Newsletter January, 1993

Anesthesia History Association Newsletter January, 1993

Volume 11, Number 1 .

How Anesthesiology Develops Thefollowillg manuscript, written byProfessor J. Rnger Maltby andtwoof hisNepali colleagues, care.ftdly documents thegradual development of thediscipline of allesthesiology ill Nepal since thefOlltldillg of thefirs: hospital ill 1888-89. It is afascillatillg story, andtheprogress ill anesthesia has been greatly accelerated since 1985 when theDepartment of'Anaesthesia at theUniversity ofCalgary ill Canada was asked toassist ill the provision o.{adequate anesthesia resources ill Nepal. JiVe are most gratiftll to Dr. Maltby, who has recently returned jrom a stint in Nepal, for providillg thishistorical backgroulld.

History of Anesthesiology in Nepal

J.R

by N.B. Rnlla, MB, BS, FFARCS* B.M. Shrestha, MB, BS, DA(UK)* Maltby, MB, BChir, FFARCS, FRCPC+

Nepal is an independent kingdom that lies between India to the south and Tibet (China) to the north. Its present population is nearly 20 million. For more than a century from 1846, it was ruled by the hereditary family of Rana, prime ministers who did very little to develop the country. It remained isolated from the rest of the world until 19511 when the Rana regime was overthrown, the monarchy restored and the borders reopened. Bir Hospital, now a 300-bed government hospital in the capital city of Kathmandu, was founded in 1888-89 and was followed by five smaller hospitals outside the Kathmandu Valley.2 During the early period of the Rana regime, the only doctors in Nepal were those who had come from India, some with a MB, BS degree and the majority with the LMF qualification from a four-year course at a Licensed Medical Faculty in India before or during the Second World War. Little is known ofanesthesia before 1933, except that anyone, either doctor or compounder (pharmacist qualified from a civil medical school in Kathmandu), was coerced into giving open drop ether or chloroform. In 1933, B.B. Singh-Pradhan (figure 1)was appointed to Bir Hospital as a medical officer. He was the first doctor to give anesthetics regularly, as well as doing other medical work. By 1951 there were about twelve Nepali LMF doctors in Nepal, and many more of Indian origin, but none had postgraduate specialty training. Most ofthe LMF doctors subsequently returned to India to complete a further two years of condensed training to graduate MB, BS before 1958 to remain on the medical register. Since 1950 foreign mission hospitals have been established, including Shanta Bhawan (now Patan Hospital) in 1956 in the Kathmandu Valley and others in rural areas, while in Kathmandu three major hospitals were built with foreign aid - women's hospital in 1959, children's hospital in 1962 and Tribhuvan University (TU) Teaching Hospital in 1984. The first Nepali doctors to obtain postgraduate qualifications did so in the UK in radiology, pathology, tropical medicine and tuberculosis. • Consultant anaesthesiologist, Bir Hospital, Kathmandu. Nepal + Professor of anaesthesia. University of Calgary. Alberta. Canada

Singh-Pradhan was the first to train in anesthesiology; he spent one year in Bombay, India, where he obtained the Diploma in Anesthesiology (DA) and returned to Kathmandu in 1955, four years before the first qualified surgeon arrived. He worked at Bir Hospital for another 20 years until his retirement in 1975. The first internist returned in 1959, and the first two surgeons in 1959 and 1960. Anesthesia equipment was still very basic in 1955 when SinghPradhan introduced endotracheal intubation in Nepal. Until the first road into the Kathmandu Valleywas completed over an 8,500-ft. passin 1956, everything - including automobiles! - was carried in by porters. There were no anesthetic machines and the circuit that he used (figure 2) consisted ofether in a Horlicks* * bottle, the top ofwhich had an inlet orifice for air and an outlet orifice with rubber tubing to inflating bellows, then corrugated tubing and a Heidbrink valve to the mask or tracheal tube. This was similar to Flagg's can,3 with self-inflating bellows added to allow controlled ventilation. The operating theaters were not heated and in winter the bottle was placed in a bowl of hot water that needed frequent replenishing. Otherwise, the temperature ofthe ether would fall to levels at which anesthesia could not be maintained. In 1967 Singh-Pradhan published his experiences with 1,000 endotracheal intubations," of which 500 were given with open drop ether, using a mask over the end of the tube, and 500 with the bottleand-bellows circuit. The advantages he claimed for intubation included "ready help for resuscitation and good relaxation and avoiding the grumbling of the tired surgeon." In 1962 Singh-Pradhan anesthetized a patientwith this circuit and endotracheal intubation for removal ofa pituitary tumor. In early 1966 Sir Robert Macintosh ofOxford, on a tour ofthe Middle East and Asia, visited Kathmandu where he encouraged use of the EMO system whose calibrated ether vaporizer was an improvement over Flagg's can. Ether and the EMO system, usually supplemented by halothane from •• Trade name for a malted milk drink that is ubiquitous in Nepali hospitals

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1993 Wood Library-Museum Paul M. Wood Fellowships To encourage and stimulate those interested in the history of anesthesiology, the Trustees ofthe Wood Library-Museum ofAnesthesiology (WLM) are once again offering a total of four Paul M. Wood Fellowships for study in 1993. Havingjust moved into a new spacious building, the selectees will welcome the increased amount of space now available for study in the comprehensive library: holdings and the abundant museum displays. The new headquarters of the American Society of Anesthesiologists (ASA) and the WLM are just a stone's throw from the old building and are situated in Park Ridge, Illinois, just a short distance from O'Hare Airport. Applications are invited from practicing and retired anesthesiologists, residents in training in anesthesia and critical care, physicians of other disciplines, historians, graduate students ofthe history ofmedicine, and other individuals with a developed interest in historical research. All submissions will be judged on their merit; however, iftwo applications are believed to be ofequal merit, preference will be given to the person who is a member of the ASA. Fellowships provide financial assistance for pursuing studies in the WLM's extensive collection of archival material, published literature of the history of anesthesiology, and the abundant museum holdings. Each Fellow will receive an honorarium of$500.00, roundtrip economy class airfare (one trip) from place of residence to Chicago and return, and a per diem support of $125.00 for a period not to exceed 15 working days, provided that the Fellow stays in commercial lodgings while

visiting the WLM. Travel support is paid only for trips within the USA, except that ASA members living in Canada and Mexico are also eligible. The curator ofthe WLM will provide good facilities and first-rate help in pursuing studies, along with duplicating facilities for any archival material selected. It is anticipated that Fellows will aim to publish in appropriate journals or books the results oftheir work at the WLM. In the last few years since the inauguration of the program, papers have been written, books have been or are being written, and papers have been presented at meetings, all acknowledging the value of the time spent at the WLM. The closing date for applications for 1993 is February 28, 1993. Prospective candidates may request application forms from: Mr. Patrick Sim, Curator Wood Library-Museum of Anesthesiology 520 N. Northwest Highway Park Ridge, IL 60068-2573 Further information regarding the fellowship may be obtained from the curator or from: Rod Calverley, M.D. Chairman, Fellowship Committee Department of Anesthesiology V.A. Medical Center 3350 La Jolla Village Drive San Diego, CA 92161

Spring Meeting of the AHA - A Call for Papers! Mark your calendars! Thursday, May 13, 1993 the Anesthesia History Association will hold its first Spring Meeting at the Gault House in Louisville, Kentucky. The all-day conference isplanned to begin with a continental breakfast. Two concurrent sessions presenting original research papers with a mid-morning coffee break occupy the morning's meeting. A midday plenary assembly capped by a guest speaker, Peter L. McDermott, M.D., newly elected President of the ASA, should make this a memorable luncheon. Paper presentations will absorb the afternoon gathering. The formal presentations will each occupy twenty minutes with ten additional minutes for questions and comments. This format insures ample time, hot only for the communication ofideas, but also for the exchange of information germane to the work under discussion. At least sixteen papers can be presented in this way during the meeting. Submission of abstracts is encouraged. Each abstract must be typed single-spaced on a standard sheet of paper, in no more than 300 to 350 words. The summary should include not only a synopsis ofthe research question, but also findings and conclusions. Send the completed abstract and four copies by January 30, 1993 to: Douglas R. Bacon, M.D. Department of Anesthesiology Roswell Park Cancer Institute Elm and Carlton Streets Buffalo, NY 14263-0001 (716) 845-5816, Fax: (716) 845-8518 The Spring Meeting ofthe AHA precedes the annual meeting ofthe American Association for the History of Medicine (AAHM), which will meet May 13-16, 1993, at the Gault House in Louisville. The AAHM is a multi-disciplinary organization which annually presents papers ofinterest in all fields ofmedical history. Thursday evening the AAHM holds a welcome reception, to which AHA members are

welcome if they register for the AAHM meeting. More information concerning the AAHM Annual Meeting and membership may be obtained from: J. Worth Estes, M.D. Department of Pharmacology Boston University School of Medicine 80 East Concord Street Boston, MA 02118-2394 (617) 638-4328 May 13,1993, will be a date to remember. This Spring Meeting promises to present many new and interesting facts from the rich history of anesthesiology. Further information and registration materials for the meeting can be obtained from Dr. Bacon at the above address.

Proceedings of the International Symposium On the History of Anesthesia In response to a number of inquiries, we would like to inform the readership ofthe present status ofthe Proceedings of the Second International Symposium on the History of Anesthesia, held in London in 1987 and edited by R.S. Atkinson, M.D. and T.B. Boulton, M.D. Of the 2,000 copies printed, all the soft-bound copies have been sold, but a few copies of the hardbound edition are still available. They may be obtained from the Parthenon Publishing Group Inc., 120 Mill Road, Park Ridge, NJ 07656, at a price of£69, which is approximately $105, according to the present exchange rate. The Proceedings of the Third International Symposium of the History ofAnesthesia, held in Atlanta in March, 1992, are being edited by B. Raymond Fink, M.D. and should be available early in 1993.

