, ‘ponos’, and ‘odyne’. Afterwards the citations provided about painful conditions and analgesic treatments were examined in more detail in the original ancient Greek language and also in classic translations in English or in Modern Greek.

Non Pharmacologic Cures Hippocratic physicians described and applied several treatments for painful conditions. The most common non pharmacologic cures were ‘phlebotomy’, purging. and also diet and rest Phlebotomy ‘Phlebotomy’ or venesection or bloodletting was a common cure for painful conditions. ‘Phlebotomy’ is a compound word derived from the Greek word for vein ‘phleps’ (genitive ‘phlebos’) and the verb ‘temno’ meaning to cut.4 One of the main sources regarding Hippocratic bloodletting is the treatise Regimen in Acute Diseases,5 where is emphasised the superiority of phlebotomy in contrast to other medicines:

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“… severe pains and disease complexes above the diaphragm can all not be resolved if a person undertakes first to treat with medications [‘pharmaka’], but phlebotomy is the master of such things” 6a The opening of a vein for bloodletting was commonly used to treat headaches. The fifth Aphorism states that when a man has pain in the back part of the head, he will be benefited by having the frontal vein in the forehead opened: “Pains at the back of the head are relieved by opening the upright vein in the forehead.7a And it is known that Ambroise Pare (1510-1590) practised venesection in head injuries on the authority of the ‘father of medicine’. Such are the Hippocratic rules for bloodletting which became the basic principles for its practice in aftertime. 5 Phlebotomy also was a treatment for painful eyes,7b or the pain of the heart. In Epidemics 5 we read that: “Androthales sometimes had pain at the heart; which phlebotomy stopped”.8a For the same case, water or ‘melicrat’ also helped the heart. 8a For ophthalmic pains, apart of phlebotomy the sixth Aphorism also suggests: “... drinking neat wine, bathing, vapour baths, bleeding [phlebotomy] or purging”. 7c Purging In the Hippocratic Corpus the objective of most regimens was the evacuation of the body ‘cavities’. On this subject Jacques Jouanna characteristically writes: “The Hippocratic physicians considered human beings to have two great cavities: the ‘upper cavity’ which is to say the chest, and the ‘lower cavity’, which is to say the stomach. Evacuation was therefore said to be either upwards or downwards. Vomiting and bowel evacuations were recommended either as preventive or curative measures… Originally their purpose was to eliminate the disease, regarded as an impurity. ...The same terms (belonging to the family ‘kathairein’ ) were used in Greek to signify purgation and purification. 9 Based on that context, purging was also a popular method for a variety of painful ailments, especially gastrointestinal ones, as is described in the Aphorisms: “Pains above the diaphragm indicate a need for upward purging; pains below indicate a need for downward purging.’’ 7d

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Diet and Rest The Greeks knew that certain corporal phenomena, which they called diseases, in Greek ‘nossoi’, had a course and origin not unconnected to geographical and atmospheric environment. The patient, in order to recover his health, had to modify his ordinary mode of living.1 Therefore, diet and rest had dominant roles in the treatment of a disease. Especially for pain, rest has a major effect on its relief: “In every movement of the body, to rest at once when pain begins relieves the suffering”. 7e Miscellaneous Remedies Throughout the Hippocratic Corpus several other analgesic remedies are described, such as use of heat or cold, ablutions, cauterisation, expectoration, incisions for pleurisies,8b or hot effusions for headaches. Some of them are quite odd by modern medical standards. For example, the author of Epidemics, indisputably one of the great Hippocratic treatises, for intestinal pains suggests: “…purge the nearest part of the intestine. Cautery, excision, heating, cooling, sneezing, the juices of the plants for things the affect, and cyceon. Harmful things: garlic, milk, boiled wine, vinegar, salt”. 8b ‘Cyceon’ is a traditional therapeutic drink, usually barley mush, cheese, wine, onions and herbs. In certain sections of the Hippocratic work great emphasis is placed on therapies where ‘opposites cure opposites’ as well as ‘like curing like’. In Places in Man it is explained that “pains are cured by opposites”. In the same passage it is stated that: “… sometimes conditions can be treated by things opposite to those from which they arose, and sometimes by things like to those from which they arose”.10a It is worth wondering whether these observations were the forerunner of later discoveries about activation or deactivation of facilitating or inhibiting mechanisms during nociception.11 ‘Pharmaka’ In addition to non-pharmacologic cures, Hippocratic physicians also employed the different therapeutic properties of various plants and substances. In Places in Man, it is clearly stated that: “… all substances that change the state of a patient are medications [‘pharmaka’]”.10b The Greek word ‘pharmakon’, which means drug, whether healing or noxious, is

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used since the Homeric times when it meant any medicinal herb with healing properties and afterwards also ‘pharmaki’, poison.4,12 In the Hippocratic Corpus 236 distinct plants are mentioned. Most of them have soporific, narcotic or poisonous properties, such as mandragora, thorn apple, henbane, hellebore and especially poppy.13 Opium Extracts The author of the treatise Fistulas for a patient with anal inflammation and protrusion suggests that he should “drink white meconium [‘mekoneion’]” if the pain does not subside by other means.13 Ancient Greeks called ‘mekon’ the opium poppy and ‘mekoneion’ its milky juice.12 In the work Diseases of Women in which Hippocrates refers to ‘mekoneion’ as ‘hypnotikon’ which means sleep inducing.15 In Diseases III, for pain in the hypochondrium due to pleurisy, the author suggests to give the patient white opium poppy to drink with other substances such as: “... cumin, flower of copper, honey, vinegar, water”.16 The opium extracts in the Hippocratic texts were mainly prescribed for painful gynaecological ailments.17,18a Other substances used for the same painful conditions include silphium (a sort of asafetida),18b cumin with honey, leek,18c cyclamen,18d and many others. Miscellaneous Medications In Regimen in Acute Diseases, the author suggests the use of black hellebore (Helleborus niger) and peplium (Euphorbia peplus or petty spurge) as purgatives that stop the pain, in combination with daucus (Athamanta cretensis), seseli or laserwort (Laserpitium latifolium), anise, and juice of silphium: “If the pain be under the diaphragm, and does not declare itself towards the collar – bone, soften the bowels with black hellebore or peplium, mixing with the black hellebore daucus, seseli, cumin, anise or some other fragrant herb, and with the peplium juice of silphium…Both (hellebore and peplium) stop pain [‘odyne’] …” .19 Hellebore is also suggested for the pain in the head, provided that this condition is not the result of: “drink, venery, grief, anxiety or sleeplessness”.6b Other treatments for musculoskeletal pains include application of fomentation and wax salves, anointments of warm oil and animal fat as plasters. “For pains of lower back and legs and hip from exertion, pour over give fomentations and bind them up with wool which still has the oil in it, and with sheepskins…”8c

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For severe tooth pain Hippocratic physicians suggested rinsing with castorium (a potion derived from the beavers’ musk gland) and pepper.8d Apart from the relief of severe toothaches, ‘castorium’ was also used for headaches: “Castorium stops headaches from the womb… for belly’s hysteric pains, the physician also suggests cloth poultices soaked with boiled fragrant white wine”.8f ‘Hypnikon’ Tooth pains were also treated with application of an unspecified soporific called ‘hypnikon’ which means sleep promotion.8e In Use Of Liquids, the word ‘hypnikon’, is used for ear and ophthalmic pains: “... warm water that promotes sleep [hypnikon], and blunts pains of the ears and eyes”.20 The word ‘hypnikon’, as well as the term ‘hypnosis’, are derived from the ancient Greek word ‘hypnos’, which means sleep.4 This is a significant association between the state of sleep and the analgesic properties of a herb, that probably reflects knowledge gained by observation of medicinal sleep.

Conclusion Hippocratic physicians described many different analgesic cures. According to the Hippocratic writings, the therapeutic approach to painful conditions included diverse, sometimes bizarre, non-pharmacological as well as pharmacological cures. The opium poppy was one of them, as well as an unspecified soporific substance. Many regimens are used in conjunction with dietary measures which Hippocratic physicians believed to have properties and effects on the body. References 1. Hippocrates. General Introduction. In: Hippocrates. Vol I. Ancient Medicine. Airs, Waters, Places. Epidemics 1 & 3. The Oath. Precepts. Nutriment. Henderson J, ed. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 2004. 2. Rey R. The History of Pain. Wallace LE, Cadden JA, Cadden SW, trans. Cambridge: Harvard University Press, 1993:20-23 3. Musaios [computer program]. Version 1.0e, 32. Los Angeles: Thesaurus Lingua Graeca, 1992. 4. Liddell HG, Scott R. A Greek-English Lexicon. Oxford: Clarendon Press, 1940.

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5. Dutton WF. Venesection; a brief summary of the practical value of venesection in disease, for students and practicians of medicine. Philadelphia: FA Davis Company, 1916. 6. Hippocrates. Regimen in Acute Diseases (Appendix). Vol VI. Potter P, trans. Cambridge, Massachusetts: Harvard University Press, 1988: (a) 4, (b) 40. 7. Hippocrates. Aphorisms. Vol IV. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 1959: (a) V.lxviii, (b) VII.xlvi, (c) VI.xxxi, (d) IV.xviii, (e) II.xlviii. 8. Hippocrates. Epidemics 2 & 4-7. Vol VII. Smith WD, ed. & trans. Cambridge, Massachusetts: Harvard University Press, 1994: (a) 5.80, (b) 6.6.3, (c) 5.58, (d) 5.67, (e) 6.6.13, (f) 7.64. 9. Jouanna J. Hippocrates. DeBevoise MB, trans. Baltimore & London: The John Hopkins University Press, 1999:156-7. 10. Hippocrates. Places in Man. Vol VIII. Potter P, ed & trans. Cambridge, Massachusetts: Harvard University Press, 1995: (a) 42, (b) 45. 11. Astyrakaki E, Papaioannou A, Askitopoulou H. References to Anesthesia, Pain, and Analgesia in the Hippocratic Collection. Anesth Analg 2010; 110:188-194. 12. Askitopoulou H, Ramoutsaki IA, Konsolaki E. Analgesia and anesthesia: etymology and literary history of related Greek words. Anesth Analg 2000; 91:486-91. 13. Lascaratos J. Kylikes zois kateunastriai. Historical and medical approach of poisonings in Byzantine era. Athens: J & J Hellas, 1994: 36. 14. Hippocrates. Fistulas. Vol VIII. Potter P, ed & trans. Cambridge, Massachusetts: Harvard University Press, 1995: section 7. 15. Hippocrates. De mulierum affectibus I-III. [book on CD-ROM]. In: Dumont DS, Smith RM. Thesaurus Linguae Greacae. Musaios Version 10d-32, 1992–1995: 201.28. 16. Hippocrates. Diseases III. Vol VI. Potter P, trans. Cambridge, Massachusetts: Harvard University Press, 1988: 16. 17. Scarborough. The opium poppy in Hellenistic and Roman medicine. In: Porter R, Teich M, eds. Drugs and Narcotics in History. Cambridge: Cambridge University Press, 1998: 4-23. 18. Hippocrates. De la Nature de la Femme. In: Opera Omnia. Tome 7. Littré E, ed. Amsterdam: Adolf M. Hakkert, 1979: (a) 388-389, 332-334, (b) 350-351 , (c) 406-409 , (d) 410-411. 19. Hippocrates. Regimen in Acute Diseases. Vol II. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 1959: XXIII. 20. Hippocrates. Use of Liquids. Vol VIII. Potter P, ed & trans. Cambridge, Massachusetts: Harvard University Press, 1995: section 1.

