Newsletter January, 1992

Anesthesia History Association Newsletter January, 1992

Volume 10, Number 1 .

TIS H A Third International Symposium on the History of Anesthesia

Time marches on and it is later than you think. Plan to attend TISHA in Atlanta from Friday, March 27 through March 31. The symposium this year willhonor the sesquicentennial ofthe first clinical administration ofether by Dr. Crawford Long on March 30, 1842. It is perhaps no coincidence that Monday, March 30, has also been declared Doctors Day throughout the country. Dr. John Steinhaus, Chairman of the Organizing Committee, and, his colleagues have developed an excellent program which should satisfy the desires of one and all. On March 28, the first full day of the meeting, the first part of the morning will be a plenary session at which several invited speakers, including Dr. E.M. Papper, will set the stage by discussing the life and times ofCrawford Long. Later in the morning there willbe a one-hour bus trip for all participants to }:£ferson, Georgia, where lunch will be served and opportunities will be available to visit the Crawford Long Museum and to rub shoulders with the local townspeople. In the evening, afte~ returning to the hotel, a group ofprofessional actors willstage a play about Crawford Long and his life and work. All day Sunday and Monday (March 29, 30) and Tuesday morning are being devoted to the presentation of free papers, of which some eighty will be presented. As special attractions, on Sunday just before lunch Dr. Robert Joy, Chairman of the Department of History at the Uniformed Services School ofMedicine, has been invited to present a talktitled, "Civil War Medicine: the Letterman Reforms and Casualty Care." On Monday in the same time frame, Dr. Roderick Calverley, Professor ofAnesthesiology at the University ofCalifornia, San Diego, and one ofthe founders ofthe Anesthesia History Association, willpresent the Crawford Long Lecture, "From Sherman to the Storm." Dr. Calverley participated in the recent Desert Storm conflict. Rounding out the scientific program will be a variety of scientific

exhibits, poster sessions and videotape programs. Technical exhibitors will also be on hand to demonstrate their wares. On Monday evening there willbe a special buffet at the Carter Center for all participants and on Sunday evening a very special event is being planned. Special tours of Atlanta and its environs are also being planned for the spouses at other times. All anesthesiologists will enjoy these outstanding events. Registration forms are included as inserts in this Newsletter for those who have not already sent in their forms. See Atlanta in the springtime and you will not be disappointed. Hotel reservations may be made at the J.W. Marriott Hotel at Lenox, which is located at 3300 Lenox Road, Atlanta, GA 30326 [Tel. (404) 262-3344]' The hotel is just minutes from downtown Atlanta or from the Airport. Adjacent to it is the Lenox Square Shopping Center, the first covered mall in the South. Mention ofthe Symposium qualifies one for special rates. We are looking forward to seeing you at this Third International Symposium.

To Join the Anesthesia History Association (Annual Dues $35.00) Please \Vrite to: Lucien Morris, M.D., Secretary-Treasurer 15670 Point Monroe N.E. Bainbridge Island, Washington 98110

Council Meeting Anesthesia History Association

Anesthesia History Association Annual Meeting - October 26, 1991

The annual meeting of the Council of the Anesthesia History Association was held on Saturday, October 26,1991 in San Francisco. The President, Dr. Betty Bamforth, presided. Others present included Drs. Maurice Albin, George Bause, Norman Bergman, Eli Brown, Selma Calmes, Rod Calverley, Ray Fink, Elizabeth Frost, Roger Maltby, Lucien Morris, John Severinghaus and Ron Stephen. The Secretary-Treasurer, Lucien Morris, reported that during the past year membership had increased by about 50 percent, the current members being 475, of whom 52 are international. The Treasurer's report, showing a reasonable balanceon hand, wasadopted unanimously, as was a projected 1992 budget. Mte some discussion, it was decided that a new Membership Directory, to included addresses and telephone numbers, should be made available at the time ofthe Third Symposium on the History of Anesthesia (TISHA) in March, 1992. The Vice-President, John Severinghaus, announced that plans were well in hand for the annual dinner, with the attendance expected to be about 140. There was discussion about the date of the annual dinner in future years.Barring changesin the usualdates ofthe ASAmeeting, it waspointed out that having the AHA dinner on Saturday evening created real conflicts with many alumni reunion gatherings and with the annual dinner ofthe Trustees ofthe Wood Library-Museum. The consensuswas that in future years the AHA dinner should be held on Sunday evening. The Editor ofthe Newsletter, Ron Stephen, noted with appreciation the excellent work which Ms. Debbie Lipscomb continues to perform on the layout ofthe Newsletter. On behalfofthe entire Association, he also expressed his thanks to Ms. Cheryl Fox and the Becton Dickinson Company for the printing and disttibution of the Newsletter. The President reported that the Wood Library-Museum was being approached to see if they would act as a repository for the Archives of the AHA. Preliminary discussions were most favorable. The Chairman ofthe forthcomingTISHA meeting, John Steinhaus, presented a status report. About 84 submissions had been received to date, including abstracts, posters and videos. The deadline for submissions had been extended to December 1. The social program is developing well and a good response is anticipated. The Nominating Committee recommended the following slate of officers for 1992: President Betty Bamforth Vice-President John Severinghaus Past President John Steinhaus Secretary-Treasurer Lucien Morris Newsletter Editor Ron Stephen Council Members George Bause, Ray Fink Selma Calmes, Leslie Rendell-Baker Eli Brown, Douglas Bacon

The 1992 Meeting with social hour and dinner was held at the Four Seas Chinese restaurant, 731 Grant St., San Francisco. It was attended by one hundred twenty members and guests. Guests included Mr. Hal Gibson from the Guedel Center and Dr. Archie Brain from England. A very brief business meeting was held. Minutes of the previous year's Meeting were accepted as published in the January 1991 Newsletter. The Secretary-Treasurer reported a membership growth of more than 50% to a total listing of four hundred seventy-five. The Association is currently solvent. The receipts for 1991 were sufficient to cover current expenses which were somewhat heavier than anticipated. Much of the attention of Association Officers and Council has been concerned with planning and support of the forthcoming Third International Symposium on the History ofAnesthesia to be held in Atlanta, Georgia, 27-31 March 1992. The meeting approved the addition to the Constitution ofa paragraph delineating the David Little Prize. Members enjoyed an excellent lecture by Dr. Ralph Henderson Kellogg, Emeritus Professor of Physiology, on the life and accomplishments of Paul Bert. Officers for the coming year include: Dr. BettyJ3amforth, President; Dr. John Severinghaus, Vice-President; Dr. John Steinhaus, Past President; Dr. Lucien Morris, Secretary-Treasurer; Dr. C. Ronald Stephen, Newsletter Editor; and Council Members Dr. Selma Calmes, Dr. B. Ray Fink, Dr. George Bause, Dr. Douglas Bacon, Dr. Leslie Rendell-Baker, and Dr. Eli Brown.

Sir Keith Sykes

Dr. Bernardo Houssay was born in Buenos Aires, Argentina in 1887. In 1947, he was given the Nobel Prize in Physiology for demonstrating that removal of the anterior pituitary gland decreased the severity of diabetes caused by pancreatectomy. Dr. Houssay was the author of a widely used Textbook ofPhysiology. He died in 1971. He was the first South American to win a Nobel Prize. Dr. Houssay was honored on a stamp issued by Argentina in 1976 (Scott #1130).

Readers may note with pleasure the fact that Professor Keith Sykes, recently retired Nuffield Professor at Oxford, was given a Knighthood in the Birthday Honours in May, 1991. Not only is this a great personal honor, it also recognizes academic achievement for which all in Anesthesiology may stand proud in the reflected honor. Congratulations to Sir Keith and Lady Sykes! - Ludell E. Morris, M.D.

Ludell E. Morris, M.D. Secretary-Treasurer

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

How It All Began Afascillatil/gaccount oIllOw thediscovery ofanesthesia was disseminated throllghollt theworldhas been brollght toliS by Mr.AJ. Wright, M.LS., who isLibrarian at theDepartment ofAI/esthesiology attheUniversity ofAlabama atBirmillgham, Alabama. fIVt> are most thall~(zd thatMr. Wright also thronitles theol/goillg bibliography ~r papers relatillg toanesthesia ill theissues of this Newsletter. fIVt> are most grate.(ztl to Mr. Wright andto Dr. AI/is Baraka, Editor ~r the Middle East Journal of Anesthesiology.jer permission to reprint this article which appeared ill the M.E.]. Anesth. 11:93-118, June, 1991.