A Dedication On Saturday afternoon, August 15, 1992, the American Society of Anesthesiologists (ASA)and the Wood Library-Museum ofAnesthesiology (WLM) welcomed a large number ofits members and guests to a reception to view their new headquarters building, library and museum. It was a gala occasion hosted by ASAPresident Dr. G.W.W. Eggers,Jr., WLM President Dr. Elliott V. Miller, and ASAExecutive Director Mr. Glenn W. Johnson. . The new building is a magnificent three-story structure with abundant room to manage the many functions of the organizations. As one looks out ofthe third floor windows ofthe new building to the former headquarters nearby, the former structure looks positively miniscule. A large part ofthe first floor, to the right ofthe sumptuous entry hall, houses the elegant new museum which the Honorary Curator Dr. George Bause, a member of the WLM Board of Trustees, has transformed, with the help ofattractive casements, into a chronological history ofthe equipment development ofanesthesiology. Members ofthe WLM Board of Trustees were on hand to explain to the passing audience details of several of the precious artifacts which have been obtained through the years. Included on the first floor, in addition to the various ASA functions, is a tastefully furnished conference room and an adjacent lunch area with a well-equipped kitchen. The second floor is devoted entirely to administrative offices and functions of the ASA. The areas are spacious and bright. On the third floor the Wood Library-Museum has its principal

August 15, 1992 domain. Many of the rooms are named for anesthesiologists who have contributed to the growth and development of the specialty. On each side ofthe largest room are the open stacksofperiodicals and textbooks related to anesthesiology. Between them are several tables with chairs at which visitors to the library may read and study. In the rare book room, under controlled conditions oftemperature and humidification, are housed the extensive collection of original books and manuscripts which have made the WLM a most valuable resource. In another spacious room one can find the comprehensive collection of Living History videotapes and cassettes which are unique in the realm ofanesthesiology. Any ofthese tapes may be seen on the spot, or they may be borrowed or purchased if desired. In yet another room is housed the detailed archives of the ASA and oather anesthesia organizations. These collections are a valuable source of reference for historians .. Nearby are bright unencumbered offices for Mr. Patrick Sim, Curator and Librarian, and hisAssistantLibrarian, Miss SallyS. Graham. Both of these most dedicated people are always delighted to welcome visitors to the Wood Library-Museum. Indeed, anyone interested in the history ofour specialty owes it to themselves to take the time to visit this new building and explore the many attractions which the library and museum have to offer. - - C:R' Stephen, M.D.

Anesthesia History Association Annual Meeting 1992 October 18, 1992 The annual dinner meeting was held in Winston's Room ofthe New Orleans Hilton on Sunday evening, October18, 1992. There were 105 members and guests attending. Speaker of the evening was Dr. Trier Morch who gave an excellent discourse on the development of ventilators. Highlight ofhis presentation was a movie showing the effect of positive pressure on blood flow in the bat wing. Final entertainment of the evening was a video record ofthe drama "Spit ofthe Devil" which had been presented as a highlight of the social program of the TISHA meeting in Atlanta the previous March. A short business meeting was held which included a briefreport by the Secretary indicating a current membership of slightly over four hundred. Ole Secher of Denmark has been nominated and approved by Council as an Honorary member. The Treasurer reported that despite some support required for the TISHA meeting the total funds of the society had increased by about ten percent as compared with the preVIOUS year. Members were reminded of the plan for a spring meeting in louisville, Kentucky on May 13, 1993, and are urged to submit papers for presentation. In addition it is planned to have an invited speaker. The meeting concluded with the formality of handing the gavel to new President Severinghaus and vesting him with the presidential medal recently presented by Dr. Aileen Adams as a gift from the History of Anaesthesia Society. New officers elected for 1992-1993 are: John Severinghaus, President; Lucien Morris, Vice President; Theodore Smith, SecretaryTreasurer. Members elected to three-year terms on the Council were Douglas R. Bacon (previously appointed for a one-year term in 1991) and William D. Hammonds. The Council for 1993 now includes John

Severinghaus, Lucien Morris, Betty Bamforth, Ted Smith, Doug Bacon, George Bause, Eli Brown, Ray Fink, William Hammonds and Leslie Rendell-Baker. C. Ronald Stephen will continue as Editor of the Newsletter. Respectfully submitted,

Lucien E. Morris, M.D. Secretary-Treasurer 1989-1992

Letter to the Editor Dear Editor: During the annual meeting of the German Anaesthetic Congress held in Berlin in 1992, I met a distributor of medical equipment and told him that I was interested in the history of anesthesia. He showed me a new, never-used Ombredanne vaporizer which his firm produced during the early 1950s. I was able to purchase this model for about $200.00 U.S. He had this item and others ofhistorical interest available and I thought that some readers of the Newsletter might be interested in a purchase. If so, please let me know at the following address and I will contact the distributor and will solve any problems associated with airmail delivery. Dr. med. Michael Goerig Department of Anaesthesiology 2000 Hamburg 20, Martinistr. 52 Hamburg, Germany

The First Canadian Woman Physician In 1991, when Dr. Harold R Griffith was honored ona Canadian postage stamp, one of the other three physicians sohonored onstamps was Dr.Jennie KiddTrout (1841-1921), who was thefirstwoman licensed topractice medicine inCanada. However, shewas notthefirstwoman topractice medicine inour neighbor tothenorth. As detailed itltheJOllowing account, Dr. Stowe(1831-1903) was thefirsttopractice medicine, albeit without alicense. Shealso was honored Otl aCanadian stamp in 1981, ostensiblyJOr herpart in the women's suffrage movement. T# are much indebted toMr. Sydell Waxman, author ofthefollowing article, andtoMr.Christopher Dafoe, Editor or'The Beaver", abimonthly magazine devoted to exploring Canada's history, JOr their kindpermissions to reprint this paper. - - Editor

Emily Stowe: Feminist and Healer by Sydell Waxman No woman had ever entered a Canadian university when Emily Howard Stowe decided to become this nation's first woman doctor. When Emily approached the University ofToronto the president was not impressed. His answer was firm and unequivocal; "The doors of the University are not open to women and I trust they never will be. " To this Emily replied: "Then I will make it the business ofmy life to see that they will be opened, that women may have the same opportunities as men." Who was this extraordinary woman? How was she able to fight society, religion, prejudice and pave the way for women's education and suffrage in Canada? Born in 1831 to Quaker parents, Emily and her five sisters were infused by their mother, Hannah Jennings, with a strong sense of equality and high academic aspirations. Women were equal in Quaker homes as well as in the affairs ofthe church. Theirs was one of the few religions that welcomed female ministers. Although Emily received support and education at home, the broader social climate in the mid1800s was not receptive to a woman with vision. It was a time when girls were trained to become wives and mothers and the education ofthe more fortunate females included such basicsas needlepoint, cooking and the social graces. Prejudice rallied against the idea of a woman studying medicine. It was widely believed that medicine was an improper profession for women and that women were mentally and emotionally unsuited to medical work. Anaesthesia and antiseptic procedures, the major medical discoveries ofthe last century, had not yet brought the medical profession to a respectable light. Even nursing was not considered suitable for women. Differences in the medical field often were handled crudely .....:.. there is a recorded instance of two obstetricians fighting a duel because they disagreed over a case. The medical field itself was unorganized and doctors were poorly educated. Surgeons operated in their street clothes. Medical students often resorted to grave-robbing and "operation assistants'lwere four strong men who held the patient down. The idea ofa woman entering this medical climate was deemed to be inconceivable and scandalous. There had actually been a woman doctor in Canada before Emily. Dr. "James" Stuart Barry had passed as a man during a 46-year medical career. From 1857-1861 Dr. Barry was Inspector-General ofMilitary Hospitals in Upper and Lower Canada, but her true sex was discovered only after her death. There were many who found the idea ofa woman doctor laughable. In fact, Elizabeth Blackwell, the first woman doctor in the United States, was admitted in 1849 to the Medical College in New York State by a student vote that thought the whole idea was indeed ajoke. Eventually Blackwell made her way to study in Paris, the world centre for medical research in the mid-1800s.

Emily Stowe's exceptional intelligence would prove to be a necessary asset and was evident even in her early academic work. At the age of16 she became a public school teacher. In 1847 teaching at such a young age was not uncommon. The Common School Acts of 1846, 1847 and 1850 stated that everyone had a right to free education, but it was not until 1871 that schooling became compulsory for four months of every year for children seven to twelve. For her work Emily received halfthe salary of a male teacher. She managed to save enough money to enter Normal School where she received her First Class Teachers' Certificate'In 1854. Then a remarkable thing happened. Her standing at school was so exceptional that she was appointed principal of the public school in Brantford. At the age of 23 Emily Stowe became the first woman principal in Canada. Her ties with religion remained strong and through her church membership she met and married in 1856John Stowe, a carriage-maker and lay preacher, later described as "a liberal-minded man whose brilliant wife could always count upon him for sympathy and assistance." When John became ill with tuberculosis, Emily was forced to return to teaching, taking a post with Nelles Academy at Mount Pleasant. The academy was an unusual octagon-shaped building and it is supposed that John Stowe built it, since the Stowe home was also this same odd shape, consisting of a wagon and blacksmith shop on the ground floor and living quarters upstairs. It was during this period ofmarriage, having children and teaching, that Emily's long-fight to become a doctor began. Struggling to support her three children, Augusta, Frank and John, Emily was in need of money, yet she was determined to enter medicine and hoped that women patients would one day be treated by women doctors. It was an age of extreme modesty and female patients remained dressed for examinations. Many women would bear pain and infections for years rather than be examined by a male doctor. This very modesty was used as an argument against women entering the medical field. An editorial in a Kingston newspaper read: We should be sorry indeed to know that Canadian maidens or matrons either, were so dead to that modesty which is woman's chief charm as to sit unmoved side by side with young men and listen to lectures ... feminine mysteries freely discussedbefore a mixed class ofyoung men and young women is not only shocking, but it is disgusting and degrading. It was suggested to Emily that she follow Dr. Barry's example and pose as a man, but she finally turned to the United States where Dr. Clemence Sophia Lozier had opened the Women's New York Medical School in 1863. Emily studied while her sister Cornelia stayed with her

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Emily Stowe...

