Newsletter April, 1990

Anesthesia History Association ewsletter April, 1990

Volume 8, Number 2

Crawford W. Long, M.D. As 1992 approaches, the Anesthesia History Association is planning assiduously to hold the 71tird Imemational Symposium otz the History o_(Anesthesia in Atlanta. 11ze dates ofthe meetitzg, March 27 to 31, 1992, will coitzdde with the 150th anniversary ofthe first administratiotz ofan ether anesthetic by Dr. Crawford W. Long on March 30th, 1842. As part ofthe meeting, it is expected that those attending will make atz exmrsiotz to JejJerson, Georgia, to visit the Crawford Long Museum. It is ther~{Orefitting to publish the thought-provoking text o_( a lecture which Dr. John E. Steinhaus, President o_( this Association, delivered in 1989, as the 23rd Ammal Crawford W. Long Museum Lecture, at the am mal Postgraduate Course itz Ane~thesia sponsored by the Department ofAnesthesia at Emory University School o_(Medidne. Dr. Steinhaus is Pro_{essor Emeritus o_( Anesthesiology at Emory University.. -Editor

Creativity and Discovery in Anesthesiology by John E. Steinhaus, M.D., Ph.D. Pro_(essor Emeritus, Emory University School o_( Medidne The first administration of diethyl ether anesthesia to James Venable for the surgical removal of a cyst on March 30, 1842, was not publicized by Dr. Crawford W. Long, as such an event would be today. Much discussion and dispute have not resolved the question of who should be given credit or recognition for this epoch-making discovery. Certainly, a milestone in the history of medicine like the discovery of anesthesia deserves sufficient attention and kudos that all who contributed to this valuable therapy can share in the recognition. Crawford W. Long was a participant in the "ether frolics" of his medical student days, and is said to have remarked on the lack of pain from the accidental bumps and trauma of the frolic. Consequently, he provided pain relief (anesthesia) to a friend, James Venable, for the surgical excision of a cyst on his neck. Venable's participation in the local ether frolics made the new adventure acceptable to the patient. Since the approval and acceptance of medical practice has been based upon the usual and customary, it is hazardous for a physician to introduce new concepts and therapies. Crawford W. Long, as a young physician located far from the medical centers ofhis day, faced restrictive societal pressures, both in his local community and from his medical colleagues. His cautious approach to this discovery was demonstrated by his repetition, in additional patients, of this epoch-making event. In two instances, he used the patient as his own control in successive surgical procedures with and without ether administration. In a profession like medicine, which both invites and needs a continuing supply of new knowledge and therapies, it is important to examine how new discoveries are made and developed. During my scientific and medical career, I have observed, at close hand, the discovery and introduction of a number of important drug therapies, and I propose to look at how these valuable therapeutic agents were introduced into medicine. It is also appropriate to note that the public attitude in the present day has changed markedly, with the growth of medical sciences, so that new "therapies" are now accepted with enthusiasm, and even at times uncritically.

My early interest in science was focused on chemistry, but as an undergraduate chemistry major, I soon found that combining molecules and sidechains into new organic chemicals did not sustain my interest, which turned instead toward the field of biology. I began my first course in microbiology in 1937. This interest intensified after I became the victim oflobar pneumonia; six months of convalescence, a year of lost schooling, and my career direction was changed to microbiology. As a graduate student in Microbiology in 1940, my research centered on chemotherapy, and in the spring of 1941, I presented a seminar entitled, Bactericidal Substances in Atztagonism, which discussed bactericidal substances produced by four groups of microorganisms, including fungi. This latter group included three genera, one of which was Penicillium. Twenty publications from 1934 to 1940 were cited, one of which was Chain & Florey's early report on penicillin. The term antibiotic was not used, even though antibiosis was well recognized. The research on penicillin provided only a small part of this presentation and there was no suggestion that it would become the important medical milestone that it later became. While a chemistry student, I was very much aware of the impact of new organic chemical compounds on industry and medicine. In the early part of the century, Ehrlich's work with arsenical compounds as "magic bullets" in the treatment of syphilis never developed into widescale medicinals for the treatment of infectious diseases, because these drugs were too toxic when given systemically. Research on the heavy metals as anti-infectives turned toward dyestuffs, which produced mercurochrome and other disinfectants as local anti-infectives in the 1920's. In 1935, Domagk discovered the effectiveness of a dye, prontosil, against streptococci, even though he did not at first understand that its breakdown product, sulfanilamide, was the effective chemotherapeutic agent. The introduction of sulfanilamide and the family of sulfa drugs provided the first effective systemic chemotherapeutic agents against the acute bacterial diseases, which also had the Continued on Page 4

Letter to the Editor The latest number of the Anaesthesia History Association Newsletter reached me recently and, as always, makes interesting reading. I applaud the chronology on pp. 14 and 15. The selection of events is perhaps a little peculiar though I guess that may be said of any such list. Significant as the E.M.O. has been in developing countries I am inclined to think that Mac's most widely followed innovation was indirect elevation of the epiglottis (Macintosh laryngoscope 1943), in which context at least Chevalier Jackson and Manuel Garcia deserve inclusion. But my purpose in writing is to ask, lest future historians are confused, that the date against the E.M.O. be revised. If the entry is still to read' designed by' the year 1952 would be more appropriate, for all that Jennifer Beinart also quotes 1956 in her 'History of the Nuffield Department'. As one of the dwindling number of survivors of 'those who were there', I feel some responsibility to get the record straight. At this juncture I cannot lay hands on actual proofbut I am sure that, as I have stated in my 'History ofLongworth Scientific Instrument Co. Ltd.' the first sales of E.M. 0 .s, made by us at Abingdon, were in late 1953 to the governmentoflndonesia. 1956 saw, I think, the placing ofa major order by the State of New York for civil defence, and may well ~e the year of actual grant of the British patent, though the provisional specification would have been filed much earlier. It was also the year in which the first journal description was published, but I am sure design was completed several years before. I enclose a photocopy [reprinted herewith] of a page of the 1974 Penlon catalogue which gives many references but also quotes 1953 as the year of introduction of the apparatus. I am writing to Penlon to see whether any more positive evidence still exists. Meanwhile, under separate cover, I am mailing you a copy of my little book mentioned above. The latest number of the Australian journal 'Anaesthesia and Intensive Care' has just arrived. It contains some most interesting memories of Mac. With kindest regards, Yours sincerely,