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Anaesthesia and Analgesia in Ancient Greece and Rome (c. 400 BCE-300 CE)

Louise CilliersI

A bstract

In the 3rd century BCE a famous Alexandrian physician named Herophilus remarked that “drugs are just like the hands of the gods”, but hastened to add that they meant nothing if not administered correctly. In the light of the imperfect knowledge of anatomy and physiology in Graeco-Roman times (c. 400 BCE - c. 300 CE), and since anaesthetics as we know them today were only introduced in the 19th century, surgery must have been a formidable experience for a patient. In this paper the sources of our knowledge of medicinal plants used as anaesthetics and analgesics will be reviewed, as well as the availability of these medicaments. Thereafter a discussion of some of the most commonly used medicinal plants used by the Greeks and Romans will follow, in particular the opium poppy, mandrake, datura, henbane, hellebore and hemlock, with an attempt to evaluate their effectiveness. It appears that medicinal plants have since earliest times been used as anaesthetics and analgesics, and could, contrary to what one would expect would be the case more than 2000 years ago, have been quite effective if correctly administered.

Introduction In the 3rd century BCE the famous Alexandrian physician, Herophilus, remarked that: “drugs are just like the hands of the gods”,II Louise CILLIERS, Department of Classical and Near Eastern Studies, University of the Free State, P.O. Box 339, Bloemfontein 9301, South Africa. II Quoted by Galen in De compositione medicamentorum secundum locos 12.966 14K, text in Von I

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but hastened to add that drugs (i.e. medicaments) meant nothing if not administered correctly by a human agent.III In the light of the imperfect knowledge of anatomy and physiology in Graeco-Roman times, and of the fact that real anaesthetics as we know them today were only introduced in the 19th century,IV surgery must have been a traumatic experience for a patient. However, medicinal plants have since earliest times been used as anaesthetics, and could have been quite effective if correctly administered. In this paper I shall be looking at the sources of our knowledge of medicinal plants in ancient Greece and Rome, as well as their availability. Then a discussion of some of the medicinal plants most commonly used by the Greeks and Romans as anaesthetics, in particular the opium poppy, mandrake, henbane, thorn apple, and hemlock. An attempt will also be made to evaluate their effectiveness. Our knowledge of medicinal plants known to the Greeks and Romans is derived from the records of various contemporary writers.V One must of course remember that chemical analyses were not yet available, and that these ancient scientists had no framework within which they could ground their observance of the effects of medicinal plants. Knowledge was gained by experienceVI which was mostly not written down, leave alone organised. The ancients further believed that the more substances in a medicament, the greater the likelihood of successful treatment, which makes it even more difficult to pinpoint the active ingredient.

The Sources The sources that I shall be referring to most in this paper are the following. The Greek scholar, Theophrastus of Eresus from Lesbos (4th century BCE), an associate and successor of Aristotle as head of the Lyceum in Athens. His two large botanical works, Historia Plantarum and De Causis Plantarum contain valuable information on plants.VII Dioscorides of Anazarbos in Cilicia (1st century CE). His famous Staden 1989: 418 T249. The doctor had to ascertain which properties or “powers”(dunameis) were in each substance of the drug and what their effect would be, taking into account the patient’s strength (cf. also Hankinson 2008: 307 and 310). IV Jackson 1988: 112-113. V Lloyd states that these early scientists “… tried to bring order and reason into a bewildering mass of more or less well grounded, more or less fantastical, popular ideas” (Lloyd 1983: 121). VI There was a delicate balance between knowledge (logos) and experience (empeiria). However, when it came to practical usage, experience proved more valuable due to the lack of technical means of measurement of e.g. the intensity of the drug (Hankinson 2008: 315). VII It also contained information on rituals and folk-beliefs and the accounts of the root-cutters, cf. the warning to dig up a plant called paeonia at night, “for if a man does it in the daytime and is observed by the woodpecker while he is gathering the fruit, he risks the loss of his eyesight, and if he is cutting the root at the time, he gets prolapse of the anus”, Historia Plantarum (HP

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De Materia Medica superseded all existing literature in classifying remedies from the animal, vegetable and mineral kingdoms. This work, which dealt with close on 1000 drugs, became the standard text for centuries to come. Pliny the Elder (23-79 CE). His 37-book encyclopaedia called the Natural History contains a valuable collection of pharmaceutical formulas. Then of course there were the Hippocratic writers (mainly 4th-2nd century BCE), Nicander (2nd century CE) with his poems on antidotes, the Roman writer Celsus (1st century CE), and the giant among all medical writers, Galen of Pergamum (129-c.210 CE). These medical writers obtained their information from the so-called rootcutters who gathered the plants in the fields and mountain glades, and who were often as knowledgeable as the doctors who treated the patients. They sold the plants to the drug-sellers who in turn sold them to the doctors in the marketplace. The plants were thus readily available and selling them became a lucrative practice. Due to the ignorance of most doctors, it soon led to widespread fraud, and good doctors like Galen travelled far and wide to acquire the genuine plants.

Some of the Plants Used for Anaesthesia and Analgesia Papaver Somniferum L - Opium Poppy The use of the opium poppy predates written history –images of opium poppies have been found on artifacts from ancient Mesopotamia (4000 BCE). Theophrastus, Dioscorides and Pliny the Elder mention various kinds of poppy. Of these the opium poppy or Papaver Somniferum L, would have been the one used by the ancient Greeks and Romans as anaesthetic and analgesic. This plant could have white, red or purple flowers. The ancients used different parts of the plant for different medical purposes. A syrup was made of the leaves of the poppy which would be good for coughs, colds and pains in the abdomen.VIII This was called meconium, but was apparently less efficacious than the juice collected from the capsule.IX This was good for the alleviation of all kinds of painX and for sleeplessness.XI It could also be plastered onto the forehead and temples or boiled and taken orally, or used as a suppository.XII A stronger dosage would have a narcotic effect which was very useful during operations -it is said to have been so effective that one patient only awoke after 3 days! From earliest times it was known that if too large a dose is hereafter) IX.8.7. Diosc. IV.64.2. IX Plin. Historia Naturalis (HN hereafter) XX.203. X Celsus V.25.3. XI Plin. HN XVIII.229. XII Diosc. IV.64.2 and 4. VIII

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taken it can result in deathXIII from respiratory failure. In fact, PlinyXIV tells us that opium was often used by the elderly infirm to commit suicide. DioscoridesXV describes the way in which the juice or latex is extracted from the capsule. Shallow cuts are to be made on the outside of the capsule, and on the following day the milky juice which has oozed out and has partially dried, has to be collected by scraping it off. The scrapings are then stored to dry and made into lozenges. It is interesting to note that opium is still today obtained in exactly the same way as described by Dioscorides.XVI TheophrastusXVII and PlinyXVIII mentioned that the juice should be extracted from the unripe seed, “when the buds are still forming” −an observation which is confirmed by modern science, because the opium percentage is then at its highest. DioscoridesXIX correctly stated that the seed of the Papaver Somniferum had no narcotic effect,XX but that it could be “baked into bread in a health-inducing diet” −today we know the rolls and bread sprinkled with the little black poppyseeds which we are told is a great source of energy. Even the oil obtained from the seeds has no alkaloid content and is used for culinary purposes.XXI OpiumXXII is the air-dried juice of the Papaver Somniferum. Modern science has established that the two main alkaloids in this poppy’s latex (juice) are morphine and codeine, and that they represent more or less 10 percent of the dried latex.XXIII MorphineXXIV binds to specific receptors in the central nervous system and suppresses them, which in turn suppress the respiratory system. This causes a slight fall in body temperature, which was noticed by both Dioscorides and Galen.XXV Diosc. IV.64.3. HN XX.197-99. XV Diosc. IV.64.7. XVI IV.64.7. XVII HP IX.15.2. XVIII HN XX.76. XIX Diosc. IV.64.1. XX Pliny (HN XX.201) erroneously believed that the seed also has narcotic properties. XXI Van den Berg M. 2008: 34. XXII The name was already known in antiquity, and is the English for the Greek word opion> poppy-juice or opium (diminutive of opos > juice). XXIII Van den Berg M. 2008: 37. XXIV Van den Berg refers to one Sertürner who renamed this alkaloid in 1816-7 after the Greek god of dreams and sleep, Morpheus, who sends dream visions of human forms. Van den Berg M. 2008: 12. XXV Dioscorides (IV.64.2) stated that the common property of the different kinds of poppy is "cooling" Cf. too Galen, who stated that drugs which seemed to serve as refrigerants of the body appeared to reduce brain function, and that a coma can be produced by poisoning with mandragora, papaver, hyoscyamus and hemlock in larger than curative doses (De symptomatum caussis I, K.VII.pp. 142-3). XIII

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Opium was also the most powerful ingredient of theriac, known as a universal cure because it was believed to contain all known antidotes. It was formerly known as ‘mithridatium’, named after Mithradates VI, King of Pontus in the first century BCE, who was said to have carried out pharmacological experiments with poison on condemned prisoners. He also tried to protect himself against poisoning by taking some of this drug every day until he was completely immune. When he had to take his own life after his own son had led a revolt against him, he had to ask an obliging Gallic bodyguard to run him through with his sword. About a century later Andromachus, the court physician of the emperor Nero, increased the opium content of the drug and changed some substances. He used viper flesh instead of the original lizard flesh and renamed it theriac.XXVI Eventually it consisted of 64 animal and vegetable products mixed with about 70 percent honey and wine.XXVII In the 2nd century CE Galen, the court physician to Marcus Aurelius, prescribed it to the emperor, who said it made him feel “in perfect peace” with himself.XXVIII In modern times opium is the source of the extremely habit-forming drug heroine; it is a semi-synthetic opiate which acts as a central nervous system depressant and an analgesic.XXIX Mandragora Officinarum L - Mandrake Mandragora was in antiquity very often associated with witchcraft, sorcery and superstition because it could cause hallucinations, and probably also because its long root was sometimes bifurcated which caused it to resemble a human figure. The fact that it was believed to be an aphrodisiac of course added to the mysticism surrounding it –there are two instances in the Bible where it is mentioned as a love potion.XXX The association of the plant with witchcraft and magic led to many superstitions from earliest times (Figure 1). Regarding the harvesting of the plant it is said that: Galen, De antidotis K XIV. 2. Galen, De antidotis K XIV.14 pp. 5-7 gives the recipe (quomodo optima theriaca componatur). It became a universal panacea, prescribed by Galen during the Antonine epidemic as prophylaxis and therapy (Galen. Ther. Pis. K XIV. pp. 280-282). XXVIII Meditations X.9. In an article Retief and Cilliers (2007: 56-65) proved that Marcus Aurelius was not an opium addict - the amount of opium in his daily dose (Galen mentions that the dose was the size of an Egyptian bean, De antidotis K XIV.4) was far too small to have any addictive properties. XXIX Van den Berg M. 2008: 41. XXX In Gen. 30:14 Leah gives Rachel mandrakes in exchange for a night of sleeping with their husband, and in Song of Songs 7:13 we read: “The mandrakes send out their fragrance, and at our door is every delicacy, both new and old, that I have stored up for you, my lover.” XXVI

XXVII

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“… one should draw three circles round mandrake with a sword, and cut it with one’s face towards the west;XXXI and at cutting of the second piece one should dance around the plant and say as many things as possible about the mysteries of love.”

Figure 1. Coloured –miniature of the human-like roots of mandragora in the fourteenth-century manuscript medical House-Book of the Centuri Family. Austrian National Library, Vienna.

