THERIAC

 

         If you are looking for a super-remedy that cures everything, reach for theriac, if you can find it. Theriac is one of the historical all-time greats of pharmaceutical success, used by emperors, kings, and anyone else who could afford it. Though it’s use has given way to the advances in pharmaceutical sciences, its history holds lessons for today.

         The origins of the theriac recipe are obscure. The story allegedly begins with Mithridates VI, king of Pontus, a large kingdom surrounding most of the eastern Black Sea. He believed that his father, Mithridates V, was poisoned (120 B.C.) and, in an attempt to head off a similar fate, he regularly took small doses of poisonous substances to build resistance. After Mithridates VI’s death, the ingredients he was taking were incorporated into a poison-preventive remedy known as Mithridatium that soon became a preventive for a number of illnesses unrelated to poisoning. Later, Andromachus, physician to Emperor Nero, modified the formula, most notably by substituting viper’s flesh for that of the lizard, in order to prevent poisoning by venomous bites. He also added opium and several other ingredients, including Lemnian earth (a red soil from the island of Lemnos), roasted copper, bitumen, additional herbal plants, and squills (a medicinal plant). The new formula eventually acquired the name “theriac,” derived from the Greek theriake, an adjective signifying “of a wild or venomous animal.” 

         Galen used both theriac and Mithridatium and wrote that he had tried theriac on roosters “with creeping poisonous beasts among

Galen (Wellcome Library)

them” and found it successful. In addition to anti-poison and antivenom effects, Galen modified theriac doses to take advantage of ingredients known to heat, dry, moisten, or cool the humors, according to the Galenic scheme. He used it for malaria with mixed results.

         The use of theriac survived the fall of the Roman Empire. After the Islamic takeover of territory east of Europe, recommendations for theriac surfaced in writings of Rhazes, Avicenna, and others and in some form was in use in medieval Europe. As the Renaissance dawned, the western world relearned theriac’s formula (or formulas, as by then pharmacists puzzled over the identity of certain ingredients or could not obtain them). Different formulas contained 40 to 60 ingredients, though numerous simplified versions of “theriac” flooded the market, prompting many cities to establish days when an official version was manufactured. Physicians, pharmacists, and government dignitaries supervised the process publicly, and certified it as genuine. 

Pharmacist making theriac under physician supervision (woodcut, Hieronymus Brunschwig,
approximately 1512. Wellcome Library)

    Modern study of old recipes shows variation in ingredients, some of whose names are no longer decipherable. The medicine developed a reputation as a cure or preventative for a variety of illnesses in addition to its actions on venoms and poisons. It was used extensively in plague epidemics both to prevent and to treat the pestilence and was considered effective for either. The ingredients, especially opium, could reduce diarrhea and cough and induce analgesia, sweating and sedation, adding patient satisfaction. Doctors gave it orally, usually in wine, or rectally, as a plaster, or by inhalation. 

Partial list of ingredients, 16th cent.
book (Wellcome Library)

         During Renaissance times the Republic of Venice enjoyed a booming pharmacy business. The state’s extensive trading with the East supplied many of theriac’s ingredients. The first chair of materia medica was established in Padua in 1533 and a botanical garden followed soon after. By 1565 there were 71 pharmacies in the Republic, organized into a Collegio, whose pharmacists underwent years of training and an examination to obtain licensure. The Collegio fixed pharmacy prices so that a pharmacist’s success rested on the quality of his products (especially theriac) and his relationship with physicians. Physicians could not own pharmacies but worked closely with favored ones. The Campana d’Oro in Verona, the most famous pharmacy, also maintained a natural history museum that was a known tourist attraction. Another one, the Farmacia Dell’Orso, still operates in Venice.

Photo of model of 16th century Italian pharmacy (Wellcome Library)

         Crowds gathered in the city every spring to witness the manufacture of theriac. Outside the licensed pharmacies benches supported numerous majolica jars containing herbs, spices, roots, gums, and other ingredients while larger jars on the top row held the snakes whose flesh was the vital component. Priors of the College of Medicine arrived to inspect the ingredients and spectators crowded in to witness the butchery of the vipers and watch the costumed workers grind and mix the herbs. Travelers sometimes came from afar to witness the spectacle. Up to 800 snakes (only females could be used) per month in some years disappeared into the concoction, eventually depleting the usual supply area near Padua.

Even at this time, arguments about the possible harms of “polypharmacy,” such as seen in theriac, appeared in print and they gained credence as botanical and pharmaceutic knowledge increased. A particular influence in the decline of theriac’s popularity in

William Heberden (Wellcome Library)

England was a publication by William Heberden, Antitheriaka: An Essay on Mithridatium and Theriaca (1745). The essay details theriac’s poorly documented recipes and debunks the agent’s supposed curative properties. Regarding its opium content, Heberden urged that if the doctor needs opium, he should prescribe it separately. Heberden was generally skeptical of reliance on ancient authorities.