Sir Anthony ]ephcott 21 Brilliant St. St. Heliers Auckland 5, New Zealand

THE E.M.O. AND OUTFITS (Pen/on Limited Catalogue, 1974 Edition) Since its introduction in 1953 the E.M. 0. Inhaler has become firmly established as the apparatus of choice for the open circuit ether/air/ relaxant technique of anaesthesia. This technique and equipment has much to recommend it clinically and wherever reliability, convenience and cost are important considerations. The E.M.O. is fully temperature compensated and incorporates an automatic thermostat valve which ensures constancy of the ether concentration over the course of a lengthy administration. The integral high thermal capacity of the E.M.O. is afforded by incorporating a fairly large mass of water. This is contained in a compartment surrounding the ether chamber where it also serves, by local convection, to even out cold spots on the wick surface from which it is separated by a thin wall of copper. This compartment, once filled, is left untouched, except for a very occasional check to see that it is still full. It is thus quite

unlike the water jacket of certain other vaporizers which require refilling before every administration. The E.M.O. is a sophisticated vaporizer oflow internal resistance, designed to enable the user to obtain known pre-determined concentrations of the vapour of a volatile liquid anesthetic agent. Although simple to use and requiring far less maintenance than gas anaesthesia machines, the design is the result of many years of research at the Nuffield Department of Anaesthetics in the University of Oxford. That the desired concentration remains effectively· constant over a wide range of respiratory rates and volumes is ensured by a carefully determined relationship between the volumes of the various chambers and flows directed through them by bell-mouthed and sharpedged orifices. Maintenance of the concentrations over long periods of time is ensured by the high thermal capacity of the construction and by a thermostat valve. The E.M.O. is intended primarily for ether/air anaesthesia, and as the system does not involve compressed gases, an essential adjunct is a self-expanding bellows or bag to enable the anaesthetist to maintain adequate ventilation of the patient in all circumstances. The three portable outfits shown differ only in the type of ventilation equipment. With each one, however, it is quite practicable to maintain adequate ventilation with the patient fully curarised for abdo~al surgery, and receiving only a 'sleep' dosage (about 3%) of ether. All outfits listed in this publication incorporate metal to metal taper connections which conform dimensionally to B.S.3849.

Anesthesia History Association President ....................... John E. Steinhaus Past President ................. Elizabeth A.M. Frost Vice-President ................... Betty]. Bamforth Secretary-Treasurer ................ Lucien E. Morris Council Membership .............. Selma H. Calmes Rod K. Calverley Miguel Colan-Morales H. Raymond Fink George Bause Maurice Albin

Anesthesia History Association Newsletter Printed and Distributed Courtesy of DESERET MEDICAL Becton Dickinson and Company Manufacturers of a Complete Line of I. V. Catheters

Did You Know? The column, "Did You K110w?," which was suggested in the last issue ofthe Newsletter by Dr. Ole Secher, Professor Emeritus at the Rigshospitalet in Copenhagen, Denmark, has brought forth some fascinating examples written by Dr. Secher. Readers are encouraged to submit their own items related to historical vignettes which may be of itzterest to others. -Editor

Did you know ... • That the first ether anesthesia in Philadelphia was given on the 29th of December, 1846, by the dentist John Foster Brewster Flagg (180272), 190 Arch Street, for a tooth extraction on a twelve year old boy. Flagg wrote the first American book on anesthesia: "Ether and chloroform. Their employment in surgery, dentistry, midwifery therapeutic etc." Lindsay and Blakiston, Philadelphia, 1850. He later became the. first Professor of anatomy and physiology of Philadelphia College of Dental Surgery, established in 1852, the name being changed in 1856 to Pennsylvania College of Dental Surgery. • That scopolamine comes from the name of a plant, Scopolia cameo fica Lin. Lin. means that the plant was named by Carl von Linne (1707-78), who was a physician and particularly a botanist in Uppsala, Sweden. He named the plant in honor of the Italian doctor, naturalist and botanist, 1\ntonio Scopolia (1713-88), Professor of Mineralogy, Pavia, who wrote a book on the plants of the province ofKrain = Carniola, formerly Austria-Hungary, today Yugoslavia. The title is: "Flora carniolica" from 1760. • That ether was probably first produced in 1540 by Valerius Cordus (1515-44), doctor and botanist in Wittenberg, Saxony. He named it "Oleum vitrioli dulce verum" =sweet oil of vitriol. The name is found in his book: "De artificiosis extractionibus liber," Strassbourg, 1561, published after his death by Conrad Gesner (1516-65), who was a

botanist and zoologist in Zurich. It was Sigmund August Frobenius (?1741), working in London as a chemist, who named the compound "ether" in an article titled: "An account of a spiritus vini aetherus together with several experiments tried therewith.'' It was published in Transactions ofthe Royal Sodety, 1730, 36:283-89. The name he took from the Greek, meaning "air."

Anesthesia History Association The following committees ofthe Association have been appointed by the President, Dr. ]olm Steinhaus, Jar the year 1990.

Program

David Little Prize

Betty Bamforth, Chrm. Ted Smith John Severinghaus

Selma Calmes, Chrm. Raymond Fink Nicholas Greene Leslie Rendell-Baker

Nominating Elizabeth Frost, Chrm. Norman Bergman James Burleson

Ac.dit Maurice Albin, Chrm. Helmut Cascorbi

Membership

Bylaws Revision

George Bause, Chrm. George Edwards Paul Goldiner

Al Hyman, Chrm. Brendan Finucane Miguel Colen-Morales

Join the Anesthesia History Association Please bring to the attention of colleagues and residents the advantages of joining the Anesthesia History Association. Founded in 1982, this organization functions as a common ground for those interested in the history of our specialty. A Newsletter is published quarterly with items ofhistorical interest and news of ongoing meetings and projects. An annual meeting and dinner with a featured speaker is held at the time of the ASA meeting. Dues are S35.00 per year and $10.00 for residents in training.

Name________________________________________________________________________________

Particular interests: ________________________________________________________________________

Send dues to: Lucien Morris, M.D., 15670 Pt. Monroe N.E., Bainbridge Island, WA 98110.