There was also a widely shared belief, mentioned for the first time by the Jewish historian Josephus (c. 37-100 CE), that gathering the root was dangerous, as the plant, when uprooted, uttered a shriek, which causes the death or insanity of those who heard it. The root was thus merely loosened with a digger, and then attached to a dog, which uprooted the plant when pulled away, but then fell down dead. Among the 20 soporifics and poisons mentioned by Dioscorides, only mandrake is recommended as a consistent anaesthetic for surgery and cautery.XXXII One cyathos could also be administered to insomniacs,XXXIII and to those in much pain.XXXIV PlinyXXXV warned that when mandragora is used as a sleeping draught, “the quantity administered should be proportionate to the strength of the patient.”XXXVI Theophrastus (HP IX.88). This is also recorded by Pliny (HN XXV.148), who, however, does not cast doubt on such practices. XXXII Diosc. IV.75.3; cf. too IV. 5 and IV. 7. XXXIII Theophrastus (HP 9.9.1) and Celsus also mention its soporific effect. Diosc. V.71 states that when compounded into pessaries and placed in the anus as suppositories, it is soporific. Celsus V.25 states that bread which has been soaked in a mixture of mandragora and wine will induce sleep. Pliny also mentions the soporific effect of mandragora (HN XXV.149). XXXIV Celsus V.3.2 also refers to mandragora as analgesic, used to relieve all kinds of pains, especially in the joints (arthritis and gout). This is correct, since the tropane based-alkaloid hyoscine normally causes central nervous system depression which lead to fatigue and a dreamless sleep. XXXV Pliny (HN XXV.149). XXXVI Pliny HN XXV. 150 states that a moderate dose would be one cyathus (=42 ml). XXXI

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He adds that some people even fall asleep by merely smelling the plant, and that too copious a whiff can lead to an inability to speak or even death.XXXVII TheophrastusXXXVIII further mentioned that the root of the plant could cause madness.XXXIX Mandragora is no longer used today. All parts of the plant are poisonous. The fresh or dried root contains highly poisonous alkaloids and is narcotic, cathartic, strongly emetic and hallucinogetic. In sufficient quantities it leads to unconsciousness and indifference to pain. High doses of atropine and hyoscyamine lead to repression of respiration and coma.XL Mandragora is probably the plant to which most references have been made in literature; it has even played a role in films and video games.XLI It is often confused with Mandrax, which, however, is a synthetic drug manufactured in the form of a tablet. Hyoscyamus Niger L - Henbane - Stinking Nightshade This plant was known by various names in antiquity,XLII amongst which Herba Apollinaris (probably because it was believed that it was this plant which put the priestess of Apollo at Delphi in a trance so that she would utter oracles). DioscoridesXLIII identifies three kinds. The plants with black seed (Hyoscyamus Niger L) as well as those with yellow seed (Hyoscyamus Muticans L) cause madness and are soporific and “must be rejected as being the worst”;XLIV Dioscorides (IV.75.3) also added the warning that if too much of the mixture was consumed, it was lethal. XXXVIII HP IX.18. XXXIX Wikepedia (http://en.wikipedia.org/wiki/Mandrake_(plant)). The Hippocratic writers refer to it on 8 occasions. In Places in Man c.39 the following is said: “In cases where patients are distressed and ill, and want to hang themselves, administer mandragora root to drink in the morning, in a smaller dose than would cause delirium”. Here the sedative properties of the root of the plant are emphasised; elsewhere the Hippocratic writers refer to its narcotic, analgesic and antispasmodic properties, and to the fact that it can lead to unconsciousness. XL Van den Berg M. 2008:60. XLI It is referred to in the Bible (Gen 30:14, Song of Songs 7:13); Machiavelli wrote a play called Mandragola in which the plot revolves around the use of mandrake potion as a ploy to bed a woman; Shakespeare refers to mandragora in four plays (Othello, Antony and Cleopatra, Romeo and Juliet, King Henry IV Part II); it is also referred to by John Webster in The Duchess of Amalfi, and in poems of John Donne, DH Lawrence and Ezra Pound; Samuel Beckett in Waiting for Godot; John Steinbeck in The winter of discontent; JK Rowling’s Harry Potter and the chamber of secrets; Salman Rushdie in The Enchantress of Florence etc. It has also occurred in some or other form in at least 7 recent films, and has been used in numerous video games. XLII Pliny (HN XXV.17) states that the Greeks called it Hyoscyamos or Adamantia, but it was also called the Herb of Hercules (Herba Heraclei). XLIII Diosc. IV.68.1 & 2. XLIV Pliny states that all kinds cause insanity and giddiness (HN XXV.35). XXXVII

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the kind with white flowers and white seed (H Alba L or Egyptian henbane), however, is “highly useful for treatments, being very mild, fatty, soft and downy”. The juice can be extracted from the fruit, leaves and stems, but according to DioscoridesXLV that extracted from the seed “is better than poppy juice and a more powerful analgesic.” A mixture of henbane, poppy and hydromel could be taken orally as anaesthetic, or used as a pain-allying plaster. As pessaries it was also suitable for numerous kinds of aches, pains, inflammations and coughing.XLVI Pliny is more careful and is amazed that it can be included among remedies −he states that: “… the drug is, in my opinion, a dangerous medicine in any form”, which “… injures the head and brain.”XLVII As an effective pain-killer it was used in earlier times to dull the pain of those who were tortured and sentenced to death, “… not only to relieve the physical pain, but also to make them oblivious to reality”.XLVIII It is said that in the Middle Ages henbane, together with mandrake and thorn apple were the ingredients of the infamous witches’ brew which caused hallucinations.XLIX Henbane contains the tropane alkaloids hyoscyamine and scopolamine which have a sedative effect on the central nervous system,L confirming the empirical observations of the ancients. Together with opioids it used to be a premedication before surgery.LI Datura Stramonium L - Thorn Apple This plant was and still is known by numerous names.LII The divergent descriptions XLVII XLVIII XLIX L LI LII XLV

XLVI

Diosc. IV.68.2. Diosc. IV.68.3. Plin. HN XXV. 37. Van den Berg M. 2008:67. Wikipedia s.v. “henbane”. Van den Berg M. 2008:79. Van den Berg M. 2008:81. Dioscorides (IV.73) states that it was also called perseion, perisson, anydron, pentodryon, enory, thryon, orthogyion. Pliny XXI.177 adds halicacabos and bladder-wort because of its usefulness

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by ancient and modern authorities have made it difficult to identify the plant we know today. DioscoridesLIII distinguished various kinds, among which the strychnon manikon (Datura Stramonium) and the doryknion. ScarboroughLIV suggested that if one combines the morphological features of the strychnon manikon and the doryknion, it represents successive stages in the growth of the Datura Stramonium, or the thorn apple as we know it today. Thorn apple is one of the most toxic plants found in the Western hemisphere. It produces in the fork of each branch a single, erect white or purplish trumpet-like flower (Figure 2). The large fruit capsules look like chestnuts (hence the name ‘thorn apple’) and contain black seeds which are the most poisonous. Tropane alkaloids occur in varying concentrations in all parts of the plant. The main alkaloids are atropine, hyoscine (scopolamine) and hyoscyamine. The greatest danger is atropine which disrupts the parasympathetic nervous system’s ability to regulate subconscious activities such as breathing and heart rate. The symptoms include dimness of sight, delirium, sometimes amounting to mania.LV It was also used as cosmetic in former times (not mentioned by Dioscorides) –it dilates the pupils, which men found attractive in women. Today it is still used for eye examinations.

Figure 2. Thorn apple (Datura Stramonium).



LIII

LIV



LV

in the case of stone and other complaints of the bladder. In English it is also known as Jimsonweed, Devil’s Apple, Devil’s Trumpet, Metelnut, Solanum. Dioscorides. IV.73 and 74. “Thorn apple in Graeco-Roman pharmacology”, Classical Philology (forthcoming). http://www.botanical.com/botanical/mgmh/t/thorna12.html

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All parts of this plant are poisonous. TheophrastusLVI described the dosage as follows: “three twentieths of an ounce in weight is given if the patient is to become merely sportive and to think himself a fine fellow; twice this dose if he is to go mad outright and have delusions; thrice the dose if he is to be permanently insane, four times the dose is given if the man is to be killed.”LVII The correct dosage was obviously obtained by way of trial and error! Even today there is an extremely high risk of over-dosing. The ancients used thorn apple as a sleep inducer (‘hypnotikon’) and analgesic −hyoscine has some sedative properties and is today still an ingredient of some medications for motion sickness, and scopolamine is used with morphine during child-birth to induce ‘twilight sleep’; it is nowadays also injected as a treatment for Parkinson’s disease.LVIII Conium MaculatumLIX - Hemlock Hemlock is arguably the most infamous poison in antiquity, due to the fact that in the 5th century BCE the law courts of Athens used it as a legal mode of execution. The most famous victim was the philosopher, Socrates, who was condemned to death in 399 BCE for allegedly not believing in the gods and corrupting the youth, and had to drink a potent solution of hemlock (Figure 3).LX Plato left a moving account of Socrates’ death in the dialogue Phaedo.LXI Doubt has been cast HP IX.11.6. Dioscorides (IV.73) agrees with Theophrastus’ dosage: “The root has a property that causes not unpleasant fantasies when a quantity of one drachma is drunk with wine, but when a quantity of two drachmai is drunk, it drives a person out of his senses for up to three days, and if a quantity of four drachmai is drunk, it kills.” Hydromel (a mixture of honey and water) is mentioned as antidote. Cf. too Pliny XXI.178. LVIII Van Wyk & Wink 2004:123. LIX The Latin word “maculatum” means “spotted” which refers to the spotted markings of purple or sometimes yellow on the lower half of the stem of the plant. LX Plato did not describe the potion as “hemlock”/ kôneion, but simply as ‘pharmakon’. However, the fact that it was known as “the executioner’s drug”, and since Socrates asked the jailor to “prepare the poison” using the word tribô which means “crush” or “pound” as in a mortar (as would have been the case with the hemlock seeds), it seems clear that the potion would have contained hemlock. LXI “The man...laid his hands on him and after a while examined his feet and legs, then pinched his foot hard and asked if he felt it. He said “No”; then after that, his thighs, and passing upward in this way he showed us that he was growing cold and rigid. And then again he touched him and said that when it reached his heart, he would be gone. The chill had now reached the region about the groin, and uncovering his face, which had been covered, he said – and these were his last words – “Crito, we owe a cock to Asclepius. Pay it and do not neglect it.” “That”, said Crito, “shall be done; but see if you have anything else to say.” To this question he made no reply, LVI

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on the accurateness of this account since the 17th century when a Swiss physician described the terrible death of 8 children who had inadvertently eaten hemlock (they had violent seizures with their backs arched, jaws clenched and foam at the mouth). This led to a debate on the way Socrates really died.

Figure 3. The death of Socrates by hemlock, painting by Jacques Louis David (1787). Metropolitan Museum of Art, New York.

However, in 2001 Enid Bloch in an articleLXII to my mind convincingly proved that Plato’s description is correct. The confusion arose, she stated, because there are various kinds of hemlock resembling each other –even today it is difficult to distinguish between them, and the effects were often ascribed to the wrong species. Linnaeus in the 17th century distinguished two kinds and gave to one species the Greek name kôneion (Conium) and to the other the Latin name Cicuta. The effects of cicuta are indeed those described by the Swiss physician,LXIII whereas those of conium are those described by Plato. A peaceful death with gradually ascending paralysis and in the end asphyxia when the respiratory organs become but after a little while he moved; the attendant uncovered him; his eyes were fixed. And Crito, when he saw it, closed his mouth and eyes” (own translation, Phaedo 117e – 118a). LXII “Hemlock Poisoning and the Death of Socrates. Did Plato tell the Truth?” Journal of the International Plato Society, published on http://www.nd.edu/~plato/bloch.htm. In the article the author paid careful attention to Plato’s words, modern and ancient medicine and modern and ancient medical authors’ views. LXIII Water Hemlock attacks the brain and spinal cord, i.e. the central nervous system, whereas Poison Hemlock attacks the peripheral nervous system and resembles the effects of the GuillainBarré syndrome (Bloch 2007:1).