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three children. She returned to Canada in 1868 with a medical degree. Anticipating a busy career, she moved her family to Toronto - only to be thwarted by a new law. She still could not legally practice medicine in Canada. The Canadian College of Physicians and Surgeons required that doctors attend one session oflectures at a Canadian university and take the matriculation exam of the College of Physicians and Surgeons before receiving a license. The problem, ofcourse, was that Emily was not allowed into the university. Financial pressures forced Dr. Stowe to set up practice.illegally, in her Toronto home. She was not the only doctor practising against the law. As late as 1871, the Ontario Medical Register shows that of 1,777 registered doctors, 500 or so practised in defiance ofthe law. Not until 1880, at age 49, was Emily able to obtain a license to practise legally. In the meantime, Emily's practice grew steadily as she discovered that women were pleased to have a female doctor. Her husband John recovered from his illness and entered dental school. Later they shared a joint practice in a house at 111 Church Street. . Emily Stowe acted as president of the Toronto Literary and Science Club that she helped to found in 1877. The group met to discuss women in the professions, women's education and the condition of women in the work force. Eventually the group succeeded in securing separate sanitary facilities in factories and acquired chairs for clerks who worked long hours. They realized that further advancement required enfranchisement. The club renamed itself in 1883 and became the Toronto Suffrage Association. Emily continued to lecture on female education, equal pay and nutrition but the ultimate goal became the vote for women. This movement quickly spread, and with Emily's help established itself in 1893 as the Dominion Woman's Enfranchisement Association. She became a popular and eloquent speaker in Ontario towns, dealing with such topics as women's legal status, crime and alcoholism, claiming on one occasion, that "The day will dawn when woman will equal man not only in the medical profession but in every other position in which she is qualified to excel." Veryfew escaped her acid pen as she continued to write on all women's issues in the daily press. In her speeches and writing she referred to men as "male-men" and God as "the Father-Mother ofNature. " She called herself"a mental scientist" and "a scientific socialist." One ofher dreams came true when her daughter, Augusta, graduated in 1887 from the Toronto School of Medicine - the first woman to study and graduate in Canada. Augusta's experience at an integrated school had been no easier than her mother's. Both women helped form the Ontario Medical College for Women in 1883, a forerunner of Toronto's Women's College Hospital. Emily had just recovered from the death of her husband in 1891 when she had to retire from medical practice following an accident at the Chicago World's Fair that left her lame. Although she retreated to Muskoka in 1893, she continued to lead the active women's group. A letter by the President of the Women's Canadian Historical Society stated that "it was from the doctor's [Emily's] liberal views that all the progress made by womeri in this province particularly and the others incidentally sprang." Emily did not live to see the day in 1916 when women in Canada first received the vote, but her name is honoured as one ofthe great suffragists. A bronze bust ofEmily Stowe can be found in Toronto's city hall. Emily's uphill fight against the conventions ofher time did not leave her bitter. In her own words her career was "one of much struggle

characterized by the usual persecution which attends everyone who pioneers a movement or steps out of line with established custom." When she died in 1903 the Toronto Globe stated that Emily Stowe "recognized prejudice and reactionary views as natural weaknesses, obstacles to be expected and to be removed from the path of progress."

* * * POSTSCRIPTS: MODES OF MEDICINE Dr. E.D. Worthington in his book Reminiscences ofSttlde/1t Life and Practice, describes the doctor's main tools and remedies around 18401850: A medical man would as soon have dreamed of going to church without his prayer book ... as of going out on his daily round ofduty without his lancet casein his pocket... It was considered the correct thing to be bled at least every spring... Some people indulged their fancy twice a year with extras whenever they had a "swimming in the head" or a reminder ofhereditary tendency to apoplexy... In our official sanctum it was a concession that bleeding and tooth-drawing were perquisites... I need hardly add that no one ever left surgery, no matter what his ailment, without being bled or having a tooth extracted... those two simple remedies were the ones we relied upon. By the time Emily Stowe opened her practice more "modern" methods were employed. There was a great beliefin the healing power of electricity, electrotherapeutics and galvanic baths (hydro-therapy). Most deaths from 1840-1880 were from typhus, cholera and smallpox. Ague or malaria was a serious problem in Canada and was prevalent until the late 1870s. Ether, first used in 1846, helped to make the patient more comfortable, but, unfortunately, it did not affect the death rate. It remained for antiseptic procedures and general cleanliness to change the medical statistics drastically. Surgical pictures of 1870 show doctors in their street clothes, with no nurses in attendance. By 1890 surgical gowns were in use and nurses were present but no masks or gloves had yet been designed. Rubber gloves were orginally used to protect the hands of nurses. Antiseptic methods were brought to Canada at an early stage by Canadians who had studied under Lister. The first Canadian doctors to use antiseptic methods were Dr. A.E. Mallock of Hamilton, Ontario, and Dr. T.G. Roddick ofMontreal. Medical circles at firstjeered at the "carbolic spray" as, initially, this antiseptic was used too vigorously and it wet everything. (One account speaks ofthe operator and his assistants wading about in long rubber boots while visitors stood on chairs to watch the operation.) Abraham Groves was an important surgeon around Emily's time and he has recorded some of his early experiences: When I began my practice in Fergus, Ontario in 1871 there was no hospital nearer than Toronto, there was not a trained nurse in Canada, and there were no skilled assistants. Little or nothing was known about germs. There were no rubber gloves, sterilized gauze or absorbent cotton and silk was the usual material used for sutures and ligatures. My early operative work was done under very primitive conditions. The operating room was usually the kitchen, there being no other room large enough in the house of those days, and Continued all Pa,!!c 10

Spinal Analgesia in Obstetrics Onceagai/I thechampion ofpain relieffor obstetric delivery has enlightened uswiththestory oftheapplication ofsubarachnoid anesthesiafor this purpose. It has been toldinanewjOllmal, the"Internationaljournal ofObstetricAnesthesia, "Volume 1, pp 47-49, 1991. fiVe are most indebted tothe Editors ofthisnewjOllmal, Dr. Felicity Reynolds ofSt. Thomas's Hospital, London, andDr. DavidM. Dewan of wakeForest University Medical Center, Winston-Salem, NiC. for their kindpermission to reprint this article. fiVe also appreciate the kindpermission of the pllblisher, Chllrchill L1vingstone Medical [ournals in Edinbllrgh for their cooperation. Some ~r the readership maybe interested in sllbscribing to this innovative international jOllmaf. _ _ Editor

The Long Road to the Introduction of Spinal Blockade in Obstetrics by G.F. Marx, M.D. The first public demonstration of a successful general anesthetic took place in Boston, Massachusetts, on October 16, 1846. Using an inhaler made of glass and wood, the dentist William Morton administered diethyl ether to a young man for extirpation of a vascular tumor of the neck.I,2 Less than 3 months later, on January 19, 1847, James Young Simpson, Professor of Midwifery at the University of Edinburgh, Scotland, used this new method of pain relief for a difficult vaginal delivery and thus introduced scientific anesthesia into childbirth.1,2 The first public demonstration of a successful spinal blockade occurred in Kiel, Germany, in August 1898. 3 On that day, the surgeon, August Bier, performed the first ofa series ofsubarachnoid blocks for leg or pelvic operations. Why a lapse of52 years between the two methods ofanesthesia? For spinal blockade to become possible, three requirements had to be met: a means of injection, a drug with local anesthetic properties, and the introduction of lumbar puncture. Although metal was available and utilized for utensils, tools, and weapons, delicate medical instruments were not invented until the mid-1800s. Hypodermic syringes were introduced independently by Francis Rynd of Edinburgh in 1845 and by Charles-Gabriel Pravaz of France in 1851. 2,4 The hollow needle came on the scene in 1855 designed by another Scot, Alexander Wood. 5 Making use of his invention, Wood, a Lecturer on the Practice of Medicine, promptly published a 'New Method ofTreating Neuralgia by the Direct Application of Opiates to the Painful Points.' After all, morphine had been isolated from opium by Serturner in 1805. Wood's first patient, an old lady, suffered from severe neuralgic pain in the 'cervico-brachial' region. Mter finding the most tender spot, Wood 'inserted the syringe within the angle formed by the clavicle and acromion, and injected 20 drops of a solution ofmuriate ofmorphia.' The pain subsided within half an hour. Cocaine was the first and only local anesthetic drug until 1905 when the clinical use of procaine (novocaine) (synthesized by Einhorn in 1899) was reported by the surgeon Heinrich Braun." Cocaine, the active principle of the leaves of the coca plant, is a white crystalloid powder; 1 g dissolves in 0.4 g ofwater. Its local anesthetic properties were discovered in 1860 by Albert Niemann, chemist at the University of Gottingen, after he extracted the potent principle from cocalleaves brought from Peru. In 1868, the Peruvian army surgeon Moreno Y. Mayz, being familiar with the numbing effects on tongue and lips of coca-leaf chewing among the Indians, remarked that these sensory paralyzing effects might be useful in medicine. This, however, was disregarded until the early 1880s when Sigmund Freud became interested in the effect of cocaine on muscular strength and endurance. On his request, experiments with the drug were undertaken in the Department of Ophthalmology at the University of Vienna. While Leopold Koeningstein was impressed with the vasoconstrictive action ofcocaine, Carl Koller realized the true value ofthe drug. In the summer of1884,