Creativity and Discovery ... Continued from First Page property of low toxicl.ty. Streptococcal septicemia, pnemonia, a~d meningitis- all highly infectious, very acute, and frequently fatal diseases - were dramatically cured by sulfa drugs. Goodman and Gilman's text, the "bible of pharmacology" for many generations of medical students, which I used as a second-year medic:J student in 1943, emphasized the importance of the sulfa drugs but did not even contain the words "antibiotic" or "penicillin." Penicillin was restricted to military use during the greater part ofWWII, and was not released for civilian use until1945. Penicillin certainly deserves its fame as a milestone in medicine, one which introduced the antibiotic era that led to highly successful treatments for most of the infectious bacterial diseases. Nobel prizes were awarded in 1945 to Sir Alexander Fleming, H. W. Florey, and Ernest Chain for their contributions to the discovery and introduction of penicillin. Even so, Wilson points out that the real breakthrough in the treatment of infectious diseases occurred with the introduction of sulfanilamide a few years earlier. In 1929, Fleming reported the antibiosis of the mold Petzidl/in twtatwn on the culture plate ofstaphylococci, and isolated the principal penicillin which lysed staphylococci in broth cultur~. Furthermore, he demonstrated that penicillin had a relatively low toxicity in animals; however, he did not treat laboratory animals infected with pneumonococci or other sensitive bacteria, although he suggested that it was {)f possible therapeutic worth. Chain comments that the lack of enthusiasm by Fleming's superior may have discouraged further investigation. Therapeutic possibilities of" antibiotics" had been suggested by Pasteur in the 1870's and repeated by numerous medical scientists during the following 50 years. Although no successful antibiotic emerged during this period, the concept of antibiotic therapy persisted until a combination ofobservations and events led to the establishment ofpenicillin. Chain and Florey's major research interest was the investigation of lysozyme, found in tears, and the mechanism of action of this lysis ~f bacteria. Their initial interest in penicillin was directed toward the lync phenomenon and not the treatment ofbacterial diseases. A colleague in their labor:ftory happened to have the penicillin culture from Fleming, because of his early study ofbacteriophage which produced a similar lytic phenomenon. The Penidllitz tzotatum culture was kept going for a number of years for no specific purpose. The purification of penicillin and its lysis of pathogenic cocci led to the definitive study of treatment of these infections, first in animals and later in man, by Florey and Chain. In discussing the element of luck in discoveries, Sir Ernest Chain states, "I do not know of a single case of a major disease for which a cure has been found because the research worker wanted to find one." His discussion of penicillin's discovery clearly indicates that neither he nor Florey was consciously directed toward finding therapeutic agents for bacterial infections, and that Fleming himself, due to lack of interest or to discouragement, did not pursue the concept of antibiotics. In summary, the disorganized introduction of antibiotics began with the very early observations of the natural phenomenon of antibiosis, and subsequent continued interest in its potential by many scientists. Later, a specific antibiotic substance that was relatively non-toxic and yet highly bactericidal, was isolated, tested, and ultimately recognized as the valuable therapeutic agent penicillin. It should also be noted that the medical-scientific community was probably receptive, by this time, due to the successful introduction of the sulfa drugs and the report of an effective antibiotic, tyrothricin, by R Dubos in 1939. The discovery of curare, the second drug I shall examine, has drastically altered the practice of anesthesiology. The action of this drug fascinated the early Europeans who visited selected areas of South

America and saw "arrow poison" used by the natives. First brought to Europe as a curiosity, it was subject to a classic scientific investigation by Claude Bernard in 1851, who showed that it caused muscle paralysis by blocking the neuromuscular junction. At this time, there was little knowledge concerning the mode of action of drugs and almost none about the specific site of action. In fact, this new concept of m~dical therapy was strongly resisted in the mid-19th Ce~tury by many_ m the medical profession who clung to the notion that disease was the unbalance of the humors. From the time ofBernard's work in 1851 up to the 1930's, there were many unsuccessful trials of curare in medical practice, directed generally toward the control of convulsive or spastic states invol~g the skeletal muscle system. Patients treated with curare frequently died due to the resiratory depression caused by the paralysis of the muscles of respiration; consequently, its usefulness was severely limite~. Although in 1940, Bennett, a neuropsychiatrist, employed curare m the new electroconvulsive therapy, to prevent vertebral fractures, Goodman and Gilman (1941) listed curare as a pharmacological tool with no established therapeutic use. As a third-year medical student on the Psychiatric Service in 1943, I observed the use of curare in electroconvulsive therapy. On one occasion, we returned to the treatment room to discover a very cyanotic patient suffering from a continuing respiratory paralysis. The medical profession did recognize the poss~bility of profound respiratory insufficiency during treatment, but did not recognize that respiratory support might be needed ~~ereafter and that the patient should be carefully observed during the recovery period, and ventilated as needed. Griffith and Johnson first reported the use of curare for muscle relaxation during anesthesia in 1942. Although curare provided muscle relaxation and paralysis in a predictable fashion, its use was not rapidly · adopted by anesthesiologists. The extensive mortality study ~n 19~4 by Beecher and Todd reported a significantly higher death rate m patients receiving curare, and was critical ofits use. Although the anesthesiologist was well prepared to deal with respiratory insufficiency during the administration of anesthesia in the early 1950's, the use of mechanical · ventilators had just begun, and the post-anesthesia recovery room was in an early phase of its development. The failure to breathe adequately introduced a new hazard for partly anesthetized patients, particularly in the recovery period. Nonetheless, curare allowed total relaxation with relatively low doses of anesthetic drugs, which reduced serious depre~­ sion of the circulatory system. Furthermore, the depth-of-anesthesia concept was definitely altered, and muscle relaxants became invaluable tools of the anesthesiologist, both for surgical relaxation and intubation. The most fascinating stages of the development of curare were its primitive use as an arrow poison, and Bernard's studies, which demonstrated its true mechanism of action at the neuromuscular junction. But it did not achieve the status of a valuable drug until modern times, when both the recognition of respiratory deficiency and techniques of artificial ventilation were well established, and the organization of patient care for the applications of these therapies could prevent serious complications or death. From the previous discussion, it is obvious that drug discoveries are seldom direct, orderly, or simple matters. The complexity of the discovery of new therapies is well illustrated by the story of the drug, lidocaine, which I have studied and em played during most of my medical career. Introduced in 1948, lidocaine has been an excellent, widely used local anesthetic, but this use does not qualifY it for even a 'junior milestone of medicine" designation. More significant, as a contribution to therapy, is its use as an antiarrhythmic. In my early studies of local anesthetic toxicity, it was noted that some local anesthetics Continued on Page 5

Creativity and Discovery ... Cot~tilluedfrom Page 4 induced marked depression of cardiac conduction. Since we were also conducting research on arrhythmias that followed experimental coronary occlusion, a selection oflocal anesthetics was administered in an attempt to reverse the ventricular fibrillation which frequently occurred. Lidocaine proved to be the most effective agent. Interest in the use of lidocaine for this purpose was limited due to the growing, successful use of electrical defibrillation. However, these studies initiated a gradual but growing interest in the use of lidocaine against less serious ventricular arrhythmias. The emergence of open heart surgery and coronary units in the 1960's stimulated strong interest in and broad acceptance oflidocaine as an antiarrhythmic. Widespread use of lidocaine drips in coronary care units across the country caused a crisis for the Food and Drug Administration, because lidocaine was not approved for use as an antiarrhythmic. A" crash course'' in the new drug's application resulted in speedy approval of lidocaine for this purpose. This again demonstrates that authorities frequently fail to recognize valuable innovations and discoveries, and often have to run to catch up. In our studies on patients to determine dosage ran_ge for lidocaine as an antiarrhythmic, we noted that this drug had a profound effect on respiratory reflexes when given as an adjuvant during general anesthesia. Coughing, bucking, and laryngospasm provoked by laryngoscopy and intubation could be readily suppressed. Compared with other drugs used for anesthesia, lidocaine suppressed the cough reflex while sparing respiration. This new, additional use of lidocaine to suppress respiratory reflexes has not been approved by the FDA, since financing for studies is not available due to the generic status of lidocaine by this time. The preparation and sale of generic drugs is not exclusive and there is no way to recover the huge costs of a new drug introduction. Although not officially approved, lidocaine has been used on a limited but continuing basis to depress respiratory reflexes. The case oflidocaine provides an example of a drug that was initially introduced for a well established local anesthesia therapy, was then used for another therapy-antiarrhythmic-becoming an agent of choice which received belated approval. Finally, lidocaine is employed for still another therapy, cough suppression, in which acceptance is delayed because regulations for drug approval are designed for new drugs that can be patented. The stories of the three important drugs just discussed illustrate the many variations and complexities of therapeutic discovery. Certainly, one important aspect of these drug introductions is timing. Although a drug may be studi~d and its action well described; as was the case with curare, its importance and usefulness may not be established until medical knowledge and practice have reached a state fertile for its application. Curare was not useful until artificial or assisted ventilation could be practically and safely managed in the face ofcurare's depressant effect on the muscles of respiration. In the early days following curare's introduction into anesthesiology, I observed much resistance to its use from the well established leaders of the specialty, who recognized its dangers but not its therapeutic potential. The dangers of these adverse side-effects diminished significantly with the introduciton of mechanical ventilation and with the improvements in respiratory management which accompanied arterial blood gas measurements. :_ the case of penicillin, the separation and extraction of an important therapeutic principle from a complex water mixture of nutrient, metabolic products, and the biological qrganism itself, required new biochemical skills. The dominant thrust of organic chemistry in the earlier period from 1920-1940 was the synthesis of new chemicals from relatively pure compounds. Furthermore, this extraction and purification of penicillin had to be completed without destroying or altering

