Newsletter April, 1993

Anesthesia History Association Newsletter April, 1993

Volume 11, Number 2 .

History of Pediatric Anesthesia in the United States The Newsletter isproud toreprint below thestory of the development o.{pediatric anesthesia in the United States aspresented by theacknowledged Dean o.{pediatric anesthesia in this country, Dr. Robert M. Smith. This article appeared originally in Paediatric Anaesthesia 1:65-73, 1991. This newJoumal.fzl!fills a real need throughout theworld, andweare indebted toDr.Gordon H. Blish of London, England, Editor, andtoAmette-Blackwell Publishers o.{Paris, FranceJor their kindpermissions in bringing thispaper andthis newJoumal to the attention of the readership.

Progress in paediatric anaesthesia in the United States by RM. Smith, MD, FFARCS, Ireland (Han)

Introduction The goals of the anaesthetist are unique in the field of medicine in that they involve neither diagnosis nor cure as major interests. Instead, our main purpose is to guide each individualpatient through a temporary period of intense stress with minimal mental and/or physical harm. Progress in anaesthesia may reasonably be measured by the steps taken toward our ability to regulate (maintain within normal limits) or control (be able to extend beyond normal limits) respiratory, circulatory, neurological and other functions upon which safety and survival depend. An effort will be made to emphasize the accomplishment of these steps in paediatric anaesthesia in the United States, and the importance of the contributions of teaching and research in their accomplishment.

The early clinical stage (1846-1940): control of pain and motion Prior to 1846 surgical operations on adults were performed under crude attempts at medication or intoxication. Most children, however, could be immobilized by several strong attendants, and medication could be omitted. The discovery and popularization of ether in the United States (US) by Long and Morton accomplished the first and most essential two steps required by the surgeon, the control of both pain and motion, thus, for the first time producing a quiet surgical field. At this time surgeons asked no more and received no more. Ether was effective, and it appeared to be easy to administer by rag or some sort of cone. Consequently a wide variety of untrained individuals might be commandeered to give it. The vomiting, convulsions, and occasional fires and deaths that were introduced along with ether were overlooked, and little further progress was made in paediatric anaesthesia in the US for several decades. Ether remained the principal agent in the US, although chloroform had considerable use and nitrous oxide, ethylchloride, divinyl ether and tribromoethanol played secondary roles during subsequent years. There was little reference to paediatric anaesthesia in medical literature between 1846 and 1900. It was not until the turn of the century that a

few individuals who had developed special interest a~J' skills began to call attention to the special needs of infants and children. Articles by surgeons and paediatricians, as well as anaesthetists, were scattered among a variety of medical publications. Chloroform was still being used, but was under increasing attack. Kopetsky (1903) advocated its elimination, and the substitution ofnitrous oxide as the ideal induction for children (using 'as much as 5 or 10%air'). James Gwathmey (1907), an outstanding figure in early US anaesthesia, cautioned further against chloroform, though using it in combination with ether and nitrous oxide in older children with his personalized inhalation apparatus. He also was one ofthe first to attempt the control oHear in children, with the recommendation that children should receive premedication with morphine 'with a few drops of the mother's cologne to the ether mask and induction ofthe child in the mother's arms or while naturally sleeping in their beds'. Although no training in paediatric anaesthesia was available at the time, the so-called art ofanaesthesia, or skill learned by trial and error, gradually evolved. There were no numbers for guidance, but observation ofskin colour and warmth, strength (or absence) ofpulse and respiration, and immobility made it possible to carry increasing numbers of children through more exacting operations. At the tum of the century tonsillectomies, popular since 1880. were reported by the thousands, and appendicectomy, first performed in 18H7. though hazardous. became commonplace. During this period orthopaedic surgery bec.uue the first paediatric surgical specialty to develop in the US, simple open drop ether serving well for patients undergoing operations tor excision of tuberculous bone, osteomyelitic infections and for correction of poliomyelitic deformities. Between 1925 and 1940 further improvements in the skills ofcaring nurse and physician anaesthetists widened the scope of surgeons considerably. During this time William Ladd, pioneer Boston paediatric surgeon, made initial progress in the correction of intestinalanomalies in infants. Ether was used for larger neonates, but with many premature infants Ladd had remarkable success using local procaine infiltration. With limbs securely wrapped, and sucking on a brandy nipple, 1000 g

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infants dozed through major procedures with serenity. The publication of Guedel's Inhalation Anesthesia in 1937, was an outstanding contribution to both adult and paediatric anaesthesia, adding increased ability to control anaesthetic depth for prolonged orthopaedic and neurological procedures. The introduction ofcyclopropane by Waters in 1934 brought about the first major change in paediatric anaesthesia since the discovery of ether. An enterprising nurse at the Boston Children's Hospital (Betty Lank, CRNA, Head Nurse Anaesthetist, Children's Hospital, 19351969) devised a miniature to-and-fro soda-lime cannister, and with home-made masks and head straps, successfully accomplished the first use ofcyclopropane for infants and children, including the historic first ligation of a patent ductus arteriosus by Gross in 1938, which initiated the evolution of congenital cardiac surgery. Much credit must be given to the nurse anaesthetists of that era. Though serving under the direct supervision ofthe operating surgeons in the operating room, they developed their own training schools throughout the country, and were responsible for much ofthe progress and the greater part ofthe administration ofanaesthesia in the US. The natural aptitude ofwomen with small children has definitely increased the effectiveness of nurse anaesthetists in paediatric anaesthesia. Progress begins with the recognition of the problem. Though few problems were solved in the first 94 years, awareness of major problems were voiced in such articles as those on convulsions (Clement 1928), fear (Leech 1935), and pain (Waters 1938).

Stage II (1940-1960): paediatric anaesthesia becomes a specialty: Further progress in clinical aspects During the years ofWorld War II (1939-1945) interest in paediatric surgery in the US continued to be limited and paediatric anaesthesia drew little attention. Immediately afterward, a burst of activity in paediatric surgery brought a demand for improvement in the anaesthetic management ofinfants and children. The sudden interest in paediatric surgery came as the result of rapidly increasing knowledge in other paediatric fields, the introduction of antibiotics, and the presence of a group of enthusiastic young surgeons spearheaded by R.E. Gross, successor to Ladd at Boston's Children's Hospital. The release of a large number of anaesthetists from military service brought a surge of recruits into the field ofanaesthesia, many ofwhom chose the challenging and relatively unoccupied paediatric area. During the next 20 years progress continued to be primarily in clinical aspects ofanaesthetic management. The attempt to control fear and psychological trauma initiated numerous studies of sedative drugs in varied dosages and combination, administered by oral, intramuscular, intravenous or rectal routes Gackson 1951; Artusio & Trousdel1958; Root 1959), as well as the use of hypnotism (Betcher 1958). That the problem offear remains unsolved is evident in the continued profusion of reports of incomplete success. Although chloroform still saw occasional use early in this stage, ether remained the standard agent throughout most of it, cyclopropane serving special use for small infants and poor risk patients. Halothane would not appear until 1956. The control of pain and motion provided by ether and cyclopropane brought sideeffects of airway obstruction, overdosage, flammability and death. Control ofthe airway and improved ventilatory management became the centre ofintensive interest. Anaesthetic equipment for children had been made by adaptation ofadult devices, while equipment for infants was ~ossly contrived or non-existent. Within a short time a variety of oropharyngeal airways and facemasks appeared as well as laryngo-

scopes and endotracheal tubes and other equipment. Numerous manufacturers were eager to help in production and marketing the innovations of inventive anaesthetists. The introduction oftracheal intubation was an obvious necessity in gaining control of the airway, and a major step in the progress of paediatric anaesthesia, but in the US it had lagged behind Britain and Canada. Even at this time it met with great resistance by many surgeons, some of whom had witnessed early mishaps, and others who preferred the noisy breath sounds that told them that their patients were still alive. Acceptance was achieved only after considerable effort and the early examples set by Rees of Liverpool, Leigh, then at Montreal, and by Deming (1952), Pender (1954) and others of the US. As with ether, the great step made by establishment oftracheal intubation brought a host of lesser problems, and a profusion of literature on related topics (Slocum & Allen 1945; Crispell & Hampton 1950; Smith 1953; Colgan & Keats 1957). Breathing apparatus was to become a major problem for many years. Since spontaneous respiration was still in general use, problems of resistance and dead space were ofprimary concern in the design ofairway equipment. To-and-fro absorption systems that had been used for administration of cyclopropane proved clumsy, became overheated, and spilled soda-lime dust into infants' mouths. Attempts were made to adapt adult circle absorption systems to paediatric use by Adriani and Griggs (1953), Leigh (1975) (see Dorsch & Dorsch 1975), and others, but large valves or awkwardness proved their undo~g and attention was turned toward infant circle systems. The Heidbrink Ohio and Foregger Bloomquist (1957) models were fashioned for small infants, with reduced dead space and small valves, and enjoyed considerable popularity until supplanted by various non-rebreathing or partial rebreathing systems. The general adoption ofAyres' T-system (1937), coming to the US several years after its conception, led to a period ofgreat confusion over variations suggested by British, Canadian, Japanese and other workers. The addition of a breathing bag by Rees (1950), followed by the addition of valves, and much indecision over proper flow rates occupied nearly 20 years, and eventually led to the acceptance of the presently designated Mapleson A system (1954) for use with spontaneous respiration and the Mapleson D system for use with controlled respiration. While US anaesthetists were mainly bystanders in these developments, they, together with the Canadians, did add to the confusion by introducing a variety ofmetal and plastic non-rebreathing valves (Stephen & Slater 1948; Ruben 1955; Lewis & Leigh 1956). These, due to difficulty in management and tendency toward obstruction, gave way to more practical T-systems, and to the increased application of adult circle apparatus which had become more acceptable following replacement of the heavy black rubber masks and breathing hoses with those of lightweight, transparent plastic. Strangely enough, although the first great step in the progress of anaesthesia had been the discovery of ether, the next great step was to be its abandonment. When curare entered the scene in 1942, it, in combination with nitrous oxide and thiopentone, provided non-flammable anaesthesia suitable for many paediatric patients, thereby dealing ether its first blow. However, curare met as firm opposition as had tracheal intubation, particulary in eastern US due to its condemnation by Beecher and Todd (1954). Overcoming these two obstacles proved the most difficult hurdles of many early paediatric anaesthetists. Shortly after its first paediatric use by Cullen (1943), tubocurarine was used as the sole agent for procedures on small infants. Questioning this practice, Scott Smith (1947) of Utah had himself thoroughly