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paralysed.LXIV DioscoridesLXV and PlinyLXVI both ascribe death to its “chilling quality” –the body begins to grow cold at the extremities.LXVII The juice was in ancient times used to induce sleep,LXVIII as a pain allaying plaster for various ailments,LXIX and also as an eye salve, while the leaves relieved every kind of swelling, pain or flux.LXX It is the seed which contains the poison. Hemlock contains coniine, a neuro-toxin which disrupts the workings of the central nervous system; it has a sedative effect, but in bigger doses causes death which is caused by “… an ascending muscular paralysis … which eventually results in death due to asphyxia, preceded by a terminal seizure due to lack of oxygen to the brain (which would be quite mild due to the paralysis of limbs).”LXXI It is a cruel way of dying, since the mind stays clear until death –the patient knows that he is dying but is unable to help himself or ask for help due to loss of speech. Recent research revealed that there is no antidote, and that artificial ventilation should be applied.LXXII

The Effectiveness of the Ancient Remedies All the narcotic plants discussed above contain alkaloids. The alkaloid content of the plant would determine the efficacy of the remedy. Alkaloids have a specific physiological effect on humans and animals −henbane and thorn apple block the parasympathetic nerve activity and have an analgesic effect, whereas the poppy and mandrake, containing amongst others morphine and codeine have analgesic and narcotic properties.LXXIII Theophrastus (IX.16.8) also stated that “the juices of hemlock, poppy and other such herbs produce an easy and painless end”. LXV Diosc. IV.78. LXVI Plin. HN XXV.152. LXVII Taken in wine, it is “invariably fatal” (Pliny XXV.152). LXVIII Celsus (V.25.5) mentions two recipes in which hemlock is one of the ingredients, to be used as analgesic or to induce sleep. LXIX Dioscorides IV.68.2. LXX Pliny HN XXV. 153-4. LXXI Wikipedia s.v. Conium LXXII Van den Berg M. 2008:99. LXXIII Van den Berg classifies the examples of the different alkaloids found in these narcotic plants as follows: (a) Pyrrolicine alkaloids: this group includes the tropane alkaloids, atropine, hyoscine and hyoscyamine from the nightshade family, and the “truth drug” scopolamine. As a group these block parasympathetic nerve activity. They have an analgesic effect. (b) Isoquinoline alkaloids: Benzylisoquinoline is the precursor of morphine alkaloids, which include morphine, codeine and thebaine (derived from papaver) and papaverine (from the mandrake). They have analgesic and narcotic properties. Van den Berg M. 2008: 218-222. LXIV

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In contrast to modern doctors who treat patients according to a specific disease,LXXIV the ancients would treat symptoms. Incorrect assumptions regarding the effectiveness of the drug were often made which could at best have the opposite effect of that intended, at worst, death. The poppy, for instance was prescribed for painful urination, whereas it is proven that morphine inhibits the voiding action and this would lead to more pain. Another example is hemlock which was prescribed to stop nose bleeding, but coniine is a vasodilator which would actually increase the bleeding.LXXV There were, however, many remedies that were effective. The reason for this was related to their analgesic qualities which would have relieved the pain symptomsLXXVI –healing could well have taken place without them! Many drugs would have had little or no direct effect other than psychosomatic. However, some researchers believe that perhaps 20 percent of the drugs prescribed by Dioscorides might have had a positively beneficial effect and that the remaining 80 percent could have had a beneficial placebo effect in patients.LXXVII Bibliography Beck LY (trans). Pedanius Dioscorides of Anazarbus. De Materia Medica. Hildesheim, Zurich, New York: Olms-Weidmann, 2005: passim. Bloch E. Hemlock Poisoning and the Death of Socrates. Did Plato tell the Truth? Internet Journal of the International Plato Society, January 2001, published on http://gramata. univ-paris1.fr/Plato/spip.php?page=imprimer&id_article=9 (accessed 1.10.2011). Cilliers L, Retief FP. Poisons, Poisoning and the Drug Trade in Antiquity. Akroterion 2001; 45: 88-100. Craik E (ed). Hippocrates. Places in Man. Greek Text and Translation with Introduction and Commentary. Oxford: Clarendon Press, 1998. Edelstein L. Ancient Medicine. Selected Papers of Ludwig Edelstein. Baltimore and London: The Johns Hopkins University Press, 1967. Emboden W. Narcotic Plants. Studio Vista, 1979. Cf. Grmek (1989: 1): “Notions of disease… do not flow directly from our experience. They are explanatory models of reality, not its constitutive elements. To put it simply, diseases exist only in the realm of ideas. They interpret a complex empirical reality and presuppose a certain medical philosophy, a pathological system of reference”. LXXV Van den Berg M. 2008: 222. LXXVI Judging from the advice given by Theophrastus, Dioscorides and Pliny regarding the plants discussed above, the most common afflictions for which pain relief was sought, were eye diseases, pain or inflammation in the joints (e.g. gout and arthritis), earache, toothache, headache, cramps, colic or inflammation in the womb. LXXVII Jackson, R. 1988: 82. LXXIV

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Grmek MD. Diseases in the Ancient Greek World. Baltimore: London, 1989. Hankinson RJ. The Cambridge Companion to Galen. Cambridge: Cambridge University Press, 2008. Horstmanshoff HFJ (ed.). Pijn en balsam, troost en smart. Pijnbeleving en pijnbestrijding in de Oudheid. Rotterdam: Erasmus Publishing, 1994. Jackson R. Doctors and Diseases in the Roman Empire. London: University of Oklahoma Press, 1988. Jouanna J. Hippocrates. Debevoise MB, trans. Baltimore and London: The Johns Hopkins University Press, 1999. Lloyd GER. Science, Folklore and Ideology. Studies in the Life Sciences in Ancient Greece. London: Duckworth, 1983. Longrigg J. Greek Medicine from the Heroic to the Hellenistic Age. A Source Book. Duckworth, 1988. Retief FP, Cilliers L. Vergiftiging in Imperiale Rome. Tydskrif vir Natuurwetenskap en Tegnologie 2000; 19.1:10-17. Retief FP, Cilliers L. Hippokrates: feit en fiksie. Geneeskunde 2000; 10:10-14. Retief FP, Cilliers L. Marcus Aurelius se siektegeskiedenis en dood: was hy ‘n opium verslaafde? Tydskrif vir Geesteswetenskappe 2007; 47.1:56-65. Scarborough J. Roman Medicine. London: Thames & Hudson, 1969. Scarborough J. Thornapple in Greco-Roman Pharmacology. Classical Philology (forthcoming). Van den Berg M. A phytochemical analysis of some ancient narcotics, with comparative notes on some South African folk medical practices. Unpublished Ph.D. thesis, Potchefstroom, 2008. Van Hooff A. Antieke artsen en euthanasie. Hermeneus 1999; 71.2: 122-127. Von Staden H. Herophilus. The Art of Medicine in Early Alexandria. Cambridge: University Press, 1989. Van Wyk BE, Wink M. Medicinal Plants of the World. Portland, Oregon: Timber Press, 2004. Wikipedia s.v. Papaver somniferum, Mandragora, Hyoscyamus niger, Conium maculatum, Datura stramonium.

A Hippocratic Physician’s Office Georgios Stefanakis, Eleni Konsolaki, Vassilia Nyktari, Helen AskitopoulouI

A bstract

Hippocrates, the first to separate medicine from philosophy and religion, founded medicine on observation, experience, logical reasoning and clinical judgment. Several of the writings attributed to the Hippocratic school describe the functions of a physician's office, in Greek ‘ietreion’, as well as the personality of the physician, in Greek ‘ietros’, and the tasks of his assistants. These treatises display detailed descriptions of the ideal location of the office, which keeps away the wind or the excessive brightness and has a supply of clean water. The office should have a good supply of a variety of instruments, scalpels, cautery irons, bandages, and different gadgets and utensils. The physician is expected to be clean, well-dressed, and kind and serious with his patients. When he operates he should be suitably located towards the light so that the part operated upon is well lighted up. At the same time, he should take into consideration the pain of his patient and adjust his technique accordingly. His assistants should be experienced and trained to follow his orders, to hand him the necessary instruments and to perform extensions and counter extensions for fractures.

Georgios STEFANAKIS, MD, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece. Eleni KONSOLAKI, MD, PhD, Department of Oral & Maxillofacial Surgery, University Hospital of Heraklion, Crete, Greece. Vassilia NYKTARI, MD, PhD, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece. Helen ASKITOPOULOU, MD, PhD, DA, FRCA, FERC(Hon), FESEM(Hon), Professor Emeritus of Anaesthesiology, Faculty of Medicine, University of Crete, Heraklion, Greece.

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Introduction Hippocrates was the first physician “to provide a momentum for the gradual shift from the theoretical and religious accounts of philosophy and superstition to the evidence-based model of modern medicine”.1 He did not only give the physician an independent standing, but also “for centuries his diagnostic system... provided the fundamental principles of medical practice”.2 The Hippocratic Corpus, the collected writings attributed to Hippocrates, contains about 60 treatises on a variety of medical topics, including diagnosis, epidemics, obstetrics, paediatrics, nutrition, and surgery. The first Aphorism, one of the most renowned of the Hippocratic works, affirms that a physician must be fully aware of the value of medicine and the resulting responsibilities towards himself, the patient and his assistants: “Life is short, the Art long, opportunity fleeting, experiment treacherous, judgment difficult. The physician [ietros] must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals.” 3a The Greek word ‘ietros’, derived from the verb ‘iaomai’ [to heal, to cure], means the healer, either the ‘physician’ or the ‘surgeon’.4 The office or surgery where a physician treats his patients till today is called in Greek ‘ietreion’.4 Several of the Hippocratic works, such as In the Surgery, Physician, On Fractures and On Joints, provide detailed information about the environment of a physician’s surgery, the equipment used and the tasks assigned to his assistants. In the works Precepts, Decorum, Physician and The Art are emphasised the physician’s professional conduct and the proper behaviour in his relations with his patients.

The Ideal Hippocratic Physician The appearance of the ideal physician is described in detail in the works Precepts, Decorum and Physician. First of all, it is a matter of dignity for the physician to look healthy, because: “... the common crowd consider those who are not of this excellent bodily condition to be unable to take care of others.”.5a However, an attempt to please is not against his dignity.6a Hence, it is very important for the physician to be clean, well-dressed, scented with natural fragrance, to be pleasing to the sick, avoiding, however, luxurious hats and sophisticated fragrances, which could have a detrimental effect on his reputation.5a,6a A healthy body is ideally combined with a healthy mind, allowing thus the physician to: “... set about his task with healthy mind and healthy body, having considered

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the case and past cases of like characteristics to the present, so as to say how they were treated and cured.”.7 As for his personality, he should be prudent, grave, kind and fair to all.5a In terms of his relationship with other people, he should respect his patients thanks to his self-control and not betray their trust, while, at the same time, he should be serious but not harsh, avoiding both arrogance and uncontrolled laughter.5a The physician should have a fine sense of humor, be warm to the patient, but, at the same time, avoid overexposure, which could make people doubt his methods of treatment.8a His communication skills should also secure a successful transition between speech and a silence.8b The Hippocratic physician knows how to make a good use of both of them: “... silent in face of disturbances, in the face of silence ready to reason and endure, ..., setting out in effectual language everything that has been shown forth, graceful in speech...”8b Throughout the Hippocratic Corpus the physician’s professional conduct is highlighted: “… especially about medical etiquette, about deontology, about his professional obligations and responsibilities.”9 A key element of this conduct is that, under any circumstance, the emphasis should be on the patient and not on his payment.6b The physician is advised not to begin his examination by securing his payment, because this could be misinterpreted by the patient as an intention of leaving or neglecting him, if there is no agreement on the payment.6b Especially in the case of an acute disease the payment’s priority could lead to the patient’s death.6b Therefore, the Hippocratic physician is encouraged to: “... sometimes give his services for nothing, calling to mind a previous benefaction or present satisfaction ... For where there is love of man, there is also love of the art. For some patients, ..., recover their health simply through their contentment with the goodness of the doctor.”.6c As a professional, the ideal Hippocratic physician should be familiar with drugs and remember at any time their properties, since: “... this in medicine is beginning, middle and end.”.8c These drugs should be either prepared and thoroughly stored before their use or made at the time of their use and the physician should collect their ingredients and prepare them properly: “You must have prepared in advance emollients classified according to their various uses, and get ready powerful draughts prepared according to formula