Diffusion of An Innovation: The First Public Demonstrations of General Anesthesia The search for pain reliefhas been among mankind's most enduring and widespread activities. The variety of methods and agents tried from hypnotism, nerve compression, alcohol, poppy and Mandragora to belladonna, lettuce, garlic and onions - and the geographical spread ofthis effort - from Egypt and India to Peru and China - has been truly astonishing. 1,2 In 1842, Crawford Long became the first person to consistently achieve patient insensibility to the pain of surgery. Knowledge ofhis achievement spread no further than his own isolated Georgia community until years later.! Not until October 1846 did the process begin which led to real breakthroughs in the ancient battle against pain. William T.G. Morton's demonstrations at the Massachusetts General Hospital in Boston were the sparks igniting anesthesia experimentation and publication around the world during 1846 and 1847. This rapid, intense diffusion of general anesthesia is one of the most striking and important aspects of nineteenth century medical advancement.

The Background Although Morton was unaware of Long's work until after his own successes with ether, he did not act in a vacuum of knowledge. Ether had a rich history of experimental, clinical and recreational use for decades prior to Morton's demonstrations. Credit for the discovery of ether belongs to Raymundus Lullius, a Spanish alchemist, who in the late thirteenth century is believed to have noticed a white liquid agent he called "sweet vitriol:' Two and a half centuries later both Paracelsus in Switzerland and Valerius Cordus in Germany rediscovered this combination of sulfuric acid and alcohol; Paracelsus also wrote about its soporific and pain-relieving character," Finally, another German, W.G. Frobenius, gave ether that name in 1730. 2 Thirteen years later Liverpool surgeon Matthew Turner recommended ether's use for a variety of complaints, including headaches.I In the nineteenth century prior to 1846, ether by mouth, inhalation pr topical application was a remedy applied for a variety of ailments. Benjamin Rush, Professor of Chemistry at the University of Pennsylvania and a figure of enormous influence in nineteenth century American medicine, 6 as early as 1801 listed ether as one ofthe "internal stimulants" in a course syllabus. In his lecture notes, Rush recommended ether by lungs for colic, pertussis and asthma." In 1805 John Collins Warren, one ofthe founders ofthe Massachusetts General Hospital and a physician who would be important at several points in the history of ether anesthesia, used inhalation ofthe agent for headaches, strangulated hernia and other problems.f Even in recent years, ether has been utilized to remove obstructed urinary catheters and maggots from ears, to stop the hiccup reflex, as a solvent for gallstones, and by rectal administration for severe status asthmaticus.? Despite ether's apparent widespread application in medical practice at this time, not all authorities advocated its use. Nathaniel Chapman, a student ofRush 's and a long-time faculty member ofthe medical school

of the University of Pennsylvania, was skeptical. "Ether is an active stimulant and antispasmodic, somewhat analogous to alcohol in its leading effects ... its impressions are so evanescent that little is gained by it, and it is difficult to imagine a case in which it should supersede wine, etc." 10 Ether also had recreational uses during this period. Entertainments or "frolics" in which ether or nitrous oxide were administered by traveling lecturers to members ofthe audience were especially popular in the United States. Gardner Quincy Colton and Samuel Colt are perhaps the best-known such showmen.l ! This use of ether was not limited to the lecture hall. Classroom and private frolics were also frequent, prompting one writer to describe ether as "the marijuana ofthe 1830s. "12 Marrill Wyman, staff physician at the Massachusetts General Hospital has left a vivid description ofsuch activity during that decade. "I remember well our amusement with sulphuric ether. .. We were especially jubilant when Mr. Whipple ordered a fresh quantity of ether, for it was apt to deteriorate by keeping. Each tested it by breathing it from the bottle until it produced unconsciousness, the other's watching the different effects upon each. We also experimented upon rats in a glass-globe until they were entirely motionless and often wondered that the treatment did them no harm. But with all our experiments we never thought oftrying the sensibility under ether, even by pricking with a pin. It was a great oversight. "13 Drinking ofether as a substitute for alcohol was also common, especially in Europe.l" The trail leading to surgical anesthesia by ether "inhalation begins with Michael Faraday, a protege of Humphry Davy, who along with others studied the exhilarating and analgesic capabilities of nitrous oxide. IS In the second decade of the nineteenth century Faraday worked with Davy at England's Royal Institution. His research with various gases apparently led Faraday to discover and describe the "very lethargic state" produced by ether vapour. Although anonymously published in 1818, the article containing this description is believed to have been authored by Faraday .16 This work also likened the effect of ether to that of nitrous oxide and may have led to the former drug's addition to the "frolic" armamentarium. Two more important uses of ether preceded Morton's demonstrations. In January 1842, in Rochester, New York, William E. Clarke soaked a towel in ether and anesthetized a young lady so her dentist could extract a tooth. Clarke, who had studied chemistry and medicine, was a frequent instigator and participant in ether "frolics" for several years prior to this event. 11 Just two months later Crawford W. Long ofJefferson, Georgia used ether on James M. Venable, who wanted two small tumors on the back of his neck removed. On March 30 Long removed one ofthe tumors; on June 6 he removed the second. The following month he used ether again for amputation of a toe. Thereafter he administered ether for at least one surgical case annually for several years. Unfortunately, Long,

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who had noticed the analgesic properties of ether during his own participation in "frolics:' failed to seize this opportunity and waited seven years to publish an account of his work. 3

The Demonstrations William Thomas Green Morton became a pivotal figure in anesthesia history. through a pair of influences, his own dental practice and his association with two men, Horace Wells, a fellow dentist and one-time partner, and Charles Thomas Jackson, a physician, geologist and chemist. Morton's Boston dental practice involved frequent fittings of false teeth plates. Unlike most ofhis peers, Morton used a type ofplate and gold solder combination that required removal ofthe entire tooth, root and all, for a perfect fit. Morton learned about this improved plate during his combined apprenticeship and partnership with Horace Wells and another Wells student, John Mankey Riggs, during 1842 and 1843. 17 This business association, which Wells considered a failure.l" dissolved after a year, but both Wells and Morton continued their individual practices and searched for a means that might alleviate the fears potential patients had concerning the pain of root extraction. On December 10, 1844, Wells attended a "laughing gas" demonstration given by Gardner Quincy Colton in Hartford, Connecticut. During this event Samuel Cooley, who had breathed the nitrous oxide, injured himself but felt no pain; Wells immediately recognized the potential application to dentistry. He arranged for Colton to bring him some of the gas the following day, when Wells allowed his former pupil, John Riggs, to extract a wisdom tooth while he was unconscious. Within a month Wells had pulled teeth without pain in fifteen cases.'? Wells then appeared in Boston and asked Morton, who had taken classesat Harvard Medical School, for introductions to some ofthe surgeons at Massachusetts General Hospital. Morton complied and introduced Wells to George Hayward and John Collins Warren. Warren invited Wells to speak to his surgery classon the subject and to administer nitrous oxide for a limb amputation. The patient decided against the operation and Wells, after his talk, attempted a tooth extraction. This effort was considered unsuccessful, 11,19 and nitrous oxide asa potential surgical anesthetic was temporarily discredited. Although its use continued in dentistry, nitrous oxide for surgery would not reappear until the 1860s when Chicago surgeon Edmund W. Andrews mixed the gas with oxygen. 20 Meanwhile, Morton, who had witnessed Wells' failure, continued his own search for a dental analgesic. In 1844, at the suggestion of Charles T. Jackson, under whom he had studied at Harvard Medical School, Morton tried liquid ether to ease a sensitive tooth during a filling. He also knew from one of the standard textbooks of the day that small amounts ofether vapor were harmless.U He started experiments on a series of animals, including goldfish, dogs, insects, caterpillars, worms, and fmally himself His attempt to anesthetize his dental assistants resulted in excited, not unconscious, patients. Another consultation withJackson elicited the suggestion that he try pure sulphuric ether instead of the commercial version. On September 30, 1846, Morton used pure ether as he removed a tooth from Eben H. Frost. The next day the Boston Journal carried an account of this event. 22 At last the stage was set for Morton to attempt his own "public" demonstration, i.e., the medical housestaffand students ofMassachusetts General Hospital would attend the operation. According to John Collins Warren, " ...The first proposal to me for the employment ofether by inhalation, for the