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curarized, and while intubated and supported with oxygen, was tested with a variety ofpainful manoeuvres. His subsequent report that he had suffered acutely led to the prompt discontinuation ofthe use ofcurarizing agents without anaesthesia. Following unsuccessful trials of several halogenated agents, the introduction ofhalothane was to deal ether its death blow and revolutionize paediatric anaesthesia. First used in England in 1956 by Johnstone (in 10% concentration) halothane was promptly popularized in the US by Stephen et al. (1957) and others. Its non-irritant odour, easy controllability, and above all its non-flammability soon gained halothane the leadership for paediatric use, a position which it still holds. The greater potency of halothane brought about the development of more accurate vaporizing devices and increased ability to control anaesthetic depth. Progress in the control ofinfants and children during anaesthesia was made in improved methods of monitoring and support. During this period the establishment of the precordial stethoscope as an essential feature of paediatric anaesthesia was an important advance, providing continuous, unaltered observation of the presence and variations of cardiac rate, rhythm and force, aswell as the state ofthe airway and adequacy of ventilation. Blood pressure cuffs were adapted for use in small infants, continuous monitoring of temperature was introduced, and electrocardiographic monitoring became popular, though adding more confusion than help at that time. The previous need for speed in paediatric surgery was relieved by improved anaesthetic control. This allowance of time for greater precision plus the use of cautery reduced serious problems of blood loss and replacement that had been major causes of paediatric mortality. While these changes were being made, surgical achievements included the first successful primary repair of a tracheo-oesophageal fistula in a neonate, and correction of a variety of congenital cardiac defects in young children that involved an exciting progression of innovative approaches. Although the anaesthetic management for great vessel repair was carried out under conventional methods (Harmel & Lamont 1946; Harris 1950; Smith 1952), William Mcquiston (1949), became the first to use hypothermia with the intent to reduce the metabolic requirement of oxygen in his closed-system cyclopropane management ofinfants undergoing Potts shunts for tetralogy of Fallot. Virtue (1955) carried this further with ice-water immersion to allow performance of brief intracardiac procedures. Extracorporeal oxygenation reached practical application in 1954, Matthews, Buckley and VanBergen (1955) and Patrick, Theye and Moffitt (1957) taking active part in the early development as disc, helix and screen methods leaped ahead of one another as successive refinements were developed. During this stage children could be carried on by-pass long enough for palliative and some corrective intracardial procedures, but it was not possible to do prolonged procedures on infants. Local anaesthesia had few adherents among paediatric anaesthetists in the US at this time. Small (1951) and Eather (1958) recommended brachial block and Berkowitz and Green (1951) reported 350 spinal anaesthetics on young children, but general anaesthesia remained the overwhelming favourite. It should be noted that the paediatric anaesthetist was then beginning to playa more important role outside the operating room. Resuscitative measures were modernized with mouth-to-mouth breathing, tracheal intubation and open-chest cardiac massage. Respiratory support with a variety of ventilating devices began, and came into much use during

poliomyelitis epidemics and for treatment of respiratory distress syndrome, status asthmaticus and tetanus. In 1953 Dr Virginia Apgar proposed her classic method of evaluating the viability of newborn infants. Progress in teaching began slowly, for advances made at individual centres were not easily disseminated. In the early 1950s residents were accepted from local adult training centres for short periods of affiliation. In time these were expanded into independent programmes that gradually attracted residents and practising anacsthctists from many areas of the US and other countries. Instruction was based on simple, practical management of infants and children undergoing standard operations, and the avoidance ofmajor complications, as well as special methods required for those of higher risk. Literature also showed definite growth. Some articles contained rather biased reports ofearly successes, but there were many of lasting value, such as those on tracheal abnormalities by Eckenhoff(1951) and Colgan and Keats (1957), the discussion of management of trachcooesophageal-stenotic repair by Zindcr and Deming (1953) and that on bradycardia following intravenous suxarncthonium by Leigh et al. (1957). The first widely read texts were published at this time. In 194H Leigh and Belton, while still in Canada published their Pediatric Allestliesia, establishing many new concepts tor the first time. This was followed by Stephen's Elements 4 Pediatric Anesthesia in 1954, and Smith's Anesthesia for lt~filllts and Chiulren in 1959 whiEtl covered progress through management for open-heart procedures and the introduction 'of halothane. Research, other than that carried out in the operating room, hardly existed. Airflow resistance (Macon & Bruner 1950; Orkin, Siegel & Rovenstine, 1954), the evaluation of breathing devices (Hunt 1955), and a few investigational studies such as that by Bunker et al. (1952), showing the greater tendency of small children to develop intraoperative stenosis, made up the greater part of this area of activity.

Stage III (1960-1980): anaesthesia without ether. Progress in teaching In the years between 1960 and 1980 the new freedom to use electrical devices in the operating theatre in addition to other clinical advances led to such clinical accomplishments as deep hypothermic arrest, kidney transplantation, craniofacial reconstruction and 1S hour genito-urinary repair. The greatest advance in paediatric anaesthesia, however, occurred in teaching and communication, while research became an active and productive component. In spite ofimpressive clinical achievements, the unmet need to control children's fears was voiced by anaesthetists (Francis & Cutler 1957), paediatricians (Rosen & Brueton 1970) and Surgeons (Koop 1973), as well as child psychologists (Korsch 1975). Predictions of the superiority of new benzodiazepines and other 'tranquilizing agents' were not realized, and while ketamine proved predictable and effective (Corsson & Oget 1971) it required intramuscular injection and produced disturbing hallucinations. Actual progress did appear in the extension ofparental visiting hours, 'sleeping in' privileges, and eventually the admission of parents ro pre-induction and induction areas. In relation to problems ofinduction, Salem's concepts ofthe management of 'the full stomach' by rapid intravenous sedation and tracheal intubation during tracheal compression (Sellick manoeuvre) became firmly established throughout the US, thereby accomplishing one of the most important steps in airway control (Salem, Wong & Collins 1973). Fortunately, after late suggestions by Revell (1959) and Neff, Burk

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and Thompson (l96H) to alter infant breathing systems, the prolonged turmoil over breathing devices petered out, and the modification ofthe Maplcson D device by BOlin and Spocrcl (1974) became generally accepted tor use with infants. Progress in maintenance of anaesthesia included the introduction of invasive monitoring of arterial and central venous pressures and blood gases, and the establishment of adjoining laboratories tor rapid determination and treatment. The combination of precordial (or oesophageal) stethoscope. blood pressure cutl (or arterial line). electrocardiogram and thermometer became standard requirements in paediatric anaesthesia. Failure to document the use of any of the above was considered 'a departure from accepted practice' in US courts oflaw. Important advances were made in supportive t1uid management. While the basic relationship ofdaily tluid allowance to body metabolism established by Holliday &: Segal (1957) continued to be honoured, the amounts of fluid and sodium were drastically increased (Bennett. Daugherty &: Jenkins 1970). the simple glucose solutions were altered to contain electrolytes (Herbert. Scott &: Lewis 1971), and additional tluid was calculated to make up tor the period of 'starvation' since the last feeding [Purman. Roman &: Lemmer 1975). Greater control of blood volume enabling surgeons to perform more extensive procedures included deliberate hypotensive techniques (Salem. Wong &: Bennett 1974), hacmodilurion, and intra-operative salvaging ofblood from the operative wound. Hyperventilation during intracranial procedures. and the use of tourniquets and positioning in orthopaedic surgery also improved control of surgical fields considerably. Surgical advances eased several problems of the anaesthetist. Correction of trachco-ocsophagcal fistula became standardized, and omphalocclc repair was greatly simplified in 1967 by Schuster's staged mesh closure. However. increased mortalirv related to congenital diaphragmatic hernia became a new problem due to earlier diagnosis of seriously impaired infants that previously had not survived the t1rst hours. The use ofpulse oximetry (Raphacly &: DO\\11eS 1973), attempted correction of pulmonary artery hypertension (Dibbins &: Weiner 1974). ventilatory support with extracorporcal membrane oxygenator (ECMO) (German. Gazzaniga &: Amlie 1977) and other contributions helped but did not solve the problem. Infant cardiac surgery was advanced another step with the application of hyperbaric oxygenation (Bernhard. Navarro &: Yagi 19(6). By increasing the oxygen carrying capacity of blood plasma at 3 and 4 atmospheres, it was possible to arrest the heart by inflow occlusion long enough tor aortic valvotomy and other bricfproccdurcs. The increased potency of nitrous oxide introduced a new anaesthetic tcarurc (Smith, Crocker &: Adams 19(4). The major breakthrough came with total cardiac arrest under deep hypothermia and simultaneous control of respiration. circulation and temperamre, enabling surgeons time tor the most complicated repair of congenital cardiac detects even in premamre infants. Anaesthetic management tor these infants involved the use of atropine, induction with ketaminc, maintenance with intermittent mcrocurine with nitrous oxide base, and invasive monitoring. Prolonged endotracheal intubation and constantly improving competence of intensive care facilities and personnel contributed greatly to increased survival (Downes &: Raphaely 1975). The introduction oflaser surgery ofthe airway demanded new control ofanaesthetic delivery including venturi and jet ventilation. Treatment ofchildren with epiglottitis became a challenge tor anacsthetists, resulting in the replacement of tracheostomy by 24 hour tracheal