Koller dropped a solution of cocaine into the eye of a frog. Almost immediately, the cornea became unresponsive. The experiment was repeated on a rabbit and a dog and, finally, Koller and a colleague, Dr. Gaertner, used the solution on each other. The results were identical in all experiments. In September, a preliminary report of these findings was presented at the 1884 Congress of Ophthalmology at Heidelberg.7,8 News of the discovery spread rapidly, both in Europe and the United States. In a Letter to the Editor ofthe November 29, 1884, issue ofthe New York MedicalJournal, Dr. William C. BurkeJr. 9 described the effectiveness of subcutaneous cocaine in anesthetizing a hand for minor surgery. Just as Morton's demonstration of general anesthesia was preceded by successful but unreported ether anesthesia (Crawford W. Long, 1842), so was Bier's use ofsubarachnoid block pre-dated by an experiment by the New York City physician, J. Leonard Corning.l" an event regarded for many years as the first spinal blockade. As described in the October 1885 New York Medical[ouma! under the title, 'Spinal Anaesthesia and Local Medication ofthe Cord', Coming set out to determine 'whether the local medication (anesthetization) of the spinal cord was within the range of practical achievement.' He decided to inject the anesthetic (hydrochloride of cocaine) between the processes of the lower dorsal vertebrae. The first experiment was performed on a young dog. Five minutes after the injection of20 minims ofa 2% solution, marked incoordination of the hind legs developed leading to weakness; the front legs were not involved. A wire brush applied to the hind legs produced no reflex response whereas, used on the anterior extremities, the limbs were 'drawn away violently'. Traces of the incoordination were observed for more than 2 h. The second experiment was undertaken on a man who had 'spinal weakness, seminal incontinence and was addicted to masturbation.' He was injected twice with 30 minims of a 3% cocaine solution; 10 min later, his legs 'felt sleepy' and he barely perceived the prick ofa needle or the currents ofa wire brush. Coming concluded 'whether the method will ever find an application as a substitute for etherization in genito-urinary or other branches ofsurgery, further experience alone can show'. In retrospect, it is extremely doubtful that his injections were made into the intrathecal space. Lumbar puncture had not been reported as yet, appearance of cerebrospinal fluid was not mentioned and, despite the large doses used, onset of action was slow and the extent of paresis limited. Most likely, the injections were made into the extradural space. Lumbar puncture was introduced in 1891 independently by Walther E. Wynter and Heinrich I. Quincke. Wynter l l reported 4 cases of tubercular meningitis in which 'paracentesis' of the 'theca vertebralis' was performed for the reliefoffluid pressure. Quincke,12 a physiologist and internist, used lumbar puncture both for diagnostic and therapeutic purpo.ses. He popularized the method at the 1891 German Congress of

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Spinal Blockade...

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Internal Medicine. Two years later, the feasibility ofinjecting medicaments by means oflumbar puncture was suggested by Hugo W. von Ziemssen.P a physician interested in infectious diseases. Subsequently, both saline and tetanus antitoxin were thus administered. Yet, it was not until 1898 that Professor Bier' attempted to use 'cocainization of the spinal cord' to render large areas of the body insensitive to the pain of major operations. He detailed the course of 6 patients, aged 11-34 years, who were managed between August 16 and 27. They underwent operations on the lower extremity or the sacrum, three for tuberculous lesions, two for osteomyelitic necroses, and one for an infected fracture of the femur. All operations were performed without major complaints; only two of the patients had increases in pulse rate and two developed severe headache and vomiting during the first postoperative days. To obtain a better assessment of the effects of this new method of anesthetization, Bier asked his assistant, Dr. Hildebrandt, to institute a spinal blockade on him. When the needle traversed the meninges, Bier feld a transient, mild, lightning-like pain in the legs. Unfortunately, the syringe did not fit properly onto the needle resulting in loss of both cerebrospinal fluid and most ofthe injectate. Hildebrandt then volunteered to substitute as evaluator ofthe method. Bier injected him with 112 ml ofa 1% solution (0.005 g) of cocaine. Eight minutes later, a small skin incision at the thigh was perceived as pressure and, soon thereafter, insertion of a wide-bore needle through the soft tissues down to the femur produced no pain. A burning cigar held to the legs was described as heat, not pain, while ether produced a feeling ofcold. At 18 min after the injection, there was decreased sensation up to the nipples. The blockade began to wear offapproximately 45 min after its onset. Despite the absence ofpain sensation, touch and pressure feelings were unchanged as were the patellar reflexes. Throughout the entire period, Hildebrandt's pulse rate remained between 72 and 75. In the evening, the two physicians went out for dinner, drank wine and smoked several cigars. Bier felt well until the following afternoon when he developed a feeling of 'pressure in the skull' associated with dizziness and a weak (small) pulse. These symptoms disappeared on lying down but reappeared immediately on getting up. He was bedridden for 9 days. Hildebrandt, in contrast, began to suffer from a severe headache and vomiting the night after the dinner. Although he felt miserable in the morning, he forced himself to go to work, performed operations and changed dressings. In the afternoon, he had to go to bed again. His complaints persisted for 3 additional days. In his classicalpaper entitled 'Experiments with Cocainization ofthe Spinal Cord,' which was published in April 1899, Bier emphasized that loss of cerebrospinal fluid during institution of the block should be minimized - most likely the result of his own experience. He advocated to place a [mger over the opening of the needle as soon as the 'stopper' is removed. Knowledge ofthe new tec1miqueofanesthetization circulated swiftly. A short report from New Orleans, 14 published the same year in the December 30 issueofthe Journal ofAmerican Medical Association stated that 'The Bier method ofintraspinal cocainization was applied successfullyin the Charity Hospital here, on December 18, by Dr. A. Matas, assistedby Drs. F.A. Larue and H.B. Gessner, and Mr. Allen, interne'. The Parisian surgeon T.H. Tuffier,15 working independently, administered his first subarachnoid block on November 9, 1899. His experiences with the first 167 patients were described in detail in the May 16, 1900, journal La Semaine Medicale. He had used 2% cocaine in doses of no more than 0.015 g for lower extremity surgery, intestinal operations, male urologic and female genital procedures. The latter

included colporrhaphies, Bartholin cyst extirpations, vaginal hysterectomies, hysteropexies and one laparotomy. Duration of anesthesia varied between 1 and 1112 h. Impressed with Bier's results and even more so with Tuffier's successful anesthesia for gynecologic procedures, Oskar Kreis, 16 a young assistant in the obstetric department at the Women's Clinic in Basel, Switzerland, introduced 'medullary narcosis' into childbirth on June 8, 1900. The patient, a 23-year-old primigravida, suffered from most severe pain during her uterine contractions. The cervix was fully dilated when at 20:50, 0.01 g ofcocaine was injected into her subarachnoid space at the L4-5 interspace. Five minutes later, there was no pain despite continued strong contractions. The sensory level reached the umbilicus; a strong needle stick was perceived as pressure; yet, motility of the legs and ability to bear down effectivelywere unimpeded. Outlet forceps delivery at 21:55 was painfree. At 02:00, the sensory block was worn off. At 03:00, the patient complained of head and neck pain, dizziness and nausea. One episode of vomiting occurred at 05:00. The headache disappeared towards evening. After studying five additional parturients, Kreis concluded that'the impression gained from the medullary narcosis in parturients is remarkable. Loss of sensation to pain with maintained mobility and unclouded sensorium is most unusual.' Only a few months later, a French report described 'Obstetric Analgesia by Injection of Cocaine into the Lumbar Subarachnoid Space'. And in 1902, an 86 page review entitled 'The Intrathecal Injections of Cocaine in Obstetrics' appeared in the French literature.!" The year 1902 also brought forth a learned report on spinal block for Cesarean section. The author, S. R. Hopkins'? from Springfield, Illinois, described a 'successful' case to show'the superiority ofspinal anesthesia over ether or chloroform in cases of Cesarean section, because of the relaxed condition of the uterine muscles likely to obtain with the patient anesthetized by either ofthe two latter methods. ' Hopkins used "one-third grain ofcocain hydrochlorate; the spinal fluid was used as the solving medium," a technique he believed to be responsible for the absense of the usual post-anesthetic phenomena of headache and vomiting. He also stated that 'the only recorded case of Cesarean section done under spinal anesthesia that I was able to find was performed by Doleris of Paris, who speaks in glowing terms of the usefulness in these cases because of the prompt and vigorous uterine contraction'. An 'original communication' written in 1901 by W.R. Stone,2° Instructor of Obstetrics at the Post-Graduate Medical School in New York City, shallserve as conclusion of this review. Stone used a sixth ofa grain of cocaine as first dose and, should complete anesthesia fail to develop, he injected a second dose ofone twelfth or one sixth ofa grain. He marvelled at the phenomenon in which a twisting and groaning woman would lie still in bed with a 'smiling countenance' within 15 min of such an injection. He found that high was well as low forceps deliveries could be performed as readily as under general anesthesia. And he ended his treatise by stating that 'the presence of an anesthetist and his expense can be dispensed with ifcocaine is employed. For, with but little practice, any physician can become competent to perform the lumbar puncture.' Today, some 90 years later, subarachnoid block in obstetrics is 'alive and well'. However, contrary to Stone's belief, the presence of an anesthesiologist is considered essential to safeguard the well-being of mother and child - despite the added expense!