prevention of pain in surgical operations. was made by Dr. W.T.G. Morton. about the middle ofOctober. !H46. Calling on me. he stated that he had possession ofa means ofaccomplishing this object. that he had made trials ofits efficacy in the extraction of teeth. and that he wished me to test its power in surgical operations. The article used for this purpose not being menrioned.I supposed it was not proper for me to demand what it was, but I think it necessary, before the responsibility ofusing it, ofsanctioning its use, to ascertain whether a trial could be made without any apprehension of danger. Having satisfied myself on this point by various questions, I agreed to give Dr. M. the desired opportunity, as soon as it should be in my power. No such opportunity having occured within a day or two in private practice, and being at that time in the performance of my tour ofduty as attending surgeon at the Massachusetts General Hospital, I seized the occasion of the first operation in that institution for the proposed experiment. The patient was a young man, about twenty years old. having a tumour on the left side ofhis neck, lying parallel to. and just below the left portion ofthe lower jaw. This tumor. which had probably existed from his birth, seemed to be composed oftortuous. indurated veins. extending &om the surface quite deeply under the tongue. My plan was to expose these veins by dissection sufficiently to enable me to pass a ligature around them. The patient was arranged for the operation in a sifting posture, and everything made ready: but Dr. Morton did not appear, until the lapse of nearly half an hour. I was about to proceed, when he entered hastily, excused the delay, which had been occasioned by his modifying the apparatus for the administration. The patient was then made to inhale a fluid from a tube connected with a glass globe. After four or five minutes he appeared to be asleep, and was thought by Dr. Morton to be in a condition for the operation. I made an incision between two and three inches long, in the direction ofthe tumor, and to my gre'it surprise without any starting, crying out, or other indication ofpain. The fascia was then divided, the patient still appearing wholly insensible. Then followed the insulation ofthe veins, during which he began to move his limbs, cry out, and utter extraordinary expressions. These phenomena led to a doubt of the success of the application, and in truth I was not satisfied myself, until I had, soon after the operation, and on various other occasions, asked the question, whether he suffered pain. To thishe always replied in the negative: adding, however, that he knew of the operation and comparing the stroke of the knife to that of a blunt instrument passed roughly across his neck. Now that the effects ofinhalation are better understood, this is placed in the class of cases of imperfect etherization"23...

This operation on Edward Gilbert Abbott, a printer and editor,24 was followed the next day by another successful tumor removal, this time by George Hayward from the arm ofa woman. However, Warren and Hayward soon suspended the use ofwhat Morton called "letheon" because they learned he planned to patent his "secret" mixture. "It now became a question, whether in accordance with that elevated principle long since introduced into the medical profession, which forbids its members to conceal any useful discovery, we could continue to encourage an application we were not allowed to use ourselves, and of the components of which we were ignorant" .25 The two surgeons did not relent until Morton - who with Jackson did indeed obtain a patenr'" - assured Warren in a letter that he would reveal the nature of "letheon." On November 7 operations with ether resumed at Massachusetts General Hospital. On that day a leg amputation and a lower jaw removal on two femaleswere performed. George Hayward removed a leg above the knee from "Alice Mohan, a young woman of twenty years ofage". 27 "It was done in the presence of two or three hundred spectators," Hayward later wrote, "and was entirely successful."28 Within days of both the October and November pairs of operations, word of Morton's "letheon" successes would begin to reach a much' wider public.

The Diffusion Accounts ofthe first operations under ether anesthesia at the Massachusetts General Hospital appeared in the daily press immediately. The Saturday evening, October 17, 1846, editors oftwo Boston newspapers

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contained what were probably heresay descriptions ofthe event. 29 The positive reactions in these accounts echoed several that Morton had received for his extraction of Eben Frost's tooth in September, about which one newspaper had declared "discovery is destined to make a great revolution in the arts of surgery and surgical dentistry. "29 By the following week eyewitness accounts of the first two operations had been published in Boston newspapers. Within a week of the second operation Morton had placed advertisements in at least two of the city's papers, just as he had done for the September tooth extraction. 29 Mail delivery at that time would have carried these newspapers to Baltimore, eastern New York and Pennsylvania in five days or less; to Ohio and Chicago in about fifteen days or less; and to New Orleans in about twelve days. Papers in those cities might then have reprinted the news, a common practice among newspapers from the colonial era to the late 1840s when the telegraph became widely used.30 Morton did not limit his publicity efforts to Boston newspapers. Sometime in November he began printing and mailing a brief notice "To Surgeons and Physicians" that announced his ability to deliver "his compound" for cases "when it is desired by the 'operator that the patient should be rendered insensible to pain'."31 Morton may have waited until the patent "problem" at Massachusetts General Hospital had been solved before mailing this item. One ofthe two extant copies was sent to John Mason Warren, physician son ofJohn Collins Warren and postmarked November 20. The text of this notice, with two sentences added, was also used in a one-page circular issued November 26 and as an advertisement in the Boston Medical and Surgical Journal issue of November 25. 31 Soon these tantalizing hints were given fuller explanation in the medical press. In its October 21 issue, the Boston Medical and Surgical Journal published its own cryptic notice: "Strange stories are related in the papers ofa wonderful preparation, in this city, by administering which, a patient is affected just long enough, and just powerfully enough, to undergo a surgical operation without pain."32

On November 9, Dr. Henry Jacob Bigelow, who had observed Morton's original demonstration, described the operation at a meeting of the Boston Society for Medical Improvements. This lecture also included information about Morton's dental cases with ether and his surgical cases after the one ofOctober 16. Bigelow says surprisingly little about the first operation at Massachusetts General Hospital; much of his talk is devoted to the history of ether use in medicine prior to Morton. Bigelow does, however, mention his own experiment with ether inhalation. On November 3 Bigelow had delivered an abstract of this lecture at the American Academy ofArts and Scicnces.P Nine days later the talk was published in the same Boston journal as the above notice.I" Bigelow's delay in publication was probably wise; by that time, ether had been used in four successful surgical cases and the patent "controversy" settled for the moment. In addition to Bigelow's article, issues ofthe weekly Boston Medical and Surgical Journal for the remainder of 1846 carried about twentytwo papers on ether anesrhesia.P This number included accounts from Philadelphia." and New York 37 as well as Salem, Massachusetts-" and John Collins Warren's own description of his October 16 operation on Abbott.39 Following these initial publications, the medical literature became crowded with ether articles in 1847 as its administration spread around the world. The British publication Lancet carried 110 articles and notices on ether in the first six months of1847 and twenty-four items in the second half of the year. 40 In October the American Journal of the

Medical Sciences published a number of reprints from around the world under the collective title "Ether Inhalation as a Means ofAnnulling Pain"."! By April, 1848, this section had become "Anesthetic Agents" and appeared in each issue.42 Publications about ether were not limited to lay and medical periodicals during 1847. A number ofbooks and pamphlets were also issued that year, reflecting the rapid diffusion of both practice and interest. Most of the at least fifty-six such titles were published in countries other than the United States and Great Britain, including France, Germany, Italy, Austria, Czechoslovakia, Switzerland, Belgium and Hungary.43-45 One ofthese titles was frequently reprinted. To help him with his patent application, Morton hired Edward Warren, a Maine lawyer. Warren put together a collection of pertinent documents entitled Some Account ofthe Letheon. The pamphlet appeared in five editions between March and July 1847, each expanding in size over the previous one.I! This combination of testimonials and endorsements was "indistinguishable from the promotional advertising pioneered by other patent medicine manufacturers." The American Society ofDental Surgeons was "outraged."46 Patent applications by dentists were apparently common, however, in both the United States and Great Britain.f? Personal correspondence was important to the spread of ether anesthesia in at least one well-known case. On November 28, 1846, Dr. Jacob Bigelow wrote a letter to his fellow American and friend living in London, Dr. Francis Boott. Bigelow was the father ofHenry Bigelow, a consulting Physician at Massachusetts General Hospital, professor at Harvard Medical School and botanist of international reputation. He had also witnessed Morton's first demonstration at the hospital. Boott shared Bigelow's interest in medical botany.48 Along with this letter, Bigelow included a newspaper reprint ofhis son's journal article: This material was put aboard the steamship packet Acadia which left Boston harbor on December 3. Boott received the letter on December 17, one day after the ship landed at Liverpool.F Boott submitted part of the letter to the Lancet and, with his dentist neighbor James Robinso~, began experiments with ether. They first used ether for a tooth extraction at Boott's home on Saturday, December 19. On that same day in Dumfries, Scotland, the Acadia's doctor, William Fraser, who had somehow learned of Morton's discovery, "persuaded his surgical colleagues to operate on a patient under ether."47 The English equivalent of Morton's "public" demonstration took place on Monday, December 21 at London's University College Hospital. The surgeon was Robert Liston, professor in the medical school and senior surgeon at the hospital. Over the weekend Liston had met with Boott and Robinson; by Monday afternoon a chemist, Peter Squire, had prepared the ether. Squire's nephew William administered the ether while Liston successfully amputed a leg of a butler named Frederick Churchill.49 In addition to the United States and England, surgical anesthesia appeared in numerous other nations and colonies in 1846 and 1847. 50 As mentioned, ether was administered in Dumfries, Scotland, on December 19,1846, and then in Paris three days later. InJanuary 1847, Switzerland, Germany, Austria and Latvia were added; in February, Czechoslovakia, Sweden, Russia, Spain and Denmark; in March, Jamaica, Canada, Norway, Finland and Cuba; in April, Portugal, South Mrica and Singapore; in June, Australia; Argentina in July and New Zealand in September. Ether administration spread as quickly throughout much of the United States. In May, 1848, the first annual meeting of the American Medical Association, formed in the spring of 1847, heard a lengthy