intubation and marked reduction in morbidity and mortality. Renal transplantation became a major team effort in which anaestherists took part and learned, among other things, that patients could survive on much less than 10 grams of haemoglobin per cubic millimetre. The institution of helicopter transportation (Hackel 1975) and the rapid development of intensive care facilities brought significant improvement in pre-operative and post-operative management. The remarkable progress in teaching and communication in this period was the result ofimproved training facilities, the establisment of annual symposia and other open forums, and in 1965 the organization of the first body of paediatric anaesthetists in the fonnation of the Section on Anesthesia of the American Academy of Pediatrics. Training opportunities developed rapidly throughout the US. Anaesthesia departments grew in size and responsibility in the hospital community. The teaching staffs were strengthened by addition of experts of profcssorial rank in the basic paediatric fields as well as respiratory therapy and intensive care, attracting men and women of increasing quantity and quality, many of whom, upon leaving, assumed positions of leadership in other insrirutions. In 1962 Digby Leigh, then at Los Angeles Children's Hospital, inaugurated the first annual paediatric anaesthesia symposium in North America. Leigh's shrewd intelligence and sharp wit made him an outstanding teacher and a delightful speaker. In addition to his other talents. he was foresighted enough to promote ih,(; monitoring of expired carbon dioxide in the mid-1960s! During subsequent years excellent annual symposia were established by Conn at Toronto, DO\\11eS at Philadelphia, Salem at Chicago, Striker and Cincinnati and others. As interest in paediatric anaesthesia accelerated, speakers for local and national anaesthesia and surgical meetings came into demand, and tor a time there was appreciable international interchange, Leigh, McQuiston, Smith, Stephen. Downes and others travelling to South America. Europe and Asia, while Conn ofToronto and Rees of Liverpool were frequent and popular visitors to the US. Although foreign travel subsequently receded, word-of-mouth teaching did not, for the requirement tor graduate study in the US created an epidemic of'refresher' courses, and whether one attended such courses or heard them on purchased tapes. there were tew who did not become familiar with the voices of Berry, Steward, and Gregory, current authorities in the tleld. As a lucid teacher and brilliant investigator, special credit is due Edward Eger, whose contributions have been spread over several decades. Deming. Bachman, Rackow, Salanitre, Marcy, and other early teachers were followed by scores of stimulating, important and unsung individuals in all parts of the US. A profusion of literature began to overwhelm the specialty, Gregory's two volume treatise leading the field in 1983. Research made definite early strides. Motoyama's description ofinfant pulmonary mechanics (1969), measurement of the uptake of gases by Salanitre and Rackow (1969), and by Eger (1974), Eger, Saidman and Branstater (1965) establishment of the concept of the minimum alveolar concentration (MAC) as a standard for measure ment ofanaesthetic potency, and Gregory, Eger and Munson's application ofMAC (1969) to show that infants require higher concentrations of halothane than adults, stand out as major contributions. During this period a great deal ofeffort was put into research in the evolving succession of muscle relaxants. Early attempts to relate age to dosage caused considerable confusion until methods were standardized and explained on phannacokinetic principles by Bachman, Nightingale and Paymaster (1964), Cook (1974), Goudsouzian, Donlon and Savarese

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(1975), and others. In searching for controllable relaxants, attention was directed toward rapidity of onset, duration of effect, reversibility and freedom from side-effects. In spite ofits value as the shortest acting relaxant, complications related to suxamethonium, malignant hyperthermia in particular, put its use into question. Stage IV: paediatric anaesthesia enters the age of automation - at what price?

With considerable assistance from the fieldsofmedicine and science, paediatric anaesthesia in the United States has made significant progress. The past 10 years have brought such remarkable accomplishments and new developments that they deserve a place in the history of the specialty. Advanced methods of clinical measurement and control, the formation ofteaching facilities throughout the country equal to those ofany other medical speciality, and the establishment of research potential capable of approaching the most complex physiological or pharmacological problems show that paediatric anaesthesia has reached full maturity as a balanced and effective medical specialty. The organization ofthe Society of Pediatric Anesthesia in 1986, which already has over 900 members, stands as more evidence of the health and enthusiasm of our speciality in this country. There have been several major changes in the direction of progress of paediatric anaesthesia in the US during the past 10 years. Tremendous energy and expense have been devoted to increasing the survival ofpremature and poor risk neonates. The greater survival has brought an influx of these infants to the anaesthetist, with associated problems such as necrotizing enterocolitis, post-operative apnoea, respiratory distress syndrome and bronchopulmonary dysplasia requiring new methods ofmanagement, and revealing new understanding ofunderlying problems. Evidence that neonates feel pain has convinced most that no surgery should be performed on neonates without anaesthesia. For intracardiac surgery on small infants combinations of fentanyl and sufentanyl with pancuronium have been found advantageous, while caudal, epidural and spinal anaesthesia have become popular for general surgery, even on premature infants. Surgery on the neonate has now been surpassed by surgery on the fetus, as in repair ofdiaphragmatic hernia in the unborn infant. Organ transplantation, however, represents probably the greatest combined achievement of anaesthesia and surgery. Kidney transplantation, and transplantation of heart and lungs definitely require considerable expertise, but liver transplantation seems to be the most demanding type of surgery yet conceived, for which the most complicated multisystem anaesthetic management is required. The combined increase in the use of regional anaesthesia and outpatient surgery has definitely been a major change in the direction of paediatric anaesthesia in the US. Local and regional anaesthesia have been promoted enthusiastically for operative and post-operative analgesia in all age groups, and the establishment ofpain management services has become an important new trend in paediatric as well as adult hospitals, patient-controlled anaesthesia (PCA) devices being managed by children as young as 5 years of age. A noticeable feature ofrecent years has been the change in standard clinical practice, which has become so mechanized and computerized that it often appears to be run 'by the numbers' rather than by personal judgement or clinical acuity. With one of the current anaesthetic machines, costing $50,000 or more, one may be guided by continuous numerical evaluation ofmultiple essential functions without looking at the patient at all. There is no doubt, however, that the ability to

measure rather than guess at the condition ofthe patient, and to he able to perform precise adjustment of specific factors, has endowed the anaesthetist with far greater capabilities in patient control and support. Indeed, the mandatory monitoring of arterial oxygen saturation and expired carbon dioxide concentration may prove to be the most valuable advance of the decade in the control and safety of our patients. In spite ofthe many remarkable accomplishments, it isdisappointing to realize that it has not been possible to gain adequate control of three of the most common and most bothersome teatures ofanaesthesia met by our small patients - namely tear, discomfort and nausea. Sedation is still one of the chief subjects of research. Recent increase in outpatient surgery has reduced the opportunity tor either assurance or sedation, and as yet the new routes of administration via nostril, lollipop or skin have not answered the problem. While general anaesthesia controls all pain, our efforts to control post-operative pain and many other types of discomfort of the awake patient arc making slow progress. Similarly, nausea remains our most common post-operative complication, and the chief cause of hospital admission afi:er outpatient operations. Finally, our great successin patient control and the obvious increase in survival of innumerable severely handicapped infants and children may mean that we have actually overshot our goaL and, together with our associated medical colleagues, have added tremendous medical. financial and ethical problems to our society. References AdrianiJ. &: GriR.g\ T. (195)) Rt.'hn:;Hhin~ arrararw.. rcrommcudanun and de ... rr iprionv of improvements in approach. Allt'.,t!lt'.,i,tlI1.!O' 14~ .1'\7-.,47. Apgar V. (195.1) Proposal fin new method of calculation of newborn infam.... Aw· ... tI".;;I! Ittld Alltl(~t'JitJ 32, 160-267. Arrusio J.F. & Trousdcl M. (195X) A rompar.uivc ...nnivof rectal Pcurothal .md morphinc ti.lr ba!ooal anesthesia upon children for tonsilh-rromv. A1Jt'''IIJ1':.ill/t~I,,?' 11, 4·B~451. Ayrc P. (19.17) Endceracbcal anc-rhcvia tilrbahil'~ with special rc tcrvncc ttl harelip and ell.,fr lip operation'. A",·.,rllf.'i" """ A,wk",'i,1 (Cleveland) 16, .>.1I1-.\.1IL Bachman L. Niahtinaale f).A. &: Pavmasrcr N.). (IcJlt4j Neuromuscular blockade in children. .1" cs,1,,·.,;,1 ~"" .~""( ...-sia 43, 744:747. . Bain J.A. &: Spocrcl \V.E. (1972) A streamlined ,mal'''l[hl,tic 'y,u.'m. ClultJdilUl AI/i1otlJl'.~iIJ Sodc,yJ",nw'19, 426-4.11. Beecher H.K. &: Todd T.P. (1954) A -rudvof th,· death, associated with ancsehcviuand surgery . .1"",11.< ,~r 140, 2-.1H. Bennett E.J.. Daughcrrv M.K. &: Jenkin, MT. (1'1711) Fluid rcquin-mcuts tt>! neonatal anesthesia and operation. AIlI'''I/'I'sitl/'~f!Y 32, .14.1-.1511. Betcher A.M. (1Y5H) Hvpno-indurtion rcchniquc-, in pediatric anevthvsia . ...t,,,..~,111'.,itJ/II.l!), 19,

.'I"",.'),

279-2RI.