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after their various kinds. You must make ready beforehand purgative medicines also, taken from suitable localities, prepared in the proper manner, after their various kinds and sizes, some preserved so as to last a long time, others fresh to be used at the time, and similarly with the rest”.8d However, while the physician should be ready at any time to perform his tasks, as it is implied by the above instruction, he is also advised to be “prepared for an opportunity and quick to take it” and, at the same time, to be “patient in waiting for an opportunity”.8b It is also remarkable that in Precepts the physician is encouraged, if he cannot deal with a disease on his own, to ask other physicians for an honest collaboration, which would avoid conflicts from jealousy: “... he should urge the calling in of others, in order to learn by consultation the truth about the case, and in order that there may be fellow- workers to afford abundant help ... It is not a mistaken idea to call in a consultant.”.6d In the works Physician and In the Surgery information can be found on the skills of the surgeon and the way he operates. As a surgeon, the doctor should be known for his skillfulness when he is incising or cauterising and, at the same time, he should also take into account the pain of the patient and adjust the speed of his technique, in order to alleviate it.5b It is fascinating that the doctor should try to reduce the intensity of the patient’s pain by been quick in the case of a single incision, or by pausing between more incisions: “... where the surgery is performed by a single incision, you must make it a quick one ... this suffering should last for the least time possible ... when many incisions are necessary ... intervals provide a break in its intensity for the patients.”5b During the operation the surgeon should be placed conveniently not only to the light but also to the part being operated on.10a If he stands, he should operate with the weight on one foot, whereas if he is seated, his feet should be in a vertical line straight up as regards the knees and with his dress well drawn together.10a The doctor should be able to perform the operation with either one or both hands aiming, at the same time, to “... attain ability, grace, speed, painlessness, elegance and readiness.”10b A physician’s dexterity is also praised when he does bandaging. He is encouraged to be quick in this performance and effective, without causing pain to the patient: “Speedily to bring the operation to an end, painlessly to do it with ease, with resource ready for anything, with neatness that it may be pleasant to look at ... Completed bandaging should be well and neatly done.”10c

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The Location of a Physician’s Office In the treatise Physician there is a detailed description of the suitable location of the ‘ietreion’, which served both as an office for consultation and as a 'surgical' hospital should keep away both the wind and the excessive brightness: “... it will be thus, if neither wind blows in, causing annoyance, nor sunshine or brightness does harm; light must be bright for those who are treating, but not do any harm to those who are being treated ... for light disturbs even more a vision that is weak.” 5c It can easily be concluded that regarding the light, the convenience of both the physician and the patient should be taken into consideration.5c It is for this reason that: “... the patient should under no circumstances directly face the brightness.”5c To compensate and exert a tight control of the light the physician is advised to use an artificial light, permitring the patient’s comfort and, at the same time, better conditions for examination.10a Both the ordinary and the artificial light can be used either as direct light or as oblique light and, whereas the use of an oblique light is not frequent, the physician is advocated to “... turn the part operated upon towards the brightest light, except such parts as should be unexposed and are indecent to look at.”10a However, he should take care not to overshadow the part he operates on.10a The supply of clean and potable water is another fundamental element in the function of the ‘ietreion’, as it is necessary for such treatments as the fixing of dislocations, sprains and fractures.10d,e Both the temperature and the quantity of water should also be checked before its use.10d The physician should ensure the appropriate temperature of the water by pouring it first over his hand.10d Water is necessary for the relaxation of the part that is being operated on, however, the surgeon should stop “while the part is still swollen up before it collapses, for first it swells and then becomes attenuated”.10d

A Physician’s Instruments As for the physician’s instruments, it is emphasised that their objective should be therapeutic and not decorative.5c,d Although the display of bronze in the surgery is considered vulgar, the physician is allowed to use bronze instruments which: “... must be well fitted for their use in size, weight and fineness”.5c

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Figure 1. Recreation of a physician's surgery according to Hippocratic writings.11 Drawing by one of the authors, E. Konsolaki.

All these instruments are placed in a proper position to facilitate the physician’s work when needed. There should be: “... neither in the way of the operation nor out of the way when wanted.”10f There is a wide variety of instruments and supplies (Figure 1). Clean, soft linen swabs are used for eyes, sponges for wounds, cataplasms and also linen bandages for lesions.5c,d,e Plenty of bandages are available for either application of pressure or loose binding.5d,10g,h However, once again, these bandages should not serve decorative purposes: “Reject graceful and showy bandages ... for this sort of thing is vulgar and purely a matter of display ... the ill person is not looking for what is decorative, but for what is beneficial.”5d Other tools (gadgets, utensils) widely used are cupping instruments and scalpels of various size and shape, depending on the damage itself.5f,g The tooth forceps and the uvula forceps are the instruments that even a learner must be familiar with, whereas ligatures are used for securing the vessels.5h,i Cautery irons and scalpels can be used for various purposes, such as for the treatment of empyema, dropsy, tooth decay, dislocations of the shoulders and operations of polyps in the nostrils, and the trepan for trephining.3b,12,13a,14,15 In the physician’s mind is sounding the Hippocratic aphorism:

A H I P P O C R A T I C D O C T O R ’ S ‘ S U RG E RY ’

“Those diseases that medicines [‘pharmaka’] do not cure, are cured by the knife. Those that the knife does not cure are cured by fire. Those that fire does not cure must be considered incurable.”3c More complex apparatus, windlasses and levers, facilitate the extension and the reduction of dislocated bones.16,17 The physician is also advised to have a second case of instruments, “methodically arranged” to be carried with him on an outside visit or journey (Figure 2).8e

Figure 2. Portable case of instruments. Votive relief from the Asklepieion of Athens. National Archaeological Museum, Athens.

The Tasks of a Physician’s Assistants In the surgery, the physician could work either alone or with the help of his assistants, who should be familiar with the cases treated in the surgery and the physician’s instruments.5c,h The assistants’ role varies, although they “have a definite role and become identified with it, … depending on the nature of the operation.”18 The assistants have to look after and hold down the patient and present the part to be operated on. At any time they must obey the physician and follow his orders in silence.10i During the operation they might hand the instruments to the physician.10f The assistants play a more important part when they perform extensions and counter extensions.13b,18 They might help fixing a dislocated wrist or a broken leg, while in the case of fractures of both legs usually two men are needed for a stronger extension.13b,17 However, strength is not the only quality required for an assistant to fix a dislocated thigh. He has to be not only the ‘strongest-handed’ but also the ‘best-trained’: “In dislocation forwards ... the strongest-handed and best-trained assistant available should make pressure at the groin with the palm of one hand, grasp-

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ing it with the other, and pushing the dislocated part downwards, while at the same time the part at the knee is brought forwards.”13c A ‘skilful’ and ‘strong’ assistant can also handle a dislocated thigh by suspending the patient from a cross-beam: “When he is suspended, let an assistant who is skilful and no weakling insert his forearm between the patient’s thighs, and bring it down between the perineum and the head of the dislocated bone. Then, clasping the inserted hand with the other, while standing erect beside the suspended patient, let him suddenly suspend himself from him, and keep himself in the air as evenly balanced as possible.”13d The assistant who will perform this type of reduction has to be an ‘experienced’ one: “... but the man who hangs himself on must be experienced, so as not to lever out the joint with his arm, but make the suspension weight act at the middle of the perineum, and over the sacrum.’13c The experienced assistant assists the physician not only in the ‘ietreion’, but also when he treats a patient at his bedside: “.Let one of your pupils be left in charge, to carry out instructions without unpleasantness, and to administer the treatment. Choose out those who have been already admitted into the mysteries of the art, so as to add anything necessary, and to give treatment with safety. He is there also to prevent those things escaping notice that happen in the intervals between visits.”.8f

Conclusions According to Hippocrates, the combination of careful observation and examination, practical thinking, and care for hygiene and patients’ comfort are the fundamentals of the Hippocratic ‘ietreion’. In the work In the Surgery all the necessary key components for its function are effectively summarised: “Operative requisites in the surgery [ietreion]; the patient, the operator, assistants, instruments, the light, where and how placed; their number, which he uses how and when; the person and the apparatus; time manner and place.”.10j There is no doubt that the Hippocratic ‘ietreion’ is an archetype even for the modern doctor’s office, with a distinct focus on the patients and their needs.

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References 1.

Doufas AG, Saidman LJ. The Hippocratic Paradigm in Medicine: Origins of the Clinical Encounter. Anesthesia & Analgesia 2010; 110: 4-5.

2.

Marketos SG, Papaeconomou C. Medicine, Magic and Religion in Ancient Greece. Humane Medicine 1992; 8: 41-44

3.

Hippocrates. Aphorisms. Vol IV. Jones WHS, trans. Cambridge, Massachusetts: Harvard University Press, 1959: (a) I.I, (b) VI.XXVII, (c) VII.LXXXVII.

4.

Liddell HG, Scott R. Greek-English Lexicon. Oxford: Clarendon Press 1996.

5.

Hippocrates. Physician. Vol VIII. Potter P, trans. Cambridge, Massachusetts: Harvard University Press, 1959: (a) section 1, (b) section 5, (c) section 2, (d) section 4, (e) section 12, (f) section 6, (g) section 7, (h) section 9, (i) section 8.

6.

Hippocrates. Precepts. Vol. I. WHS Jones, trans. Cambridge, Massachusetts: Harvard University Press, 1923: (a) section X, (b) section IV, (c) section VI, (d) section VIII.

7.

Hippocrates. The Art. Vol. II. WHS Jones, trans. Cambridge, Massachusetts: Harvard University Press, 1959: section VII

8.

Hippocrates. Decorum. Vol. II. WHS Jones, trans. Cambridge, Massachusetts: Harvard University Press, 1959: (a) section VII, (b) section III, (c) section IX, (d) section X, (e) section VIII, (f) section XVII.

9.

Von Stadten H. “In a Pure and Holy Way”: Personal and Professional Conduct in the Hippocratic Oath? J Hist Med Allied Sci 1996; 51: 404-437.

10. Hippocrates. In the Surgery. Vol III. Withington ET, trans. Cambridge, Massachusetts: Harvard University Press, 1959: (a) section III, (b) section IV, (c) section VII, (d) section XIII, (e) section XXIII, (f) section V, (g) section XI, (h) section XVIII, (i) section VI, (j) section II. 11. Konsolaki E. Head injuries in Antiquity. PhD Thesis, University of Crete, 2011. 12. Hippocrates. Affections. Vol V. Potter P, trans. Cambridge, Massachusetts: Harvard University Press, 1988: section 4. 13. Hippocrates. On Joints. Vol III. Withington ET, trans. Cambridge, Massachusetts: Harvard University Press, 1959: (a) section XI, (b) section XXVI, (c) section LXXVI, (d) section LXX. 14. Hippocrates. Diseases II. Vol V. Potter P, trans. Cambridge, Massachusetts: Harvard University Press, 1988: section 36. 15. Hippocrates. On Wounds in the Head. Vol III. Withington ET, trans. Cambridge, Massachusetts: Harvard University Press, 1959: section XXI. 16. Hippocrates. Instruments of Reduction (Mochlicon). Vol III. Withington ET, trans. Cambridge, Massachusetts: Harvard University Press, 1959: section XXXVIII.

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17. Hippocrates. On Fractures. Vol III. Withington ET, trans. Cambridge, Massachusetts: Harvard University Press, 1959: section XV. 18. Jouanna J. The Doctor and the Public. In: Hippocrates. DeBevoise MB, trans. Gilman SL, ed. Baltimore, Maryland: The John Hopkins University Press, 1999: 89-90.

