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The early steps of chloroform anaesthesia in Turkey during the Ottoman Empire in the 19th century
Annales Françaises d’Anesthésie et de Réanimation 24 (2005) 377–382 http://france.elsevier.com/direct/ANNFAR/
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The early steps of chloroform anaesthesia in Turkey during the Ottoman Empire in the 19th century Les premiers pas de l’anesthésie au chloroforme en Turquie dans l’Empire Ottoman Yesim Isil Ulman * Cerrahpasa Medical Faculty, Department of Medical History and Ethics, Istanbul, Turkey Available online 03 February 2005
Abstract Objective. – The aim of this study was to research the pioneering steps for the employment of chloroform in Turkey in comparison with the developments in the West i.e. in the United States and in Europe. The development of anaesthesiology in the West started in the first half of the 19th century. As an anaesthetic substance, ether was first employed in a medical operation by R. Liston in December 1846. But taking into consideration of its bronchially irritant effect, British gynaecologist Dr. J.Y. Simpson preferred to utilize chloroform in obstetrical operations in 1847. The paper aims at shedding light on the earlier steps for modern anaesthesiology in Turkey in that sense. Methods. – The survey used evaluation of archival documents, first hand-original sources such as the annual medical reports of the Medical School, books, official journals, and newspapers of the time, and also secondary sources concerned with the subject. Results. – In view of the findings of the survey, chloroform, as an anaesthetic material, began to be administered surgically in Turkey much earlier than it was already known. It was experienced and used in operations at the surgical clinic of the Imperial School of Medicine at the Capital city, Istanbul in 1848. The Crimean War (1853–1855) induced to the prevalent surgical use of chloroform in Istanbul on the soldiers back from the front. In other words, it was evidenced that surgeons started to make use of this anaesthetic substance in the Ottoman Empire, shortly after it was put into medical practice in Europe. Conclusion. – This study deals with that phenomenal progress of chloroform anaesthesia in the medical history in Turkey during the second half of the 19th century. © 2005 Elsevier SAS. All rights reserved. Résumé Objectif. – Le chloroforme a été utilisé pour la première fois en obstétrique en 1847, par J.Y. Simpson en Ecosse. Le but de cette étude était de trouver les preuves des premières utilisations du chloroforme en Turquie et de comparer avec l’histoire de cet emploi dans les pays occidentaux comme les États-Unis et l’Europe. Méthodes. – Recherche dans les archives médicales de l’Université d’Istanbul, dans les livres, dans les journaux officiels et les quotidiens de l’époque et recherche dans les publications historiques ultérieures. Résultats. – Le chloroforme en tant qu’agent anesthésique a été administré en chirurgie beaucoup plus précocement qu’il était habituellement établi. Il a été utilisé en 1848 au cours d’opérations à la Clinique Chirurgicale d’Istanbul dépendant de l’Ecole Impériale de Médecine. La guerre de Crimée (1853–1855) a entraîné une utilisation très large à Istanbul pour des intervention sur les soldats revenant du front. Ainsi, le chloroforme a été utilisé en chirurgie dans l’empire Ottoman, peu de temps après son introduction pour la médecine en europe.
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An earlier version of this text at a preliminary stage was published at the Proceedings of the 36th International Congress on the History of Medicine Tunis, 87–94, 1998. * Kalamis, Tevfik Pasa sok. 6/7, 34720 Fenerbahce-Kadikoy-Istanbul, Turkey. Tel.: +90-2164184248; fax: +90-5245418755. E-mail address: [email protected] (Y.I. Ulman). 0750-7658/$ - see front matter © 2005 Elsevier SAS. All rights reserved. doi:10.1016/j.annfar.2004.11.001
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Conclusion. – Cette étude démontre la rapidité de l’introduction au début de la deuxième moitié du XIXe siècle de l’anesthésie au chloroforme dans la pratique médicale en Turquie. © 2005 Elsevier SAS. All rights reserved. Keywords: History of medicine in Turkey; History of modern anaesthesiology; Chloroform; Istanbul Imperial Medical School; Servicen Effendi; Crimean War; Dr. G. Scrive; Dr. Cemil Pacha Mots clés : Histoire de la médecine ; Histoire de l’anesthésie ; Chloroform ; Istanbul Imperial Medical School ; Servicen Effendi ; Crimean War ; Dr. G. Scrive ; Dr. Cemil Pacha
1. Introduction: steps towards modern anaesthesia in Europe The development of modern anaesthesiology started in the first decades of the 19th century. In March 1842, Dr. Crawford W. Long (1815–1878), having previously noted the anaesthetic effects of ether, employed it in the removal of a small cervical cystic mass from the patient, and subsequently used it in other cases (1842–1843). But Long did not publish the report of his results and he had no one to pursue and expand his work. In 1800, Sir Humphrey Davy (1788–1829) of Penzance, England, experimented upon himself with nitrous oxide and stated its potential advantage in surgical operations. In 1844 Horace Wells (1815–1848), a dentist from Hartford, Connecticut, began to use nitrous oxide in dentistry, and communicated his results to his friend and former partner, William Thomas Green Morton (1819–1868) of Charlton, Massachusetts. A fatal case, however, caused Well’s withdrawal from practice and led to his tragic death. Meanwhile, Morton had been studying medicine and learned from Dr. Charles T. Jackson, an able chemist, the anaesthetic effects of chloric ether. Morton visited and persuaded Dr. John C. Warren to use this new anaesthetic in a trial operation at Massachusetts General Hospital where a congenital, superficial, vascular tumor below the jaw was successfully extirpated by Dr. Warren on 16th October 1846. This was followed by excision of a fatty tumor, on the next day, by Dr. Hayward, accompanied with Morton as anaesthetist, and a limb amputation by Robert Liston in December 1846, both under ether anaesthesia. On 18th November 1846, the discovery was announced to the world in paper by Henry J. Bigelow, published in Boston Medical and Surgical Journal [1]. Sir James Y. Simpson (1811–1870), a professor of obstetrics in Edinburgh, used ether in midwifery practice on 19th January 1847, but because of its foul odour and bronchially irritant effect, he took up chloroform on 4th November 1847. Impressed with its advantages, Sir Simpson published his results a week later. He was the first to employ chloroform in obstetrics and labour as a general anaesthetic agent in Europe [2]. As a matter of fact, chloroform had been discovered as a chemical substance by S. Guthrie, J. Liebig and E. Souberian independently in 1831, and it was experimented as an anaesthetic on animals successfully by French physiologist Flourens (1794–1867) in 1847 [3]. Until 1900, chloroform was the preferred anaesthetic at the Western countries. Since 1840s a great many other agents have been invented, numerous
anaesthetic techniques have been described and improved; and anaesthesia has become an independent specialty [4,5].