Berkowitz S. &: Green B.A. (ttJ51) Spinal ancvrhcvu in children: n'p0rt on J5lJ paricntv under 3 Yl.'ar, of ag;l· . .-1r1l'.I"'/'I,.,11·(",I.')' 12, J7(1~JH7. Bernhard W.F.. Navarro ltV. &: YaF:i H. (PJh(,) Cardiovascular ~ur~lTY in infants performed under hyperbaric conditions. J ;J.
inhalation anesthesia. SJl~f!t:r)' 13, 261-26H. Deming M.V. (1952) Agents and technique' for induction in infants and young children. Allt'srl".';" ,III" AII"(et'si" 31, 1U-IIH. Dibbins A.W. &: Weiner E.S. (1974) Mortality from neonatal diaphragmarir hernia.j"'lnldl P,rdiattic S"~e"ry 9, 49-57.

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Paediatric Anaesthesia...

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Dorsch .I.A. &. Dorsch S.E. (I t175) {I"da.'tlludiu.,! Aw,.•t!U');d 0lu;/,lIIt·Ilt, Znd c-dn, p. 237. Williams and Wilkins. Baltimore. DO\\l1t,'S J.J. &: Ruphaclv R.C. (JlJ75) Pc..[iutri.... intensive c arc . ...JIII'StlII'J;ll/l~I!Y 43, 1JH-250. Earhcr K.E. (I'J5H) Axillary brnrbial plexus block. .111".,th...,.;"",.~)' 19, (,H.>-(,H4. E....k..· nhoffJ.E. ()951) S0111I.' anatomic consid c-ratious ofrhc inhmr larynx intlueucing l'I1l]Otracheal alll·s{·Ill.,'sia. .-t"l'.itl/l·J;11/1~l!Y 12, -to1-41O. Egcr E.1. (ItJ74) .i.I1" ...t1I1'/;C l 'l'tdk,' ,Ult! ..1(1;1'11. Williams and Wilkins. Baltimore. Em-r E.I.. Saidman L.J. &: Br.msrarcr H. (1965) Minimum alvcolur rrincentrarion: a standard of ;1I~l'stl1l'tic putc.'t1t:Y..4ul'-"bnit1/t1gy 26, 75l1-7ld. Francis L. &. Cutler 1t.1'.(1t)57) Psvchologiral prcpamriou and prcmcdicarion for pediatric .mcsrhesia....J.llf:.,J1I'sit1Jt l,l!)' 18, W(I. Furman E.B.• Roman D.G. IS Lcuuner LA.S. (Jl175)Specific rher;,py in water, electrolyte ami blood volume replacement during pediatric anesthesia. Alldl'.,·,JW.';eJ 42, lR7-192. Ccnn.m j.C.. (;auulig;t A.H. IS Amlie R. (1977) Managt.'mt·lltof pulmonarv insufficiency ill di;lpllragll1atichernia usillgt·xrran1rptlft..11 cirrularion with ;1 l11l'mhranc.'llxygt·lutor.}tJUnlIJJ l~r lhlidlrif SJl~I..It''1· 12, ')(15_t)I(I. Coudsouzian N.(; .. 11l111111l1J.N. &: Sa\';lrt.'sl'J..I. (It175) Reevaluation ofdosagc and duration of action of d-ruborurarim- in tilt." pt·di;(rric agt' ~UlIP. A'lI·Jlhc.':;ll/t~\?' 43, 416425. (;rt'uuf\' G.A. (Ed.) (Jlm.1) PnJidrrif Aun·rh,:';,l. Churchill Davidson. Nt'W York. (;rt'~or;' (; .A.. Egt'r E.I. &: MlIl1S111l E.S. (I tlht))Tht' rclanonship between agt' and halothane rcquin-uu-nr in l11;1n. A,,,.srlll'...it'Jt~l!)' 30, 4HH-4tl I. CUt·tld A. (l1).'7) 1"lt"l.uit11l •..J.Il'·ir/ll'...iu. The Macmillan Company. New York. (;w,lthmt·yJ.T. (IIW7) Ancsrhrsiologv in infants and children. Phl;llrric." 19,7.14-7.11:1. Havkvl A. (1')75) A uicdical transport sysrt'lU t1.lr tht' neonate....J.tt"irlt,·.,·ill/l~t,?· 43, 25H2(17. Harmel M.H. &: LUlIo11t A. (11)4h) Allt'stllt."sia in slIr~ic;ll rrcanucnr of congenital pulmonic ..tt'II11Sis. ...J.lh·.•r1t1'...it,/t~l!r 7~ 47749:-1. Harris A.J. (19511) Mall;lgt'l1lt'm uf .1IIt·srht·si;1 t~lr t:ougt·nital hcan opa,lnous iu t:hildreu. ...J.llt·.•tiIC";ll/t~l!r 11~ .l2H-J.12. Ht·rllt'rt W.l.. SetHI E.B. &. Lt'\\;s (;.H. (1971) Fluid 11I.lIugt'l11l·m llf pt'dbrric slirgiral p.ltit·IUS. ...J.1I1·.•tiW.':;,J .1Ild •..J.Il"(l!/".•ill (Clt·n·I.II1t1) 50~ J7C,-JHll. rllll1ilby M.A. &: St·~,tl \V.E. (11)57) Tht' maiutt:lul1t"t' nt't,tI t1.1r w;Ht..·r in part'mt'ral rht'r;tpy. lhlilllrif.' 19~ H2.1-K\I. Hullt K.H. (ll)55) Ih·..i~r,llKt· in ft·spir.t[ur~· \'aln's ,lIul clIIisras. A'It,..r1lC";11/1~1!)' 16~ It)(}~1I5.