In Paris, residents last witnessed a Venice-like, public theriac manufacture in 1798 and the French Pharmacopeia listed theriac until 1884. Theriac is now a historical curiosity. Why did it have such a long life? The significant opium content certainly contributed to public and medical acceptance. And no doubt heavy promotion by purveyors, from doctors and elite pharmacies to itinerant peddlers, influenced an expectant public. Not unlike purveyors of vitamins and immunity boosters today.

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

SOURCES:

 

Eamon, William, The Professor of Secrets: Mystery, Medicine, and Alchemy in Renaissance Italy. 2010; National Geographic.

 

Heberden, W, Antitheriaka. An essay on mithridatium and theriaca. 1745. Available at: https://wellcomecollection.org/works/ty3m7h5g

 

Berman, A, “The Persistence of Theriac in France.” 1970; Pharmacy in History 12(1): 5-12.

 

Fabbri, C N, “Treating Medieval Plague: The Wonderful Virtues of Theriac.” 2007; Early Science and Medicine 12: 247-83.

 

Rankin, A, “On Anecdote and Antidotes: Poison Trials in Sixteenth-Century Europe.” 2017; Bull Hist Med 91 (2): 274-302.

 

Palmer, R, “Pharmacy in the Republic of Venice in the Sixteenth Century.” Chapter in The Medical Renaissance of the Sixteenth Century, A. Wear, R K French, I M Lonie eds. 1985, Cambridge Univ Press.

         

         

         

 

 

 

 

 

 

 

 

 

 

 TYPHUS AND REVOLUTION IN RUSSIA

         Russia and eastern Europe provided the setting of the largest outbreak of typhus ever recorded. Typhus had been a problem in Russia for centuries. The cold winter climate and a relative lack of bathing and personal hygiene were ideal for louse reproduction. A famine year, 1892, saw the largest outbreak of the disease before WWI, with 184,162 cases registered. The role of lice, under suspicion for some years, became clear only in 1909 when Charles Nicolle, working in Tunis, demonstrated louse transmission  of the disease, for which he received the Nobel Prize. The tiny, causative Rickettsia remained invisible. 

Charles Nicolle (Wikipedia)

         Medicine in the pre-revolutionary Russia, though lacking the organization and sophistication seen in Europe, was improving. Following the emancipation of the serfs in 1861, the government created “zemstvos,” self-governing units throughout the countryside whereby peasants had reasonable control over their own affairs. Hired “feldshers,” the rough equivalent of physician assistants, provided most of the rural medical care. The wretched living conditions faced by the zemstvos crystallized the need for a public health approach to disease control and a growing number of well-educated, liberal-minded physicians fostered this approach. World War One and the Bolshevik revolution,  however, changed everything.

Early in the war, typhus broke out among Russian soldiers imprisoned in a large camp near Cottbus, Germany. Two researchers assigned to the camp, Stanislaus von Prowazek, a brilliant Czech

Stanislaus von Prowazek (Wikipedia)

zoologist already known for his discovery of the agent of trachoma, and Henrique da Rocha Lima, a Brazilian physician working at the Bernard Nocht Institute in Hamburg, discovered that the typhus germ entered the body when louse feces were scratched into abraded skin, not during a bite. Tragically, both men contracted typhus, von Prowazek dying from it and da Rocha Lima surviving. Da Rocha Lima also found the offending organism under the microscope and named it Rickettsia prowazeki in honor of Howard Ricketts (who had succumbed to

Bust of da Rocha Lima (Wikipedia)

typhus while studying it in Mexico) and his deceased colleague at Cottbus. 

Typhus exploded in war-torn Serbia in 1915. The American Red Cross sent a commission, headed by Richard Strong from Harvard, to help. Strong was stunned by sights of extreme poverty, hospitals filled to over 400% of their capacity with louse-covered sufferers, virtually absent sanitary facilities, and crippled medical help (126 doctors had already died). The team constructed large steam generators, often using locomotives, and ovens of various types to sterilize clothing while the wearers of the clothing went into showers rigged in railroad cars or were doused with kerosene or benzene. These louse-killing measures, along with appropriate isolation practices, stemmed the epidemic, though only after about 150,000 deaths claimed by the disease.

Illustrations from Strong, et al, in Serbia

In Russia, the worst came a little later. Cases were apparent during the war, but real acceleration began in 1918, when Petrograd reported almost 11,000 cases and Moscow close to 7,000. Masses of troops were returning to their homes, either as deserters or released after the 1918 peace treaty of Brest-Litovsk, bringing lice and disease with them. The demilitarized soldiers who clogged the railroads, a subsequent civil war, a new and disorganized Bolshevik government, financial collapse, and subsequent famines, all created the conditions for a massive epidemic. Large numbers of city dwellers, escaping food and fuel shortages, moved to the countryside, spreading the germs further. The final tally is unknown but estimates of the total number of typhus cases run between 15 and 35 million (1918-22), involving the entire country from the Baltic to the Pacific. As an added calamity, scurvy, typhoid, tuberculosis, dysentery, cholera, and other diseases of social and economic collapse battered the population, along with a huge influenza epidemic.