HERBAL PAIN MEDICINES

in Ancient Egypt and Minoan Crete Adelais G Tsiotou, Evangelia K KalliardouI

A bstract

The properties of the opium poppy, mandragora and henbane were well known in both Egyptian and Minoan civilisations, due to the communication and trade between them, as depicted in works of art and literature. Various preparations of those herbs were effectively administered for healing, sedative and analgesic purposes. The therapeutic qualities of plants that grew in Crete specifically, such as dittany and crocus were invaluable in treating a wide range of pathologic conditions, from ocular disorders and snake bites to breast swelling, menstrual pains and inflammation. In Egypt, plants such as coriander, cumin and garlic were used to relieve digestive problems, painful conditions or to promote endurance, as archaeological and historical documents suggest.

Introduction Ancient Egyptian and Minoan medicine had several similarities in their use of herbs to treat painful conditions. Although practical cures and remedies using herbs, minerals and animal parts were used, medicine was an empirical art of a religious and magic nature. The ancient Egyptians communicated by the sea with the nearby islands of Crete and Thera, as well as with Mycenae. Many prescriptions included in Egyptian medical books originated from the ‘kefti’ (meaning people of the sea or the islands), a name attributed to Cretan people.1,2 The poppy plant, Indian cannabis, saffron, henbane (Hyoscyamus Niger), deadly nightshade (Atropa Belladonna), mandrake, water-lily and acacia are some

Adelais G TSIOTOU MD, PhD, Department of Anaesthesia, Children’s Hospital “P. & A. Kyriakou” Athens, Greece. Evangelia K KALLIARDOU, MD, PhD, DA, Department of Anaesthesia, Children’s Hospital “P. & A. Kyriakou” Athens, Greece. I

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of the plants with analgesic, tranquilising and anti-rheumatic properties used by both Egyptians and Cretans. The present paper describes the practice of herbal medicine in ancient Egypt and Crete and discusses the ways herbs were administered.

Use of Herbs by Egyptian and Minoan medicine Opium Poppy - Papaver Somniferum L Egyptian medicine was widely respected throughout the ancient Mediterranean world. Homer in the Odyssey admits that in Egypt: “...every one in the whole country is a skilled physician, for they are of the race of Paeeon” 3 Herbs played a major role in this medicine. Egypt was the land in which, according to Homer: “....earth the grain-giver, yields herbs in greatest plenty, many that are healing in the cup, and many baneful”.3 According to Herodotus in Histories II 84, physicians were specialised : “The practice of medicine is very specialized among them. Each physician treats just one disease. The country is full of physicians, some treat the eye, some the teeth, some of what belongs to the abdomen and others internal diseases”. 4 Egyptian medicine was based on experiment and observation as well. The Ebers and Edwin Smith Papyri depict the religious base of that medicine (all physicians were priests), expressed by the worship of the gods of pain, Sekhamet the lion– headed goddess (Figure 1) and Seth. An interesting section in the Ebers Papyrus describes several charms and invocations that were used to encourage healing. One used before taking a herbal remedy was as follows: “Come Remedy! Come thou who expellest (evil) things in this my stomach and in these my limbs!” 5,6 In Minoan times both empirical and magical medicines were practiced as illustrated in the statutes of the Snake Goddess and the Poppy Goddess (Figure 2). The poppy plant was regarded as a magic or poisonous plant and its hypnotic qualities were well known. Later, it was also administered for healing. Opium is the dried latex obtained from opium poppies and contains five main alkaloids, morphine, codeine, papaverine, thebaine and noscapine.7 ‘Shepnen’, opium was used in religious ceremonies and is mentioned by Homer (9th century BCE) in Iliad as ‘nepenthes’.7,8

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Figure 1. Sekhamet, the lion–headed goddess of pain.

In Greek Mythology the goddess Demeter, in despair over the seizures of her daughter Persephone, which had been provoked by Pluto, ate poppies in order to fall asleep and forgot her grief and accordingly she offered poppy to Triptolemus also in order to induce sleep.9 Helen of Sparta, to make Telemachus and his comrades forget their sorrows, offered them opium, which she had obtained from the Egyptian Polydamna, wife of Thon: “Presently she cast a drug into the wine whereof they drank, a drug to lull all pain and anger [‘nepenthes’], and bring forgetfulness of every sorrow.... Medicines of such virtue and so helpful had the daughter of Zeus, which Polydamna, the wife of Thon, had given her, a woman of Egypt, where earth the grain-giver yields herbs in great plenty, many that are healing in the cup, and many that are baneful.”10 During the Minoan age the use of poppy was widespread, as many archaeological discoveries prove. The famous Poppy Goddess –‘Patroness of Healing‘– bears on her head three movable pins resembling the heads of the poppy (Figure 2).11 In the Minoan civilisation, opium was used to relieve the pain of infants’ teething by rubbing it against their gums.12 From the Minoan Crete the poppy and its effective latex (juice) opium were carried by sea trade to mainland Greece. The Egyptians were familiar with the opium poppy and the pomegranate poppy as well. According to some authorities, the poppy-juice is mentioned un-

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A

B

Figure 2. Two Minoan goddesses (dated 1600 BCE). Archaelogical Museum of Heraklion. A. The Snake Goddess. B. The Poppy Goddess, patroness of healing, with three poppies in the front of her tiara.

der the name ‘seter-seref ’ in the Ebers papyrus (1500 BCE).11 Archaeological and literary sources suggest that the earliest appearance of opium in Egypt in the form of liquid preparations can be traced back to the 19th Dynasty. These preparations of opium in water or wine for medical purposes were imported from abroad in containers of globular-conical shape whose dimensions, analogous to those of the poppy head, were indicative of their contents.11, The shape of the vases also indicates that opium must have been stored in liquid form, which would be easy owing to the solubility of its components in water or wine.9,11,13,14 The Egyptians cultivated a unique strain of opium called ‘opium thebaicum’ in their famous poppy fields around 1300 BCE. This unique thebaicum strain containing a high amount of thebaine -one of opium’s twenty four alkaloids- was very medicinal but not so soporific. Many classical Egyptian royal tombs were decorated with paintings of opium poppies among other medicinal plants. Ancient Egyptian texts included an opiate preparation as a “remedy to prevent the excessive crying of children”.9,15 In Egypt, priests, magicians and warriors mainly administered opium, believed

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to have been given by Isis to Ra, as treatment for headaches.15 The priest-doctor administered drugs in fourteen different ways from pills, to poultices and ointments, mixed with animal fat (Figure 3).17 It is characteristic that in a tomb of the 19th Dynasty an oleaginous ointment containing morphine was found.11,18

Figure 3. Fresco from an Egyptian tomb showing the priest-doctors preparing medicines by mixing the ingredients.

Mandrake - Mandragora Officinarum L Mandrake is a solanaceous plant found growing all around the Mediterranean. In Egypt, mandrake was introduced from the East Mediterranean region. The Egyptians believed that mandragora was the special gift to medicine from the god Ra, their sun god.19 It was thought to be an aphrodisiac and was mixed with alcohol to induce unconsciousness. Its poisonous properties were well known in the Egyptian as well as the Minoan civilisation. Mandrake was also used to promote healing, to facilitate pregnancy and provide a soothing sleep.20 Its forked root, resembling the form of the human body, contains hyoscine, a powerful alkaloid that has the ability to cause hallucinations, delirium and, in larger doses, coma. It was the presence of these solanaceous alkaloids, as well as the shape of the root, that led to the mandrake’s association with magic, witchcraft and the supernatural.21 Henbane - Hyoscyamus Niger L Henbane has a similar pharmacological profile to mandrake and contains the alkaloids hyoscyamine, atropine, hyoscine and atroscin. Hyoscyamus Niger L and, additionally, Solanum Nigrum, black nightshade, Datura Stramonium, thorn apple, Atropa Beladonna, deadly nightshade, Mandragora Officinarum L, mandrake, are members of the Solanaceae family (from the Latin ‘ solanum’, nightshade) and have sedative properties. Egyptians and Minoans knew that combinations of solana-

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ceous plants and extracts from the opium poppy had increased efficacy. Mandrake with crushed opium and henbane seeds in wine was used to induce sleep.22,23

Medicinal Plants in Minoan Crete During the Bronze Age (1100-1500 BCE) in Crete many herbals were used for the treatment of different conditions, such as thyme for wound healing, and fennel and leaves of acacia against toothache. The most important and widely used ones were dittany and saffron. Dittany - Origanum Dictamus Dittany was popular in Minoan Crete and ancient Greece as a highly therapeutic plant. Its name, ‘dictamon’, was derived from the Cretan mountain Dikti. The main constituent of its essential oil is carvacrol. As a medicinal plant, dittany was utilised to heal wounds, relieve pain, cure snakebites, stomach illnesses and rheumatism and facilitate childbirth through its oxytocic properties. Hippocrates recommended it for diseases of the stomach and digestive system, rheumatism, arthritis and also to regulate menses. 24,25 The dittany of Crete was famous for its alleged property of expelling arrows imbedded in soldiers. Wild goats were reputed to seek out the plant after being struck by arrows, as it was thought that by eating the plant the arrows would fall out immediately.26,27 This observation motivated the shepherds to ingest the plant and later make compresses of its leaves to heal open wounds. In the tale of the Trojan wars by Virgil in Aeneid, book XII, 411 the hero Aeneas was severely wounded by a deeply imbedded arrow that could not be extricated. His mother Venus went to Mount Ida, on the island of Crete, and retrieved ‘Cretan dittany’, which she applied to the wound, the arrow dropped out and the wound was cured immediately.28 In ancient times, it was also believed that a snake would allow itself to be burned to death rather than cross through ‘Cretan dittany’.29 Saffron - Crocus Sativus Saffron was another medicinal plant used by the Aegean people. Saffron harvest is shown in the frescoes of the Minoan palace of Knossos in Crete, which depict the saffron flowers being picked by young girls and monkeys.30 Saffron contains carotenoid components that increase the oxygen in plasma. Close examination of ancient sources make clear that saffron was indeed an active ingredient in numerous medications for its healing and anti-inflammatory properties. It was used for skin wounds, internal inflammations and ulcerations, but additionally as a digestive, diuretic, aphrodisiac, sleep inducer and for the relief of pain. It was allegedly

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effective for the treatment of headache, gout, ear problems, cough and pleurisy, and as an antidote to poisoning. Saffron was of great value for women, since it relieved breast swelling in lactation and menstrual pains, and was useful for the treatment of uterine infections. Its effect in uterine complaints received the attention of many ancient medical authors. Saffron had the amazing power to treat and heal almost any uterine symptom with the symptoms of the menopause being a major indication, a property still accepted by contemporary herbal medicine. The first botanically accurate visual presentations of saffron's use as a herbal remedy are illustrated on the wall paintings found in Akrotiri, in the Greek island of Thera (Santorini), which show the ‘coming of age’ of young women. A fresco from the same site depicts a woman using saffron to treat her bleeding foot and also a Greek goddess supervising the plucking of flowers and the picking of stamen for use in the manufacture of this therapeutic drug (Figure 4). The Therans and Minoans had discovered that applying topical ointments containing saffron to their eyes resulted in the relief of various ocular disorders. 31

Figure 4. Saffron crocus flowers, represented as small red tufts, are gathered by two women in a fragmentary Minoan fresco (dated 1600-1500 BCE) from the Aegean island of Thera (Santorini).