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report on anesthesia by its Committee on Surgery. This document was very favorable and thus gave approval to the practice by a newlyorganizing group of orthodox physicians. "Within the past year," the report noted, "the inhalation of ether has been extensively used throughout the United States. It is resorted to in most ofthe large hospitals of the country, and at the public clinical dispensaries of the schools as a preparatory measure before all important operations, as well as in the private practice of many physicians and surgeons. The medical press ofthe country teems with casesand results in which ether has been safely employed, under a variety ofcircumstances. "51By the spring of 1847 ether anesthesia had even reached rural outposts like Alabama. 52 Several hospital case lists show frequent use ofether. At the Massachusetts General Hospital more than 130 cases in 1846 and 1847 involved ether administration; this number included eleven procedures performed on an outpatient basis. In 1847 ether was used in nineteen surgical cases at New York Hospital. In Philadelphia, eight cases were recorded at the University of Pennsylvania Clinic,' and twenty-eight cases at the Jefferson Medical College Clinic. 51 The introduction ofanesthesia by itself seems to have increased the sheer number of operations performed, at least in some locations. In April, 1847, Lancet editorialized that "the number ofsurgical operations in some ofour hospitals has been more than doubled since the introduction into practice of the use of ether vapor. "51 Pernick notes that surgery in emergency casesincreased dramatically at MassachusettsGeneral Hospital; such cases almost quadrupled in the year 1846-7, while the rate for other cases increased 2.4 times. However, Pernick further observes that surgery rates increased much less quickly at Pennsylvania and New York Hospitals, where anesthesia had little immediate effect on the development of surgery. Surgical technique could not advance appreciably until much later in the century, when infection control, the establishment ofpathology and physiology as sciences and medical and surgical practice based on research and teaching had all matured. Anesthesia was thus the first in a chain of necessary developments. 54 VarIous kinds of experimentation both resulted from and contributed to the further diffusion ofether anesthesia during 1847. By the middle of that year an intense search for a better inhalation agent than ether was underway and would continue for several more years. Ether's drawbacks included a strong odor and its irritation of the lungs. In November, 1847 Scottish surgeon James Young Simpson found one such drug, chloroform, which would quickly become the anesthetic of choice among many physicians. The manner in which Simpson happened upon chloroform, his behavior as soon as he realized its potential and even the element ofcontroversy resemble the pattern ofMorton's to a remarkable degree. 55,56 In addition to a search for a different anesthetic agent, a different route of ether administration was also tried. Russian surgeon Nikolai Ivanovich Pirogoffwas the author of an early text on ether, published in St. Petersburg in the spring of 1847. At about this same time he administered ether rectally, "convinced that he had found a better method... which gave less trouble to the patient and the surgeon. "57 Pirogoff was thus the first to try this method in humans; however, it apparently disappeared until 1884 when its reintroduction into clinical practice by Molliere and others occurred. Their results were not encouraging and rectal anesthesia again lay dormant until its revival by Cunningham, Sutton and especially Gwathmey early in the twentieth century.58 Experimentation with different inhalers for administering ether was

also widespread in late 1846 and 1847. Morton had designed his own apparatus, and this spirit of invention was followed by numerous others, especially in Europe. Thus there is Hooper's inhaler (for Boott and Robinson), Squire's inhaler (for Liston), Charrier's inhaler, Dieffenbach's inhaler, and so forth. 59 Another element in the diffusion ofanesthesia was undoubtedly the vociferous debate over who "discovered" anesthesia, which began soon after Morton's demonstrations became known and which occupied Morton, Wells, Jackson, and others and each one's followers for years to come. The details ofthis "ether controversy" have been extensively explored elsewhere. 60-62 The publicity surrounded by this debate probably created further interest in ether administration.

Diffusion of Innovation Theory The diffusion of innovations throughout a culture or cultural segment has become a subject ofintense research in the twentieth century. The "classical model" of diffusion theory has a structure which may help illuminate the rapid spread of anesthesia during 1846 and 1847. Diffusion theory is a subset of communications research. "Communication is essential for social change," according to Rogers. "Social change is the process by which alteration occurs in the structure and function ofa social system." Rogers suggests"three sequential stages in the process of social change; (1) invention... (2) diffusion ... and (3) consequences. "63 Barnett, an earlier writer on fbange in society, notes that"All cultural changes are initiated by individuals. "64 The role ofindividuals and the communication processes among them in the diffusion of ether anesthesia has been outlined above. The sociological process of diffusion has been defined "as the (1) acceptance, (2) over time, (3) of some specific item - an idea or practice, (4)by individuals, groups or other adopting units, linked (5) to specific channels ofcommunication, (6) to a social structure and (7) to a given system of values, or culture."65 Formalized interest in diffusion originated with European and American anthropologists at the beginning of the twentieth century. In the 1920s and 1930s sociologists also began to study diffusion. Topics covered by these two groups included such things as the Sun Dance ofthe Plains Indians, the spread ofhybrid com use by Iowa farmers and the city-manager form of municipal government. Both these scholarly efforts shared the "concentric circle" diffusion hypothesis and the assumption "that informal communication among adopters was the key to diffusion. "65According to one estimate, between 1945 and 1980 some 3000 diffusion ofinn ovation studies were published. In reflection of the grmving bureaucratization ofmodem life, research shifted focus in the late 1960s from diffusion among individuals to diffusion within organizarions.v" The study of innovation diffusion in medicine has been a small but very significant part ofthe field as a whole. A landmark diffusion study was published in 1966 by sociologist James Coleman and others, who tracked the spread ofthe new antibiotic tetracycline among physicians in four small Indiana towns. 67 This work found that informal communication among the physicians was the primary mechanism ofdiffusion. A study published prior to the Coleman one, but in reaction to preliminary work published by Coleman and his colleagues, suggested "the possibility" that the large-city pattern ofdiffusion ofinnovation of a new drug may be dependent on more impersonal methods of communication than is the case in a smaller community."68 Since Coleman's work a number of diffusion studies related to aspects of medical practice have appeared. Among the areas covered have been health care organizations,69,70 bum care,"! coronary artery bypass surgery,72 "the top ten clinical advances in cardiovascular and

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pulmonary medicine and surgery in the last 30 years"?" and computerized tomography and magnetic resonance imaging.74 The "dissemination of .. medical findings and associated changes in clinical practice" among anesthesiologists has also been studied.P Various models have been proposed to help explain the process of innovation and diffusion. These include a "desperation-reaction" model,76 the application ofepidemic or social contagion theories to the transmission ofideas,77,78and, at the organizational level, the linear or "science push" model and the market pull model.I? However, Rogers has distilled from more than seven decades ofdiffusion research what he calls the "classic model" of diffusion among individuals.63,66 The structural elements of this model make it especially useful in considering an historical event such as the introduction and adoption of surgical anesthesia. Rogers identifies four major parts of the classicalmodel: the innovation, communication channels, time, and members of a social system. "The newness of an innovation does not just involve new knowledge, but also persuasion, or a decision to adopt," Rogers notes. 66 Five characteristics of an innovation have been identified by research as affecting the rate of adoption: 1. Relative advantage: Is the innovation perceived as better than the practice it replaces? This advantage need not be objective and may be tied to such factors as convenience or prestige. 2. Compatibility: Is the innovation consistent with existing values, experiences and needs of potential adopters? 3. Complexity: Is the innovation difficult to understand and use? 4. Trialability: Can the innovation be experimented with on a limited basis? 5. Observability: How visible are the results of an innovation to others? The second important element ofthe classicalmodel is communication channels. "The essence of the diffusion process is the interaction by which one communicates a new idea to another or to several others. "66 Peer adoption of an innovation and communications about that adoption are frequently of more importance than scientific evidence about the innovation. Time is an element involved at several stages of the diffusion process. Adopters ofan innovation are categorized according to how early or late they enter the process. Thus the adoption rate is measured for a system, not an individual. Rogers also observes that "Innovations that are perceived by receivers as having greater relative advantage, compatibility, trialability, observability and less complexity have a faster rate of adoption than others. "66 The final major element concerns characteristics ofthe social system in which the innovation occurs. "Diffusion and social structure are complexly interrelated. The social structure of a system impedes or facilitates the rate of diffusion and adoption of innovations through what are called system effects. Diffusion may also change the social structure itself when the innovations are of a restructuring nature. "66 As far as innovation is concerned, the two most important figures in a social system are the innovator and the opinion leader. "Often the most innovative member ofa system is perceived as a deviant from the social system and is accorded a somewhat dubious status and low credibility. That person's role in diffusion, especially in persuading others of the innovation, is likely to be limited. Opinion leaders provide others in the system with information and advice about innovations. "66

These elements of the classical diffusion of innovation model provide a structure by which the innovation, adoption and spread ofsurgical anesthesia can be examined and illumined.