Family living in boxcar, man lost legs to frostbite (Library of Congress)

Russian doctors, now down-graded as “bourgeois” in the new regime, knew the principles of control of typhus. Even Lenin knew, evidenced by his cry to attendees of the 1919 Party Congress, “All attention to this problem, comrades. Either lice will conquer socialism or socialism will conquer lice.” In fact, in the ensuing civil war, typhus was killing or incapacitating significant numbers of both the Red Army and the White Army as they battled it out for the future of Russia. Lenin’s government centralized medical services under the new “People’s Commissariat for Health Protection,” or NKZ, and provided crucial money for epidemic control. Gradually, as the Red Army prevailed, delousing activities similar to those employed in Serbia escalated and eventually gained the upper hand. Railroad stations and other public places, even railroad cars, where large numbers had gathered to escape the bitter cold, were especially targeted for delousing. Famines continued to plague the country and slow the efforts, but by 1923 typhus was under reasonable control. 

The American Red Cross played a role. Its mission to Siberia began in February 1919 as the “Inter-Allied Typhus Train,” partly as an anti-Bolshevik maneuver by the wartime allies and partly as a

American Red Cross Nurses, Russia (Wikipedia)

humanitarian effort. Departing from Vladivostok, the Train carried disinfection and delousing steam equipment, adopted from the Serbian experience, across a vast area. Along with their own medical personnel, the team hired Russian feldshers and other health workers and provided extensive educational materials about typhus transmission (sometimes resented by local doctors). In just over a year the Train covered 11,00 miles and treated over one million White Army soldiers and local civilians. The advancing Red Army made it dangerous to continue, however, and it terminated in May 1920.

Typhus had cemented its reputation as a disease of war, poverty, and famine. By World War II, in contrast, the advent of the insecticide DDT and awareness of the danger of lice served to prevent a massive recurrence of the scourge. It is now an uncommon disease and hopefully will remain so.

A full index of past essays is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

 

SOURCES:

 

Patterson, K D, “Typhus and its Control in Russia, 1870-1940.” Medical History 1993; 37: 361-81.

 

Nachtigal, R, “Russian Public Health during the First World War.” J of Slavic Military Studies 2023; 36 (1): 73-95.

 

Sackmann, W, “Fleckfieber und Fleckfieberforschung zur Zeit des Ersten Weltkrieges.” Zeitschrift für Klinische Medizin 1924; 100(1): 203-22.

 

Irwin, J F, “The Great White train: typhus, sanitation, and U.S. International Development during the Russian Civil War.” Endeavor 2012; 30 (10): 1-9.

 

Jaenicke, L, “Stanislaus von Prowazek (1875-1915) – Prodigy between Working Bench and Coffee House.” Protist 2001; 152: 157-66.

 

Field, Mark G, Soviet Socialized Medicine: An Introduction. 1967, The Free Press, N.Y.

 

Strong, R P, et al, Typhus Fever with Particular Reference to the Serbian Epidemic. 1920, American Red Cross at Harvard Press, Cambridge, Mass.

 

 

 

 

 

         

 

    REVEALING THE AGENT OF SYPHILIS:

SCIENCE AND CONTROVERSY

      

         

         In late nineteenth century Germany, reforms in the attitude toward venereal diseases, in the form of better public education, improved statistics, and more government funding, ensured frequent headlines in the press. It was also a time when scientists were uncovering the role of bacteria in numerous diseases that previously defied understanding. Naturally, a search for the agent of syphilis was of great importance. 

One investigator, John Siegel, followed an oblique pathway. During an epidemic of an unknown disease characterized by ulcers in the mouth, Siegel, a general practitioner, wondered if the disorder was a human form of foot and mouth disease. Working in a home laboratory, he failed to find a bacterium behind foot and mouth disease and wondered about parasites. After further training under Prof. Franz Schulze, a respected parasitologist at the Zoological Institute in Berlin, he published papers claiming that protists in the genus Cytorrhycetes were the cause of foot and mouth disease as well the cause of variola/vaccinia, syphilis, and scarlet fever. Such broad assertions aroused skepticism, but the prominence of Schulze, his mentor, prevented outright disbelief. The Imperial Health Office (Kaiserliche Gesundheitsamt), alarmed by an increase in venereal disease in military troops, wanted confirmation of Siegel’s claim for syphilis and asked Fritz Schaudinn to investigate.