References 1. Keys TH. The History of Surgical Anesthesia. New York: Schumann's. 1947.

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Anesthesia Hist Association Annual -eting New Orleans -:tober 18, 1992 Photog1 by Miguel Colon-des, M.D. Dr. & Mrs. Johrl Severinghaus

Al Betcher, 'Trier Alorch, Nick Creme Lucien Morris

Lucien Morris, Trier Morch, Ray Pink andiriends Richard Clark atuifrielld'i Maurice Albin, Trier Morch

Ernst Tria M, A1.D., the evening's speaker

Betty Ban~forth Alon 11lirmie, Gertie Marx

Miguel Colen-Morales, Mrs. Parsloe, Mrs. Colan-Morales, Carlos Parsloe

Dr. & Mrs. Rod Calverley andiriends Johll Steinhaus

Trier Morch, Alan llf/innie

Patrick Sim, Bah Smith John Severinghaus

Selma Calmes

Seymour Brown

Spinal Blockade. . . Continuedfrom Page 7 2. Frost EAM. Essayson The History ofAnesthesia. Georgetown: McMahon Publishing, 1985. 3. Bier A. Versuche uber Cocainisirung des Ruckerunarkes. Dtsch ztschr Chir 1899; 51:361-369. 4. Schaer HM. History of pain relief in obstetrics. In: Marx GF, Basse! GM, eds. Obstetric Analgesia and Anaesthesia. Elsevier: New York, 1980. 5. Wood A. New method of treating neuralgia by the direction application of opiates to the painful points. Edinburgh Med Surg J 1855; 82:265-281. 6. Braun H. Ueber einige neue ortliche Anaesthetica. [Stovain, Alypin, Novocain). Dtsch Med Wochenschr 1905; 31:1667-1671. 7 .Koller C. Vorlaufige Mittheilung uber lokale Anasthesirung am Auge. Klin Montsbl Augenheilkd 1884; 22:60-63 (Beilageheft). 8. Koller C. History of cocaine as a local anesthetic. Letter to Editor. JAMA 1941; 117:1284. 9. Burke WC Jr. Hydrochlorate ofcocaine in minor surgery. NY Med J 1884; 40:616-617. 10. Corning JL. Spinal anesthesia and local medication of the cord. NY Med J 1885; 42:;483-485. 11. Wynter WE. Lumbar puncture. Lancet 1891; i:981-982. 12. Quincke HI. Die Technik der Lumbalpunkrion. Verh Desch Ges Inn Med 1891; 10:321-331. 13. von Ziemssen HW. Allgemeine Behandlung der Infektionskrankenheiten. jena. 14. Medical News. Intraspinal cocainization. JAMA 1899; 33:1659. 15. Tuffier TH. Anesthesie medullaire chirurgicale par injection sous-arachnoidienne. La semaine medicale 1900; 20:167-169. 16. Kreis O. Ueber Medullarnarkose bei Gebarenden. Ctrbl Gynakol 1900; 28:724-729. 17. Doleris J. Analgesie obstetricale par I'injection de cocaine dansI' arachnoide lombaire. Compt rend Soc d' obst, de gynec et de paediat de Paris 1900; 11:328330. 18. Malartic H. Les injections rachidiennes de cocaine en obstetrique. Paris: G. Steinheil, 1901. 19. Hopkins SR. Case of cesarean section under spinal anesthesia. JAMA 1902; 38:1355. 20. Stone WR Cocainization of the spinal cord by means oflumbar puncture during labor. AmJ Obstet & Dis Women Childr 1901; 43:145-154.

Emily Stowe. . . Continuedfrom Page 7 either a double ofboards laid on trestles or the kitchen table was used as an operating table. Milk pans were used as basins, sea sponges for wiping and horsehair, taken directly from the horse's tail generally from the doctor's horse was used for sutures. If the operation had to be done at night a coal-oil lamp supplied the light. Chloroform was the one anaesthetic. It was dropped from a bottle with a split cork, the inhaler being a towel. Grove also tells of successfully transfusing a female patient, using her husband's blood which he withdrew in a rubber piston syringe, kept warm in a basin standing in hot water and injected directly into the arm. It was probably the first recorded transfusion in Canada, just as his was the first appendectomy in 1883. . When Emily Stowe started her practice, ether was widely used, but Pasteur and Lister had not yet convinced the world ofthe importance of germs and antiseptic methods. Her career paralleled one of the most active and inventive times in medicine.

History of Anesthesia and Related Fields in Philately by Miguel Colen-Morales, M.D.

Rene Laennec (1781-1826) revolutionized the diagnosis ofchest diseases through his discovery and systematic development ofauscultation and by designing the tubular stethoscope which has become the simplest and most reliable monitoring device during anesthesia for both cardiac and respiratory function. He described most pulmonary diseases, such aslung cancer, bronchiectasis and tuberculosis in his classic treatise "Traite du diagnostic des maladies du poumon et du courer", first published in 1819. Laennec died of pulmonary tuberculosis at the age of 45. His portrait, very appropriately, is represented on the seal of the American College of Chest Physicians. Rene Laennec was honored by France in a stamp issued in 1952 (Scott no. 685).

New Members It has been suggested that in this and future issues ofthe Newsletter, new members of the Anesthesia History Association should be made known to the membership. There follows the new members who have joined since August, 1992.

J.J. Andrews, M.D., Galveston, Texas David Zangrando, M.D., Seattle, Washington Lynn Clinton, M.D., Monrovia, California E.S. Striker, M.D., Pittsburgh, Pennsylvania Col. S.N. Mukherji, Maharashtra, India Evan Kock, CRNA, San Diego, California John M. Desio, M.D., Cheektowaga, New York Carroll L. Chambers, Jr., M.D., Homewood, Alabama Luis Cummings, jr., M.D., Ponce, Puerto Rico Judy C. Floyd, Germantown, Tennessee Kunio Ichiyanagi, M.D., Yamagata, Japan

The Writings ofJohn Snow In theAnnalsof theRoyal College ofPhysicians andSuroeons ofCanada 24:481-5, December, 1991, there was allarticle by oneof themembers ojthe Anesthesia History Association, who lives in Regina, Saseatihewan, relatillg tothepublished works ofJohll SIIOW. Withpermission ofDr. Shephard andtheEditors o/the Annals RCPSC, it is ourpleasure to reprint this paper for the bell~Rt of our readers. - - Editor

John Snow, The Compleat Physician: A Reassessment Based on His Writings by David A.E. Shephard MB, FRCP Introduction John Snow (1813-1858) is best known for his work in two different . fields, anesthesia and epidemiology. The first physician to specialize in anesthesia, and the doyen of anesthesia in England in his day, Snow changed an empirical craft into a practice with the beginnings of a scientific discipline. He did so as a clinician, a researcher and an educator. His clinical stature is evident in his anesthetizing Queen Victoria in 1853 and again in 1857; his prominence in research is manifest in the 18 papers on volatile anesthetic agents that he published from 1848 to 1851; 1 and his influence asan educator is apparent in hisjournal articles, his monograph on ether-' and his text on chloroform.' In the same period, he did his work on the epidemiology ofcholera. He began to formulate his ideas on the spread of cholera in 1848, and published the first edition ofhis classic monograph "On the Mode of Communication of Cholera" in 1849.4 He continued to lecture and write on the topic, but it was his investigation of the 1854 cholera epidemic in London and the epidemiological proof ofhis hypothesis.! that established his reputation as an epidemiologist. A founding member and councillor of the London Epidemiological Society, Snow was one of the first to apply epidemiological principles of medicine. His study ofthe spread ofcholera in 1854 was ofsuch excellence that Frost praised it as "a nearly perfect model" of epidemiological analysis." Snow's seminal achievements are ofscientific and biographic interest. Especially intriguing is the question why it was Snow, rather than any of his equally competent colleagues, who gained the prize of priority - and in two medical fields. This question has not been addressed. One way ofdoing so is to examine his writings, which yield insight into the nature of the man, what motivated him and how he worked. The purpose of this article is to discuss Snow's writings in this light.

Snow on Anesthesia Snow was a prolific writer. On anesthesia, he wrote 38 journal articles, two monographs, four letters and one pamphlet, mostly on cholera. One could select many examples from Snow's publications to illustrate aspects of his personality and his approach to his work, but two from his writing on anesthesia and two on cholera will suffice. The first excerpt is from the opening paragraph of his book "On Chloroform and Other Anesthetics: Their Action and Administration." Snow relates an everyday observation to the basic element underlying inhalational anesthesia respiration: "Inhalation is simply the act ofbreathing, or at least so much ofit as consists ofinspiring, or drawing air into the lungs. The term is usually applied when any...substance is added to the air which the patient breathes ...Th[e] process ofinhaling smoke, as I first witnessed it in a gentleman...is very instructive, as showing that the lungs become emptied oftheir contents by three rather full expirations and inspirations. When this gentleman took his cigar from his mouth to speak, the smoke could be seen issuing thickly with each word

till there was a momentary pause as he took a fresh inspiration, then the smoke could be seen issuing with each word as before, only not so thick, and after another inspiration, the smoke could still be perceived in the expired air, but in a very diluted state; but after a third inspiration, it could no longer be seen till he had resumed his cigar."?