2. The Ottoman modernization movements in view of medical education in Turkey For evaluating this procedure in Turkey, it is necessary to look over the modernization movements on every phase of the society together with all its institutions at the turn of the 19th century culminating with the Tanzimat Bill of Reforms (1839). Determined efforts for the modernization in the first decades of the 19th century also reflected on the field of education. Modern institutions of higher medical education started with the establishment of The Imperial School of Medicine and Surgery (Tibhane-i Amire ve Cerrahhane-i Mamure) in 1827 [6,7]. The School developed rapidly and brought about demands for an educational reform and a more functional training, that necessitated a larger building [8,9]. An old palace school in Galatasaray at Pera (Istanbul) was modified and rebuilt to that aim in 1838, and began to serve as the Imperial School of Medicine (Mekteb-i Tıbbiye-i Adliye-i Sahane) in 1839 [10,11]. With respect to its location, this institution has been mentioned as “Ecole Impérial de Médecine de Galata-Sérai (l)” or “Medical College of Galata-Serai” or “Galatasaray Medical School” in foreign sources [12,13]. The Imperial School of Medicine operated there as a modern medical institution for 10 years until it was devastated in a great fire at Pera on 11 October 1848 [14]. The annual activities of this School were regularly presented to the Sultan in a report during the ceremonial final examinations, organized in grandiose manner in Sultan’s presence at the end of each academic year [15] Through these reports we learn that, backed with the Imperial protection and support, many reformative actions were launched out at the Imperial School of Medicine at Galata-Serai to provide for basic knowledge to students from all communities of the Ottoman Empire, and to apply a new education programme integrating both western (French) and eastern (Turkish, Arabic, Persian) languages at the preparatory classes; while the teaching language of medicine and surgery department remained only as French. First of all, the education period was prolonged to 9, later to 10 years. Lectures of all branches were included in the curriculum and the teaching staff practiced and instructed at the clinics where patients were treated bas-
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ing on the latest medical knowledge available. The teaching staff was joined by professors graduated from the Western medical schools, such as Dr. Karl Ambros Bernard (1808– 1844), Dr. Sigmund Spitzer (1813–1895) from Austria. By permission to dissect on human cadavers (1841), the students were able to consolidate clinical information with physiological and anatomo-pathological findings. They were trained at the bedside of patients at wards, and the interns were allowed to operate together with their professors, with impressively low mortality. Outpatients were examined and treated at the School polyclinic by professors and residents from the teaching staff, by turns [16–18]. The initiative of contemporary pharmacy in the Ottoman Empire was supported by graduation from the Class of Pharmacy at the Imperial School of Medicine where a central drugstore was set up both for student practice and for the distribution of pharmaceuticals throughout the Empire. Furthermore, a course of midwifery for female practitioners was opened for the first time inside the same institution. At the Vaccination Office of the School, smallpox serum was produced and delivered gratis for people from all around the country. Chemistry, physics laboratories, botanic garden, and a library comprising contemporary publications were founded; museums of natural history and anatomy were compiled to provide materials for the lectures. The four graduates of the School who were taken to the final graduation examinations at the Vienna School of Medicine in February 1848 passed them successfully, and this proved the higher level the School had attained since its establishment [19].
3. Use of chloroform surgically at the Istanbul School of Medicine (1848) The first experimentation and application of chloroform owe a great deal to this contemporary and modern scientific atmosphere of the Istanbul Medical School [20]. Although Dr. Bernard, the chief of professorial staff inserts information about the anaesthetic drugs in his pharmacopeia [21], a curious experiment at School describes the state of affairs at that time more than ever. As stated above the Ottoman State was keenly interested in the developments achieved at the Imperial Medical School as well as other institutions of education. Sultan Abdulmecid (reigned in 1839–1861) used to visit the School every year to honour the majestic graduation ceremonies and to observe the progress of that institution personally. On his visit on 25 July 1848, after having ceremoniously been welcomed by the Grand Vizier, other viziers, Chief Physician and state dignitaries; teaching and administrative staff and the students of the School, Sultan Abdulmecid rested for a while and gave audience to some of the high ranking officials at the Imperial Chamber; and with his procession into the Grand Hall, the examination started. First of all, two Muslim and two Christian candidates [22] were inquired upon various branches of medicine and surgery by their professors, and giving com-
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pletely correct answers, they deserved being graduated. After kissing the floor of the Sultan, they got vested with doctoral robes, and took the professional oath on their own sacred religious books, respectively. Succeeding the newly graduated physicians, the midwives received their diplomas and swore professionally [19]. Later a young Muslim student, aged 10, delivered a speech fluently in French for giving thanks. Later it was passed to the medical chemistry experiments, which the Sultan Abdulmecid watched and observed very attentively. While responding a question addressed to him,Yusuf Effendi, a student from the fifth class, gave a very clear chemical description of chloroform and, told its outstanding effects on animal metabolism, and then introduced the recent application of chloroform in Surgery by Dr. Servicen (1815–1897), a member of the professorial staff of the Imperial Medical School. Being satisfied with all the points of Yusuf Effendi’s answer, Mr. Antoine Calleja, the professor of chemistry and pharmacy at School, experienced and displayed perfectly the anaesthetic effects of chloroform on several animals and on the student Yusuf Effendi himself who had replied to the previous question. All of these demonstrations happened in the presence of Sultan Abdulmecid and the ministers. At the close of the ceremony, the Sultan expressed his satisfaction with the activities of the School, the Chief Physician, the professors, and the employees; and left the School in parade [23] (Annexe 1). Although the experimentation on humans (a student of medicine here) is open to discussion in this example in view of medical ethics, this event gives a strong evidence that chloroform was taught as a chemical substance and experimented on animals as an anaesthetic and it was also employed in surgical operations at the clinic of the Imperial Medical School during the 1847–1848 academical year. As stated at the activity report [24] of 1847–1848 academical year, a series of operations were realized successfully by the professors such as the extirpation of osteo-sarcoms, tonsils, fistulas, lipomas, polyps, regenerative malformations at neck; operations of radical hydrocele, cancerous formations; lithotomy, lithotripsy, tenotomy, herniotomy, rhinoplasty; amputations of extremities, carcinomas, breast; various other ophtalmological operations; and by interns such as several operations on ear, larynx, pharynx, eye, lip, abdomen and so on [19]. The information above proves that anaesthesiology, in its modern sense, started to be used at the Medical School in 1848 shortly after its first successful applications in Europe.