J.ll'kSllll K. (11)51) PsyelIl1h1!--rlt',ll prc.·p;lr,tril1Il,tS,lll1t·r!h1d llfrt·tlut·il1~pl'rsl1naliry dun~t's in dlildrt·l1. ...J.III'.•ti,,..i•tl/tlgy 12~ 29J-.1IIII. JOhllShlill'M. (Jt)511) TIlt' IHIIIl.1ll clrtliu\..tScul.tfrc.·sPl1l1St' hl Flul1t1UUl' ;nut·stht'sia. Bri,i..:h f.'um,,] t,( •..J.'M,)'llt,·ii,J 2R~ 21)~-297. Kotlp E.<.:. (Itl?J) Prl·p.lrll1gtht' p,Hit.·m .lIld his t:lI11ih- t~lrhospit;,1 ami slirgay.ln (;.II1S 5.1. (EtI.) SIl~l!i('JI H·.li,Jtrli·.'·' (;nlllt' &: Srr.tUl1l1. Nt'\\" Yllfk. Kopt·[sk\· S..I. (Jlm.\) Tht' sdt'ction of ,Ill,lt·.stht'~i.1 in dliltlrt'l1. .\tt'dif,rI Rn't1fll 14, 5.\45.1H. Korsell B.M. (tt)]S) TIlt" child ,lIld tht' Ilpt'rarin~ roOI1l . ...J.tl,·...,],I"..it'/,~l!y 43,251-257. Ll11k B.E. (JlM;) Cvd0l'rllp.l11t· in int:tl1t ..ur!!t·~· . .llllmilll t~(.-4t11..n·f'UI A":":lldlJtitlll t~( .'·Uf.'" AUC..tilt'l;.,·r.' 2L 2J:-<-252. 1.t·l·lh B.C. (1').'.5)Prt'l1lt:tlic.ltioll in dlildrt·ll . .--t,h·.•tih·.i•,r.lIIIJ AII,J(t,It·.':;ll (elt'n'bnd) 14, 2HJ2Kll. Leil!;h M.D .. Mt.·Clw D.D .. Bdtl1l1 M.K. &. Ll'wis (;.H. (P)57) Hrath-t"ardia t1.1lltl\\;ul!; illtr;1\'~'IIlH1" ,llll1linisrratilll1 ut slityil1ddlOlil1t' t·hloridt.· to int;ll1fs ;lnd t"hild~t'n. AII....:till'.•·ill/t~I!), 18. h'JH-7112. l...:iuh M.D. &: Bdron M.K. ()t)4H) PI',/;.l1r;( AUt·...t],!'..i,1. Manl1ilbn. Nt.'w York. Lt'\~;s B.(;. & L..:i~.dl M.n. ()t)5h) Lt'\\;!'o-Lt'igh nOI1-rd,rt';lthing \·.Ilve. AlIl·.•til....:;tl/l~l!J' 17, hl:-<-hl'}. Macon E.B. &. Brunt.'r H.I). (11)511) TIll' sc1t.·lHitic ,lSpt·t:r ott'l1thur,tcht';I) mht·s. ..1'h·."r1lf.,·itl/l~l!}' 11, .\ 1J-.'2I1. Maplt.·..IHl W.\V. ()954) Tht' dimin,trillil tIt rd'rt';lrhing in \";lritHls st'mi-t.·lost'd;111;tt'.stht,tit" ,VSrt'IIIS. Bril;."J, f"llm"/,,{ ...J.'ltll·...tlll'..:;,' 26• .12J-.U~. . Marrht'ws I.H., Hucklt'~' 1.1. IS \!;ll1Bt'rl!;l'll F.H. (1')55) Anllt' dli.'cr llflllw-tlow t'Xrr,lcorport.·al cir~lIbtilln of (t'rt:hral physitllo~y . ..-l.tll·..:tlll'..:ill/l~l..?· 16. Illl). McQuiswll \V.O. (tt)4 1») Ant'stlwric prohlt'ms illt-,Irdiat" "lIrgt'~· in childn·n. ...J."....:IJ,f..:;11/1~l!r 10,5'JII-I>IIII. MO((IY;lI11a E.K. (I'U.'»)Ht''''pirahln' phy..il1logy.In Smith R.M. (Ell.)...J.tll·.•tlll·.•ill'/;lf b!I:JIIr"'lIld CIr;Mn·lI. C.V. Mo.. hy. Sr. Louis. Nt·tt"W.H., Rurk S.F. &: Thompson H.. (JlJhX) A \"t'lHuri t"irntbhlr t1.lr ,tlw~tlwtic sy~rl'I1\S. .~I1,·.<,J,...
Revell D.G. (1959) Circulator to eliminate mechanical dead space in circle absorption systents, CdtldJ!i,JII AUdI'J,h"iid Silrit'ry jtmrllal 6, 98-103. Root B. (1959) Preanesthetic medication for children: comparison oforal and intramuscular routes. AI1('Jlhf'.\ill/l~l..ry 20, 49-54. Rosen M. &: Bructon M. (1970) Emotional disrurbances in children having tonsillectomy and adenoidectomy aged 5-6 years. Exccrpta Medical Foundation 686. Ruben H. (1955) A new non-rcbrcarhing valve. A,,,',<",,',<;',/,~W 16, 643-644. Salanirrc E. &: Rackow H. (1969) Pulmonary exchange of nitrous oxide and halothane in infants and children. AI/l·.'tftn;',f".w 30, 388-394. Salem M.R .. Wong A.Y. &: Collins V.J. (1973) Thc patient with a full stomach. Artl'S/fteJiol".w 39,4J5410. Salem M.R.. Wong A.Y. s: Bennett EJ (1974) Deliberate hypotension in infants and children. AUI'...thrsia IJl1I1 AH,J/l..Jf.·.\id 53, 975-981. Schuster S.S. (1967) A new method for staged closure of large omphaloccles. S"~l!"')', Cp,m.I".,?, ,,,,,IOf,.<,mjc.' 125, 837-841. Slocum C &: Allen CR. (1945) Ororrachcal anesthesia for chciloplasry. Alle.8) P"in rdid in childrcn. .~II,,'tinm J.tlntol ,~(S,,~~e')' 39,470-475. Vimll' R.W. (1955) H)7""ftmrtir At"·.
Spring Meeting Anesthesia History Association May 13, 1993, and the Galt House, Louisville, Kentucky, are the time and place of the Spring Meeting of the Anesthesia History Association. The Program Chainnan, Dr. Douglas Bacon, has arranged an excellent program of nineteen scientific papers, including such topics as the History of Malignant Hyperthennia, the Evolution of Anesthesia for Coronary Artery Surgery, and biographical portraits of such historical figures as Horace Wells, Noel Gillespie and Emory Rovenstine. The special guest speaker will be Peter McDennott, M.D., President of the American Society of Anesthesiologists. Registration materials and reservation fonns for the Galt House may be obtained from: Dr. Douglas R. Bacon Department of Anesthesiology Roswell Park Cancer Institute Elm and Carlton Sts. Buffalo, NY 14263-0001 This meeting is being held in conjunction with the annual meeting of the American Association for the History of Medicine scheduled for May 14-16 at the Galt House. Registration materials for this meeting may be obtained from: Dr. Gene Connor 5704 Apache Road Louisville, KY 40207 Plan to attend both meetings!

An Octogenarian at Work Recently, in theJanllary-February 1993 issue oftheBulletin ~rtheCal!(omia Society ~rAnesthesiologists, there was reprinted an articlefrom The Rotarian, November, 1992, describing the actions 4 one ~r our senior members, Dr. John Dillon, at the time ~r Hurricane Iniki Oil the island ~r Kallai, Hawaii, ill September, 1992. fIVe salute Dr. Dillon who, at 82 years ~r age, pe~ronned sudi noble work for so mOllY in a time ~r need, and we extendoursympathies and hope that his home is beillg restored. fIVe also thani: the Editor 4 the CSA Bulletin andThe Rotarian .(or permissions to brillg this newsioorthy item to Ollr attention.

Rotarian at Work by Monroe Richman The warning sirens began to sound on the island ofKauai, Hawaii, U.S.A., during the early morning hours ofFriday, 11 September 1992. Civil defense authorities had been broadcasting over local radio and television stations about the impending approach of Hurricane Iniki. With winds of209 kilometers per hour (130 m.p.h.) and gusts up to 257 kilometers per hour (160 m.p.h.), Iniki was being announced as the worst hurricane of the century to strike the Hawaiian islands. In the community ofPoipu Beach, on the island's south coast, John Dillon and his wife, Charlotte, and their cat, Blackie, prepared to evacuate their home. John is president of the Rotary Club of Poipu Beach. Now 82, he has lived on Kauai for more than 20 years following his retirement as professor emeritus and chairman of the Departtnent ofAnesthesiology at the University ofCalifornia at LosAngeles School of Medicine. The designated evacuation center for Poipu Beach was the elementary school in nearby Koloa. By 7 A.M. on Saturday, the parking lot was jammed with hundreds ofcars and nearly 1,000 people were crowding into the shelter. Iniki struck later that day, and John and Charlotte remained in the storm shelter with their neighbors as the eye of the hurricane passed directly over Poipu Beach and Koloa. The silence of the eye was followed hours later by the vicious return of winds and rain. Iniki left massive devastation in its wake. When John and Charlotte returned home the next day, they were dismayed to find their house almost totally destroyed. Ten years earlier, they had suffered the ravages of Hurricane Iwa, but Iniki was worse. People wandered about, stunned by the magnitude of their losses. The destruction of 10,000 homes - half the houses on Kauai - was shocking enough, but the island was also without water, telephone service, and electric power. Mter feeble efforts to minimize further effects of water damage on their home, John's thoughts turned to his neighbors. A ham radio operator for years, he knew that the only communication between Kauai and the outside world would be by amateur radio. Telephone satellite towers lay strewn about. Power poles had been scattered like matchsticks. Kauai was effectively cut off from the rest of the world. John's assessmentwas correct. His station, KH6FMT, was to become a beacon of hope from the island of Kauai. He quickly improvised a makeshift antenna, hooked his radio to his car battery, and began to seek contact with the outside world. Ignoring his own plight, John began to help his neighbors. As word ofhis action spread, people ofKauai flocked to his makeshift radio station to ask that messages be sent to their concerned families on the mainland. John made hundreds ofemergency calls all over the United States. When families and relatives heard that their loved ones were safe, they reacted with deep emotion. John was back on the radio Sunday helping officialsofKauai Electric

convey a lengthy message to Citizen's Utility in Arizona establishing an emergency plan to rebuild the island's electrical system. John's work expedited the rebuilding ofthe electric grid on Kauai. That same day he relayed more messages to families on the U.S. mainland. John worked tirelessly throughout the period following Hurricane Iniki. One week later he and Charlotte still had to drive 4.H kilometers (three miles) to get drinking water. By this time, the innovative broadcaster had improvised solar charges for his batteries and continued to assist people with the only form of communication from" that part of Kauai. One result ofJohn's efforts was a U.S. $2,500 conrriburion from the Rotary Club ofSun Valley, California, to the Poipu B~;ch club to assist in relief efforts. A member of the Sun Valley club heard one ofJohn's radio messages, and asked how the club could help. When the final story is written about Hurricane Iniki, RotarianJohn Dillon will be a major character. With his cheerful spirit and composure, he will stand out as a Rotarian truly demonstrating what is meant by Service Above Self.

History of Anesthesia and Related Fields in Philately by Migllel Colon-Morales, M.D.