Saffron was of great value as an export, particularly to Egypt where the plant did not grow. Medical papyri reveal that the ancient Egyptians suffered from many ophthalmic diseases, including conjunctivitis, blepharitis, ectropion, trichiasis, pterygion, leucoma, glaucoma, cataract and especially trachoma. Saffron was a

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powerful ingredient in many Egyptian ophthalmic medications. According to the Coptic Medical Papyrus, from eighty-six eye prescriptions twenty included saffron as an ingredient.31-33 Egyptian healers used saffron for the treatment of internal haemorrhage from the stomach, mixing and crushing its seeds with other herbals. The ointment or poultice was applied on the body. The physicians expected this to “… (expel) blood through the mouth or rectum which resembles hog’s blood when it is cooked.’ 34 Urinary tract conditions were also treated with an oil-based emulsion of premature saffron flower mixed with roasted beans; this was used topically on men. Women ingested a more complex preparation.34

Medicinal Plants in Egypt Ebers Papyrus contains 877 prescriptions and recipes of medicinal plants. Many plants are mentioned there, such as the balsam-tree, laurel berry, colchicum, wild cypress, whortleberry (cubeb), mustard, willow bark (rich in salicylates), myrrh and sandal-wood. Leaves of acacia (in Greek ‘akakia’, a name given by Dioscorides) were used against toothache while acacia nuts helped in the healing of burns thanks to the tannic oil that it included. 35 Furthermore, the Egyptians used coriander, cumin, onion, garlic, juniper, fennel, cassia, linseed, aloe and frankincense, the latter containing tetrahydrocannabinol with hashish – like effects. Honey was widely used together with castor oil, coriander seeds, yeast and milk all of which were excellent ingredients for wound care.36 Castor oil combined with figs and dates was used as a laxative. Coriander - Coriandrum Sativum Seeds of coriander were found in the tombs of Tutankhamen and in other ancient burial areas, since the plant was offered to the gods by the king. Coriander was appreciated mostly for its digestive properties, but its cooling and stimulating properties were known as well. A spice made by the plant or the seeds was used in cooking to eliminate flatulence, while a drink was recommended for those suffering from gastric and urinary complaints including cystitis.37,38 Cumin - Cuminum Cyminum Cumin is a herb indigenous to Egypt. It was used in various formulations. The seeds had stimulant and flatulence relieving effects. A powder made by cumin mixed with wheat flour and a little water was applied on aching or arthritic joints. Additionally, powdered cumin was mixed with grease or lard to form a suppository that was used to disperse heat from the anus and to stop itching.38

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garlic - Allium Sativum Cloves of garlic have been found in Egyptian burial sites, including the tomb of Tutankhamen and the sacred underground temple of the bulls at Saqqara.39 Garlic was an important healing agent for the ancient Egyptians and other Mediterranean civilisations. Raw garlic was routinely given to asthmatics and to those suffering from other bronchial-pulmonary complaints.40,41 In a, somewhat, cryptic statement about the pyramid builders by Herodotus, it is claimed that they consumed large quantities of garlic and onion to improve endurance.42

Conclusions Herbs played a major role in Egyptian and Minoan medicine. The ancient Egyptians communicated with Minoans and many prescriptions included in the Egyptians’ medical books were derived from them. Poppy plant, Indian cannabis, saffron, henbane, nightshade, mandrake, water-lily, acacia and many others, are some of the plants used by both civilisations providing analgesic, tranquilising and antirheumatic effects among many others. References 1.

Castiglioni A. Medicine in ancient Egypt. In: Storia della Medicina. Castiglioni A, ed. Papaspyrou NS, trans. Athens: Minotaur Press, 1961: 57-73.

2.

Castiglioni A. Medicine in ancient Greece. In: Storia della Medicina. Castiglioni A, ed. Papaspyrou NS, trans. Athens: Minotaur Press, 1961: 118-15.

3.

Homer. The Odyssey. Butcher SH, Lang A, trans. The Harvard Classics. New York: PF Collier & Son, 1909: 14.

4.

Herodotus. In: The boys and girls’ Herodotus. New York and London: GP Putnam’s sons, 1908: 91-107.

5.

Plinio Prioreschi. Primitive and Ancient medicine. In: A History of Medicine. 2nd edn. Omaha: Horatious Press, 1995: 257-364.

6.

The Papyrous Ebers. Ebbell B, trans. Copenhagen: Levin & Munksgaard, 1937: 30.

7.

Askitopoulou H, Ramoutsaki I, Konsolaki H. Anaesthesia and Analgesia: Etymology and Literary history of related Greek words. Anaesth Analg 2000; 91: 486-91.

8.

Homer. Iliad. Murray AT, trans. Loeb Classical Library. Cambridge, MA: Harvard University Press, 1976-1978.

9.

Kapoor LD. Opium poppy. In: Botany, Chemistry and Pharmacology. New York: Haworth Press, 1995: 1-16.

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10. Homer. Odyssey. Murray AT, trans. Loeb Classical Library. Cambridge, MA: Harvard University Press, 1976-1978. 11. Kritikos PG, Papadaki SN. The history of the poppy and of opium and their expansion in antiquity in eastern Mediterranean area. Bulletin and Narcotics 1967; 19: 2527. 12. Jedakis G, Martlew H. Minoan and Mycenaean tastes. Ministry of Culture, National Archeological Museum eds. Athens: Capon Press, 1999: 262-268. 13. Askitopoulou H, Ramoutsaki IA, Konsolaki E. Archaeological evidence on the use of opium in the Minoan world. In: Diz JC, Franco A, Bacon DR, Rupreht J, Alvarez J, eds. The History of Anaesthesia. Amsterdam: Elsevier, 2002: 23-30. 14. Macht DI. The history of opium and some of its preparations and alkaloids. JAMA 1959; 64: 477-81. 15. Brownstein MJ. A brief history of opiates, opioid peptides and opioid receptors. Proc Natl Acad Sci 1993; 90: 5391-5393. 16. Diamantopoulos A. Medicine in Ancient Egypt. Patras, Greece: Technogramma Press, 1994:40-41. 17. Nunn, JF. Ancient Egyptian Medicine. London: British Museum Press, 2000. 18. Saber Gabra Cf. Papaver Species and Opium through the Ages. Bulletin de l’Institut d’Egypte 1956: 40. 19. Walker K. The Story of Medicine. New York: Oxford University Press, 1955. 20. Reeves C. Drug and the prescription. In: Egyptian Medicine. Risborough, UK: Shire Publication, 1992: 55-62. 21. Carter AJ. Myths and mandrakes. R Soc Med 2003; 96: 144-147 22. Carter AJ. Narcosis and nightshade. BMJ 1996; 313: 1630–2. 23. Long DJ, Tipping R, Holden TG, Bunting MJ, Milburn P. The use of Hebane (Hyoscyamus niger L) as a hallucinogen at Neolithic ‘ritual’ sites: a re-evalution. Antiquit 2000; 74: 49-53. 24. Hippocrates. Coan prenotions, anatomical and minor clinical writings. Potter P, ed & trans. Loeb Classical Library Series. Cambridge, MA: Harvard University Press, 2010: 373. 25. Baumann H. The Greek Plant World in Myth, Art, and Literature. Stearn WT Stearn ER, eds. London: Herbert Press, 1993. 26. Aristotle. History of Animals. Cresswell R, trans. Saint John’s College, Oxford University, London: HG Bohn, 1862: 238. 27. Thanos CΑ. Aristotle and Theophrastus on plant-animal interactions. In: Arianoutsou M, Groves RH, eds. Plant–animal interactions in Mediterranean-type ecosystems. Dordrect, The Netherlands: Kluwer Academic Publishers, 1994: 3-11.

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28. Virgil. Aeneid. Fairclough HR, trans. The Loeb classical library. Cambridge, MA: Harvard University Press, 1918: 326. 29. Rigatos G. Herbs in Greek Civilization. Athens: Diachronic Editions, 2001. 30. Evans ΑJ. The Palace of Minos at Knossos. London, 1921-1936: 718-721. 31. Forsyth PY, Young P. The medicinal use of saffron in the Aegean Bronze Age. Classical Views 2000, 44: 1931. 32. Nunn JF. Ancient Egyptian Medicine. London: British Museum Press, 1996: 192, 201, 215. 33. Andersen SRy. The eye and its diseases in Ancient Egypt. Acta Ophthalmol Scand 1997; 75: 338-344. 34. Willard P. Secrets of Saffron: The Vagabond Life of the World’s Most Seductive Spice. Boston: Beacon Press, 2001: 34-35. 35. Murray MA. The book of Thoth: Ancient Egyptian Legends. London, 1920. 36. Forrest RD. Early history of wound treatment. J Royal Soc of Med 1982; 75: 198-205. 37. Zucconi LM. Medicine and Religion in Ancient Egypt. Religion Compass, 2007; 1: 26–37. 38. Aboelsoud NH. Herbal medicine in ancient Egypt: A review. J Med Plant Res 2010; 4: 82-86. 39. Soyer A. The pantropheon or The History of food and its preparation: from the earliest ages of the world. Boston: Ticknor, Reed, and Fields, 1853: 81. 40. Barile E, Zolfaghari B, Sajjadi SE, Lanzotti V. Saponins of Allium elburzense. J Nat Prod 2004; 67: 2037–2042. 41. Helou L, Harris IM. Garlic. In: Herbal products: Toxicology and Clinical Pharmacology. Tracy TS, Kingston RL, eds. 2nd edn. New Jursey: Humana Press, 2007: 123150. 42. Herodotus. The Histories. Sélincourt A, trans. Baltimore: Penguin, 1954.

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DIFFERENT CONCEPTS OF ‘Anaesthesia’

In Late Greek and Roman Antiquity Elisabeth Astyrakaki, Vassilia Nyktari, Helen AskitopoulouI

A bstract

‘Anaesthesia’ is a very old word, first cited in ancient Greek texts of the Classic era 2500 years ago. A significant number of citations also appeared later on, in Hellenistic and early Roman texts. The purpose of the present study was to investigate the various meanings of the word ‘anaesthesia’ throughout the literature of late Greek antiquity. In Hellenistic times (323-31 BCE), the main citations of the word ‘anaesthesia’ were found in the texts of Theophrastus and Epicurus. In the early Roman times (31 BCE-330 CE), many references to ‘anaesthesia’ were found in the texts of Plutarch, Strabo, Lucian, Aelian, Artemidorus, Galen, Diogenes Laertius, Dioscorides and many others. The word ‘anaesthesia’ had multiple meanings in the texts of Hellenistic and Imperial times. For example, it was used to depict stupidity, apathy, insensibility or indifference to the common weal. More interestingly, from a medical point of view, scientists and physicians of this era used the word ‘anaesthesia’ to describe the ‘loss of sensation’ and ‘absent mindedness’. By these meanings medical scholars of the times approached more the modern definition of ‘anaesthesia’.

Elisabeth ASTYRAKAKI, MD, PhD, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece Vassilia NYKTARI, MD, PhD, Department of Anaesthesiology, University Hospital of Heraklion, Crete, Greece. Helen ASKITOPOULOU, MD, PhD, DA, FRCA, FERC(Hon), FESEM(Hon), Professor Emeritus of Anaesthesiology, Faculty of Medicine, University of Crete, Heraklion, Greece.

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Introduction The Greek word ‘anaesthesia’, meaning lack of sensation, is a compound word derived from the Greek privative ‘an’ and the verb ‘aesthanomai’, which means to perceive through the senses, that later passed as a loan into other languages.1 The word ‘anaesthesia’ was first cited in ancient Greek sources. Throughout the writings of the ancient Greek civilisation, the word had numerous meanings. In the classic ancient era, the word ‘anaesthesia’ was found many times in the texts of prominent authors. The historian Thucydides (460-400 BCE) with the word ‘anaesthesia’ described political indifference and disinterest, while in Plato’s texts (427-348 BCE) the word had the philosophical meaning of “the oblivion of the soul from the movements of the body” or ‘want of perception’. In the writings of Hippocrates (c. 460-380 BCE) ‘anaesthesia’ was used for the first time in the medical context as the ‘loss of sensation’ and ‘unconsciousness’.2 The purpose of the present study was to investigate the various meanings of the word ‘anaesthesia’ throughout the texts of late Greek antiquity, that is in the Hellenistic and early Roman or Imperial periods. The electronic programme Thesaurus Lingua Graeca (TLG), a database of the entire ancient Greek literature, was searched for references to the word ‘anaesthesia’ in the texts of Hellenistic and early Roman times.3 The program includes search options for a combined search in a particular work, author or in all classic literature, and automatically provides the number of citations together with the relevant text. Specifically, ‘αναισθησία’, the Greek word for ‘anaesthesia’, and its derivatives were searched. The relevant citations were then examined in the original Greek texts and compared to classic English translations.