Discussion The advantages of using ether inhalation to relieve surgical pain were immediately perceived. John Collins Warren vividly described how most surgeons must have reacted. "The granite-faced surgeon... unbent completely. "80 "A new era has opened on the operating surgeon. His visitations on rhe most delicate parts are performed. not only without the agonizing screams he has been accustomed to hear, but sometimes in a state of perfect insensibility, and occasionally. even with an expression of pleasure on the part of the patient. Who could have imagined that drawing a knife over the delicate skin of the face, might produce a sensation ofurunixed delight? That the turning and twisting of instruments in the most sensitive bladder, might be accompanied by a delightful dream? That the contorting ofanchylosed joints should coexist with a celestial vision? If Ambrose Pare. and Louis, and Dessault, and Cheselden, and Hunter, and Cooper, could see what our eyes daily witness. how they would long to come among us, and perform their exploits once more. And with what fresh vigor does the living surgeon, who is ready to resign his scalpel, grasp it. and wish again to go through his career under the new

auspices. n80

Another American surgeon, A.L. Cox, agreed that anesthesia offered the surgeon "the prospect of a most gratifying triumph of his art."37 European reaction was similar. In Scotland, the Dumfries Courier of January 11, 1847, noted: "The immense advantage ofbeing able to perform the numerous severe operations necessary in surgery upon a patient in a state of unconsciousness are very obvious. The chief one is undoubtedly the avoidance of the dreadful pain endured by the hapless sufferer; and in many cases treatment may be resorted to, which was often withheld from the dread of inflicting suffering doubtful in its results. or under which death, from the infliction, might have ensued. Moreover many skillful surgeons can never become good operators from the want of the great nerve required in this branch oftheir profession; but with the unconscious patient under his hands. the most sensitive medical man may apply the knife or the saw with ease and confidence. "81

The German surgeon Dieffenbach wrote in a letter at the end of 1847, "The wonderful dream that pain has been taken away from us has become reality. Pain, the highest consciousness ofour earthly existence, the most distinct sensation of the imperfection of our body, must bow before the power of the human mind, before the power of ether vapor. "82

Reaction to anesthesia was not uniformly ecstatic. Many objections were raised to the procedure,83 not the least ofwhich was the legitimate concern that the administration ofether and later chloroform could be dangerous to the patient. A minority of physicians also considered the abolition of pain to be undesirable. As anesthesia experience accumulated, these and other objections faded. The nineteenth century has been described by philosopher Charles Pierce as the "Age ofPain" ,84 but in the half-century prior to Morton's demonstrations, man's attitude toward pain underwent a gradual but dramatic change. For centuries, pain was given a moral and religious justification as befits the word's derivation from Latinand Greek words meaning punishment and penalty respectively.P This attitude was manifested in medical practice in the system of Benjamin Rush, who advocated "unrestrained" use of such remedies of bloodletting and emetics. "For Rush, the more dangerous the disease, the more painful the remedy must be."84 Although his system "was largely discredited by the 1830s," Rush's influence on American medicine continued well

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How It All Began. . . Continuedjrom Page 7 beyond that decade 85 and is perhaps responsible for the expectation of today's American patient that doctors will treat their condition aggressively. Late eighteenth and early nineteenth century developments led to a changed environment in medicine. As William Welch noted late in 1896, "The shackles of philosophical speculation and dogma which bound medicine at the opening ofthis century had been broken"86 by the works in experimental medicine of men such as Pierre Louis. Frenchman Louis developed the science of clinical statistics, which allowed the measurement oftherapeutic efficacy. As might be expected, "the results revealed most existing remedies as impotent at best. "85 During the early decades ofthe nineteenth century, close observation, animal experimentation and equipment development began to supplant therapeutic "speculation and dogma" in a number ofother areas, in medicine as well as the physical sciences.V At this time, surgery underwent increasing professionalization. This process is exemplified by the career ofPhilip Syng Physick, "the first American to gain prominence as a full-time st,lrgeon."84 Physick studied under famed surgeon John Hunter in Edinburgh; in 1792 he returned to Philadelphia to study further under Rush. Physick "was responsible for developing many practical procedures and technical devices useful for the practice of surgery in the preanesthetic era" including methods of amputation and the design of an instrument for bladder stone removal. "88 Amputations, vascular and bone and joint surgery, and gynecological surgery performed by professional surgeons became increasingly common by the 1840s. 89 But with most operations, these were performed almost exclusively as a last resort when all other therapies had failed. Even so, a surgeon such asJohn Collins Warren could perform almost 500 major and minor operations between 1822 and 1846. 90 Thus the skills ofsurgeons were increasing prior to anesthesia, but the pain of surgery and enormous death rates from shock and infection limited severely the surgeon's practice. Anesthesia radically changed that environment for both surgeons and patients. "Not only were surgeons choosing to operate on a greater proportion of their patients... but there also were many more patients showing up for surgery. "91 Ether anesthesia also gave orthodox physicians a powerful new weapon in their competition with sectarian medicine. Although some physicians were becoming less "heroic" in their application of Rush's system, these"conservative" practitioners still faced a host ofother systems; hydropaths, vegetarians, Grahammites, Eclectics, homeopaths and varous offshoots of Thomsonian medicine, among others. A national association of homeopaths was organized in 1843; at about the same time "a small elite ofleading orthodox physicians initiated a series of 'medical reform conventions' " 92that led to the formation of the American Medical Association, the New York Academy of Medicine and similar groups. Members of many of the medical sects attacked anesthesia because it increased the frequency of surgery.P! Yet anesthesia provided orthodox medicine with a "treatment" for surgical pain that its practitioners could offer potential patients. The relative ease with which ether anesthesia could be administered also helped its rapid diffusion. Once the nature ofMorton's "letheon" was revealed, physicians had an agent with which most of them were already familiar. Ether was easy to synthesize and had a boiling point low enough "so that at room temperature it exerted a vapor pressure great enough to allow the patient to inhale an effective concentration. "12 That ether could be inhaled was also important; "intravenous and local anesthesia required the invention ofthe hypodermic needle"

and "the ability to avoid infection."12 Both of these developments came after 1846; use ofinhalation as a route ofdrug administration was ancient.?" Finally, ether inhalation was a method that was simple enough to administer on a trial basis - even, as frequently occurred, to oneself And the results ifether was effectively used were obvious: the patient did not struggle or scream during surgery. The role of such communication channels as personal correspondence, newspapers and journals in the diffusion ofanesthesia has already been discussed. At the time ofMorton's demonstration, less than fifty years had passed since the American medical journal, American Medical Repository, had begun publication in New York in 1797. By 1850, 117 medical periodicals had begun publication in the United States. 95 Two ofthese were the New EnglandJournal ofMedicine and Surgery, a quarterly founded in 1812, and the Boston Medical Intelligencer, a weekly, in 1823. By 1828 these two publications had merged to become the weekly Boston Medical and Surgical Journal, which continues today as The New England Journal of Medicine.P" Thus, by 1846 the Boston Medical and Surgical Journal was one of the longest-running and no doubt influential medical periodicals in the United States; "the average life expectancy of a medical magazine was short" one Writer has noted. 95 Low subscription prices helped to spread these journals widely; the cost of the Boston Medical and Surgical Journal was only two dollars a year in 1827. 95 Although early articles published in the Boston Medical and Surgical Journal probably were influential because of the)ournal's reputation,34,39,97 the knowledge about the authors among their peers was perhaps even more important. Henry Bigelow was certainly wellrespected in the medical profession. In December 1846 Cox asserted, "There was no room to doubt the respectability of the source from which the information was derived" in reference to Bigelow's November article.F Cox then describes the operation under ether he performed the day after reading Bigelow's paper! Undoubtedly, the most important name associated with Morton's demonstration wasJohn Collins Warren. Born in 1778, Warren in 1846 was both at the pinnacle ofAmerican medical practice and at the end of his career. He retired from Harvard Medical School in 1847, nine years before his death. The son ofa well-known physician, Warren was a man of incredibly varied accomplishments and interests. "By the time he was fifty, John C. Warren was noted for a number of operations," including the first successful repair ofstrangulated hernia in the United States, cataracts, arterial ligation for aneurysms, lithotomies, harelips and arnputations.ff Warren helped organize the Boston Society for Medical Improvement around 1803 and initially suggested the establishment of a medical journal in Bosron.P" This publication, the New England Journal of Medicine and Surgery, also included George Hayward and Jacob Bigelow among its sponsors. In addition to his medical interests, Warren was active in other areas. He participated in such groups as the National Philosophy Club and the Bunker Hill Monument Association.P" helped in the reconstruction of a mastodon skeleton.V helped build the large collection ofskulls for a pherological sociery.P? and served as President of the American Medical Association. Warren also had a long professional interest in pain relief In the very first issue in 1828 of the Boston Medical and Surgical Journal he published an article entitled "Cases ofNeuralgia, or Painful Affections of Nerves."96 He also experimented unsuccessfully with somnambulism, a variant of mesmerism, for operative pain relief. loo And, of course, he lent his personal prestige to Horace Wells' attempt to use nitrous oxide as a surgical anesthetic. Thus, Warren was probably recep-