The second excerpt comes from an article he wrote on ether in March 1847, three months after ether had been first used in England: "It will be at once admitted that the medical practitioner ought to be acquainted with the strength ofthe various compounds which he applies as remedial agents, and that he ought, ifpossible to regulate their potency. The compound ofether vapour and ofair is no exception to this rule, although it might be supposed to form one, as the practitioner stands by to watch , " its effects... It occurred to my mind that by regulating the temperature of the air whilst it is exposed to the ether, we should have the means of ascertaining and adjusting the quantity ofvapour that willbe contained in it: for the proportion of vapour in any given volume of air saturated with it at any particular temperature, is to the whole volume as the elastic force ofthe vapour at that temperature is to the atmospheric pressure at the time and place."N

In these excerpts, Snow expressed himselfas he thought - precisely and clearly. The passagesindicate his interest in clinical medicine and in the clinical application ofphysiology and physical chemistry. As a clinician, he wasan acute observer and quick to interpret a simple physiological observation with respect to its relevance to anesthesia; as a scientist, he applied his knowledge of physical chemistry in improving the administration ofanesthesia. It was Snow who introduced the quantitative approach to the use of ether and chloroform. He first saw ether being given on December 28, 1846,9and quickly identified the problems and defects ofanesthesia in its earliest days, when it was a rag-andbottle craft. He designed an inhaler for the administration ofether and another for chloroform, and so introduced measurement into anesthesia. By applying the principles ofphysiology and physical chemistry to anesthesia, he enhanced its practice, so that it could evolve from an empirical craft to a scientific discipline, and his inventive genius, expressed in his inhalers, set the pattern for the development in inhalational apparatus that characterized English anesthesia for the rest of the 19th century. I

Snow on Cholera The problems that confronted Snow in the study of cholera were quite different from those of anesthesia. His abilities as a clinician and as a scientist, and his genius for problem-solving, however, are just as evident in his publications on cholera. The first excerpt on cholera illustrates Snow's clinical intelligence. He understood, as early as 1849, that the disease was spread not in a "miasma" of the atmosphere, but through the activity of a self-replicating micro-organism: ..... we have arrived at two conclusions - first, that cholera is a local affection ofthe alimentary canal; and secondly, that it is communicated from one

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John Snow's Writings...

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person to another. The induction from these data is that the disease must be caused by something which passes from the mucous membrane of the alimentary canal ofone patient to that ofthe other, which it can only do by being swallowed; and as the disease grows in a community by what it feeds upon ...it is clear that the cholera poison must multiply itself by a kind of growth, changing surrounding materials to its own nature like any other morbid poison... " II

Snow's understanding of pathology and ofepidemiology led him to embrace a contagionist approach rather than the anticontagionist one, the miasma theory, which was more commonly held in this prebacteriologic era. 12 His understanding of the pathology of cholera was acute, and it led him to describe cholera in words that are not an anachronism roday: "As cholera commences with an affection of the alimentary canal, and as...the blood is not under the in£luence ofany poison in the early stages of this disease, it follows that the morbid material producing cholera must be introduced into the alimentary canal must, in fact, be swallowed accidentally..." 13

The second excerpt illustrates Snow's thorough approach to a clinical public health problem. In 1848, he had begun to believe that cholera was spread not through an aerial "miasma" arising from poor sanitary conditions, as most ofhis contemporaries thought, but as a disease that was communicated from person to person most often by the fecal pollution of water, and sometimes by the contamination of food or fomites. By 1854, he tested his hypothesis that cholera was transmitted by the pollution of water supplies with a fecally borne agent: "When the cholera returned to London in July [1854].. .1resolved to spare no exertion which might be necessary to ascertain the exact effect of the water supply on the progress ofthe epidemic. in the places where all the circumstances were so happily adapted for the inquiry. I was desirous ofmaking the investigation myself, in order that I might have the most satisfactory proofofthe truth or fallacy ofthe doctrine which I had been advocating for five years. I had no reason to doubt the correctness ofthe conclusions I had drawn from the great number of facts already in my possession, but I felt that the circumstances ofthe cholera-poison passing down the sewers into a great river. and being distributed through miles ofpipes. and yet producing its specific effects, as ofso startling a nature, and ofso vast importance to the community, that it could not be too rigidly examined. or established on too fum a basis." 14

Snow's contribution to the understanding ofcholera lay in the proof ofthe "doctrine" he had first formulated in the latter part of1848. His epidemiological investigation of the disease, particularly in 1854 enabled him to present this proof His careful work, informed as it was by irrefutable logic, eventually convinced all that cholera was a communicable disease transmitted primarily in water and sometimes secondarily in food and fomites. The disappearance of cholera from England after 1866 was the result of the ascendancy of Snow's doctrine. In this respect, his contribution to public health has been inestimable.

The Case-Books of Snow Snow also left unpublished writings in the form of three casebooks. 15 These handwritten records cover his clinical work, in general practice and in anesthesia, during the last decade of his life. The thousands of entries provide a glimpse of Snow's personality and his approach to work. The fact that he made an entry for virtually every patient he saw from July 1848 to June 1858, says much about his diligence and compulsiveness, which made him so methodical an anesthetist and so thorough an investigator. The case-books are a mine of information about Snow's clinical practice, and about medicine and surgery in the mid 19th century. They

are lacking only in reference to Snow's research in anesthesia and epidemiology, which was separate from his clinical practice. He did, however, describe the use ofchloroform to relieve the suffering ofthe cholera victim, and he recorded its use in cases ofother medical disorders such as neuralgia, tetanus and delirium tremens. Snow's case-books add interest to his writings. His published work gives an indication ofSnow the physician and investigator; his informal case-books enable us to catch glimpses of the good doctor and the sought-after anesthetist. One of the first excerpts from his case-books, dated Tuesday, July 18, 1848, is a description ofa chloroform anesthetic. Since there seems to be no records ofSnow's first 47 cases ofanesthesia with chloroform, this is the first description that we have access to. By July 1848, Snow had been giving anesthetics for about 18 months, but he still found it important to record the clinical signs ofanesthesia. In this way, he built up a body ofknowledge about the clinical practice ofanesthesia, partly tor his benefit but also for the benefit ofothers who gave anesthesia. In this excerpt, Snow's powers ofobservation come across well- as does a sense of the benefit patients felt in undergoing surgery without pain: "Tuesday 18 July Mrs. Moody, 64 Cadogan Place. Patient of Mr. Sampson, Chester St. rook Chloroform to have some loose folds ofintegument removed from the verge ofthe anus. She inhaled steadily and became unconscious without any excitement. In about three minutes there was a slight tendency to snoring and the operation was commenced although the sensibility of the conjunctiva was only in part removed. There was no flinching or crying, and a little contraction ofthe features and increased quickness ofrespiration were the only effects of the operation, till just at the conclusion when there was a kind ofhysterical sobbing which lasted about a minute afterwards, immediately after which she enquired what was the matter, and said she felt confused about something. but in another minute was quite collected and felt surprised and thankful that the operation had been done. Of middle age."

Mrs. Moody is not well know, but another ofSnow's patients is. On April 7, 1853, Snow anesthetized Queen Victoria. "Thursday 7 April Adrninstered Chloroform to the Queen in her confinement...At twenty minutes past twelve by a clock in The Queen's apartment I commenced to give a little chloroform with each pain, by pouring about 15 minims by measure on a folded handkerchieL.Her Majesty expressed great relief from the application, the pain being very trifling during the uterine contractions, whilst between the periods of contraction there was complete ease. The effect of the chloroform was not at any time carried to the extent of quite removing consciousness...The infant [Prince Leopoldj-wasborn at 13 minutes past one by the clock in the room (which was three minutes before the right time) consequently the chloroform was inhaled for 53 minutes ... the Queen appeared very cheerful and well, expressing herself much gratified with the effect of the chloroform."

This particular anesthetic gave royal approval to what had been a controversial aspect of this new therapeutic modality: the use of anesthesia to relieve the pain ofchildbirth. Second, Snow describes the technique of anesthesia that became known as chloroform la reine. His choice of a handkerchiefis interesting, because Snow is identified with the development of sophisticated inhalational apparatus in place of domestic devices like handkerchiefs and gloves, which he did not usually favor. 16 However, Snow was by then a competent anesthetist - he was giving over 400 anesthetics yearly - and in anesthetizing the Queen, he knew what he was doing. Years of clinical practice and research - even using himself as the experimental subject at times had given him absolute confidence. Snow's mention of the dose of chloroform and the incorrect time given by the Queen's clock are typical ofhis methodical nature and his

a

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desire for accuracy. He always had an eye for detail, and the naturalist's need to record what he saw and did. Even when he had become prominent as an anesthetist, Snow maintained his general practice. Many of the entries in his case-books, especially in the early years, were about the cases he saw in general practice. Obstetrics made up a fair proportion ofhis work, and sometimes he had to resuscitate neonates. His interest in neonatal asphyxia is significant, for a paper Snow wrote asearly as 1841 17showed a depth of understanding of the physiology and pathology of respiration that explains the rapidity with which he discerned the problems ofanesthesia in its earliest days. The following entry, dated July 18, 1849, concerns the attempted resuscitation ofa footling infant who gave no signs oflife at birth: "Air was blown gently by the mouth into the child's mouth almost constantly the nostrils being closed and the larynx pressed gently backwards,but the lungs were not expanded the air passing chiefly into the stomach ...this kind ofartificial respiration had some effect however on the citculation or heart for when discontinued the heart's action became slower and less audible The child was occasionally placed for a short time in warm water. A gum elastic catheter was at last procured and passed into the larynx, by who the lungs were distended - but the heart's action had already ceased."