4. Crimean War and its effects in view of medical history The 1850s witnessed a crucial turning point for Turkey in many aspects. When Russians waged war against the Ottoman Empire, Britain and France were sided with Turkey and sent troops to support the Turkish army, supplied with health personnel, too. Besides its historical, social, and political influ-
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ences, the Crimean War (1853–1855) has a remarkable effect almost changing the paradigm of medicine in Turkey, then. An Ottoman archival document dating back those years is considerably important regarding the use of anaesthetics at that time. Dr. Charles Johnson, a British physician from the allied forces, used a special mixture of ether and chloroform for narcosis before the surgical operations on the wounded soldiers. He was awarded with a medal of the fifth degree by the Ottoman State for his invention and success in operations [25]. Interestingly enough, this war is dated with the first use of anaesthesia in military for France. It is reported that Dr. Scrive administered chloroform on numerous cases by means of a rolled compress attached to a funnel in a cardboard horn truncated at the head, which was invented by another surgeon from Brest, Auguste Reynaud [26]. Scrive published his memories and medical experiences in Turkey at Paris in 1857 [27]. The foreign physicians embarked in Istanbul on occasion of this war worked at the hospitals of their nations at the Capital City, and they made use of the latest techniques in surgical anaesthesia. This fact was stated by a Turkish scholar, too, at a coursebook on anaesthesia later in 1891 [28]. Foreign doctors also led the establishment of a scientific society of medicine (Société Impériale de Médecine) in Constantinople (Pera) in 1856, gathering together the notable physicians and researchers of Turkey in all nations. This society organised regular scientific sessions and published a monthly medical journal called Gazette Médicale d’Orient by which issues of the scientific discussions and literature of the time can be traced. For instance, clinicians and surgeons in Istanbul discussed Drs. Morton and Jackson’s studies on anaesthesia and dragged attention to the importance and advantages of chloroform in respects of its easy application, prompt and complete effect compared with the other anaesthetical drugs; but also they warned against its perils and the consequential deaths sometimes [29]. Medical literature of the prominent centres of medicine in Europe were attentively run through and novel applications were discussed and experimented at the clinics [30,31]. Nearly at those years, it is cited that Dr. Castro achieved narcosis by chloroform for a carotis ligature in 1861 [32].
5. The situation of the hospital and Medical School later in the 19th century In accordance with the inclinations in the West, chloroform seemed to be the most preferred one in Turkey during the 19th century, although the other anaesthetics such as ether, cocaine, azot protoxide were also used [33–35]. Dr. Serpossian’s series of lectures on chloroform at surgical narcosis demonstrate that this anaesthetic was well in the clinical routine in Istanbul at 1880s [36]. As for the medical school, it owes a great deal to Prof. Dr. Cemil (Topuzlu) (1866–1958), an eminent surgeon and clinician who studied surgery in Paris and launched out a reformation in the teaching of surgery including modern anaesthe-
sia at Imperial Medical Faculty backed with the governmental support [37–39]. In a statistics dating 1890s, concerning 3000 chloroformisation by Surgeon Dr. Cemil Pasha without any mortality, its side effects during the artificial respiration, rhythmical traction of the tongue and many others were combated successfully [40]. As a matter fact, chloroform was already in the School curriculum and it was even dealt with a dissertation in 1891 [41]. Surgeon Dr. Cemil Pasha was an active member of the Société Impériale de Médecine where he participated plenty of sessions and published many communications. He succeeded in resuscitating a cardiac failure case by heart massage due to the administration of chloroform. This case has been cited in the international medical literature, although the patient was lost during post-operational period [42]. The reciprocal close connections with the western medical centres manifest itself in Dr. Morton’s letter from New York to Société Impériale de Médecine, asking for his studies on anaesthesia could be issued at the journal. Upon this request, Dr. Zavitziano wrote a report introducing his works at the Gazette Médical d’Orient [43].
6. Conclusion Following and coping with the novel techniques and developments in the contemporary European science have been a governmental policy in Turkey to achieve the welfare of the country for centuries. Various attempts and prevalent reformative movements were started by the State and supported by the actors of civil society such as the educational, cultural circles who were in close contact with the western centres. The story of chloroform and modern anaesthesia with all its concurrent works, studies and experiments during the previous century is a distinguished example to prove this progressive trend in view of medical history, as well as to show the profits of intercultural relationships.
Acknowledgements I am deeply indebted and thankful to Prof. Dr. NuranYıldırım for her scientific support and advices.