Schaudinn, born into a prosperous East Prussian farming family in 1871, had studied at the Friedrich-Wilhelm University in Berlin, where his talent in zoological studies attracted the attention of the same Franz Schulze who had mentored Siegel. Schulze encouraged Schaudinn to study protists and before long the latter earned a name for new

Fritz Schaudinn (Wikipedia)

 discoveries and superb microscope skills. He was asked to participate in a malaria project in the Dalmatian coast, where Germany maintained a marine research station at Rovigno. Schaudinn and his team, using quinine and anti-mosquito measures, cleared the area of malaria. While there, he founded a journal, the Archiv für Protistenkunde. Among other projects, he described new protozoa, distinguished  Entameba histolytica from Entameba coli  microscopically, and determined the pathogenicity of one ameba from the other by experiments on himself. It was a productive period (though he also made an erroneous microscopic observation that delayed knowledge of the malaria parasite’s liver stage).

He returned to Berlin as chief of a new department of protozoology in the Imperial Health Office, from where he was asked to assess the findings of Siegel. Schaudinn obtained the assistance of Erich Hoffmann of the dermatology service at the Charité Hospital (dermatologists were the syphilis specialists at the time). In March 1905, Schaudinn demonstrated, for the first time, slender spirochetes in syphilitic lesions and in lymph nodes adjacent to lesions, all carefully prepared by Hoffmann. Schaudinn saw the spirochetes both with and without staining, noting the pale blue coloring with Giemsa stain (thus the name Spirochaete pallida, later changed to Treponema pallidum). He did not say the organisms caused syphilis, only that he saw them, and in lymph nodes he saw no others. 

How did Schaudinn see what others had failed to see for so long? Two explanations have been offered. First, he was an expert microscopist, often known to spend all night peering through his instrument. Second, he had a new Zeiss apochromatic microscope (the lens corrected for three colors of light rather than the two of achromatic lenses, improving clarity). In later papers, after consistently finding spirochetes alone in syphilitic lymph nodes, he maintained that they were the causative organisms, though attempts at culture had failed. Schaudinn and Hoffmann presented their findings before the Berlin Medical Society in May 1905 and were surprised to be met with a hostile skepticism, one member huffing that spirochetes could be added to the 25 previous causes of syphilis that had been alleged.

Photos of treponema from Schaudinn and Hoffmann's original paper (Hathi Trust)

           Meanwhile, many other workers saw the organisms. Metchnicoff and Roux, recently able to transmit syphilis to apes, saw the slender organisms. Organs of infants born with congenital syphilis showed them. Robert Koch, informed while performing tropical disease research in Africa, wrote Schaudinn from Dar es Salaam, congratulating him. Mail applauding him came from the bacteriologist Carl Fraenkel, the dermatologist Karl Herxheimer, Aldo Castellani (the discoverer of the trypanosome of African sleeping sickness), and the chemist/bacteriologist Gustav Giemsa, whose stain Schaudinn had used.

Schaudinn received invitations from the Universities of London and Cambridge, but eventually accepted a position as protozoologist at the new Bernard Nocht Institute for Tropical Medicine in Hamburg. Shortly after this, the Kaiser invited him to attend the International Congress of Medicine in Lisbon in 1906. A committee of the Congress had unanimously chosen Schaudinn to receive a prize for his work, but the German medical establishment intervened, objecting that Schaudinn lacked an MD degree and was too young to qualify for such a prestigious award. The award eventually went to Alfonse Laveran for his discovery of the malaria parasite in 1880. He was 86. The dermatology section of the Conference, provoked, hosted an extravagant tribute in Schaudinn’s honor, which touched him deeply.

Schaudinn had suffered for some time from perirectal abscesses. Heading home by ship from Lisbon, he became quite ill with pain and fever, requiring emergency surgery aboard ship. After landing, his condition worsened. An abscess the size of a “small child’s head” was opened but he developed overwhelming sepsis, perishing in June 1906. He was 35 years old, his brilliant career cut short. 

Schaudinn left behind a wife and two children, whose grief may have been softened by the creation at the Bernard Nocht Institute for Tropical Medicine, his last research home, of the Schaudinn Medal, awarded every two years for excellence in protozoan research. 

 

Remember: A list of prior history of medicine entries with corresponding links is available at: https://museumofmedicalhistory.org/j-gordon-frierson%2C-md

The website for the SSVMS History of Medicine Museum is: https://museumofmedicalhistory.org

SOURCES:

 

Kuhn, C, Aus dem Leben Fritz Richard Schaudinns. 1949, Georg Thieme Verlag, Stuttgart.

 

Mollenhauer, D, “Founder of Archiv für Protistenkunde: Fritz Schaudinn - his Unfinished Life.” 2000; Protist, 151: 283-7.