Snow kept himself informed about medicine and the basic sciences by reading the literature, and he did what he could for his patients with the knowledge and techniques that were available to him. Even so, particularly as a general practitioner, much ofhis therapy was traditional: he was not averse to the use ofleeches, for example, and he prescribed the standard tonics and potions ofthe day. It was as an anesthetist and an epidemiologist that he was inspired. Snow worked with many prominent London surgeons - men like William Bowman, Edward Cutler, William Fergusson, Caesar Hawkins, Robert Liston and Richard Quain. As their anesthetist, Snow witnessed their surgery. As a result, his case-books constitute a valuable source ofinformation about the types ofoperations being performed in the mid 19th century. All were performed on or near the surface ofthe body. Amputations of limbs and digits were common, as were dental extractions and operations on the breast. Operations on the bladder, anus and genitalia were frequent, but so were delicate procedures on the eye, the nose, the mouth and the throat. Often working in difficult circumstances, Snow showed his competence, giving anesthesia to patients who often had advanced disease, in homes, hotels and hospitals. In his career, Snow gave some 4,500 anesthetics to patients with a variety ofmedical and surgical conditions, and who were in a variety of states of preparedness for surgery. Most anesthetics went well, but Snow, without relatively innocuous drugs and reassuring monitors, experienced an anxiety that the modern anesthetist seldom feels - but can emphathize with. Snow lost three patients directly from anesthetic causes, only because he refused to withhold anesthesia if he thought that he could thereby relieve the suffering of his patients.

Snow the Man Snow's writings tell us much about the man and his attributes. He was dedicated to his patients and his profession; thorough in his work; a careful observer who reasoned logically from what he observed, experienced or read; and an imaginative researcher. He had an open mind nourished by a sense of the history ofmedicine, yet aware ofthe fresh paths that physicians must take to permit medicine to advance. Snow advanced medicine as an expert in two areas, and he is usually regarded as a specialist. Anesthetists admire him as the first physician to

specialize in anesthesia, and epidemiologists respect him as the epidemiologist's epidemiologist. Most of the accounts of Snow's lite and work have appeared in the literature ofeither anesthesia or epidemiology and public health. As a result, a one-sided view of Snow has emerged. Anesthetists know less about his work as an epidemiologist than they should, while epidemiologists know less about his work in anesthesia than they should. Most other physicians remember him only for the anecdotal aspects of his work, such as his anesthetizing Queen Victoria or his advising that the pump-handle of a polluted well be removed during the London cholera epidemic of 1854. No comprehensive biographic study ofSnow is yet available to correct this, and to provide an account that might have an appeal for both general and specialized readers. One ofthe results ofthe incomplete literature on Snow is that, while his qualifications as a specialisthave received attention, those emphasizing his background as a generalist have not. He excelled as a specialist in anesthesia and epidemiology, but it was because he derived his clinical acumen and understanding ofmedicine as a generalist that he achieved what he did in those two different areas. Only a physician with a profound knowledge of respiratory physiology and pathology, as he showed in his paper on neonatal asphyxia,17 could so immediately master the problems ofanesthesia in its earliest days; only a physician with an interest in environmental and public health problems, ashe showed in several endeavors,18-21 could so readily apply the principles of epidemiology in elucidating the problem of the transmission"'ofcholera.

A "Compleat" Physician One way of taking a broader look at Snow's contributions to medicine is to regard him as a "compleat" physician. Snow lived in an era when it was the rule rather than the exception for educated individuals to interest themselves in "natural history." He was no different from many other Victorians in being interested in a multiplicity of aspects of life. In medicine, many physicians who are now remembered as "specialists" were at heart "generalists," or at least had interests in more than one field. In England, one such physician was Jonathan Hutchinson, who is known for his work in surgery, ophthalmology, dermatology and syphilologyP - and who had a profound knowledge ofthe flora and fauna ofsouthern England Oackson R, personal communication, 1989). In the United States, another such physician was Harvey Cushing, who, though an accomplished physiologist and endocrinologist, is remembered as the father ofneurosurgery-! and whose literary ability won him a Pulitzer prize for his biography of William Osler, another generalist and specialist.P' Like Snow, Hutchinson and Cushing succeeded in their fields by virtue, at least partly, of their general knowledge of medicine. Snow was the"compleat" physician not only in his generalist background and his range ofinterests. which are evident in his writings, but also in his abilities. He was trained as a general practitioner, but his inclination led him to take the training ofan internist. He obtained the first membership of the Royal College of Surgeons and the licentiateship of the Society of Apothecaries (in 1838); then the decrees of bachelor ofmedicine and bach~lor ofsurgery ofLondon University (in 1843); then the highest degree of doctor of medicine from the same university (in 1844); and finally the licentiateship ofthe Royal College ofPhysicians ofLondon (in 1850).That Snow went so far when just the first one or two qualifications would have enabled him to practise as a doctor says much for his desire to upgrade his education, as it does for his initiative in an era when the maintenance of competence was not

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stressed as it is today. For Snow, his education had to be as complete as possible, so that he could practise the best medicine he could. In consequence, he became as complete a physician as any of his colleagues. Benjamin Ward Richardson, a contemporary of Snow, remembered him as "one ofthe soundest and most acute ofour modem physicians,"25 and it is as such that we might remember Snow. But Snow was also a remarkable medical scientist, having attributes that enabled him, rather than anyone else in his day, to solve several basic problems in medicine. In anesthesia, it is Snow rather than James Robinson, Francis Plomley or Francis Sibson who is remembered for his leadership; in epidemiology, it is Snow rather than William Budd, William Farr or Edmund Parkes who is remembered for research into cholera. For the light they shed on those qualities that made Snow a great medical scientist, his writings are a mine of information. Of the attributes that appear in Snow's writings, particularly diligence, perseverance, a wide knowledge of medicine, observation, perception, insight, logic and creativity, it is the last that may be the key to his achievements as a medical scientist. Creativity is essential in the solution ofdifficult problems, and it is this that sets the genius apart from the talented.I" Snow manifested some attributes of the creative thinker. These include: receptivity to creative ideas, or open-mindedness; immersion in the subject, or dedication to the task at hand; the ability to ask the right questions, and also to use errors previously made; "detached devotion" ;27 and persistence.P Snow, who lived alone, also seemed to thrive on the solitude that nourishes creativity in some individuals. 29 If the highest degree of creativity amounts to genius, Snow must be regarded as a genius. The genius seems to be set apart from others, as Snow. One observer said that he was "very peculiar. "30 Hirsh said that "the genius is ever a stranger in a strange land, a momentary sojourner in a strange interlude".26 Snow, who died at the age of 45, was a "momentary sojourner" on earth. Though his life was short, his art was long. His achievements were profound, and his contributions advanced medicine in two fields. In his day, his work in anesthesia and in public health benefitted many. The groundwork that he laid in these two fields has proved ofsuch lasting significance that it has benefitted countless people since his death in 1858. This is the measure of the greatness of John Snow, anesthetist and epidemiologist, but also the complete physician. References 1. Snow J. On narcotism by the inhalation of vapours. This 18-part series of papers was published in the London Medical Gazette from 1848 to 1851. The citations are as follows: 1848;6:850-4; 1848;6:893-5; 1848;6:1074-8; 1848;7:330-5; 1848;7:412-7; 1848;7:614-6;1848;7:840-4; 1848;7:1021-5; 1849;8:228-34; 1849;8:451-6; 1849;8:9835; 1849;9:272-7; 1850;10:622-7; 1850;11:321-7; 1850;11:749-54; 1851;12:622-7; 1851;48:1053-7; 1851;48:1090-4. 2. Snow J. On the inhalation of the vapour of ether in surgical operations: Containing a description of the various stages of etherization, and a statement of the results of nearly eighty operations in which ether has been employed in St. George's and University College Hospitals. London: John Churchill, 1847. 3. Snow J. On chloroform and other anaesthetics: Their action and administration. London: John Churchill, 1858. 4. Snow J. On the mode of communication of cholera. London: John Churchill, 1849. 5. Snow J. On the mode of communication of cholera. 2nd ed. London: John Churchill, 1855. 6. Frost WH, ed. Snow on cholera. London: Oxford University Press and Commonwealth Fund, 1936:i.x(See also facsimile edition, New York: Hafner, 1965). 7. Snow J. On chloroform. 1858:25. 8. Snow J. On the inhalation of the vapour of ether. Lond Med Gaz 1847;39:498502. 9. Ellis RH. In: RobinsonJ. A treatise on the inhalation ofthe vapour ofether forthe prevention ofpain in surgical operations (1847). Facsimileedition. Eastbourne: Bailliere Tindall, 1983:x.