Annexe 1 Du rapport de l’année scolaire 1848: “Tous les ans à l’issue de l’année scolaire, pour couronner dignement les examens généraux, S.M.I. le Sultan, accompagné de tous les ministres et les hauts fonctionnaires, se rend à l’école de médecine de Galata-Sérail. Quelques uns des meilleurs élèves y subissent leur thèse pour le doctorat, en présence de S.M.I qui préside aussi à la distribution des prix. Cette imposante cérémonie qui témoigne assez de l’intérêt que le Sultan attache au progrès des études et au développement de l’instruction pu-
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blique dans son Empire, a eu lieu mardi dernier avec toute la pompe accoutumée. S.M.I est arrivée à l’Ecole de GalataSérail vers deux heures de l’après midi ; le Grand Vézir, le Cheik-ul-Islam, tous les ministres et les hauts fonctionnaires l’y avaient précédé. S.M.I. a été reçue à la porte extérieure de l’établissement par S. Exc. Ismail Efendi, médecin en chef de l’Empire ; tous les professeurs et les employés de l’Ecole avaient été rangés dans la première cour sur le passage du Sultan. Les élèves, en uniforme, formaient une double haie depuis le porte d’entrée jusqu’au pavillon où se trouvent les appartements et après avoir donné audience aux ministres et aux principaux fonctionnaires, S.M.I. se rendit dans la salle des examens, où tout avait été disposé comme les années précédentes. On tira les questions au sort et quatre élèves, dont deux musulmans, Rachid Abdullah et Méhémed Sadik, deux chrétiens Théogènes Strati et Constantin Jean, furent examinés devant le Sultan. Leur réponses ont été complètement satisfaisantes. Ils ont revêtu ensuite la robe de docteur, et prêté serment, les élèves musulmans sur le Coran, et les chrétiens sur l’Évangile. Les sages-femmes formées cette année à l’Ecole, ont à leur tour prêté serment de la même manière Après ces épreuves, un tout jeune musulman, à peine âgé de 10 ans, prononça avec assurance et une pureté de prononciation remarquable pour son âge, les paroles suivantes qu’il avait apprises par cœur sous la direction de M. Lahaille, professeur de 4e classe.... L’élève qui a prononcé ce discours, ainsi que deux de ses condisciples, à peu près du même âge que lui, furent ensuite interrogés sur la langue arabe par le professeur Ismail Efendi. Toutes leurs réponses furent d’une clarté et d’une précision parfaites, et le Sultan, voulant donner aux jeunes élèves une preuve de satisfaction, et les engager en même temps à redoubler d’efforts daigna accorder une récompense à chacun deux.... On passa ensuite à des expériences de chimie médicale qui intéressent vivement le Sultan. Joussuf Efendi, élève de 5e classe, répondant à une question qui lui fut adressée, développa avec une grande lucidité l’histoire chimique du chloroforme, fit connaître son action merveilleuse sur l’économie animale, et, par suite, sa récente et utile application à la chirurgie, faite récemment par M. Le docteur Serviçen. Satisfait en tous points des réponses de Joussuf Efendi, M. Ant. Calleja, professeur de chimie et de pharmacie, fit l’expérience de l’action de cette singulière substance, expérience qui lui réussit parfaitement sur divers animaux, ensuite sur l’élève qu’il venait d’interroger. Jamais examens n’avaient été subis d’une manière aussi satisfaisante et S.M.I, à l’issue de la séance, a témoigné sa haute satisfaction aux professeurs et aux employés de l’établissement Cette solennité a constaté aux yeux du Sultan et de tous ministres, des progrès réels. S.M.I. a témoigné sa satisfaction à S. Exc. le médecin en chef, qui veille avec tant de zèle et de sollicitude à la prospérité de cet établissement. Selon l’usage, M. Le Docteur Spitzer, premier professeur de l’Ecole, a remis au début de la séance, à S.M.I, un rapport sur les travaux de l’Ecole pendant la présente année..”.
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Source : Journal de Constantinople Echo de l’Orient. Constantinople : Turquie, Nogués F, editor. Couturier-Imp. du Journal. 1848;106:1.
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[24] The annual reports and the concerned news of the Imperial Medical School (at Galatasaray) have been studied through the collections of Journal de Constantinople et des Intéréts Orientaux (1843–1846) and Journal de Constantinople, Echo de l’Orient (1846–1866) published successively in French in Istanbul in the 19th century. The editorial boards of those newspapers have adopted a policy backing the modernization movements of the Ottoman Empire. Therefore, they gave place for every news on this subject and especially the Imperial Medical School at their columns. The above-mentioned reports found in them are qualified as the first-hand, original referential sources in as much as that they were published as son as they were actually issued. For more information about these newspapers see: Groc G. et Caglar I. La presse francaise de Turquie de 1795 à nos jours. Istanbul, Turkey: Edition Isis; 1985 121. [25] Ottoman Archival Records. A.Amd. No: 57/1, (1 Muharrem 1271) 24 September 1854. [26] Rüttimann M, Kowalski JJ. Evolution de l’anesthésie au cours des conflits armés. Mis à jour 01/10/2000. http://www.char-fr.net/docs/ textes/anest-milit.html. [27] Scrive G. Relation médico-chirurgicale de la Campagne d’Orient; du 31 mars 1854, occupation de Gallipoli, au 6 juillet 1856, évacuation de la Crimée. Paris: Librairie de V. Paris: Masson; 1857 p. 485. [28] Sabri H. Mubtel-i hiss-i mevzi (Local anasthesia), Ceride-i Tibbiye-i Askeriye. Istanbul: Turkey 1891;20:93–4. [29] Gazette Médicale d’Orient, organe de la Société Impériale de Médecine de Constantinople 1857;1(3):33–5. [30] Expérience sur le chloroforme dans l’empoisonnement par la strychnine. Gazette Médicale d’Orient 1857;2:32.