the active principal. The drug lidocaine introduces a further complexity in that its introduction as a local anesthetic was not unique and its addition to the therapeutic armamentarium was modest. Its acceptance and use as an antiarrhythmic had a greater impact on therapy, but was delayed by the manufacturer who thought it might jeopardize his growing, lucrative market oflidocaine as a local anesthetic. Furthermore, there was a lack of demand for a better antiarrhythmic for treating acute ventricular arrhythmias. This latter deterrent was rapidly reversed with great advances in open heart surgery and establishment of coronary care units. As mentioned earlier, lidocaine produced a crisis for the FDA because it was widely used before it was approved by the FDA as an antiarrhythmic. The use of lidocaine as a suppressant of cough reflexes during anesthesia has also been inhibited by our system of drug introduction. The cost of new drug approval by the FDA is in the millions of dollars and is supported by the profits from a new drug patent. By the mid1960's, lidocaine had lost its patent protection and became a generic drug. Other pharmaceutical companies could then manufacture and sell the drug without developmental costs. Although lidocaine's action on respiratory reflexes is relatively unique, anesthesiologists have managed laryngospasm and related problems by varied techniques and have not seriously looked for drugs that produced this limited action on the central nervous system. Whether or not this will become an important therapy, only the future will tell. Another element worthy of note in the discovery :i.'nd introduction of these drugs is the role that chance plays in the process. With penicillin, Chain pointed out that Fleming's observation of the lysis of staphylococci by the mold penicillin on an agar plate could only occur with two different temperatures of incubation, the staphylococci growing better at 37° and the mold quite adequately at room temperature. He suggested that this history-making observation occurred because Fleming was not a tidy bacteriologist and allowed old cultures to sit around the laboratory for long periods before disposing of them. Chain and Florey state that their initial research on penicillin was not a search for a therapeutic agent, but rather a study of the process oflysis, and it just happened that colleagues with no active research programs i~ ~his area had maintained over a period of years a culture of the ongtnal Pet~idllill tzotatum obtained from Fleming. The role that indirection plays is illustrated in the introduction of the antiarrhythmic action oflidocaine, since the initial stimulus came from research on the toxicity oflocal anesthetics, particularly the action on cardiac conduction. It was observed furthermore that lidocaine depressed respiratory reflexes during studies of its antiarrhythmic action in patients. Upon recovery from anesthesia, some of these patients not only tolerated the oral pharyngeal airway, but even tried to talk with the airway in place. Another interesting feature of these discoveries is the frequent lack of acceptance of the new therapy by authorities and experts in medical science, government, and industry. Chain speculates that the failure of Fleming to follow his early interest in penicillin may have been due to the total lack of interest in the potential of antibiotics by Fleming's immediate superior. He also _cites his own failure to obtain modest financial support from the Medical Research Council for his initial studies on penicillin. Fortunately, support came from other sources. It was mentioned earlier that curare was not widely adopted by the well established leaders in anesthesiology who were convinced that the older anesthetic agents, ether and cyclopropane, were more effective and safer. They focused almost entirely on the adverse action, and could see little, if any, of the benefits that have since been amply demonstrated. Lidocaine's acceptance as an antiarrhythmic was very slow in coming. A young anesthesiologist, during his required military Collti1111ed 011 Next Page

Creativing and Discovery ... Colltimu:dfrom Page 5 service, began his announced use oflidocaine during open heart surgery at Bethesda. Its effectiveness led the cardiac surgeon and his group to compare lidocaine with other antiarrhythmics. The pubication of this study led to widespread adoption oflidocaine as the agent of choice for treating ventricular arrhythmias. As might be expected, the young physician finds new ideas and therapies more acceptable and is willing to adopt them. Finally, the curiosity and the drive on the part 'of individual researchers, scientists, and physicians to understand, to discover, should never be understated, ignored or unappreciated. The attempt to relate observations in these searches often results in what Severinghaus has called the "Ah Ha! principle." While all new discoveries must survive critical examination, care must be taken to avoid rejection due to orthodoxy or unquestioning adherence to accepted medical practice or current scientific understanding. A stimulus to this process of discovery and creativity, for the anesthesiologist, is his or her recognition of unmet need or limitations in our practice at present. If we are satisfied with the current state of affairs, little will happen. For the practice of anesthesiology, it is my opinion that monitoring must be developed to a point where all important physiological variables are recorded during anesthesia. Death, if it occurs, during anesthesia, should be attributable to the patient's disease. Consequently, the cause of death must be definitely established. Adoption of monitoring has been slow because the profession has been satisfied by its practice with limited monitoring. Much of anesthesia practice comes from empirical knowledge due to our limited understanding of anesthetic drug action in the central nervous system. Consciousness, anxiety, and pain are all poorly understood. This knowledge gap illustrates the need for creativity and discovery in our specialty. The central nervous system as the major site of action is understood only in a limited fashion: consequently, states of consciousness, pain, and anxiety are areas that need a substantial research effort. In closing, a few comments are appropriate on who should get credit, and we are missing the main event. Our admiration for persons who discover new medical information or introduce valuable new therapies leads us to focus on the recognition for such contributions. Such discoveries may have been due to chance or, on the other hand, persistent research efforts. Recognition of the event may be due to timing or other external events and has little to do with the merit of the individual. The discovery of new knowledge should be its own reward; and recognition, although pleasurable, should be a secondary consideration. If personal gain or recognition is the primary goal, truth often suffers and personal satisfaction may well be shattered. The unhappy outcome of the claims ofHickman and Wells, and even Morton, to the discovery of anesthesia demonstrates this latter course. Certain reasonable data on the discovery of anesthesia can be reasonably established, including Crawford Long's first administration of ether, and Morton's first public demonstration. The allocation of credit is much more complicated, since no guidelines or rules have been laid down. If one views Crawford W. Long's professional life, service, and accomplishments, the medical profession can only feel proud of this physician's contributions. I would· only repeat that the discovery of a new medical therapy should be its own reward, and that all who contribute to our major discoveries should share in the credit.