10. Duncum BM. The development of inhalation anaesthesia: With special reference to the years 1846-1900. London: Oxford University Press, 1947;17:24-5,181,320. 11. SnowJ. On the pathology and mode ofcommunication ofcholera. Lond Med Gaz 1849;44:745-52. 12. Ackerknecht E. Anticontagionism between 1821 and 1867. Bull His Med 1948; 22:562-93. 13. Snow J. On the mode of communication of cholera. 2nd ed. 1855;15. 14. Snow J. On the mode of communication of cholera. 2nd ed. 1855;76. 15. Snow's three case-books are held by the Royal College of Physicians of London. They are handwritten, but under the editorship of Dr. R.H. Ellis and the auspices of the Royal Society of Medicine, they have been transcribed and will be published in the near future. 16. Snow J. On chloroform. 1858;78-9. 17. Snow J. On asphyxia, and on the resuscitation of stillborn children. Lond Med Gaz 1841;29:222-7. 18. Westminster Medical Soc-iety, Dec. 16, 1837. Lancet 1837;1:463. 19. Snow J. Arsenic as a preservative of dead bodies. Lancet 1838-39;1:264. 20. Snow J. Case of acute poisoning by carbonate of lead. Land Med Gaz 1844: 35:248-50. 21. Snow J. On the pathological effects of atmosphere vitiated by carbonic acid gas, and a diminution of the due proportion of oxygen. Edin Med Surg J 1846;65:49-56. 22. Mettler C. History of medicine: A correlative text, arranged according to subjects. Philadelphia: The Blakiston Company, 1947;270,650.779,780,1046,1084. 23. Fulton JF. Harvey Cushing: A biography. Springfield: Charles C. Thomas. 1946. 24. Cushing H. The life of Sir William Osler (2 vols). Oxford: The Clarendon Press, 1925. 25. Richardson BW. The life of John Snow, MD: A memoir: In Snow J. On chloroform and other anaesthetics: Their action and administration. London: John Churchill, 1858:xxxix. 26. Hirsh N. Genius and creative intelligence. Cambridge: Sci-Art Publishers, 1931;288-9. 27. Henle M. The birth and death of ideas. In: Gruber HE, Terrell G, Wertheimer M, eds. Contemporary approaches to creative thinking. New York: Atherton Press, 1962. Cited by Arieti S. Creativity: The magic synthesis. New York: Basic Books, Inc., 1976;345-6. 28. Roe A. A psychological study of eminent biologists. Psychological Monographs 1951;65:14. 29. Storr A. Solitude. London: Flamingo/Fontana Paperbacks, 1988;84:129,201-2. 30. Richardson BW. The life of John Snow, MD: A memoir: In Snow J. On chloroform and other anaesthetics: Their action and administration. Landon: John Churchill, 1858:x.

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Dr. B.B. Singh-Pradhan, the.first physician toadminister anesthetics regularly in

Nepal. an Oxford miniature vaporizer (OMV), continued to be the standard equipment used by almost all anesthesiologists outside Kathmandu. The next qualified anesthesiologist to return to Nepal was P.D. Shrestha, who joined the Military Hospital in Kathmandu in 1964 with a DA(UK). In 1965 a second anesthesiologist, G.P. Rajlawot, joined Bir Hospital with a DA from Agra, India. Soon after his arrival in Kathmandu, he gave the anesthetic for the first closed mitral valvotomy in Nepal, using an Indian Boyle's (nitrous oxide and oxygen) machine. He stayed for seven years before emigrating to England. N.B. Rana, now the senior anesthesiologist in Nepal, returned to Bir Hospital in 1966 with an FFARCS from UK and soon introduced modern balanced anesthesia. This was not immediate because, although the Boyle's machine was there, it could not be used regularly because the hospital had only two cylinders ofoxygen and one ofnitrous oxide. For the first year he usually gave open drop ether, preceded in children by an ethyl chloride induction. Thiopental, gallamine, and a few endotracheal tubes were also available. He was the first to use gallamine in combination with the bottle-and-bellows circuit. He soon introduced curare as well, and the use ofmuscle relaxants made abdominal surgery not only easier, but almost halved the operating time. Spinal anesthesia was the only regional anesthetic commonly used; procaine was the only local anesthetic agent and was too short-lasting for many operations. Lidocaine became available several years later and bupivacaine is now also available in Kathmandu. A new surgical building was added to Bir Hospital in 1968, the operating theaters were named in Singh-Pradhan's honor, and new anesthetic equipment was purchased. There were two Boyle's machines, an East Radcliffe and a Howells ventilator, 200 gallon PIV nitrous oxide cylinders and 24 c. ft. cylinders ofoxygen. Rana arranged for a separate

oxygen store and pipeline to the operating rooms to avoid the possibility of internists using all his oxygen on the wards! Trichloroethylene was introduced in 1968 and halothane, not available by ordinary routes, was obtained in 1970 through a personal friendship with the local Hoechst representative. There were few changes during the next fifteen years. There were no anesthetic drug or equipment manufacturers in Nepal in 1965. Only a limited selection was available from India and the same holds true today. Until 1974 oxygen was imported from India, and in 1992 there is still only one major oxygen manufacturing plant in Nepal. Nitrous oxide must still be imported at great expense from India and is only used regularly in two hospitals in Nepal. Until 1976 the only trained anesthesiologistsin the country worked in Kathmandu at Bir Hospital and the Military Hospital, providing occasional service at the women's and children's hospitals. In 1985 the women's hospital had 7,500 deliveries per year, and 90 percent of obstetric anesthetics were still open drop ether given by junior obstetric staff.5 B.M. Shrestha was the first of two anesthesiologists who worked in hospitals outside Kathmandu between 1976 and 1983. He was the first Nepali anesthesiologist to use endotracheal intubation outside Kathmandu. Because of the acute shortage of trained anesthesia personnel, he outlined a program for trainingjunior doctors, nurses and paramedical staff to give anesthetics." He trained three doctors himself, but the training was not formally recognized and his ideas were not taken up by the ministry ofhealth. Meanwhile, at Patan Hospital.ran by the United Missions to Nepal (UMN) hospital, an American anesthesiologist established a one-year training course for nurse anesthetists." Two nurses completed the first course and five more have been trained since by other foreign anesthesiologists. They work at three UMN hospitals in Nepal and in private non-governmental hospitals in Kathmandu. Only at Patan Hospital are they under direct supervision of an anesthesiologist. A recent one-year audit at Patan and one rural UMN hospital showed a total of 6,753 operations with no anesthetic deaths." The new 300-bed TU Teaching Hospital in Kathmandu was completed in 1984, but had no anesthesiologists. There were 80 surgeons in the country, but only seven anesthesiologists. Two of the four major hospitals in Kathmandu had all seven anesthesiologists. Outside Kathmandu, for a population of15 million, there were nine 50- to lSD-bed

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Thejirs: anesthetic circuit used with endotracheal anesthesia in 1955 in Nepal. See textfor description.

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government hospitals with surgeons and obstetrician-gynecologists, but not a single anesthesiologist. Anesthetics were often given by junior doctors or auxiliary health workers, or the surgeon used local anesthesia. The ministry of health recognized the critical shortage of anesthesiologists and the Institute ofMedicine ofTribhuvan University approached the University ofCalgary in Canada to assistthe local anesthesiologists in establishing a one-year diploma program based in·Kathmandu. The origins and development of this program have been described elsewhere.? The year 1985 marked the beginning of a new era. Dr. (now Professor) Roshana Amatya was appointed head of anesthesiology at the TU Teaching Hospital, and the Diploma in Anaesthesiology program became established. Each year since then four anesthesiologists have graduated with a DA(TU). Three anesthesiologists returned from India in 1985-86, having completed the three-year training for MD in Anaesthesiology, and one from the UK with a DA. For the first time the children's hospital and the women's hospital in Kathmandu each had its own anesthesiologist, and in 1991 specialist coverage was possible for all obstetric emergencies. In 1986 two of the first group ofDA(TU) graduates were posted to rural hospitals and in 1992 all nine major hospitals outside Kathmandu had at least one trained anesthesiologist. Three senior Kathmandu anesthesiologists have taken additional training in cardiac and neuroanesthesia as more specialized surgical programs have been introduced. Annual anesthesiology symposiums were introduced in 1986. The Society ofAnaesthesiologists ofNepal was founded in 1987, it became a member of the World Federation of Societies of Anaesthesiologists during the 9th World Congress in Washington, D.C. in 1988, and two Nepali anesthesiologists attended the 10th World Congress in The Hague. Many DA graduates want a higher degree, not just a diploma, and discussions are now under way on a curriculum for establishing a Nepali higher degree in anesthesiology.

Anesthesia History Association C. Ronald Stephen, M.D., C.M., Newsletter Editor 15801 Harris Ridge Court Chesterfield, MO 63017 U.S.A.

References 1. IUj PA. Kathmandu and the Kingdom ofNepal, 8th ed. Kathmandu: Nabeen Publications, 1990: 10. 2. Dixit H. Medicine in Nepal. J Nep Med Assoc 12(5&6):43-53, 1974. 3. Macintosh RR. Saved by the Flagg. in: Atlcinson RS, Boulton TB (eds): The History of Anaesthesia. London: Royal Society of Medicine, 1990: 8-9. 4. Singh BB. Endotracheal anaesthesia at the Bir Hospital, Kathmandu, Nepal. J Nep Med Assoc 6(2):59-63, 1968. 5. Maltby JR, Malla DS, Dongol HR. Open drop ether for Caesarean section: a review of 420 cases in Nepal. Can Anaesth Soc J 34:51-5, 1987. 6. Shrestha BM. Development of anaesthetic service in eastern part ofNepal. J Nep Med Assoc 21(2):35-8, 1983. . 7. Fell TE. Experiences with nurse anaesthesia in Nepal 1982-83. J Nep Med Assoc 21(Souvenir issue):94-6, 183. 8. Munday DF. Evaluation ofthe work ofnurse anaesthetists at Patan and Tansen hospitals during the year 1989 to 1990. J Nep Med Assoc 31:150-3, 1991. 9. Maltby JR, Arnatya R, Rana NB, ShresthaBM, Tuladhar TM, McCaughey 1). Anaesthesia training and development in Nepal 1985-90. Can J Anaesth 38:10510, 1991.

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