 

Lindenmann, J, “Siegel, Schaudinn, Fleck and the Etiology of Syphilis.” 2001; Stud Hist Biol & Biomed Sci, 32(3): 435-55.

 

Thorburn, A L, “Fritz Richard Schaudinn, 1871-1906: Protozoologist of Syphilis.” 1971; Brit J Vener Dis 47: 459-61.

 

Medina-de la Garza, C E et al, “Fritz Schaudinn: zoólogo y protozoologo.” 2012; Medicina Universitaria, 14(57): 231-8.

 

Risse, G, “Schaudinn, Fritz Richard,” Dict of Scientific Biog, 1981.

Schultz, O T, “Fritz Schaudinn: A Review of his Work.” 1908; Bull Johns Hopk Hosp 19: 169-173.

 

 

 

 

 

 

         

         

         

 

         

 THE CREATION OF THE AMERICAN 

MEDICAL ASSOCIATION

 

         By 1800, the still new United States could boast of five recognized medical schools, all in the eastern states. Over succeeding decades medical practitioners seized opportunities to form new medical schools, appoint themselves professors, and derive further income from student fees. Between 1830 and 1847 the number of medical schools doubled. To discourage dropouts, pre-med requirements were negligible, the two-year curriculum was reduced to 16 weeks a year (some going to 13 weeks), and final exams were geared to pass most of the students. 

         Many doctors saw this trend as damaging to the profession. Dr. Nathan Smith Davis of the New York State Medical Society was especially concerned. Smith, born in poverty in a log cabin, obtained a medical education at a long-since defunct school in Fairfield, N.Y., opened a practice in Binghamton, engaged in

Nathan Smith Davis MD 
(Wikipedia)

teaching, and became active in the State Medical Society. Learning about earlier unsuccessful attempts to standardize medical education, he worked to convene a national meeting to address the problem.

         Davis, through the N Y Society, invited delegates from every state medical society and each medical school in the country to attend a conference to establish educational standards and to consider the formation of a national medical society. In spite of opposition, the organizers met in the Medical Department of NYU on May 5, 1846. Eighty delegates attended, representing sixteen states (of 25 at the time). Efforts by naysayers to cancel the meeting were defeated decisively, ending further resistance to the idea of a national organization. 

         In short order, officers were elected, rules established, and, responding to the broadening interests of the group, committees were organized to report at future meetings on topics such as education, medicine, surgery, hygiene (public health), medical ethics, medical literature, and the like. Medical education remained a leading issue and the delegates were expressly asked to consider the thorny question of whether professors in medical schools could also issue licenses, a common practice at the time.

         The following year, 1847, delegates to the first “National Medical Convention” met in the Academy of Natural Sciences in Philadelphia to formalize the national association. The delegates

 Academy of Natural Sciences of Philadelphia (Graham's Magazine, 1852)

chose “The American Medical Association” as their name and drew up a constitution designed to be as representative as possible. Two classes of membership were adopted. The largest group consisted of delegates, some chosen by state and local medical societies (the number based on membership tallies), and others chosen by medical schools, hospitals of at least 100 beds, and other medical institutions (usually two per institution). Along with delegates from areas without medical societies, they comprised the voting members and served one-year terms. Another delegate class, permanent members, comprised those who wished to continue their association with the AMA as nonvoting members. Officers served for one year and the same city could not host the meetings twice in a row. The first president of the AMA was Nathaniel Chapman, Professor of the Theory and Practice of Medicine at the University of Pennsylvania. He was chosen because “of his age, his high attainments, and his

Nathaniel Chapman (Wikipedia)

position as one of the oldest and most eminent teachers in the Union,” and not because of medical innovations or research. His biographer describes him as a “friendly anachronism, venerated for his age and position but ignored as a medical theorist.”

The new AMA focused on medical education. The delegates passed resolutions extending the teaching period to three years, with at least two years of six-month lecture periods and three months of dissection, and stipulating attendance records. Pre-med requirements included adequate basic science and mathematics, proficiency in English, enough Latin and Greek to read medical tracts and write prescriptions, and testimony of good moral character. The question of using outside examiners for license qualification, furiously resisted by many medical school delegates, went to a committee for further study.   

The Convention adopted a medical code of ethics that was virtually a reprint of the widely known and valued 1803 work by the British physician, Thomas Percival. A resolution encouraging the registry of births, deaths, and marriages passed easily, various standing committees were assembled, and Baltimore fixed as the first annual meeting place for the new-born AMA. 