[31] Hernie inguinale gauche étranglée depuis quinze à vingt heures, réduction facile par le taxis avec chloroforme. Gazette Médicale d’Orient 1861;2:31–2 [de la Gazette Médicale de Paris]. [32] Erengul A. Anesteziyoloji ve Reanimasyon. In: Unat EK, editor. Tip Dallarinda Ilerlemelerin Tarihi. Istanbul: Turkey: Cer. Tip Fak. Yay; 1988. p. 34 4. [33] Munif. Kloroforma dair (Sur chloroforme). Vakayi-i Tibbiye 1882; 60(3):265–8. [34] La Cocaïne. (résumé de la communication faite par M. le Dr. Van Millingen dans la séance de la Société Impériale de Médecine, de 19 Décembre 1884). Gazette Médicale d’Orient 1885;27:180–2. [35] Von der Hayde H. De l’emploi du protoxyde d’azote. Gazette Médicale d’Orient 1885;3:51–5 1885;5:73–6. [36] Serpossian. La chloroforme dans l’anasthésie chirurgicale. Revue Medico-Pharmaceutique 1889;1:2–7; 1889;2:23–6; 1889;3:44–6; 1889;4:57–8; 1889;5:72–73. [37] Unver S. Turkiye’de eter narkozunun tarihcesi. In: Modern Tedavi Mecmuasi. 1951:1 off-print. 1952. p. 1–2. [38] Topuzlu C. In: Hatemi H, Kazancigil A, editors. Istibdat, Mesrutiyet, Cumhuriyet devirlerinde 80 yillik hatiralarim. 2nd edition. Istanbul: Turkey, Istanbul Univ: Cer.Tip Fak.Yay; 1982. p. 32–3 No: 2971. [39] Oncel O, Erdemir AD. In: Cerrahide iki harika devrim, Anestezi, asepsi, antisepsi. Istanbul. Turkey: Nobel Tip Kit.; 1998. p. 183–5. [40] Gazette Médicale d’Orient Organe de la Société Impériale de Médecine de Constantinople 1896;20:298. [41] Yildirim N. Mekteb-i Tibbiye-i Mulkiye-i Sahane’de 1891 yilinda yayinlanan anesteziye dair bir tez. Tarih ve Toplum 1993;113:29–30. [42] Pacha C. Le massage du cœur dans les syncopes chloroformiques. Gazette Médicale d’Orient 1903;21:348–54. [43] Gazette Médicale d’Orient Organe de la Société Impériale de Médecine de Constantinople. 1895;40:69.
Article special
The early steps of chloroform anaesthesia in Turkey during the Ottoman Empire in the 19th century Les premiers pas de l’anesthésie au chloroforme en Turquie dans l’Empire Ottoman Yesim Isil Ulman * Cerrahpasa Medical Faculty, Department of Medical History and Ethics, Istanbul, Turkey Available online 03 February 2005
Abstract Objective. – The aim of this study was to research the pioneering steps for the employment of chloroform in Turkey in comparison with the developments in the West i.e. in the United States and in Europe. The development of anaesthesiology in the West started in the first half of the 19th century. As an anaesthetic substance, ether was first employed in a medical operation by R. Liston in December 1846. But taking into consideration of its bronchially irritant effect, British gynaecologist Dr. J.Y. Simpson preferred to utilize chloroform in obstetrical operations in 1847. The paper aims at shedding light on the earlier steps for modern anaesthesiology in Turkey in that sense. Methods. – The survey used evaluation of archival documents, first hand-original sources such as the annual medical reports of the Medical School, books, official journals, and newspapers of the time, and also secondary sources concerned with the subject. Results. – In view of the findings of the survey, chloroform, as an anaesthetic material, began to be administered surgically in Turkey much earlier than it was already known. It was experienced and used in operations at the surgical clinic of the Imperial School of Medicine at the Capital city, Istanbul in 1848. The Crimean War (1853–1855) induced to the prevalent surgical use of chloroform in Istanbul on the soldiers back from the front. In other words, it was evidenced that surgeons started to make use of this anaesthetic substance in the Ottoman Empire, shortly after it was put into medical practice in Europe. Conclusion. – This study deals with that phenomenal progress of chloroform anaesthesia in the medical history in Turkey during the second half of the 19th century. © 2005 Elsevier SAS. All rights reserved. Résumé Objectif. – Le chloroforme a été utilisé pour la première fois en obstétrique en 1847, par J.Y. Simpson en Ecosse. Le but de cette étude était de trouver les preuves des premières utilisations du chloroforme en Turquie et de comparer avec l’histoire de cet emploi dans les pays occidentaux comme les États-Unis et l’Europe. Méthodes. – Recherche dans les archives médicales de l’Université d’Istanbul, dans les livres, dans les journaux officiels et les quotidiens de l’époque et recherche dans les publications historiques ultérieures. Résultats. – Le chloroforme en tant qu’agent anesthésique a été administré en chirurgie beaucoup plus précocement qu’il était habituellement établi. Il a été utilisé en 1848 au cours d’opérations à la Clinique Chirurgicale d’Istanbul dépendant de l’Ecole Impériale de Médecine. La guerre de Crimée (1853–1855) a entraîné une utilisation très large à Istanbul pour des intervention sur les soldats revenant du front. Ainsi, le chloroforme a été utilisé en chirurgie dans l’empire Ottoman, peu de temps après son introduction pour la médecine en europe.
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An earlier version of this text at a preliminary stage was published at the Proceedings of the 36th International Congress on the History of Medicine Tunis, 87–94, 1998. * Kalamis, Tevfik Pasa sok. 6/7, 34720 Fenerbahce-Kadikoy-Istanbul, Turkey. Tel.: +90-2164184248; fax: +90-5245418755. E-mail address: [email protected] (Y.I. Ulman). 0750-7658/$ - see front matter © 2005 Elsevier SAS. All rights reserved. doi:10.1016/j.annfar.2004.11.001
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Conclusion. – Cette étude démontre la rapidité de l’introduction au début de la deuxième moitié du XIXe siècle de l’anesthésie au chloroforme dans la pratique médicale en Turquie. © 2005 Elsevier SAS. All rights reserved. Keywords: History of medicine in Turkey; History of modern anaesthesiology; Chloroform; Istanbul Imperial Medical School; Servicen Effendi; Crimean War; Dr. G. Scrive; Dr. Cemil Pacha Mots clés : Histoire de la médecine ; Histoire de l’anesthésie ; Chloroform ; Istanbul Imperial Medical School ; Servicen Effendi ; Crimean War ; Dr. G. Scrive ; Dr. Cemil Pacha
1. Introduction: steps towards modern anaesthesia in Europe The development of modern anaesthesiology started in the first decades of the 19th century. In March 1842, Dr. Crawford W. Long (1815–1878), having previously noted the anaesthetic effects of ether, employed it in the removal of a small cervical cystic mass from the patient, and subsequently used it in other cases (1842–1843). But Long did not publish the report of his results and he had no one to pursue and expand his work. In 1800, Sir Humphrey Davy (1788–1829) of Penzance, England, experimented upon himself with nitrous oxide and stated its potential advantage in surgical operations. In 1844 Horace Wells (1815–1848), a dentist from Hartford, Connecticut, began to use nitrous oxide in dentistry, and communicated his results to his friend and former partner, William Thomas Green Morton (1819–1868) of Charlton, Massachusetts. A fatal case, however, caused Well’s withdrawal from practice and led to his tragic death. Meanwhile, Morton had been studying medicine and learned from Dr. Charles T. Jackson, an able chemist, the anaesthetic effects of chloric ether. Morton visited and persuaded Dr. John C. Warren to use this new anaesthetic in a trial operation at Massachusetts General Hospital where a congenital, superficial, vascular tumor below the jaw was successfully extirpated by Dr. Warren on 16th October 1846. This was followed by excision of a fatty tumor, on the next day, by Dr. Hayward, accompanied with Morton as anaesthetist, and a limb amputation by Robert Liston in December 1846, both under ether anaesthesia. On 18th November 1846, the discovery was announced to the world in paper by Henry J. Bigelow, published in Boston Medical and Surgical Journal [1]. Sir James Y. Simpson (1811–1870), a professor of obstetrics in Edinburgh, used ether in midwifery practice on 19th January 1847, but because of its foul odour and bronchially irritant effect, he took up chloroform on 4th November 1847. Impressed with its advantages, Sir Simpson published his results a week later. He was the first to employ chloroform in obstetrics and labour as a general anaesthetic agent in Europe [2]. As a matter of fact, chloroform had been discovered as a chemical substance by S. Guthrie, J. Liebig and E. Souberian independently in 1831, and it was experimented as an anaesthetic on animals successfully by French physiologist Flourens (1794–1867) in 1847 [3]. Until 1900, chloroform was the preferred anaesthetic at the Western countries. Since 1840s a great many other agents have been invented, numerous
anaesthetic techniques have been described and improved; and anaesthesia has become an independent specialty [4,5].