Selected References

David Wilson. I11 Search q{Pellidllill, New York, Alfred A. Knopf. 1976. K. Bryan Thomas. CURARE: Its Historya11d Usage, Philadelphia, Lippincott, 1963.

John Parascandola, Ed. Tize History q(Amibiotics, A Symposium. Madison, WI: American Institute of the History of Pharmacy, 1980. Louis Goodman, Alfred Gilman. Tize Phamuu:ological Basis q( Tizerapeutics, New York, MacMillan, 1941. N.L. Carden, J.E. Steinhaus. Lidocaine Resuscitation from Ventricular Fibrillation. Cirmlatio11 Res 4:460, 1956. J.E. Steinhaus, Lewis Gaskin. A Study of Intravenous Lidocaine as a Suppressant of Cough Reflex. A11esthesiology 24:285, 1963.

History of Anesthesia and Related Fields in Philately by Miguel Colon-Morales, M.D. The LUNGS and the HEART are undoubtedly the two most important organs in the body with which the anesthesiologih has to deal during the administration of any anesthetic. Maintenance of adequate oxygenation and organ perfusion is perhaps the most important fimction of the anesthesiologist in his daily practice. During the last decade, enormous efforts have been made worldwide to create public awareness about the ill effects of smoking on these two vital organs. The importance of preventing both pulmonary and cardiovascular disease and/or restoration of normal or near normal function of both these organs prior to surgery and anesthesia is paramount to the good practice of anesthesiology. ' Several countries have issued stamps with the purpose of educating their communities about the danger of smoking to our health.

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Ambulatory Surgery It was 22 years ago when Dr. wallace Reed and his partner, Dr. john L Ford began to think about establishing afreestanding ambulatory care clinicJor the treatment of patients twt necessarily requiring hospitalization. 11zis novel idea met with some opposition, partirolarlyfrom hospitals and bureaucratic institutions, but these two pioneers forged ahead and a scant two years after the concept _first blossomed, opened in Phoetzix, Arizona, the _first _freestanding surgicetzter of its kind. 11ze story oftheir trials and tribulations, and oftheir perseverance and detennitzation, is told in thefollowing article, which was origitzally presetzted at the 1988 meeting o_(the Sodetyfor Ambulatory Anesthesia (SAMBA) in Phoenix. Little did these innovators realize that, in less than a quarter o_(a century, up to 50 percent o_(operative procedures in this country would be pe~{Onned on atz ambulatory basis. T# are indebted to Dr. Reed_{Or permissiotz to publish this accozmt o_(his patl~finding endeavor. -Editor

H·ow It All Began by wallace A. Reed, M.D. Exerotive Director, Surgicenter Phoenix, Arizona It all began as a series of conversations between my partner,John L. Ford, and myself back in 1968 as we became increasingly sensitive to complaints by patients about the cost of their surgery. The epitome of the complaints about cost was that of an uninsured barber from a nearby community whose two children were having adenoidectomies. He told us that it would take all of the income from some 250 haircuts to pay for those two procedures. That made a deep and lasting impression on us. There were also other parties complaining about the cost of medical care. The government was among these. In fact, then-President Lyndon Johnson had appointed a National Advisory Committee on Health Facilities to find out how the country's health needs could best be met. The Commission's report concluded in 1968, among other things, that: 1) experimentation is needed to develop effective programs for financing health services from a variety ofsources; and 2) communities should aim to improve the less developed components of comprehensive health care, such as the organization and delivery of ambulatory health care services. John Cashman, Director of Community Health Services for the Department ofHealth, Education and Welfare, quoted his boss, Robert Finch, as saying, "This Nation faces a breakdown in the delivery of health care unless, and until, immediate concerted action is taken by the government and the private sector." The insurance industry was also complaining. Mr. Nathan Stark, a member of the Health Insurance Advisory Council, saw the solution in 1) stimulating experiments and innovations in the organization and delivery of health care services, 2) obtaining broader health insurance coverage for alternatives to inpatient care, and 3) involving the medical profession increasingly in the effort to control costs.

What about health care leaders themselves? What were they saying? Well, the report of the American Hospital Association on outpatient care, published in 1969, concluded: "In the years ahead, significant improvements must be made in the delivery of health services to ambulatory persons if good health care is to be provided to the people of this country. Hospitals, physicians, other health care personnel, planning agencies, and financers of health services, including their associations and agencies, all have special and collective responsibilities to assure the provision of optimum ambulatory care." At the same time, Dr. Russell V. Lee was saying that hospital costs are too high because many of those who are hospitalized do not need much of the fantastically expensive equipment which is there. Such patients could be cared for in less expensive surroundings. He suggested a core

hospital should be surrounded with a number of closely associated special purpose facilities. The facilities for most ambulatory surgical patients in 1968 were not well organized. The patients themselves were dissatisfied. They were unhappy with the cost of their care and how they received that care. Surgeons were not at all pleased with the service;1to ambulatory patients. They were inconvenienced by having to move from the main operating room suite to the emergency room or a small treatment room. More often than not, a needed instrument was missing, and the whole operation was delayed while someone retrieved the missing item from the main operating room. Anesthesiologists felt at a disadvantage treating these surgical patients in the cramped quarters ofthe Emergency Room. Nurses complained about interrupting their major assignments to take care of less significant cases. On the other hand, for patients at George Washington University Medical Center in Washington, D.C. and at the University of California at Los Angeles, there was a more attractive environment. At both of these institutions, ambulatory surgery programs were initiated because of a shortage of hospital beds. Marie Levy sent me a copy of the report she and Charles Coakley made after a year's trial of the new program at George Washington University. They had a separate suite of rooms for ambulatory patients and had 2121 admissions during the period from April, 1966, through March of 1967. The response of patients was overwhelmingly positive. David Cohen and John Dillon began their program at the University of California, Los Angeles, in 1963 and succeeded in publishing their results in JAMA in June, 1966. Dr. Dillon informed me in a personal communication that the Editor ofJAMA did not want to accept the article for publication because it was at such variance with accepted practice at the time. Indeed, in the first sentence of their comments, the authors state, "The concept of outpatient general anesthesia is at variance with much established custom." The abstract of this paper follows. It is possible to conduct a program of anesthesia for outpatient surgery without compromising patient safety. Intelligent selection of cases and anesthesia method minimizes the incidence of complications. The feasibility and practicality of outpatient surgery were demonstrated by the fact that only 33 of804patients (4.1%) were admitted as inpatients, and most ofthese during the early part ofthe study period. A properly equipped and staffed outpatient surgical unit is necessary; the availability of such a facility