         The Baltimore meeting in 1848, the first annual meeting, opened with a speech by the new president, Nathaniel Chapman, who established the convention of serving a one-year term. The just-approved requirements for pre-med education were upheld in spite of complaints, even by Harvard faculty, that they were too severe (though there was no ability to enforce them). Furthermore, the delegates added hospital bedside teaching as another obligation. A report on the growing problem of adulterated drugs imported to the U.S. (after Europeans tightened their laws) startled participants. Major problems cited were Peruvian bark (sent after the quinine was leached out), adulterated quinine, rotten or spoiled rhubarb root, and diluted opium. Oliver Wendell Holmes reported on the sad state of American medical literature and the sparsity of translations of good European articles. 

Transcription of the first annual
meeting of the AMA (Trans of 
the AMA, v1, 1848,Hathi Trust)

         The surgical section devoted generous time to the new anesthetic agents, ether and chloroform, introduced in the previous two years. New developments in medicine, vital statistics, public health reports, and indigenous medical botany filled the remainder of the agenda. 

In spite of disputes over issues of education, reasonable harmony prevailed and leaders in medicine leant their support. The AMA endured. Nathan Smith Davis, the driver of the early efforts, had skillfully guided the organization through the birth process. He later accepted the chair of Physiology and Pathology at Rush Medical College. However, when the dean of the school refused to institute some of the AMA medical school requirements, Davis and sympathetic faculty left and founded a new school, the Medical Department of Lind University, which eventually morphed into Northwestern University Medical School (now the Feinberg School of Medicine). Davis later served as president of the AMA, editor of its journal, and wrote a history of the AMA up until 1855.

         

SOURCES:

 

Fishbein, M, A History of the American Medical Association 1847 to 1947. 1947; W.B. Saunders.

 

Davis, N.S., History of the American Medical Association from its Organization up to January 1855.1855; Lippincott, Grambo & Co.

 

The Transactions of the American Medical Association, Instituted 1847. v 1, 1848; American Medical Assoc.

 

Code of Ethics of the American Medical Association Adopted May, 1847. 1871; Turner Hamilton.

 

Leake, C. D., Percival’s Code: A Chapter in the Historical Development of Medical Ethics. 1923; American Medical Assoc.

 

Obituary (Davis), Science, 1904; 20 (NS): 237-40.

 

Richman, Irwin, The Brightest Ornament: A Biography of Nathaniel Chapman, M.D. 1967; Pennsylvania Heritage, Inc, Bellefonte.

 AMERICA’S FIRST PSYCHIATRIC 

SERVICE

          It is well known that, in colonial times, society treated people suffering from mental illness with a disdain unimaginable today. Some victims wandered the streets, but more often they were confined in jails or basements, poorly fed and cared for, and frequently enchained. Philadelphia, before the Revolutionary War, saw a rapid growth in population, including many suffering from physical and mental diseases and impoverishment. Dr. Thomas Bond, who had studied medicine in London and Paris and was impressed with the hospitals he visited, joined forces with Benjamin Franklin to petition the Philadelphia Assembly for a public hospital. The first in the colonies, it opened in 1751 "to care for the sick poor of the Province and for the reception and care of lunaticks." 

Pennsylvania Hospital, 1755 (Wikipedia)

         Benjamin Rush, a prominent physician, European educated, active in politics, a signer of the Declaration of Independence, and a director of hospitals during the Revolution, joined the attending staff of the Pennsylvania Hospital in 1783. Rush found the mentally ill housed in cells in the hospital basement, often chained to the wall, lying on dirty straw and fed a meager diet. There was no heating in winter, and they received no particular therapy. Before long, on the retirement of John Morgan, Rush took over the professorship of

Benjamin Rush by Charles Wilson
Peale (Wikipedia)

Clinical Medicine. He initiated visits to the basement cells in his rounds with students - a first - and was soon in charge of all mentally ill patients. He installed stoves in the basement cells, countering the belief that the insane were insensible to cold and, with the help of an important board member and an indignant letter to the newspapers, persuaded the hospital to build a new above-ground wing for psychiatric patients.

         Developments in the approach to mental illness were brewing elsewhere. In France, Phillippe Pinel had just assumed directorship of the Hospice de Bicetre, a hospice that housed, in degrading conditions, some 200 mentally ill patients. With

Phillipe Pinel, by Anna Mérimé

the belief that many were curable or at least improvable, Pinel instituted “moral treatment,” consisting of a psychological approach to therapy that he outlined in a 1794 paper. Release from severe confinement, better food, attempts to understand the illness, and elementary occupational therapy were mainstays of “moral treatment.” Bleeding, purgatives, and water baths were still used but more sparingly. Pinel’s first book was in 1801, by which time Rush and Pinel probably knew of each other.

         In England, in the 1790s, William Tuke, a Quaker merchant in York, outraged at the death of a woman in a local asylum, organized the York Retreat, recognized for its psychological approach to treatment. Another Englishman, Dr. Francis Willis, with whom Rush corresponded, ran a sanitarium for wealthy patients and treated King George III for madness (conjectured now to have been porphyria) in 1788. Willis took a more psychologic approach than Rush who, thinking that illness in body as well as mind were at fault, tended more to bleeding, purgatives, and so forth. 