2. The Ottoman modernization movements in view of medical education in Turkey For evaluating this procedure in Turkey, it is necessary to look over the modernization movements on every phase of the society together with all its institutions at the turn of the 19th century culminating with the Tanzimat Bill of Reforms (1839). Determined efforts for the modernization in the first decades of the 19th century also reflected on the field of education. Modern institutions of higher medical education started with the establishment of The Imperial School of Medicine and Surgery (Tibhane-i Amire ve Cerrahhane-i Mamure) in 1827 [6,7]. The School developed rapidly and brought about demands for an educational reform and a more functional training, that necessitated a larger building [8,9]. An old palace school in Galatasaray at Pera (Istanbul) was modified and rebuilt to that aim in 1838, and began to serve as the Imperial School of Medicine (Mekteb-i Tıbbiye-i Adliye-i Sahane) in 1839 [10,11]. With respect to its location, this institution has been mentioned as “Ecole Impérial de Médecine de Galata-Sérai (l)” or “Medical College of Galata-Serai” or “Galatasaray Medical School” in foreign sources [12,13]. The Imperial School of Medicine operated there as a modern medical institution for 10 years until it was devastated in a great fire at Pera on 11 October 1848 [14]. The annual activities of this School were regularly presented to the Sultan in a report during the ceremonial final examinations, organized in grandiose manner in Sultan’s presence at the end of each academic year [15] Through these reports we learn that, backed with the Imperial protection and support, many reformative actions were launched out at the Imperial School of Medicine at Galata-Serai to provide for basic knowledge to students from all communities of the Ottoman Empire, and to apply a new education programme integrating both western (French) and eastern (Turkish, Arabic, Persian) languages at the preparatory classes; while the teaching language of medicine and surgery department remained only as French. First of all, the education period was prolonged to 9, later to 10 years. Lectures of all branches were included in the curriculum and the teaching staff practiced and instructed at the clinics where patients were treated bas-
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ing on the latest medical knowledge available. The teaching staff was joined by professors graduated from the Western medical schools, such as Dr. Karl Ambros Bernard (1808– 1844), Dr. Sigmund Spitzer (1813–1895) from Austria. By permission to dissect on human cadavers (1841), the students were able to consolidate clinical information with physiological and anatomo-pathological findings. They were trained at the bedside of patients at wards, and the interns were allowed to operate together with their professors, with impressively low mortality. Outpatients were examined and treated at the School polyclinic by professors and residents from the teaching staff, by turns [16–18]. The initiative of contemporary pharmacy in the Ottoman Empire was supported by graduation from the Class of Pharmacy at the Imperial School of Medicine where a central drugstore was set up both for student practice and for the distribution of pharmaceuticals throughout the Empire. Furthermore, a course of midwifery for female practitioners was opened for the first time inside the same institution. At the Vaccination Office of the School, smallpox serum was produced and delivered gratis for people from all around the country. Chemistry, physics laboratories, botanic garden, and a library comprising contemporary publications were founded; museums of natural history and anatomy were compiled to provide materials for the lectures. The four graduates of the School who were taken to the final graduation examinations at the Vienna School of Medicine in February 1848 passed them successfully, and this proved the higher level the School had attained since its establishment [19].