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tive to Morton's request to demonstrate ether, although one ofWarren's biographers has claimed that Warren had to be convinced by his son, John Mason Warren. lOi Nevertheless, Morton could not have found a better sponsor for his demonstration. Morton's influence on the diffusion of anesthesia is much more problematic. He seems to some degree at least to .fit the classical model's portrait of the innovator. Born in 1819, Morton departed the family farm in Charlton, Massachusetts, at 17 and went through various business failures before studying dentistry and ending up in partnership with Wells by 1842. Ludovici quotes Morton's wife and one ofhis biographers as asserting "that he had a high destiny to fulfill, that he was a searcher; that he was constantly on the lookout for something to win attention to himself .. motivated by a devouring ambition... a man ofstrong impulses ...had a fiery nature steadied by fortitude, and that he craved for action, longing to find something new and original." 102 Henry Bigelow described Morton as "earnest and persevering beyond conception."103 Another biographer contends that Morton was "by nature a secretive man."104An individual with these qualities could easily have made one of the most important advances of nineteenth-century medicine and then spent the rest of his life embroiled in a fantastically bitter controversy over who should receive credit. Although Morton attempted to enter the social system oforthodox medicine by attending classes at Harvard Medical School, his profession ofdentistry made him something ofan"outcast" from that system. Boston dentists ofthe time engaged in fierce turfbattles and"depended mostly on notoriety to keep them in the public eye; or on some kind of 'private' operation. They guarded their professional secrets closely... "102 Such behavior' would not have impressed members of the medical community. As previously shown, news of anesthesia and its adoption spread rapidly through the "system" ofworld medicine. However, that spread was not uniform through each segement ofthat system. Tirer has recently shown that North American medical centers outside Boston were not as quick to adopt anesthesia as that city. "Conservative Philadelphia was especially slow; physicians there considered anesthesia to be a 'Yankee Dodge'."105 More generally, Pernick has observed, "Anesthesia won acceptance with a speed unprecedented in the history of pre-twentieth century medical innovation. Yet surgeons used it conservatively and selectively,"106 due to safety concerns and other factors, such as racial prejudices about pain susceptibility. Anesthesia for every surgical patient would not become standard until much later in the century. Despite these factors, anesthesia's spread was still quite rapid when compared with that ofother medical innovations. Salicylate therapy for rheumatoid arthritis was not accepted until"some 70 years after the initial studies demonstrating its efficacy. "107 Semmelweiss' ideas about infection were rejected for almost twenty years until Joseph Lister's work in the 1860s. 108 Finally, some consideration must be given to the broader social context into which surgical anesthesia was introduced. Boston's tradition of advancement through learning stretched back to the Puritans of the colonial era. In May, 1780 the American Academy ofArts and Sciences in that city was chartered by the state legislature. John Adams was the founder and second president of this second-oldest learned society in America.P? By 1840 over a hundred lyceums were active in Massachusetts.U? With Harvard College as the driving force, Boston reigned as the premier intellectual center of the country. Morton's demonstrations took place in the middle of a decade of

intense technological advancement in the United States. Samuel Morse's telegraph was introduced. Elias Howe patented a sewing machine. John Deere invented a plow with a steel moldboard. In Massachusetts, "William F. Channing and Moses Farmer designed a telegraphic fire-alarm system for Boston, the first in the country. Charles Goodyear... vulcanized India rubber. Uriah Boyden of Boston and James Francis invented water turbines for the mills of Lowell. "ilO Anesthesia was another entrant into this stream ofdevelopment in American society.

Conclusion Anesthesia spread rapidly around the world after Morton's public demonstrations in Boston in October and November 1846. The elements of thisdiffusion can be clearly seen in the classical model ofinnovation theory. Application of this model to the adoption of anesthesia emphasizes several important points. Anesthesia spread so rapidly because Morton was allowed to conduct a series of demonstrations, because several important"opinion leaders" gave the blessing oftheir reputations to the enterprise, because the scientific, medical and social environment had developed to a degree that anesthesia could be accepted. William Osler has written about the October 16, 1846, demonstration and subsequent diffusion of ether anesthesia that "the full credit for its introduction must be given to William Thomas Green Morton. "35 Yet the different results after Morton's and Long's uses ofether cannot be contributed solely to Morton's gift for tireles§ self-promotion or his residence in one of America's leading intellectual and medical centers of the time. Morton had the benefits of diffusion, aided by numerous individuals, that transformed his use of ether from a mere localized oddity into a true innovation.

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Pernick M.S.: A Calculus ~f SlIfferillg: Pain, Pr~{essiollalism, andAllesthesia ill NineteenthCmtllry America. New York: Columbia University Press, p. 212-216, 259, 1985. 54. Greene N.M.: Anesthesia and the development ofsurgery (I 846-1896}. Allesth.Allalg. 58:5-12, 1979. 55. Cranefield P.F.: J.Y. Simpson's early articles on Chloroform. BIIII. N. Y. Acad. Med. 62:903-909, 1986. 56. Duncum B.M.: TIle Development ~f lnualation Allaesthesia. London: Oxford University Press, p. 166-181, 1947. 57. Secher 0.: Nikolai Ivanovich Pirogoff. Allaesthesia 41:29-837,1986. 58. Keys T.E.: TIle Historyof SlIrgical Allesthesia. Huntington, New York: Krieger, p. 4647,1978. 59. Duncum B.M.: TIle Developmmt ~f Illhalatioll Allaesthesia. London: Oxford University Press, p. 130-155, 1947. 60. Ludovici L.J.: Calle ~fOblivioll; a Velldetta ill Scimc<. London: Max Parrish, 1961. 61. Duncum B.M.: TIle Developmellt ~f Illhalatioll Allaesthesia. London: Oxford University Press, p. 115-129, 1947. 62. Beecher H.K., Ford C. and Nathan P.: Rices trials of a public benefactor: A commentary.]. Hist. Med. Allied Sci. 15:170-183,1960.