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Ambulatory Surgery ... Continued from Previous Page

It was at this time, too, that we began to define our objectives: 1) to make the "ambulatory patient" a matter of greater concern; 2) to makes rapid exp~nsion of surgical capabilities feasible in streamline the delivery of his/her medical services; 3) to reduce the civil disaster. This flexibility is an attractive feature which cost of his/her care; 4) to work for a broadening of his/her insurance can be helpful in obtaining funds for such expansion. An coverage; and 5) to provide a pleasant atmosphere for patient, staff and estimated $28,000 in savings to patients or insurance comsurgeons. panies was achieved and approximately 1,000 hospital Soon our building plans had progressed to the point where support days were saved during the study period. services were taken into consideration and where the attractiveness of the free-standing Surgicenter occupied our minds. Noting the results of the programs in Washington. and Los Angeles, It now became necessary for us to go public with our plans; and as we we were encouraged to receive from Dr. Domette a letter containing did so, a hot political battle developed. As we fought successfully for his observation that, "A safe and efficient facility for performance of approval by the Comprehensive Health Planning Council ofMaricopa general anesthesia and minor surgical procedures need not be affiliated County and the State Department ofHealth, we stirred up competition either administratively or geographically with a hospital." from the hospitals, which now announced reduced charges for outIt was at this point we began doodling and sketching. The first sketch patient surgery even before we had opened our facility. The announcewas made on the back of a small tent table advertisement at the ment from Doctors Hospital was made just one month after our Smugglers Inn. At the time of that first sketch, we were focusing on groundbreaking on August 8, 1969 (Figure 1). admitting, operating, and recovering the patients. There was a lack of Needless to say, there was another battle going on atthe same time to almost all support services. obtain financing. Our bankers were not exactly pleased with the idea of putting up money for a single purpose building to be devoted to a controversial We earnestly hope that you will find it idea. So they asked us to supply evidence of support from the professional compossible to attend the groundbreaking of munity and from third party payers. This evidence took. the form ofletters SURGICENTER from Dr. Larry Li~e~, a pediatric surFriday - 12:45 p.m. ·· August 8, 1969 geon who is now a Senior Vice President with Arizona Blue Cross, and from Mr. 1040 East McDowell Road Dan Pettengill, an Aetna Insurance ComPhoenix, Arizona pany actuary, and a memo from Dr.Louis M. Rousselot, the Deputy Assistant Secretary of Defense, who wrote under the A new and unique short-stay surgical subject "Surgicenters": "We think this facility which we feel will benefit the is an interesting and worthwhile conmedical community. cept." Metropolitan Life Insurance Com\·lALLY REED pany, acting on the recommendations of John L. Ford, M.D. PHOENIX HAYO!l. HILTON GRAHAI-l Mr. Joseph Clune, a Group Staff ManWallace A. Reed, M.D. ager, went a step further and developed JOHN FORD a plan "to inspect each new facility as it developed and opened, and recommend ... whether or not ... we should accept such a facility . . . " For several years, the Metropolitan SURGICENTER is a medical facility designed to inspection was the only form of survey provide quality surgical care to the patient whose operation is too demanding for a doctors office, by outsiders to which these facilities yet not of such proportion as to require hospitalizawere subjected, with the result that it tion. The numerous advances in surgical technique was sought after as the equivalent of together with the new local and general anesthetic what earlier on was known as "The Good agents have demonstrated in other areas that such Housekeeping seal of approval." We owe a facility will be most popular and efficient. a great debt to Metropolitan and Mr. Joseph Clune for voluntarily taking on Presently, facilities of the advanced type which is this assignment. As of October, 1978, of being established in Phoenix are in operation in Capetown, South Africa; Upsala, Sweden; London, over 130 facilities visited, fewer than 60 England; and Munich, Germany. had been recognized, which shows that the Metropolitan was rather selective in Many urgent appeals have come from the governbestowing its seal of approval. ment, labor, industry and the medical profession to Blue Cross approval was not obtained streamline the delivery of medical care and to until early in 1970, and it was 1972 reduce its cost. The private insurance industry and the government have investigated and approved this before the Federal Employees covered new approach and have assured support for the by Blue Cross were included. ambulatory patient treated at a SURGICENTER Contimted on Page 9 facility.

Ambulatory Surgery ... Cotztirmed from Previous Page Nevertheless, even without Blue Cross approval, in 1969 when we were able to demonstrate to the bankers that Aetna and the CHAMPUS program were supportive and that we could get professional liability insurance, they approved the financing. We held a dedication ceremony in February, 1970 and opened for business on February 12 with a team of four nurses, one business manager, one plant manager, and two anesthesiologists. Two of the. nurses are still with the team. On opening day five different surgeons, brave souls, used the facility, and five operations, four of them requiring general anesthesia, were performed. Mter a year of operation, we had added four nurses, one anesthesiologist, a business office helper and an orderly. By August of 1970, i.e., after about 6 months of operation, we had 225 surgeons on our staff and approval from 44 insurance companies. Meanwhile, as interest in the concept spread rapidly across the country, there were numerous requests to the Maricopa County Medical Society and the Arizona Medical Association regarding our standing in the professional community. These two organizations showed enthusiastic support for our ventUre. Endorsement from the American Medical Association was obtained in 1971. In 1972 we were honored by receiving the Gerard B. Lambert Award, given for those ideas which improve patient care and reduce costs. A letter of congratulations on receiving this award was sent by Barry Goldwater. In 1973 the American Society of Anesthesiologists approved a document titled, "Guidelines for Ambulatory Surgical Facilities," in which it is stated, "The ASA endorses and supports the concept of ambulatory surgery and anesthesia and encourages the anesthesiologist to play a role ofleadership in the development of this concept in both the hospital and freestanding setting." During the ensuing years, we encountered and overcame numerous additional obstacles, each one of which could be the subject of an interesting story in itself. We developed the philosophy "to convert obstacles into opportunities." The Society For Advancement ofFreestanding Ambulatory Surgical Care was formed in 1971, incorporated here in Arizona, and developed standards for accreditation of its organizations. Dr. Robert Knapp, Dr. Boyden Crouch, Mr. Bernard Kershner, Mr. Robert Williams, Dr. Robert Lykins and Dr. Harry Wong were among those who helped develop the By-laws and standards. This organization, now known as FASA (Federated Ambulatory Surgery Association), fused its survey procedures into the Accreditation Association for Ambulatory Health Care in 1979. Other centers began to develop in 1974 and joined with us in the accomplishments which followed. Included were centers irritated by Dr. Goolsbee and Dr. Gibbons in Kansas City, Dr. Knapp in Wichita, Dr. Natofin Chicago, Dr. Belshe in St. Cloud, and Dr. Wong in Salt Lake City. With Dr. Paul Healey's significant help, the organization of freestanding surgical facilities obtained the blessing of the American College of Surgeons in 1980. The early days of the Medicare story culminated in the signing in 1974 of a contract for a demonstration project with 6 centers, of which the Phoenix center was one. The anesthesia technique "paramalgesia," as described by the Surgicenter, is derived from the following: PARalysis, provided by a muscle relaxant; AMnesia, provided by a barbiturate such as thiamylal sodium, 100-200 mg; and AnALGESIA, provided by N20:02, 4.5:1.5 L.