3. Use of chloroform surgically at the Istanbul School of Medicine (1848) The first experimentation and application of chloroform owe a great deal to this contemporary and modern scientific atmosphere of the Istanbul Medical School [20]. Although Dr. Bernard, the chief of professorial staff inserts information about the anaesthetic drugs in his pharmacopeia [21], a curious experiment at School describes the state of affairs at that time more than ever. As stated above the Ottoman State was keenly interested in the developments achieved at the Imperial Medical School as well as other institutions of education. Sultan Abdulmecid (reigned in 1839–1861) used to visit the School every year to honour the majestic graduation ceremonies and to observe the progress of that institution personally. On his visit on 25 July 1848, after having ceremoniously been welcomed by the Grand Vizier, other viziers, Chief Physician and state dignitaries; teaching and administrative staff and the students of the School, Sultan Abdulmecid rested for a while and gave audience to some of the high ranking officials at the Imperial Chamber; and with his procession into the Grand Hall, the examination started. First of all, two Muslim and two Christian candidates [22] were inquired upon various branches of medicine and surgery by their professors, and giving com-
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pletely correct answers, they deserved being graduated. After kissing the floor of the Sultan, they got vested with doctoral robes, and took the professional oath on their own sacred religious books, respectively. Succeeding the newly graduated physicians, the midwives received their diplomas and swore professionally [19]. Later a young Muslim student, aged 10, delivered a speech fluently in French for giving thanks. Later it was passed to the medical chemistry experiments, which the Sultan Abdulmecid watched and observed very attentively. While responding a question addressed to him,Yusuf Effendi, a student from the fifth class, gave a very clear chemical description of chloroform and, told its outstanding effects on animal metabolism, and then introduced the recent application of chloroform in Surgery by Dr. Servicen (1815–1897), a member of the professorial staff of the Imperial Medical School. Being satisfied with all the points of Yusuf Effendi’s answer, Mr. Antoine Calleja, the professor of chemistry and pharmacy at School, experienced and displayed perfectly the anaesthetic effects of chloroform on several animals and on the student Yusuf Effendi himself who had replied to the previous question. All of these demonstrations happened in the presence of Sultan Abdulmecid and the ministers. At the close of the ceremony, the Sultan expressed his satisfaction with the activities of the School, the Chief Physician, the professors, and the employees; and left the School in parade [23] (Annexe 1). Although the experimentation on humans (a student of medicine here) is open to discussion in this example in view of medical ethics, this event gives a strong evidence that chloroform was taught as a chemical substance and experimented on animals as an anaesthetic and it was also employed in surgical operations at the clinic of the Imperial Medical School during the 1847–1848 academical year. As stated at the activity report [24] of 1847–1848 academical year, a series of operations were realized successfully by the professors such as the extirpation of osteo-sarcoms, tonsils, fistulas, lipomas, polyps, regenerative malformations at neck; operations of radical hydrocele, cancerous formations; lithotomy, lithotripsy, tenotomy, herniotomy, rhinoplasty; amputations of extremities, carcinomas, breast; various other ophtalmological operations; and by interns such as several operations on ear, larynx, pharynx, eye, lip, abdomen and so on [19]. The information above proves that anaesthesiology, in its modern sense, started to be used at the Medical School in 1848 shortly after its first successful applications in Europe.
4. Crimean War and its effects in view of medical history The 1850s witnessed a crucial turning point for Turkey in many aspects. When Russians waged war against the Ottoman Empire, Britain and France were sided with Turkey and sent troops to support the Turkish army, supplied with health personnel, too. Besides its historical, social, and political influ-
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ences, the Crimean War (1853–1855) has a remarkable effect almost changing the paradigm of medicine in Turkey, then. An Ottoman archival document dating back those years is considerably important regarding the use of anaesthetics at that time. Dr. Charles Johnson, a British physician from the allied forces, used a special mixture of ether and chloroform for narcosis before the surgical operations on the wounded soldiers. He was awarded with a medal of the fifth degree by the Ottoman State for his invention and success in operations [25]. Interestingly enough, this war is dated with the first use of anaesthesia in military for France. It is reported that Dr. Scrive administered chloroform on numerous cases by means of a rolled compress attached to a funnel in a cardboard horn truncated at the head, which was invented by another surgeon from Brest, Auguste Reynaud [26]. Scrive published his memories and medical experiences in Turkey at Paris in 1857 [27]. The foreign physicians embarked in Istanbul on occasion of this war worked at the hospitals of their nations at the Capital City, and they made use of the latest techniques in surgical anaesthesia. This fact was stated by a Turkish scholar, too, at a coursebook on anaesthesia later in 1891 [28]. Foreign doctors also led the establishment of a scientific society of medicine (Société Impériale de Médecine) in Constantinople (Pera) in 1856, gathering together the notable physicians and researchers of Turkey in all nations. This society organised regular scientific sessions and published a monthly medical journal called Gazette Médicale d’Orient by which issues of the scientific discussions and literature of the time can be traced. For instance, clinicians and surgeons in Istanbul discussed Drs. Morton and Jackson’s studies on anaesthesia and dragged attention to the importance and advantages of chloroform in respects of its easy application, prompt and complete effect compared with the other anaesthetical drugs; but also they warned against its perils and the consequential deaths sometimes [29]. Medical literature of the prominent centres of medicine in Europe were attentively run through and novel applications were discussed and experimented at the clinics [30,31]. Nearly at those years, it is cited that Dr. Castro achieved narcosis by chloroform for a carotis ligature in 1861 [32].
5. The situation of the hospital and Medical School later in the 19th century In accordance with the inclinations in the West, chloroform seemed to be the most preferred one in Turkey during the 19th century, although the other anaesthetics such as ether, cocaine, azot protoxide were also used [33–35]. Dr. Serpossian’s series of lectures on chloroform at surgical narcosis demonstrate that this anaesthetic was well in the clinical routine in Istanbul at 1880s [36]. As for the medical school, it owes a great deal to Prof. Dr. Cemil (Topuzlu) (1866–1958), an eminent surgeon and clinician who studied surgery in Paris and launched out a reformation in the teaching of surgery including modern anaesthe-
sia at Imperial Medical Faculty backed with the governmental support [37–39]. In a statistics dating 1890s, concerning 3000 chloroformisation by Surgeon Dr. Cemil Pasha without any mortality, its side effects during the artificial respiration, rhythmical traction of the tongue and many others were combated successfully [40]. As a matter fact, chloroform was already in the School curriculum and it was even dealt with a dissertation in 1891 [41]. Surgeon Dr. Cemil Pasha was an active member of the Société Impériale de Médecine where he participated plenty of sessions and published many communications. He succeeded in resuscitating a cardiac failure case by heart massage due to the administration of chloroform. This case has been cited in the international medical literature, although the patient was lost during post-operational period [42]. The reciprocal close connections with the western medical centres manifest itself in Dr. Morton’s letter from New York to Société Impériale de Médecine, asking for his studies on anaesthesia could be issued at the journal. Upon this request, Dr. Zavitziano wrote a report introducing his works at the Gazette Médical d’Orient [43].
6. Conclusion Following and coping with the novel techniques and developments in the contemporary European science have been a governmental policy in Turkey to achieve the welfare of the country for centuries. Various attempts and prevalent reformative movements were started by the State and supported by the actors of civil society such as the educational, cultural circles who were in close contact with the western centres. The story of chloroform and modern anaesthesia with all its concurrent works, studies and experiments during the previous century is a distinguished example to prove this progressive trend in view of medical history, as well as to show the profits of intercultural relationships.