During the last decades Transfusion Medicine has evolved hand-inhand with the progress in the practice of anesthesiology and surgery. It is very important that anesthesiologists possess appropriate and updated knowledge of the safe use of blood transfusion in daily practice. Participation of anesthesiologists in Hospital Transfusion Committees is essential for maintenance of awareness of transfusion risks ami indications for its use in the operating room. Knowledge about the Type and Screen (T-S) versus Crossmatching is valuable also for safety. cost containment and effective uses of blood available. The booklet, "Questions and Answers about Blood Transfusions." published by the Anierican Society of Anesthesiologists, is a valuable source of information about blood transfusions. Blood donors were honored by Francein a stamp issued in J95'J. Scott #AJ30.

A Man of Ideas In thefollowing paragraphs Lucien Morris, M.D. has recountedjar liS the novel andexdting contributions which Daniel G. Revell has made to theprogress of anesthesia. we are indebted totheEditor oftheBulletin of the Calijomia Society o.fAnesthesiologists andtoDr. Morris.for theirpermissions toreprint thisarticle. A display ojDr. Revell's Circulator can be seen ill theMuseum o.fthe WOod Library-Museum ofAnesthesiologists at theAmerican Sodety ofAnesthesiology Headquarters ill ~~ ~ Ed'I tor " --

A Salute to Daniel G. Revell, M.D. The Contributions of a West Coast Colleague by Liden Morris, MD., FFARCS, FFARACS Many of the venturesome physicians associated with anesthesia in the relatively unpopular earlier days of our specialty (40 to 75 years ago) were inveterate gadgeteers motivated by practical problems of everyday clinical experience. Daniel Revell deserves special attention because ofhis persistence in the development ofthe concept of forced circulation ofgases around the circle absorption system and through the mask, which, thereby, provided a solution to vexing problems caused by the existence of deadspace and resistance in anesthesia apparatus. I first heard ofDaniel Revell at a University ofWisconsin anesthesia staffseminar in 1948. Professor Ralph Waters had just returned from a regional meeting in Regina, Saskatchewan where he had been an invited speaker. In his report Dr. Waters clearly identified Revell's circulation concept as the one idea from that meeting which excited his admiration. It is noteworthy that the paper he cited actually had been read in absentia. Dan Revell was, at the time ofthat Canadian meeting, in the process of moving his family from Winnipeg, Manitoba to Victoria, British Columbia where he continued in the clinical practice of anesthesia for twenty years. Revell's home-made device was intended to wash out from under the mask the carbon dioxide laden end-tidal volume just exhaled, providing fresh gases for each successive inspiratory volume. Revell was motivated by a desire to have the benefits ofcyclopropane for his "wee patients," infants and neonates, at the Winnipeg Children's Hospital where he was Chief Anaesthetisr.! The problem he set out to solve, although most acute for pediatric patients, has been and continues to be of concern to all patients subjected to inhalation anesthesia. Inherent in all respiratory apparatus and anesthesia systems are the twin problems of external deadspace and resistance which combine to increase the work of breathing. All masks impose external deadspace and cause rebreathing of the end-tidal volume which, thereby, alters the composition of the inspired mixture (decreasing Fi02 and increasing FiC02) much the same as breathing through a paper bag. So-called non-rebreathing systems, using valves and a flow of fresh gases equal to the respiratory minute volume (RMV), do not in any way remove the deadspace under the mask nor mitigate its effects. Efforts to reduce the deadspace of masks by modification of design has been rather perfunctory except for the flattened face pieces of RendellBaker design and even these have an appreciable deadspace in mask and chimney Y piece with a consequent undesirable percentage increase in RMV. The rebreathing caused by a standard face mask will cause a patient to increase RMV by 30% in order to maintain normal levels of PaC02. 2 Avoidance ofthe unwanted effects ofexternal deadspace by those who have not had access to a circulator has led, over the years, to a variety of management compensations. Aniong these are the current practices of a) otherwise unnecessarily frequent intubation, b) prevalence ofwasteful high flow usage ofgases, c) overuse ofpositive pressure ventilation rather than the more physiologic spontaneous respiration, and d) markedly increasing the relative volume and partial

pressure of oxygen in the fresh gas flow. The 1948 presentation by Revell described a rather complicated arrangement to clear the deadspace associated with the mask and its connections. This had two important components: a) a divided chimney with a septum to separate inlet and outlet for the mask, and b) a system oflevers and pulleys powered by an automobile windshield wiper motor to provide circulation of gases around the closed circle carbon dioxide absorption system and through the mask. t This effectively prevented rebreathing and the consequent need to increase RMV, thus avoiding an increased work of breathing. Revell was innovative in providing a physiologic ~er for perplexing and enduring problems of anesthesia maskS" and associated apparatus. His first effort was generally viewed as a slightly mad fantasy of an enthusiastic gadgeteer. Only a few individuals such as Ralph Waters and Digby Leigh saw it as a practical solution to a recognized worrisome problem and were encouraging. Subsequent models of the pump3,4 were progressively improved and simplified, but the divided chimney for the mask remained the same. It was an important component to provide inlet and outlet for gases and thus effectively air conditioning the mask. The final choice for the pump was an adaptation of a vacuum-powered fan originally used for the removal ofmist from the inside ofan auto windshield. When ultimately satisfied with the pump and fan arrangement, Revell made a few units for interested colleagues and friends but was slow to publish or make the equipment available through a supplier. Thus, it was 1960 before a commercial prototype was made and then that was neither well publicized nor particularly well received. Some individuals were intrigued by the potential benefits of circulating anesthetic gas mixtures through the patient circuit and sought to accomplish this by using the venturi principle.!,S,6 The most successful ofthese was suggested by William Neff, M.D. of Northern California." However, venturi function requires two liters or more of fresh gasjet flow which is a volume inconsistent with use in the closed system and, therefore, disappointing. Daniel G. Revell was born in Chicago, Illinois on the 4th ofNovember 1904, ofCanadian parents, during a time when his father was teaching in the Department of Anatomy at the University of Chicago. In 1907 the family moved from Chicago to Edmonton, Alberta where Dan's father was appointed analyst for the Provincial government and later became Professor and Chairman ofthe Department ofAnatomy in the Medical School ofthe University ofAlberta. Dan grew up, then, in a faculty family and university environment, receiving all his education in Edmonton including the M.D. degree at the University of Alberta in 1932. During high school he was fortunate in having a good introduction to technical skills ofdrafting, woodworking, forging, and the use ofmachine tools. These arts once learned have been developed and of good use throughout professional life and retirement including

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Daniel G. Revell, M.D....

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the making of a xylophone, present day repair and renovation of antique clocks, cabinet making, and the design of artistic mobiles and wind chimes. Dan has an inquiring mind, an inventive spirit, and an ability to recognize problems, seek solutions and to provide innovative practical answers; most often adapting to hispurposes common ordinary objects and materials at hand. For his post-graduate medical education experience Dr. Revell went east to Ontario. At the Toronto Western Hospital during his internship, a month exposure on anaesthesia piqued his enterest. In the subsequent year he was the first resident in anaesthesia at the Toronto Sick Children's Hospital where, under the tutelage ofDr. Charles Robson, he had a heavy work load and gained lots of experience. Dr. Robson showed him how easy it was to intubate some children by inserting fingers into the pharynx and guiding the tube through the glottis. Here, too, Revell demonstrated his innovative capability and implementation of Thomas Edison's admonition: "If there is a better way of doing it, let's fmd it." In that year at 'Sick Kids' the most ingenious device he made for his own use was an ether dripper. It attached by prongs to the surface ofa Yankauer open drop mask, connected by tubing with a reservoir of ether for either gravity or pressure feed, and with a spigot valve, modified from a toy steam engine, to control rate of continuous drip. This allowed one hand to be free ofholding the ether bottle and available for other uses such as the recording ofobserved vital signs. He also made an ethyl chloride vaporizer to facilitate open drop induction and smooth transition to maintenance with ethyl ether. Other innovative devices were made for surgical problems, including an orthopedic hook for distraction ofan impacted hip, and a head holder for use during craniotomy in pediatrics. In 1934 Dan traded hospital environment for the great outdoors in. the rugged mining country of northwestern Ontario. He married a graduate nurse from the Toronto Western Hospital and together they spent the next four years at Red Lake, built a two-story log house and undertook a pioneer medical practice, making the rounds ofseven mining areas by dog sled, skis, propeller-pushed ski-mobile or boat. Mter four interesting years in the bush, Dan and his wife returned to the relatively more civilized life in Edmonton, having grown in maturity and self reliance. He then limited his medical practice to anaesthesia and became certified in the specialty. Again he began to make equipment to facilitate his work, including a relatively thermostable and portable ether vaporizer. In 1940 there was an opportunity to go to the Winnipeg General Hospital as second in command of anaesthesia, where Revell continued to make improvements on both the ether vaporizer and the ether dripper. With the expansion of hostilities and Canadian involvement in WWII, Dr. Revell joined the Royal Canadian Army Medical Corps in 1941 and served for four years of which about half that time was in southern England and Normandy, where he used effectively in the field an improved version of his ether vaporizer. In 1945 on return to Canada he resumed work at the Winnipeg General Hospital. A year later he assumed the duties of Chief of Anaesthesia at the Winnipeg Children's Hospital. It was while there that, in 1946, he devised the first model circulator and the divided chimney for the mask. He recalls with satisfaction the first case in which the circulator and divided chimney were used in an adult Heidbrink circle absorption system for a laparotomy in a four-year-old: "There was no hyperpnea." This was a striking demonstration that some ofthe observed changes during anesthesia were not the effect of anesthetic agents per se, but rather due to the deficiencies ofthe equipment used.