The caseload increased from 123 in the first full month (March) to 256 in July, less than 6 months later. The total caseload for the first year of operation was 2500. By December, 1987, the total number of patients treated at the Surgicenter was 107,252. The registration of the "Surgicenter" name as a Service Mark was accomplished in August of 1971. The name later became so popular that it was ruled to be "generic"; so about ill this certificate amounts to now is a souvenir. The tenets which we believe are responsible for our success in implementing our objectives are noted in Table I. The key ingredients are a skilled team of nurses, surgeons and anesthesiologists who concentrate on delivering compassionate care at a technical level proportional to the surgical need. Incidentally, as a final observation for those who may have been wondering about it, the cost of an adenoidectomy today in terms of the number ofhaircuts needed to pay for it is around 80 as compared with 125 in 1968. The price ofhaircuts has tripled from $2.00 to $6.00 while the cost of an adenoidectomy has doubled (from $250.00 to $500.00).

TABLE I Objectives of a Surgicenter 1. Develop a level of care proportioned to the surgical need. 2. Conduct ourselves as an upward extension o~the surgeon's office. 3. Eliminate explosive agents. 4. Eliminate cafeteria and in-house laundry services. 5. Eliminate unnecessary laboratory tests. 6. Eliminate routine pre-op chest plates. 7. Develop a one-page medical record. 8. Develop one all-inclusive facility fee. 9. Provide a pre-op screening physical exam at no charge for all patients, whether scheduled for local or general. 10. Provide a cassette and clipboard for each patient and a taperecorder in each O.R. for easy dictation and STAT checking of dictation by the surgeon. 11. Provide pleasant and comfortable decor, more suggestive of a doctor's office than a hospital. 12. Make a post-op telephone call to every patient. 13. Provide a top-notch group of nurses for O.R. and P.A.R. 14. Provide an anesthesiologist on the premises until the last patient is discharged.

Brit. med. ]., 1869, Mar. 13. 325. Percy Leslie, Birmingham. Artificial respiration apparatus. The dyspneic or collapsed patient, who is already short of breath, or h_; would not be needing artificial respiration, is apparently expected to pedal and do his own "assisted" breathing!!

Anesthesia and Robert Liston Anecdotes abound conceming the beginnings ofanesthesia and how it spreadfrom the United States to other countries. With the kitzd pennission ofDr. Elliott Miller, President of the Wood Iibrary-Mztseum, and the Department ofAnaesthesia of the Massachusetts General Hospital, the following story relates the way itz which the famous Scottish surgeon, Robert Liston, first used ether anesthesia for a major operation in London on December 21, 1846. It is believed that the temz "Yankee Dodge" originated wjth Dr. Liston, as the following tale indicates. Therein is the derivation ofa recently-completed videocassette titled, "The Yatzkee Dodge," tzarrated in large part by Dr. Leroy D. Vandam. This videotape brilliantly describes the relevant roles of Crawford Long, Horace JIVe lis, William Thomas Green Morton and Charles 11wmas Jacksotz itz the discovery of anesthesia. It is obtainable by loan or purchase from the Wood LibraryMuseum. -Editor

The word of Dr. William T.G. Morton's ether demonstration on October 16, 1846 spread quickly around the world. Steam packets from Boston carried the message to Halifax, London and Dumfries. Hope of extinguishing the pain of surgery had been raised for years. This hope was now realized and a few physicians were quick to seize the , opportunity. On November 28, 1846 Professor John Bigelow wrote a letter to an old friend, Dr. Francis Boott, describing the event. Travel time to England by steamer was an average of fourteen days. The winter of ·1846 was particularly stormy and the letter, carried aboard the 'Acadia', was not received until nineteen days later, on Thursday, December 17 by Dr. Boott, an American expatriate, living in London. Dr. Boott persuaded a dentist named James Robinson to give ether to a young lady at Boott's home on Saturday for the extraction of a molar. This was the first ether anesthesia in England. Boott also informed Robert Liston, a famous London surgeon, of the message from Dr. Bigelow. On December 21, 1846 the first major operation under ether anesthesia was performed by Mr. Liston. He amputated the leg of a patient at North London Hospital. As Peter Squires was about to commence the administration of ether to Frederick Churchhill, Liston announced "We are going to try a Yankee dodge today, gentlemen, for making men insensible". The patient did not move during the operation and Liston commented "This Yankee dodge, gentlemen, beats mesmerism hollow." On that date Mr. Liston wrote a letter to Dr. Boott describing the event. An account of this letter was published in the Lancet 1:5-8, January 2, 1847. The Lancet version of the letter follows: Clifford Street, Dec. 21, 1846 "My dear Sir, - I tried the ether inhalation today in a case of amputation of a thigh, and in another requiring evulsion of the great toe-nail, one of the most painful operations in surgery, and with the most perfect and satisfactory reesults. "It is a very great matter to be able thus to destroy sensibility to such an extent, and without, apparently, any bad result. It is a fine thing for operating surgeons, and I thank you most sincerely for the early information you were so kind as to give me of it. "Yours faithfully, "Robert Liston. "To Dr. Boott."

The original copy of Liston's letter disappeared for 135 years and resurfaced in 1982, when it was placed for sale at auction by Sotheby' s in New York. K. Garth Huston, M.D. purchased the original letter in Liston's handwriting on behalf of the Wood Library-Museum of Anesthesiology, where it is currently held. The story of the 135 years is not known but there are reasons to believe it was held in the Boston area for much of this time. Curiously,

the original letter differs in some important aspects from the version in the Lancet. A transcription of the original letter is: 5 Clifford S. Dec. 211846 My Dear Sir I tried the ether inhalation today in a case of amputation of the thigh & in another requiring evulsion of both sides of the great toe-nail one of the ·most painful operations in Surgery & with the most perfect and satisfactory results. I SHOULD HAVE APPRIZED YOU OF MY INTENTION BUT I MADE UP MY MIND TO MAKE THE EXPERIMENT ONLY A FEW MINUTES BEFORE THE OPERATION. THE PATIENT HAD St!JFFERED FROM COUGH AND SOME TINGED EXPECTORATION AND IWAS DOUBTFUL OF THE PURPOSE OF USING THE ETHER UNTIL I WENT TO THE HOSPITAL& SAW THE CONDITION IN WHICH HE WAS- It is a great matter to be able thus to destroy sensibility to such an extent & without apparently any bad results- It is a fine thing for operating Surgeons and I beg (to) thank you for the early information you were so kind as to give me of it. Believe (me to be) Faithfully Rob Liston Dr. Boott