The York Retreat, 1792 (Wikipedia)

          Rush published his own book on mental illness, entitled Medical Inquiries and Observations upon the Diseases of the Mind, released in 1812. He classified mental illnesses based on symptoms. Disease classifications at the time were varied and based on beliefs now obsolete. Fever, for instance, constituted a separate entity,

Title page, Rush's text
(Wikipedia)

divided into various categories such as intermittent, remittent, bilious, and so forth. He was completely ignorant of the causes. A similar situation existed for mental illness. Rush stated boldly (without much evidence) that “…the cause of madness is seated primarily in the blood vessels of the brain, and that it depends on the same kind of morbid and irregular actions that constitute other arterial diseases.” These actions are “a part of the unity of disease, particularly of fever, of which madness is a chronic form, affecting that part of the brain which is the seat of the mind.” The mind was in the brain but a separate entity. 

         Rush could know nothing of the ideas of modern neurophysiology. Humoral theories, though waning, still influenced medical thought, as did the idea of “the unity of disease.” Therapies of the day consisted mainly of bleeding, cupping, purges, and emetics, intended to move corrupting substances to the outside and relieve vascular congestion. Focused on the blood vessels, Rush employed bleeding liberally, claiming success in many cases (though he was later criticized for excess bleeding). He did away with straightjackets, primarily because they prevented access to the arms for bleeding and for taking the pulse. As a substitute he created a special "tranquilizer" chair (see illustration) that immobilized the patient but allowed access to the arms. The seat had a hole

Tranquilizer chair (National Library
of Medicine)

through which the results of purgatives could pass to a container below and, in some cases, a padded box could be placed over the head to diminish visual stimulation. He also used a chair that would spin around, the idea being to alter the circulation, the seat of the trouble, in the brain. Kindness, attention to the patient’s history, dream analysis, and occupational therapy, were other innovative treatments.

         Few patients demonstrated the need for therapy more than Rush’s own son, John. After a promising medical education, he later made several suicide attempts, and eventually became incurably psychotic. Treatments did not help in his case. In correspondence, Rush commiserated with his close friend, John Adams, who had lost a son to alcoholism.

Though Rush’s life was filled with other projects, in the realm of psychiatry he made an important advance by considering mental illness (“lunacy”) a medical condition, amenable to therapy, and, despite bloodletting, he encouraged a humane and integrated approach to healing. He was America’s first psychiatrist and he created the nation’s first psychiatric ward.

 

SOURCES:

 

Fried, Stephen, Rush: Revolution, Madness, and the Visionary Doctor Who Became a Founding Father.  2018; Crown, N.Y.

 

Binger, Carl, Revolutionary Doctor: Benjamin Rush (1746-1813). 1966; W.W.Norton, N.Y.

 

Meyer, A, “Revaluation of Benjamin Rush.” Amer J Psych 101 (4): 433-442.

 

Shryock, R, “The Psychiatry of Benjamin Rush.” Amer J Psych 101 (4): 429-32.

                                    Muscles’ Monikers Through Time

by Roy A. Meals, MD

While interest in and knowledge of anatomy increased steadily during the Renaissance, differentiating and naming the newly observed muscles proceeded with fits and starts. True, more than a millennium before, Galen had described muscles by their location and function, but he did not actually name them. For instance, “Two of the muscles on the inner side of the forearm…flex the fingers,” and “The next largest…flex the whole wrist,” are examples, obviously confusing to a student embarking on his first anatomical studies.

Vesalius (1514-1564) tended to number all anatomical structures and cross-referenced them in the text and drawings of his seminal Fabrica (1543). In addition to naming two jaw muscles and the six-pack, Vesalius also named an arm muscle the anterior cubitum

Andreas Vesalius by Jan van Calcar, the artist who
made woodcut prints for Vesalius (Wikipedia) 

flectentium musculus—though it seems, in this case, a nice succinct number would have been more user-friendly. Had all the muscles retained numbers, however, it could get cumbersome. For instance, somebody might ask you to flex your number 489 and you couldn’t remember which one it was, out of the roughly 650 that humans have.

One of Vesalius’s teachers, Sylvius (1478-1555), in Hippocrates et Galeni physiologicae partem anatomicam isagoge (Anatomical Introduction) (1555), named many anatomical structures, especially vessels and muscles “for the sake of brevity and the perspicuity of thing.” Possibly because Sylvius did not illustrate his work, his terminology did not catch on. Fifty years later, Bauhin (1560-1624) rekindled interest in descriptive terminology by referring readers of his unillustrated Theatrum anatomicum (1605) to Vesalius’s depictions in Fabrica. After that, naming proceeded in full force over the next 300 years.