63. Rogers E.M.: Comm'micatioll ~f Innovations: A cross-cultural approach. 2nd ed. New York: Free Press, p. 6-38, 1971. 64. Barnett H.G.: Innovation: TIle Basis ~f Culturol ChOllge. New York: McGrawHiIl, p. 39, 1953. 65. Ka12 E., Levin M.L. and Hamilton H.: Traditions ofresearch on the diffusion ofinnovation. Am. Social. Rev. 28:237-252, 1963. 66. Rogers E.M.: Diffusion ofinnovations: An overview. In: Roberts E.B. et al., Biomedical Innovation. Cambridge, Massachusetts: MJT Press, p. 75-97, 1981. 67. Coleman J., Met12CI H. and Katz E.: Medical Innovation: A Di[lilsioll StlIdy. Indianapolis: Bobbs-Merril, 1966. 68. Winick c.: The diffusion ofan innovation among physicians in a large city. Sociometry 24:384-396, 1961. 69. Greer A.L.: Advances in the srudyofdiffusion ofinnovation in health care organizations. Milballk Mem. Fund: Q. HealthSoc. 55:505-532, 1977. 70. Tannon c.P. and Rogers E.M.: Diffusion research methodology: Focus on health care organizations, In: Gordon G., Fisher G.L., eds. TIle D![Ii,sioll ~f Medical Techllology: Policy Olld research plOlmillg perspectives. Cambridge, Massachusetts: Ballinger, p. 51-77, 1975. 71. Jordan N.S., Burke J.F., Fineberg H. and Hanley J.A.: Diffusion ofinnovations in burn care: Selected findings. Bllms 9:271-279, 1983. 72. Anderson G.M. and LomasJ.: Monitoring the diffusion ofa technology: Coronary artery bypass surgery in Ontario. Am.]. Pllblic Health 78:21-254, 1988. 73. Smith R.: Comroe and Dripps revisited. Br. Med]. 295:1404-1407, 1987. 74. Hillman A.L. and Schwartz J.S.: The adoption and diffusion of CT and MRI in the United States. Med. Care 23:1283-1294, 1985. 75. Fineberg H.V., Gabel R.A. and Sosman M.B.: Acquisition and application ofnew medical knowledge by anesthesiologists: Three recent examples. Allethesiology 48:430-436, 1978. 76. Warner K.E.: A "desperation-reaction" model of medical diffusion. Health Servo Re~ 10:369-383, 1975. 77. Goffman W. and Newill V.A.: Generalization ofepidemic theory: An application to the transmission of ideas. Nature 204:225-228, 1964. 78. Burt R.S.: Social contagion and innovation: Cohesion versus structural equivalence.Am. ]. Social. 92:1287-1335, 1987. ' 79. Smith R.: The roots of innovation. Br. Med]. 295:1335-1338. 1987. 80. Robinson V.: Victory Over Paill: A History ~f Anesthesia. London: Sigma, p. 128, 1946. 81. Sykes W.S.: Essays all the First Hundred Years ~f Anaesthesia. Huntington, New York: Krieger, 1:55, 1972. 82. Frankel W.K.: The introduction of general anesthesia in Germany.]. Hist. Med. Allied Sci. 1:612-617,1946. 83. Pernick M.S.: A Calm Ills ~f S,~(ferillg: Paill, Pr~{essiollalism, alldAnesthesia ill NineteenthCenturyAmerica. New York: Columbia Universiry Press, p. 35-92, 1985. 84. Pernick M.S.: 11Ie Ca/m/lls~fS,!(ferillg ill Nineteenth-Century Surgery. Hastings Center Rpt 13(2}:26-36, 1983. 85. Pernick M.S.: A Calculus of SI~fferillg: Pain, Proftssiollalism, alldAnesthesia ill NineteenthCmtllry America. New York: Columbia University Press, p. 14, 1985. 86. Welch W.H.: The influence of anesthesia on medical science. Bostoll Med. SlITg. ]. 135:401-403, 1986. 87. Rhodes P.: All Outliue History ~f Medicine. London: Bunerworths, p. 91-104, 1985. 88. Walton J., Beeson P.B. and Scott R.B., eds.: TIle Oxford Companion to Meduine. Oxford: Oxford University Press, p. 1069, 1986. 89. Hall C.R.: The rise of professional surgery in the United States: 1800-1865. BIIII. Hist. Med. 26:231-262, 1952. 90. Warren E.: TIle li.{e ~fJolm Collins Wtzrrm, M.D. Boston: Ticknor and Fields, 2:349357, 1860. 91. Pernick M.S.: A CalmIlls ~f S,!(ferillg: Paill, Pr~{essiollalism, andAllesthesia ill NineteenthCmtllry America. New York: Columbia University Press, p. 221, 1985. 92. Pernick M.S.: A Calculus of SII(ferillg: Pain, Pr~{essiollalism, and Allesthesia ill NineteenthCenturyAmerica. New York: Columbia University Press, p. 26, 1985. 93. Pernick M.S.: A Calculus ~f S'~fferillg: Pain, Pro{essiollalinn, alldAnesthesia ill NineteenthCelltllryAmerica. New York: Columbia University Press, p. 89-90, 1985. 94. Gravenstein J.S.: The history ofdrug inhalation: A briefoverview.Allesth. Allalg.59:140145, 1980. 95. Shafer H.B.: "Medical Literarure." In: 11Ie Americall Medical Prolession 1783 to 1850. New York: Columbia University Press, p. 174-199, 1936. . 96. Garland J.: Medicaljournalism in New England. Bostall Med. SlIrg.]. 190:865-879, 1924. 97. Hayward G.: Some account of the first use ofsulphuric ether by inhalation in surgical practice. Bostoll Med. SII~~.]. 36:229-234, 1847. 98. Truax R.: TIleDoctors Wtzrrm ~fBostoll: FirstFamily~fSllrgery. Boston: Naughton i"iimin, , p. 154-155, 1968. 99. Cassady J.H.: Medicine and the learned society in the United States, 1660-1850. In: Oleson A., Brown S.c., eds.: TIlePIITSIIit ~fIGlOwledge ill theEarlyAmericoll Repllblic. Baltimore: Johns Hopkins University Press, 261-278, 1976. 100. Keys T.E.: TIle History ~f SlIrgicol Allesthesia. Huntington, New York: Krieger, p. 1314,1978. 101. Truax R.: TIleDoctors Warrell ~fBostoll: FirstFamily~fSllrgery. Boston: Naughton Mimin, p. 193-194, 1968. 102. Ludovici L.J.: Calle ~f Oblivioll: A Vmdetta ill Scimet. London: Max Parrish, p. 34-35, 1961 103. Bigelow J.H.: A history ofthe discovery ofmodern anaesthesia. Am.]. Med.Sci. 141:164184, 1876.

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Nitrous Oxide-Oxygen Apparatus One oftherevered members ofourAnesthesia History Association, Dr. Leslie Rendell-Baker, isanauthority 011 the history ofthedeueloment ofanesthesia apparatlls. In thejollowingpaper hedescribes the evolution ofthemeans ofdelivering nitrous oxide andoxygen ill calibratedamounts. Without these developments it would notbe the mostfreqllently employed anesthetic gas today. 1# are most indebted to Dr. Rendell-Boker andto Dr. David Wilkinson, Editor of theProceedings of the History of Anaesthesia Society, for their permissions to reprint this article which appeared ill the Proceedings, Volume 8b, pp. 92-96, 1990.

The Development of Nitrous Oxide-Oxygen Apparatus by Professor L Rendell-Baker This is the story of how three American dentists - S.S. White, Charles K. Teter and Jay A. Heidbrink - became interested in nitrous oxide and oxygen anaesthesia, designed their own apparatus and became major manufacturers of anaesthetic equipment. They were ably supported by two physicians - one, Dr. Elmer 1. McKesson, became an important manufacturer who also practised and taught anaesthesia, and ran a pioneer anaesthetic group praet;ice for all the hospitals in Toledo, Ohio. The other physician, James T. Gwathmey of New York, probably one of the first Americans who specialised in anaesthesia, designed his own machine which gave birth to the British Boyle apparatus. He also helped to found the American Society of Anesthesiologists. Dentists were always interested in anaesthesia for much of their practice inflicted pain on their patients. Since 1863, when Gardner Q. Colton popularised the use of nitrous oxide, many dentists prepared this gasand administered it to their patients from a gasometer. However, it was not until compressed gases from cylinders became available nitrous oxide from Coxeter in London in 1869 and from Johnston Bros in New York in 1871, and oxygen in 1888 - that apparatus providing variable percentage mixtures became feasible.

Frederick Hewitt In London, Frederick Hewitt commenced experiments with various mixtures ofgas and oxygen in 1886 using a gasometer. He first reported success with 12%oxygen and 88% nitrous oxide in 1889. This encouraged him to design a portable apparatus with separate bags for each gas. The nitrous oxide came up a central passageway in the apparatus, and up to 10%oxygen was added from small holes around the periphery. An outside quadrant control opened the holes. In 1897, when his book 'Nitrous Oxide/Oxygen Anaesthesia for Dental Operations' was published, Hewitt advised starting anaesthesia with 2-4% oxygen in nitrous oxide, gradually increasing to 8-9% oxygen before removing the mask for the dentist to extract the teeth. This hypoxic mixture, though tolerated for short dental procedures, became hazardous when used for more prolonged general surgical operations.

S.S. White The Philadelphia dentist and manufacturer, S.S. White, was greatly impressed With Hewitt's publications and in 1900 produced an apparatus based on his design. It had cylinders of nitrous oxide and oxygen which filled individual bags. When a control lever was opened nitrous oxide flowed to a mixing chamber, and from there to the patient. Oxygen was added by opening a control which was calibrated, like Hewitt's, from 0-10% oxygen. This machine had no reducing valves or flow meters and was equipped with a non-rebreathing system. Like Hewitt's, it was designed for short dental procedures only. Purchasers

of White's machine were strongly advised to buy and read Hewitt's book on dental anaesthesia (which was on sale for $1.25) and to follow his advice.

Charles K. Teter In 1903, Charles K. Teter, a Cleveland, Ohio dentist, introduced his apparatus with which he popularised nitrous oxide-oxygen anaesthesia for general surgery. He convinced George Crile, the famous surgeon and founder ofthe Cleveland Clinic, ofthe superiority ofthe mixture. Later, in 1914, Crile and Lower, with their nurse-anaesthetist, Miss Agatha Hodgins (who was to become the first President ofthe Association ofNurse Anesthetists), introduced the concept oPbalanced anaesthesia.' They termed their combination of narcotic premedication, nitrous oxide-oxygen with a local anaesthetic field block, 'AnociAssociation.' Teter's machine also had separate bags for nitrous oxide-oxygen. It had two reducing valves with taps to control the flow of nitrous oxide and oxygen. It is said that each Teter machine came with instructions on how it should be used to produce anaesthesia. Later reports blamed Teter for spreading the idea that 5-10%oxygen in the mixture was adequate, cyanosis could be disregarded and that a state of hypoxia was essential to 'gas' anaesthesia. High consumption ofgaseswas a problem with Teter's machine. Its originator reported in 'Dental Cosmos' in 1907 that, for his longest case of2 hours and 48 minutes (anaesthesia for laparotomy with division of adhesions) nearly 600 gallons of nitrous oxide were used - approximately one and a halfE cylinders, and 80 gallons of oxygen - approximately half of an E cylinder.