Adult Closed Closed Circle For Paediatric Anaesthesia Revel Clrcuialor

Fresh Gas and VapOlW

Note the lise of Revell Circulator, Divided Chimney, vapollr analvzer, andcalibrated 0xygell analyzer.

Revell provided a different answer and indeed had fo~~d a better way. This remarkably simple concept completely negates the adverse rebreathing effects of applying the mask to a face. The circulator has been of major interest to all who use the truly closed system,for which it wasoriginallydesigned.Benefits ofeconomy, reduction in the work ofbreathing, maximum humidity, avoidance of pollution and sharpening ofclinical skills as well as an increase in learning opportunities are among the advantages gained. I believe the introduction ofthe circulator tor use in circle absorption anesthesia systems was soundly based on an understanding ofrespiratory physiology. It is equally beneficial for respiratory cripples ofall ages, and certainly does no harm to the healthy - why impose an unnecessary extra load of increased respiratory effort on any anesthetized patient? It has been our good fortune and privilege to have known Daniel Revell and his wife Bonnie for more than thirty-five years and we have enjoyed their generous hospitality on the many occasions of our visits to Victoria. Dan is, as always, a modest and unassuming man, with quiet humor and a wide range of interests and challenging ideas. Our times together have been pleasurable and (sometimes) productive. Maybe it's because we were both born in Illinois and both married native Canadians!

References 1. Morris L.E.: The circulator concept. lnternational Anesthesia Clinics 12(3): IH198. 1974. 2. Roffey P.].. Revell. D.G .• Morris. L.E.: An assessment of the Revell circulator. Allesthesiology 22(4):583-590. 1961. 3. Revell. D.G.: Circulator to eliminate mechanical dcadspace in circle absorption systems. Canadian Anaesthetists Soc[oumal 6:90-103. 1959. 4. Revell. D.G.: Improved circulator for closed circle anaesthesia. Canadian Anaesthetists SocjOllmaI6:104-107, 1959. 5. N~ff, Wm. 8., Buree, 5.5. andThompson, R: A velltllri drculatorIor anesthetic systems. Allesthesiology 29:838. 1968. 6. Takaoka, K.: New valveless circuit with circulation ofgases. Brazilian journal ~r Allesthesiology 18(4):478-482. 1968. 7. Flynn. P.].. Morris. L.E. and Askill, S.: Inspired humidity in anaesthesia breathing circuits: Comparison and examination of effect of Revell circulator. Canadian Anaesthetists SocjollmaI31:659-663, 1984.

Recollections of Emery A. Rovenstine, M.D. One ofthefew people stillalive who isfamiliar withthel!{e andwork of Dr. Rovenstine isAlbert M. Betcher, tlOW 82 years ofage. In thejollowingpersonal review, Dr. Betcher details hiscontacts with Rovie, the ways ill which his it!f!lIellce spread, andsome of the maneuvers which ledto the formation of the American Board of Anesthsiology. Dr. Betcher himse[{has played aprominent role in the development ofanesthesia ill this COlltltry. Followillg service ill theSecond fiVorld fiVor, ill which herose tothe ranl: of Lt. Colonel, hewas appointedDirectorofthe Department ofAtlesthesiology ill theHospitalforJoitltDiseases ill New York City.Hebecame all Associate Clinical Projessor o.{.Anesthesia at the Einstein College ojMediane (II 1962. He was President oftheNew York State Society ofAllesthesiologists in 1954-55, andPresident of theAmerican Society o.{Anesthesiologists in 1962-63. His interest ill the history of anesthesia ledtohisappointment to the Board of Trustees of the fiVood LibraryMuseum o.{ Allesthesiology in 1952, becoming its President in 1956. In 1975 he was honored by receivino the Distitlgllished Service Awardof the ASA. l# are pleased topllblish thefollowillg account which was presented at the 1993 meeting o.{ theAcademy of Anesthesiology.

Emery Andrew Rovenstine, M.D. -

Historical & Personal Perspectives

by AlbertM. Betcher, M.D. I have attended every Rovenstine lecture except one since it was inaugurated in 1962. I have seen the ballroom filled to capacity each year, with the added trappings ofthe introduction ofthe ASA officers, presentation ofthe Distinguished Service Award (DSA) to the honoree ofthe previous year and now the presentation ofthe Award to the best research honoree. Everything stops at 11:15 a.m. No other activity takes place at that time. I have often thought, how many of the attendees know who E.A. Rovenstine was? Why do we give such an honor, perhaps in perpetuity to him? How did it come about? The inscription in the ASA Annual Meeting program below his photograph tells us ofhis accomplishments: that he had been Chairman of the Department of Anesthesiology, New York University and Director ofAnesthesia, Bellevue Hospital, a founder and Past President of the American Board ofAnesthesiology, Past President of the ASA, and recipient ofthe DSA. It also tells us why we honor him: because of his stimulating influence, anesthesiology developed in stature; because of his devotion to education, students with ability followed in his footsteps; because ofhis pursuit ofknowledge through research, an era of science in anesthesiology developed; and because of these efforts, anesthesia is safer. And finally, a third and fourth generation of anesthesiologists benefiting from the stimulating influence ofthis great physician are participating in this annual meeting. E.A. Rovenstine, or Rovie/Chief, as he preferred to be called by residents and friends, died in 1960. The first lectureship was endowed in 1962 by E.R. Squibb & Co., the manufacturer of cydopropane. Cydo was in its heyday at the time. Mter all, the halothane hepatitis controversy was on the front burner and we were one year away from the National Halothane Study. The company had every reason to believe that the use of cydopropane would go on. Rovie and his mentor, Ralph Waters, were its major proponents then. Thus, it was natural for the former to be so honored and for Waters to introduce the lecturer, Francis D. Moore, the Surgeon in Chief at Massachusetts General Hospital. The Postgraduate Assembly of Anesthesiologists of the New York State Society of Anesthesiologists also began its own Rovenstine lectureship in 1971. The first one was a panel and was structured as follows:

First Annual E.A. Rovenstine Panel Chairman: Emanuel M. Papper, M.D. -

Miami, Florida

Panelists: Lecture No.1 The PGA and its Impact on Anesthesiology Albert M. Betcher, M.D. - New York, New York

Lecture No.2 Shock Solomon G. Hershey, M.D. -

Bronx, New York

Lecture No.3 Progress in the Development of New Neuromuscular Blocking Agents Richard J. Kitz, M.D. - Boston, Massachusetts After three years the format became the same as at th~ ASA meeting. Now to the story ofE.A. Rovenstine: He was bornJuly 20, 1895, in Atwood, Indiana, the son of Charles A. Rovenstine. The father ran a general store for 54 years under a sign which read: DryGoods, Groceries,

Shoes andNOtiOIlS, Drugs, Medicines andConjections. Although he derked in his father's general store after school, he was

crazyabout all sports, but more so about baseball, becoming the catcher on the high school baseball team. He was also on the high school basketball team and in his senior year played in the state basketball tournament. There is a story that the referee was Arthur Guedel, a former athlete himself, who was picking up some extra money officiating while teaching at the medical school. Guedel was a large burly man and it seemed to Rovie that every time he had the ball, Guedel would get in his way. And so in the final period when this happened, Rovie put his head down and butted Guedel in the stomach. According to this story, Guedel was supposed to have turned the youngster over his knee and spanked him. Rovie also wanted to be a school teacher and spent summer vacations while still in high school attending Winona State Teacher's College at Winona Lake, Indiana. Upon graduating from high school in 1913 at the age of 17, he was appointed teacher at a one-room elementary school in Stony Point, Indiana. At the same time he played semiprofessional baseball. After a year of teaching he entered Wabash College on an athletic scholarship. He still wanted to play baseball, but because of the scholarship he had to play under the name of Jack Andrews. His fingers always showed the effects of receiving the pitchers' throws. Following his graduation from college in 1917 he enlisted in World War I and-was sent to France after being commissioned a second lieutenant. He spent three years in the service as officer in charge-ofan engineering demolition squad, for which he was decorated at Verdun by the French government. Upon discharge from the Army of Occupation in 1919, he was appointed asa combined mathematics, physics and chemistry teacher and athletic coach in a high school in northern Michigan. Mter three years he transferred to a high school in LaPorte, Indiana,