Liston incorrectly used the word "apprized" (gave the value of) rather than apprised (gave information to). He omitted the word "to" added in parenthesis above and omitted it similarly in other letters, lending further authenticity to this document. The events that day were momentous. Liston apparently wrote this letter in haste the same evening prior to a dinner party at which he demonstrated anesthesia on one of his surgical assistants. He wrote a letter to Professor James Miller, a friend and colleague in Edinburgh, in which he quoted St. Paul "Rejoice, and again I say rejoice!". Some important and yet unanswered questions remain about this letter. Why were Boott and Robinson not at the hospital for this operation when they lived only a few hundred yards away? Liston had been in the home ofBoott to observe the early demonstrations. There were other important persons who had time to gather for the operation, yet Liston wrote "but I made up my mind to make the experiment only a few minutes before the operation". The other questions of interest are the location of the letter for 135 years, and the reason it was rtot made known.

Crawford W. Long, M.D. As the Anesthesia History Association continues its preparations for the Third International Symposium of the History of Anesthesia to be held in Atlanta in 1992, honoring the sesquicentennial of Crawford Long's first administration of an ether anesthetic, anecdotes of the occasion will arise. One such story has been found in the minutes of the 1937 meeting of the newly-formed American Society of Anesthetists. It was recorded that, during a recent trip of Dr. Brian W. Sword through the southern part of the country, he obtained the following statement from a Dr. Venable. "January 19th. In compliance with the suggestion ofDr. B.C. Sword, it is my desire that this picture of Dr. Crawford W. Long be delivered to the library of the American Society of Anesthesia, to be permanently held and hung in the archives of the Society, Charles S. Venable. Witnessed by Dr. Sword." The picture is a steel engraving of Dr. Long. Dr. Venable is the grandson of a cousin of Mr. Venable, who was the first patient to whom Dr. Long administered anesthesia for a surgical operation on March 30, 1842. The picture now hangs in the Rare Book Room of the Wood -Editor Library-Museum in Park Ridge, Illinois.

Adolph Friedrich Erdmann, M.D. (1867-1953) In an earlier issue of the Newsletter, Dr. Ole Seeber enquired if anyone had information pertaining to Dr. Erdmann's life. The following was obtained from the files of the Wood Library-Museum. Adolph Friedrich Erdmann was born in Brooklyn, New York, on December 27, 1867. He attended Colgate University, earning a B.A. degree in 1893, and then obtained an M.D. degree in 1897 from Long Island College Hospital. He immediately became an anesthetist at the Long Island College Hospital, serving in that capacity there until1922. He was then an anesthetist at the Brooklyn Eye and Ear Hospital, where he remained until1937. On October 16, 1905, he called seven colleagues interested in the relief of pain to an organizational meeting in a Brooklyn hospital. In this way the Long Island Society of Anesthetists, the first anesthesia society in America, was formed, with Erdmann as its secretary. As Dr. Buchanan stated in 1937 at the newly created American Society of Anesthetists, "he (Dr. Erdmann) was the father of organized anesthesia in the United States." He became Active Member Number One of the American Society of Anesthetists. An excerpt from his obituary in 1953 states: "His life exemplified that of a good physician and a good citizen." -Editor

British Medical Joumal, 1892, I, 180. George Foy's oxygen apparatus, made by Fannin and Company, of Dublin. (Thomas Beddoes pointed out that oxygen was an antidote to asphyxia.) The rubber bladder on the right was attached through a stop-cock to a cylinder of oxygen and to a vulcanite mouthpiece.

In T1ze LA11cet of December 14th, 1878, Joseph Mills, the adzninistrator of chloroform at Bart's, described the use of this flexible mouth or nose tube for use with Junker's inhaler so that the anaesthetic could be adzninistered during operations on the mouth and pharynx. Until he made this suggestion the chloroform was delivered into a facepiece which got in the surgeon's way.

LAt~cet, 1896, 2, 1314. T.B. Abbott, of Aberford. Portable oxygen apparatus, suggested after his experience of a colliery explosion at Micklefield in May, 1896. Oxygen was valuable for resuscitation, but large cylinders could not be taken over the falls ofroofin the workings. Made by Reynolds and Branston, Leeds, it used a 10 cu. ft. cylinder.

From the Literature by A.]. Wright Librarian Department of Anesthesia University ofAlabama at Binningham O'Sullivan EP. Dr. Robert James Minnitt 1889-1974: A pioneer of inhalational. 1 Rny Soc Med 82:221-222, 1989. Outlines Minnitt's career, especially "his life long dedication to the relief of pain during labour." One portrait, thirteen references.

Saidman LJ. Fifty years of Anesthesiology. Anesthesiology 71:1-7, 1989. Features anecdotal comments celebrating the journal's golden anniversary by current editor, Dr. Saidman, and previous editors, Drs. Eckenhoff, Vandam, Keats, Greene, Larson and Michenfelder. Fascinating.

Pallister WK. Sir Geoffrey Stephen William Organe. Anaesthesia 44: 461-461, 1989. Reviews life -and career (1908-1989) of Organe, who in 1968 became the fifth British anaesthetist to be knighted.

Schmitz R, Kuhlen FJ. Analgesics and narcotics before 1600. A nearly unknown chapter in drug history. Pharm Unserer Zeit 18:11-19, 1989. This German-language article has not been examined. Perhaps its authors are unfamiliar with Edgar Ellis' Andent Anodynes (1946).

Papper EM. Anesthesiology at the Columbia Presbyterian Medical Center in New York City: A personal memoir. NYSSA Sphere 42(3):617,1989. Dr. Papper's reminiscences and philosophical observations about academic anesthesia. One illustration, one portrait. Peabody JL. Historical perspective of noninvasive monitoring. 1 Peri-

SobanD, Ruprecht J, Keys TE, Schneck HT. The history ofscopolamine - with special reference to its use in anesthesia. Anaesthesiol Reanim 14:43-54, 1989. This French-language article has not been examined. ·,iJ

tzatol 7:306-308, 1987. This article has not been examined. Persand TVN. Historical development of the concept of a pulmonary circulation. Can 1 Cardiol 5:12-16, 1989. This article has not been examined.

Duroy's method for the detection and estimation of chloroform. A retort with two tubes is attached to a porcelain tube which passes through a charcoal furnace and ends in a glass tube which dips into a vessel containing silver nitrate solution. · I .. · ;I Chloroform, if present, is decomposed in the heated porcelain tube to produce hydrochloric acid, which forms a white precipitate in the silver nitrate solution, the ~ residue of which is analysed volumetrically.

Anesthesia History Association

C. Ronald Stephen, M.D., C.M., Newsletter Editor 1580 l Harris Ridge Court Chesterfield, MO 63017

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