Many anatomists pitched in and gave the muscles descriptive names and fortunately renamed the anterior cubitum flectentium musculus the biceps. Some of the original names were outright poetic. Consider, for instance, the contributions of Jan Jesenius (1566–1621), a Bohemian physician, politician, and philosopher. He was professor of anatomy in Wittenberg and later at Charles

Jan Jesenius (Wikipedia)

 University in Prague, where he also performed the city’s first public autopsy, an event said to have attracted 1000 onlookers. He named the muscles controlling the eyeball’s movement amatorius (muscle of lovers), superbus (proud muscle), bibitorius (muscle of drinkers - contraction of the medial rectus muscles would make one cross-eyed), indignatorius (muscle of anger), and humilis (muscle of lowliness). Twenty years later, early in the ThirtyYears War, Jesenius was executed for his Protestant views rather than his muscle naming. It is too bad that in 1895 anatomists standardized the nomenclature and dully renamed the eye muscles according to their location (superior, inferior, medial, lateral) and alignment (rectus [straight] and oblique). 

            In the eighteenth and nineteenth centuries the language in anatomical tomes began to move away from Latin to modern languages, confusing the terminology in a different way. In addition, new “systems” were proposed, such as that of Monro in Scotland and Francois Chausser in France, who both proposed a new terminology for muscles based on their sites of origin and termination. A few muscles’ names do identify their origins and insertions. For instance, the sternocleidomastoid is the strappy muscle on the side of the neck that turns your head to the side. One end attaches to the breastbone (sterno) and collar bone (clavicle, cleido) and the other end fastens to the mastoid process of the skull, which is palpable just behind the earlobe. By the nineteenth century, anatomists had identified and named nearly everything, but often with multiple synonyms first in Latin and later in more modern languages. In a non-muscular example, one author in 1917 listed 16 names for the pineal body, including “parietal eye” and “penis cerebri.” Anatomists and clinicians came to recognize that this towering Babel of terminology should be simplified to have clear meaning, logical consistency, and compact form.

            The German Anatomical Society began the reform process in 1887. The prominent Swiss anatomist Wilhelm His, Sr. (his son, W.

Wilhelm His, Sr. (Wikipedia)

 His, Jr., described the bundle of His) spearheaded the effort, forming a committee of prominent anatomists that in turn consulted  anatomists from several countries. In 1895 their efforts coalesced into the Basle Nomina Anatomica (BNA), the first compilation of standardized anatomical names, written in Latin. Several revisions have ensued.

            Some muscles received names of objects they resemble. Piriformis, a hip muscle, is pear-shaped. The deep calf muscle, the soleus, is sandal-shaped. Overlying it is the bulgy gastrocnemius, literally the belly of the leg. In each palm and sole are four worm-shaped muscles, lumbricales manus and lumbricales pedis, respectively. The Latin name for earthworm is Lumbricus.

Illustration from the Basle Nomina Anatomica, 1895 (Internet Archive)

         Other muscles received names according to their location, such as the subclavius (under the clavicle) and the intercostales externi (external layer, between the ribs). The number of parts determines a few labels: Bi- means two, and the biceps has two origins, one from the shoulder blade, one from the upper arm bone. The triceps has three origins, and the quadriceps has . . . well, guess. Length is another determinant. Thumb in Latin is pollux, and it has two muscles that fold (flex) the thumb across the palm—the flexor pollicis longus and flexor pollicis brevis. And a muscle’s action may determine the name; the cremaster, which lifts the testicle, derives from the Greek for “I hang.” 

(Courtesy of Roy Meals, Wikipedia, and British Library)

         Revisions of the nomenclature continued. In 1950 the newer International Anatomical Nomenclature Committee (IANC) took over the job. It was succeeded by the International Federation of Associations of Anatomists (IFAA) that issued, in 1998, its Terminologia Anatomica, containing both Latin and English versions of nomenclature.

         In today’s world where schools, buildings, and military bases are receiving new names after second thoughts on their historical origins, one wonders what monikers future committees will bestow on muscles and other anatomical structures.

 

References

Buklijas, Tatjana: “The science and politics of naming: reforming anatomical nomenclature, ca. 1886-1955.” Journal History Medicine Allied Sciences. 2017;72(2):193-218

Eychleshymer, Albert C.: “Anatomic Nomenclature.” JAMA 1915;64(19):1569-1570.

 

Harrison, R. J., and E. J. Field. Anatomical Terms: Their Origins and Derivation. Cambridge: W. Heffer and Son, 1947.  

Musil, Vladimir et al: “The history of Latin terminology of human skeletal muscles (from Vesalius to the present).” Surg Radiol Anat. 2015;37(1):33-41.

Sakai, Tatsuo: “Historical evolution of anatomical terminology from ancient to modern.” Anatomical Science International, 2007;82:65-81.