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with the same teaching program, but after two years he was restless and in 1924, at the age of29, decided to enter Indiana University College of Medicine. During medical school he met and took a course in anesthesia with Arthur Guedel. In his second year he was a student instructor in pharmacy and in the last two years was able to support himselfby working after school in a drugstore in a black neighborhoodin Indianapolis. In later years he told an interviewer that the druggist had built up quite a reputation in the neighborhood manufacturing and selling love potions. The pills came in two strengths: medium and strong. The medium pills were white and sold for 50 cents; the stronger ones were pink and sold for a dollar. "They must have worked," said Rovie, "people kept coming back for them." Mter graduating in 1928 he took his internship at the University hospital. He then returned to laPorte where he set up a general practice and gave anesthesia on the side. That was the customary thing to do, particularly if you had some training in anesthesia. He carried out his general practice for two years, but found he wanted to spend more time giving anesthesia. He went to see Arthur Guedel who advised him to take a residency under Ralph Waters in Wisconsin; he thus became one ofWaters' first two residents. Rovie spent the years 1930 to 1935 with Ralph Waters at Madison, Wisconsin, first as resident and then as Assistant Professor. It is to Ralph Waters that Rovie owed his dedication as teacher, researcher, awareness of the basic sciences, and his role as academician. The Anesthesia Department at the University ofWisconsin was the focal point for the advancement of the specialty in the early thirties. Other universities began to call Waters for help in setting up their departments. In 1935 NYU-Bellevue asked Ralph Waters to suggest someone to head their Department of Anesthesiology: Rovie was his recommendation. The new Chief arrived in New York in the fall of 1935 after being appointed as Professor of Anesthesiology and Chairman ofthe Department at New York University-Bellevue. At that time Bellevue was its teaching hospital since it did not have a University hospital. Not until after World War II did the Postgraduate Hospital become its University Hospital. He was anything but a smashing success. He was unpopular with the local anesthesiologists and too midwestern for the surgeons who couldn't care less for the idea of a full time new anesthesiology department. In those days Bellevue was divided into four divisions: Division 1 which was controlled by Columbia; Division 2 by Cornell; Division 3 by NYU; and the 4th being an open division. He was only allowed to do cases on the NYU division. As one could imagine, he spent a lonely year working alone, and at a time that two anesthetists threatened to ruin him professionally if he didn't leave town. One Sunday afternoon while attending ~ New York Giants professional football game, his wife committed suicide by opening the petcocks of the gas range. His mentor, Ralph Waters, who felt personally responsible whenever he placed one ofhis residents or staff. came to New York and offered to take him back with him to Madison, but Rovie refused. He was determined to stick it out. Gradually. however, he began to win over the surgeons in the other divisions, who noted the improved anesthesia on the NYU division. After some incidents in which he was called to resuscitate several patients, he began to be called on emergency cases on all the divisions. Then began the renaissance ofanesthesiology in which doctors flocked to Bellevue for training and went on to establish their own well-known departments such as:John Adriani at Charity Hospital, New Orleans; Stuart Cullen, first at Iowa and then University ofCalifornia San Francisco; E.M. Papper, who went to Columbia, Physicians and Surgeons; and Perry Volpitto who went to the University of Georgia, to name a few.

In the beginning the early residents split their time between Bellevu, and Madison. It was very difficult to get into Rovie 's residency program. Paul Lorhan, who went on to the University of Kansas, told me many years ago that he had to settle for one ofthe lesser NYC hospitals because of the number of applicants to Bellevue. Rovie was a great showman and always felt that anesthesia had to be sold to the other medical specialties. He became sought after as a visiting professor, spending a month at the Radcliffe Infirmary at Oxford in 1938 and conducting a series ofseminars at South American universities and in other countries. Also in 1938 he became one of the founders ofthe Affiliated American Board of Anesthesiology. He was a key figure in bringing it about, which I shall relate to you later. Four years after his first witc died, he was again married in 1<.139 to Jewell. She was a real businesswoman who never failed to astonish Rovie with her capacity to make money. When one considers that he took the lull-time professorship at NYU in 1935 for an annual salary of S5.000. one can sec why he was impressed. She is still alive and is in good health. She always welcomes calls. And now how I came to know this man. As an ROTC reservist I was called to active duty early in IlJ41 and was attached to the Station hospital at Fort Dix, NJ as chicfofthc Anesthesia and Operating Room Section. At the Tilton General Hospital. which was also at Fort Dix. the ChicfofAncsthcsia and Operating Room Section was Steven J. Martin. with whom I became very friendly. He had trained with Ralph Waters and also had been with Rovic for a time in New York:.?He was giving three-month courses in anesthesia to newly inducted medical otllcer's and which I sat in on whenever the opportunity arose. Ttl nil'. it W,IS postgraduate training. Early in IlJ42I found out that Rovic was giving a course in regional anesthesia. an area in which I knew vcrv little. When I talked to S~eve Martin about it. he volunteered to call R<;vie about Inting me sit in tor a week. which he did and Rovic agreed. I rook .1 week otlas part of my accrued leave and spent a very ri~'h week of learning experience. Also, I got to know Rovie. He was at all times warm and generous and treated me as one of the students, Later that year the American Board of Anesthesiology (ABA) announced that rhev would give a year's credit toward board cliuibilirv for service in the 'military. 'Since i had already had a year of trai~ling ,;t the Jersey City Medical Center. I applied tor permission to take the written exams. As the final date tor applying approached I still had not heard from the Board. I asked Steve Martin tor advice and he called Rovic, who was then one of the first Directors of the ABA. Back came the information that the chiefat [crscv Cirv claimed that I rcallv did not have a full residency. It was apparent to me that he tl'ared that' I would come back as a diplomate and unseat him. Rovic suggested that I go Sl'l' my ex-chief and get another letter. This I did. and he gave me that letter, especially when I told him I was also to get a letter t~om the Medical Director, with whom I had an excellent relationship because I had been the first to have been called up for military service from the hospital. I took and passed Part I of the boards early in IlJ43. followed by orders transferring me to an overseas general hospital being fi.mned at Fort Dix. Since I knew I could not take the orals tllr a year, I realized I would be overseas when the time came. Again Steve Martin came to my rescue, suggesting I go sec Rovie about getting permission to take Part II earlier. I called and was given an appointment by his secretary. Phyllis Sperber, who by that time had gotten to know me very well. Rovie was as gracious as he could be about my request. He informed me that the full Board would be meeting in New York tor the first time in two vcars due to wartime travel restrictions and he would take my request up then. The Directors did agree to allow me to take the Orals, with the COlltilll/l''/

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proviso that the result would not be given until the year was up. To my surprise, shortly after sitting for the Orals I was informed that I had passed. I assumed they had forgotten, but long afterward when I was on the Board, the late Dave Little told me he had read some of the old Board minutes and from what he told me, I believe Rovie had something to do with my getting the result earlier. In 1943 the ASA and the ABA were still in the one office in the Squibb building in New York. Rovie was not only on the Board but was President ofthe ASAin 194344. He was the only one to serve two terms as President of the ASA because elections could not be held. To further add to my good fortune, I showed the notification letter to the Commanding Officer of the overseas outfit who immediately got me a promotion to major. From time to time I dropped a note to Rovie about my overseas experiences, especially how I was treating trench foot. Although he never replied, after the war he told me how much he appreciated hearing from me. Mter I was discharged from the military service at the end of 1945, I went to see Rovie about a hospital appointment. By this time he was consultant to almost every hospital in New York City and no hospital would appoint anyone unless they first called him. And so on January 6, 1946, I was appointed to the Hospital for Joint Diseases where I spent a good many years. In the meantime Rovie inaugurated the idea of a Post Graduate Assembly (PGA) in 1945 to be held every other year. In 1947 he invited me to head one ofthe committees ofthe PGA. That meeting was so successful that it became an annual affair. It also led to my friendship with Paul Wood and Lewis Wright, both ofwhom furthered my progress in the specialty. At their suggestion and with their help I wrote the history of the ASA at its 50th anniversary in 1956. In 1947 Rovie also introduced and invited all anesthesiologists in the metropolitan area ofNew York to attend a weekly Morbidity and Mortality conference. It was held every Monday afternoon between 4:00 and 6:00 p.m. in the old K Amphitheatre. It was filled to capacity at every session and ran for years, even after it was turned over to Lou Orkin. We were invited to submit our cases as well. Paul Wood also suggested I speak to Rovie about the inside story of how we finally got the ABA. I knew from my research that we had been in trouble because in order to qualify, we needed petitions from a Section ofthe American Medical Association and two national societies in our specialty. We had no Section on Anesthesiology then, but the Section on Surgery was willing to sponsor us as an Affiliated Board. Paul Wood, as Secretary of the New York Society of Anesthetists, had per-

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

suaded it to change its name to the American Society ofAnesthetists in 1936. However, the other Society (International Society ofAnesthesia & Analgesia), was controlled by Francis McMechan who disliked the AMA enough to refuse to go along. However, there was a society called the American Society of Regional Anesthesia, which had been formed jointly by anesthesiologists and neurosurgeons ofBellevue hospital to honor Gaston Labat. He had introduced regional nerve blocks in this country and had published a classictextbook on the subject. They really wanted to name the Society after him, but he refused to allow it. This Society had sort of faded away because the neurosurgeons had lost interest. The organization had not met in several years. Information, including the membership list, was in the Bellevue Anesthesiology office. Rovie, aided by Paul Wood, sent out 104 postcards announcing a meeting to vote on whether to join with the ASA to ask for an Affiliated Board ofAnesthesiology. The two ofthem wrote up minutes approving the move. With the AMA Section of Surgery sponsoring us as one ofthe petitioners, and now having two national anesthesia societies, we were able to complete the requirements to become an Affiliated Board ofthe American Board ofSurgery. That is why the ABA seal, created by Paul Wood, contains the initials, ASA-ASRA-ABS. There is nothing more to add except to say that Rovie continued to receive many honors after World War II. He was really a very shy man, troubled by psoriasis, and went out ofhis way to place his residents in university centers. In 1958 while bending down he suffered some cracked ribs which turned out to be pathological fracfures. The primary site was the prostate. Following an orchiectomy he lived with the disease for 18 months before passing away on November 9,1960, at the age of65. Truly a man for histime, he merits the Annual Memorial Lecture named for him.

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