Acknowledgements I am deeply indebted and thankful to Prof. Dr. NuranYıldırım for her scientific support and advices.
Annexe 1 Du rapport de l’année scolaire 1848: “Tous les ans à l’issue de l’année scolaire, pour couronner dignement les examens généraux, S.M.I. le Sultan, accompagné de tous les ministres et les hauts fonctionnaires, se rend à l’école de médecine de Galata-Sérail. Quelques uns des meilleurs élèves y subissent leur thèse pour le doctorat, en présence de S.M.I qui préside aussi à la distribution des prix. Cette imposante cérémonie qui témoigne assez de l’intérêt que le Sultan attache au progrès des études et au développement de l’instruction pu-
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blique dans son Empire, a eu lieu mardi dernier avec toute la pompe accoutumée. S.M.I est arrivée à l’Ecole de GalataSérail vers deux heures de l’après midi ; le Grand Vézir, le Cheik-ul-Islam, tous les ministres et les hauts fonctionnaires l’y avaient précédé. S.M.I. a été reçue à la porte extérieure de l’établissement par S. Exc. Ismail Efendi, médecin en chef de l’Empire ; tous les professeurs et les employés de l’Ecole avaient été rangés dans la première cour sur le passage du Sultan. Les élèves, en uniforme, formaient une double haie depuis le porte d’entrée jusqu’au pavillon où se trouvent les appartements et après avoir donné audience aux ministres et aux principaux fonctionnaires, S.M.I. se rendit dans la salle des examens, où tout avait été disposé comme les années précédentes. On tira les questions au sort et quatre élèves, dont deux musulmans, Rachid Abdullah et Méhémed Sadik, deux chrétiens Théogènes Strati et Constantin Jean, furent examinés devant le Sultan. Leur réponses ont été complètement satisfaisantes. Ils ont revêtu ensuite la robe de docteur, et prêté serment, les élèves musulmans sur le Coran, et les chrétiens sur l’Évangile. Les sages-femmes formées cette année à l’Ecole, ont à leur tour prêté serment de la même manière Après ces épreuves, un tout jeune musulman, à peine âgé de 10 ans, prononça avec assurance et une pureté de prononciation remarquable pour son âge, les paroles suivantes qu’il avait apprises par cœur sous la direction de M. Lahaille, professeur de 4e classe.... L’élève qui a prononcé ce discours, ainsi que deux de ses condisciples, à peu près du même âge que lui, furent ensuite interrogés sur la langue arabe par le professeur Ismail Efendi. Toutes leurs réponses furent d’une clarté et d’une précision parfaites, et le Sultan, voulant donner aux jeunes élèves une preuve de satisfaction, et les engager en même temps à redoubler d’efforts daigna accorder une récompense à chacun deux.... On passa ensuite à des expériences de chimie médicale qui intéressent vivement le Sultan. Joussuf Efendi, élève de 5e classe, répondant à une question qui lui fut adressée, développa avec une grande lucidité l’histoire chimique du chloroforme, fit connaître son action merveilleuse sur l’économie animale, et, par suite, sa récente et utile application à la chirurgie, faite récemment par M. Le docteur Serviçen. Satisfait en tous points des réponses de Joussuf Efendi, M. Ant. Calleja, professeur de chimie et de pharmacie, fit l’expérience de l’action de cette singulière substance, expérience qui lui réussit parfaitement sur divers animaux, ensuite sur l’élève qu’il venait d’interroger. Jamais examens n’avaient été subis d’une manière aussi satisfaisante et S.M.I, à l’issue de la séance, a témoigné sa haute satisfaction aux professeurs et aux employés de l’établissement Cette solennité a constaté aux yeux du Sultan et de tous ministres, des progrès réels. S.M.I. a témoigné sa satisfaction à S. Exc. le médecin en chef, qui veille avec tant de zèle et de sollicitude à la prospérité de cet établissement. Selon l’usage, M. Le Docteur Spitzer, premier professeur de l’Ecole, a remis au début de la séance, à S.M.I, un rapport sur les travaux de l’Ecole pendant la présente année..”.
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Source : Journal de Constantinople Echo de l’Orient. Constantinople : Turquie, Nogués F, editor. Couturier-Imp. du Journal. 1848;106:1.
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[24] The annual reports and the concerned news of the Imperial Medical School (at Galatasaray) have been studied through the collections of Journal de Constantinople et des Intéréts Orientaux (1843–1846) and Journal de Constantinople, Echo de l’Orient (1846–1866) published successively in French in Istanbul in the 19th century. The editorial boards of those newspapers have adopted a policy backing the modernization movements of the Ottoman Empire. Therefore, they gave place for every news on this subject and especially the Imperial Medical School at their columns. The above-mentioned reports found in them are qualified as the first-hand, original referential sources in as much as that they were published as son as they were actually issued. For more information about these newspapers see: Groc G. et Caglar I. La presse francaise de Turquie de 1795 à nos jours. Istanbul, Turkey: Edition Isis; 1985 121. [25] Ottoman Archival Records. A.Amd. No: 57/1, (1 Muharrem 1271) 24 September 1854. [26] Rüttimann M, Kowalski JJ. Evolution de l’anesthésie au cours des conflits armés. Mis à jour 01/10/2000. http://www.char-fr.net/docs/ textes/anest-milit.html. [27] Scrive G. Relation médico-chirurgicale de la Campagne d’Orient; du 31 mars 1854, occupation de Gallipoli, au 6 juillet 1856, évacuation de la Crimée. Paris: Librairie de V. Paris: Masson; 1857 p. 485. [28] Sabri H. Mubtel-i hiss-i mevzi (Local anasthesia), Ceride-i Tibbiye-i Askeriye. Istanbul: Turkey 1891;20:93–4. [29] Gazette Médicale d’Orient, organe de la Société Impériale de Médecine de Constantinople 1857;1(3):33–5. [30] Expérience sur le chloroforme dans l’empoisonnement par la strychnine. Gazette Médicale d’Orient 1857;2:32.
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