Hellenistic Period (323-31 BCE) In the Hellenistic era, the main quotations of the word ‘anaesthesia’ were found in the texts of Theophrastus and Epicurus. Theophrastus of Eresus In the texts of Theophrastus of Eresus (372-287 BCE), a Greek philosopher and scientist and also a student of Aristotle, the word ‘anaesthesia’ was found six times (Table 1). In his work Characters one can see the depth of Theophrastus’ knowledge regarding the human soul. In this work, where 30 personality types are depicted, the word ‘anaesthesia’ is used to describe the state of ‘sluggishness’: “Stupidity one may define as sluggishness in what a man says or does …”5

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Table 1. Main references to ‘anaesthesia’ in the texts of Late Greek Antiquity. writers

main works

quotations (n)

Theophrastus

Hellenistic period (323-31 BCE) Characters

6

Epicurus

On Sense and Sensibilities Epicurus to Herodotus

6

Strabo Plutarch Artemidorus Galen Dioscorides Diogenis Leartius Lucian Atheneus Aeleian

Imperial period (31 BCE-330 CE) Geography Parallel Lives Oneirocritica Galenic Corpus De Materia Medica The lives of Emminent Philosophers True Story Deipnosophists De Natura Animalium

2 68 1 287 3 8 4 3 1

Epicurus Epicurus (341-270 BCE) was a Greek philosopher and the founder of the school of Epicureanism. According to Epicurian philosophy the concepts of ‘good’ and ‘bad’ are derived from impressions of pleasure and pain. ‘Good’ is whatever is pleasant, while ‘bad’ is what is painful. The greater part of the extant texts of Epicurus is embodied in the tenth book of The lives of Philosophers by Diogenes Laertius, which contains the life and doctrines of Epicurus. This source provides six citations related to ‘anaesthesia’ (Table 1). Epicurus used the word ‘anaesthesia’ to depict the loss of sensation, as in this citation from his work Epicurus to Herodotus: “Hence, so long as the soul is in the body, it never loses sentience [anaesthetei] through the removal of some part …”4a In the same work, the author used the word ‘anaesthesia’ to describe death as a state without feeling: “Death is nothing to us; for the body, when it has been resolved into its elements, has no feeling, and that which has no feeling is nothing to us…” 4b

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Imperial Period (31 BCE-330 CE) During the early Roman era many references of the word ‘anaesthesia’ were found in the texts of Plutarch, Strabo, Lucian, Aelian, Artemidorus, Galen, Diogenes Laertius, Dioscorides and many others (Table 1). Strabo Strabo (64 BCE-24 CE), a Greek historian, philosopher and geographer, in his work Geography used the word ‘anaesthesia’ as synonymous to stupidity: “Cyme is ridiculed for its stupidity [anaesthesian], owing to the repute, as some say, that not until three hundred years after the founding of the city did they sell the tolls of the harbour, and that before this time the people did not reap this revenue. They got the reputation, therefore, of being a people who learned late that they were living in a city by the sea.”6 In the same work, Strabo used the word ‘anaesthesia’ to depict the ‘apathy’ and ‘insensibility’ of the Corsican slaves: “Whenever any Roman general invades the country (Cyrnus or Corsica), and, penetrating into the wilds, seizes a vast number of slaves, it is a marvel to behold in Rome how savage and bestial they appear. For they either scorn to live, or if they do live, aggravate their purchasers by their apathy and insensibility [anaesthesia], causing them to regret the purchase-money, however small.”7 Plutarch The Greek historian and biographer Plutarch (46-120 CE), in his writings used frequently (68 times), the word ‘anaesthesia’. Plutarch wrote numerous works on many subjects. The most popular are the 46 Parallel lives, biographies planned to be ethical examples in 23 pairs (one Greek and one similar Roman person). One of these pairs is Solon and Publicola. In Solon, Plutarch used the adjective ‘anaesthetos’ to depict the man who is indifferent to the ‘common weal’: “He (Solon) wishes, probably, that a man should not be insensible or indifferent to the common weal, arranging his private affairs securely and glorying in the fact that he has no share in the distempers and distresses of his country, but should rather espouse promptly the better and more righteous cause, share its perils and give it his aid, instead of waiting in safety to see which cause prevails…”8a In the life of Nikias, Plutarch uses the adjective ‘anaestheton’ to describe a ‘silly’ situation: “As for Timaeus, he may possibly have been moved to write thus in the exer-

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cise of the same critical taste which led him to correct the language of Philistus and abuse Plato and Aristotle; but as for me, I feel that jealous rivalry with other writers in matters of diction is altogether undignified and pedantic, and if it be practised toward what is beyond all imitation, utterly silly [anaestheton] …”8b In the life of Otho, Plutarch with the adjective ‘anaesthetos’ describes the ungrateful manner: “Celsus replied in a manner that was neither ignoble nor ungrateful [anaesthetos], saying that the very charge made against him afforded proof of his character, for the charge was that he had been loyal to Galba, from whom he had received no special favours.”8c Artemidorus Ephesius In the middle of 2nd century CE, Artemidorus, a professional diviner, wrote his work on the interpretation of dreams, Oneirocritica. In this work, he used the word ‘anaesthesia’ to define mental obtuseness: “… dreaming that one has no nose signifies mental obtuseness [anaesthesia] and the hatred of prominent people as well as death to the sick…”9 Galen Galen of Pergamum (129-201 CE), a prominent medical writer, was considered only second to Hippocrates in his importance to the development of medicine. The foundation stone of his writing activity was Galen’s loyalty to the Hippocratic logic. It was Galen who first introduced the notion of experimentation to medicine. Galen used the word ‘anaesthesia’ or its derivatives 287 times. Well known for his contribution to the medical anatomy, Galen uses the word ‘anaesthesia’ mainly in the context of the anatomy of the nervous system.10 A detailed account is given in an accompanying paper. Dioscorides Pedanius Dioscorides Pedanius (1st century CE), a Greek physician who served as a surgeon in Nero’s army, was the first medical scholar and the most quoted, to use the term ‘anaesthesia’ from a pharmacological point of view, to describe how mandragora produces anaesthesia, in his work on Materia Medica.11,12 Diogenis Laertius Diogenis Laertius also used the adjective ‘anaesthetos’ to describe a stupid fellow.13

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Lucian Lucian of Samosata (125-180 CE), was famous for his witty narrations in his writings. In his True Story, a fictional narrative work, he describes a scene where the central character, being trapped in a giant whale, tries to escape by setting fire inside the long animal. Lucian, with the adverb ‘anaesthetos’ describes the insensitivity of the whale at the begining of the burning: “For seven days and seven nights he was unaffected [anaesthetos] by the burning, but on the eighth and ninth we gathered that he was in a bad way…”14 Athenaeos Athenaeos, a Greek writer of the 3rd century CE, wrote the work Deipnosophistes (in English The Learned Banqueters). In this work he used the word ‘anaesthesia’ to denote human stupidity and boorish dullness, as when the Boeotians were accused by their Athenian neighbours: “… But really this is the kind of symposium appropriate to ‘Boeotian insensibility’…”15 In the same work, Athenaeus describes Midas’s stupidity and lack of sense by naming him as: “... the most senseless [anaestheton] animal in the world”.16 Aelian Aelian (175-235 CE), although a Roman author, in his works preserves quotations and knowledge from earlier authors of Greek-Roman antiquity. In his work On The Nature of The Animals he refers to Agatharcides who asserts that there is in Libya a certain race of men who are called the Psylloi. Their bodies have an unusual and marvellous quality: “…they alone are uninjured by the numerous creatures that bite or strike. At any rate they do not feel either the bite of a snake or the prick of a spider which is fatal to others, or even the sting planted by a scorpion, and whenever one of these creatures comes near and touches a Psyllian and inhales the odour from him, it is as though it had tasted some drug that brings on a drowsiness inducing insensibility, for it becomes quite weak and relaxed until the man has passed by…”.17

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Conclusions The word ‘anaesthesia’ had several different meanings in late ancient Greek literature. For example, it was used to describe the loss of sensation, absent mindedness, stupidity, apathy, insensibility, and indifference to common wellbeing. Physicians of this period assigned to the word ‘anaesthesia’ a more rational and scientific meaning which approaches more the definition of modern anaesthesia. References 1.

Askitopoulou H, Ramoutsaki IA, Konsolaki E. Analgesia and anesthesia: etymology and literary history of related Greek words. A & A 2000; 91: 486-91.

2.

Astyrakaki E. Evolution of the concept of Anaesthesia in Ancient Greece: Classic Times. In: Drury PME, ed. The History of Anaesthesia. Proceedings of the 6th International Symposium on the History of Anaesthesia. Cambridge: Conservatree, 2007: 87-95.

3.

Musaios [computer program]. Version 1.0e, 32. Los Angeles: Thesaurus Lingua Graeca, 1992.

4.

Diogenes Laertius. Lives of Eminent Philosophers. Epicurus. Hicks RD, trans. Cambridge Massachusetts: Harvard University Press, 1970: (a) X.65, (b) X.139.

5.

The Characters of Theophrastus. Bennet CE, Hammond WA, trans. New York: Longmans, Green, and Co, 1902: IX The stupid Man.

6.

Strabo. The Geography of Strabo. Jones HL, ed. Cambridge, Massachusetts: Harvard University Press, 1924: 13.3.6.

7.

The Geography of Strabo. London: George Bell & Sons, 1903: 5.2.7.

8.

Plutarch. Lives. Bernadotte P, trans. Cambridge, Massachusetts: Harvard University Press, 1914, (a) Solon 20.1; (b) Nikias 1.5; (c) Otho 1.1.

9.

Artemidorus. The Interpretation Of Dreams. Oneirocritica. White RJ, trans. New Jersey: Noyes Press, 1975: 1.27.

10. Galenus. De nervorum dissectione. [book on CD-ROM]. In: Dumont DS, Smith RM. Thesaurus Linguae Greacae. Musaios Version 10d-32, 1992–1995: 2.831.4. 11. Morch ET, Major RH. Anaesthesia. Early use of the word. Anesth Analg Cur Res 1954; 33: 64-8. 12. Astyrakaki E, Papaioannou A, Askitopoulou H. References to Anaesthesia, Analgesia & Pain in the Hippocratic Collection. A & A 2010; 110(1):188-94. 13. Diogenes Laertius. Lives of Eminent Philosophers. Menedemus. Vol I. Hicks RD, trans. Cambridge Massachusetts: Harvard University Press, 1972: II.128.

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14. Lucian. A True Story. Vol I. Harmon AM, trans. Cambridge Massachusetts: Harvard University Press, 1913: II.1. 15. Athenaeus. Deipnosophistae. Vol II. Gulick CB, trans. Cambridge Massachusetts: Harvard University Press, 1967: V.186.f. 16. Athenaeus. Deipnosophistae. Vol V. Gulick CB, trans. Cambridge Massachusetts: Harvard University Press, 1963: XII.516.c. 17. Aelian. On the Characteristics of Animals. Vol III, Books 12-17. Scholfield AF, trans. Cambridge Massachusetts: Harvard University Press, 1958: book 16.27.

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