Willis D. Gatch As an economy measure, Willis D. Gatch ofJohns Hopkins Hospital, introduced in 1910, the rebreathing principle. His apparatus had an 8litres capacity breathing bag which was filled with nitrous oxide from a cylinder. The face mask contained valves which provided either nonrebreathing or total rebreathing ofthe gas in the bag. For induction, the valves were set to non-rebreathing and the patient took in 100%nitrous oxide from the bag. Once anaesthesia had been achieved, a small puff ofoxygen was added to somewhat restore the patient's colour and then the valves were set to rebreathing. The patient rebreathed 16 times from the bag before the mixture was removed. Gatch calculated that the carbon dioxide in the bag would not rise above 4%, which the physiologist Haldane had said was the limit that could be tolerated. Gatch noted that the patient's respiration was vigorous and the pulse was full and bounding. The American physiologist, Yandell Henderson, had stated that conserving carbon dioxide prevented surgical shock. Mter Gatch's publication in 1910, and its support by Henderson, most apparatus included a rebreathing bag. COil

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Nitrous Oxide-Oxygen. . . Continuedjrom Page 11 Elmer I. McKesson In 1911,Elmer McKesson ofToledo, Ohio produced a new apparatus which provided accurate percentage flows ofboth gases by means ofa single control; as the oxygen percentage was increased the nitrous oxide percentage decreased. For economy, intermittent flows ofgases and fractional rebreathing were provided, using what we would now call a Mapleson A breathing system. McKesson illustrated the first description of his apparatus in 1911 with five of his anaesthetic records. These charted pulse, blood pressure, respiratory rate and the 10% oxygen given for appendectomy, oophorectomy, etc.! Unfortunately, McKesson's advocacy of 'secondary saturation,' during which hypoxia - to the point of respiratory arrest or arrhythmia before oxygen was given - set a poor example and gave rise to many cases of hypoxic cerebral damage in the years that followed. McKesson designed a large aneroid BP manometer and brachial stethoscope to enable readings to be made easily during anaesthesia. In 1930 he introduced the first automatic recording anaesthesia apparatus, the 'Recording Nargra£' This set down the patient's tidal exchange and the percentage ofoxygen given while the blood pressure could also be noted by a simple manual control.

Jay A. Heidbrink Dissatisfied with the Teter apparatus, Jay Heidbrink introduced his own machine in 1912.This had no flow meters but did possessreducing valves. One control adjusted the nitrous oxide pressure and a further control set the desired oxygen percentage between 0 and 25%.The total flow ofgas mixture, in gallons per minute, could be regulated. A 6lf2 Iitres capacity reservoir bag was provided, with a Mapleson A type system to permit partial rebreathing. The apparatus also had a stop watch attached. In his papers Heidbrink instructed the user to adminster 93%nitrous oxide with 7% oxygen at a rate 00 gallons per minute for one minute by the watch. At the end ofthis time the oxygen was to be shut offand nitrous oxide alone given for 40 seconds or until the degree of anaesthesia desired for dental operations was reached. The anaesthetist should then tum on 7% oxygen with 93% nitrous oxide. In the average case anaesthesia would have been maintained without changing the proportions of gases. When Dr. Heidbrink retired in 1938 he sold his company to the Ohio Chemical Company of Cleveland and the combined organisation moved its operations to Madison, Wisconsin at that time. In the 1970s, the British Oxygen Company bought Ohio and changed its name to Ohmeda and Anaquest.

Accurate flow meters In 1910, the German physician Neu had Karl Kupper's Rotameter flow meters modified for nitrous oxide and oxygen anaesthesia. Unfortunately, the high cost ofthe Rotameters and ofimported nitrous oxide in Germany, prevented wide acceptance of this apparatus. A pity, for these were the first accurate flow meters. They didn't come into widespread use in Britain until 1937. In 1912, Boothby and Cotton introduced the bubble flow meter which was adopted for Gwathmey's machine in New York and later by Boyle for his version of the Gwathmey apparatus.

James T. Gwathmey The apparatus devised by Gwathmey in 1912 (with the improved

version of the bubble flow meter) mixed expired and fresh gases. In 1913; Gwathmey, Teter and Crile took part in an International Symposium in London on nitrous oxide-oxygen anaesthesia and did much to popularise the method in Britain.

First World War On the outbreak ofwar, George Crile took an American Red Cross hospital unit, which included Agatha Hodgins, his anaesthetist, to Paris. Colonel Berkeley Moynihan, a British Army Consultant Surgeon, was 'sold' on Miss Hodgins' nitrous oxide-oxygen anaesthesia and AnociAssociation method for the wounded. For her demonstration Miss Hodgins used the Ohio Monovalve machine - the company's first anaesthesia apparatus, produced in Cleveland, Ohio in 1912. Like others, it had separate bags for nitrous oxide and oxygen and also twostage reducing valves which filled the bags to a pre-set pressure. In the centre it had a control valve with three positions. The first gave 100% nitrous oxide, the second gave a variable mixture ofoxygen and nitrous oxide and the third gave pure oxygen. A further control varied the flow of nitrous oxide. Boyle attended the London symposium in 1913 and was greatly impressed with Gwathmey's apparatus, so much so that he imported one in 1914 and adapted it for British cylinders, retaining Gwathmey's inefficient breathing system. Thereafter all such machines made inBritain were called after Boyle even though he, in one Q(pis papers in 1917 said: 'the machine I use is Gwathmey's.' While serving from 1915 in a British military hospital in France, Geoffrey Marshall (later Sir Geoffrey) built an apparatus with bubble flow meters to give nitrous oxide-oxygen-ether anaesthesia to war casualties.More compact than Boyle's, it became the standard model in British army practice after 1916. It had the same breathing system as the Boyle apparatus, with the bag attached to the face mask.

Sir Ivan Magill Towards the end of the war, Ivan Magill and Stanley Rowbotham were sent by the British army to a maxillo-facial trauma unit near london. As general duties medical officers with no surgical expertise, they were assigned the duty of giving anaesthesia to these most difficult problem-cases. Initially they used insufflation of ether and oxygen through narrow bore catheters, and then they introduced the presentday wide-bore tubes for spontaneous respiration with nitrous oxide, oxygen and ether. Between 1919 and 1932, they developed the repertoire oftechniques and equipment for endotracheal and endobronchial anaesthesia for maxillo-facial and thoracic surgery that we use today. Magill introduced the 'blind' nasal intubation method in 1928 and the breathing system, now known as the Mapleson A system in 1932. Not bad for two self-taught, unskilled, general practitioner anaesthetists! Asit was not possible to have the Boyle apparatus breathing bag near the surgical field - usually the patient's face in these cases - Magill re-attached the bag to the machine once more. The tubing separates the fresh gas from the expired gas permitting efficient carbon dioxide removal. Examination ofAmerican equipment - McKesson's of1911 and Heidbrink's of1920 - shows that they, in fact, had the Mapleson . A system before Magill reintroduced it in 1932 in Britian.

Closed circuit anaesthesia In 1915, the American pharmacologist Dennis Jackson introduced an in-circuit carbon dioxide absorption apparatus. An electrically driven pump circulated the gases around the system and through the absorbent. The patient breathed to and fro from a large mechanically

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The Dripps Library in Philadelphia For those who have nothad theprivilege ofvisitillg theRobert Dunnino Dripps libraryillPhiladelphia, theJollowillg description should whettheappetite ofthose who visit orlive illPhiladelphia. 1# are milch indebted to Dr. Arthuro. McGowall, Editor of theBulletin o.fthe California Society o.fAllesthesiologists, andtotheauthors, [anet H. Stokes, M.A. andDavidE. Lollgllecker, M.D.,for permission to reprint this interesting accolltlt which comes to liS Ilia theArthur E. Guedel Memorial Anesthesia Center.

The Dripps Library of Anesthesia University of Pennsylvania School of Medicine by[anet H. Stokes, M.A. andDavidE. Lonyneceer, M.D. The Robert Dunning Dripps Library, named in honor of the first chairman of the Anesthesia Department at the University of Pennsylvania, opened in February 1980 on the fifth floor ofthe Dulles Building at the Hospital of the University of Pennsylvania. Its initial role was threefold: a repository oftexts and journals; an educational and information resource for Penn anesthesia residents as well as for the entire Delaware Valleyanesthesia community; and it also holds a small collection of memorabilia from the early days of the department. The Library has a collection ofapproximately 550 anesthesia, critical care and related texts and 38 journals-about half the journals are bound and always available in the Library. (When the Library was first opened, other libraries, especially the Guedel Memorial Anesthesia Center, contributed to the collection and were particularly helpful in providing early issues of essential journals.) For its first ten years, the Dripps Library was staffed by a full-time librarian who maintained accessto over 100 databases, as well as written indices such as IndexMedicus. She responded to both internal requests and inquiries from physicians throughout the Delaware Valley. In fact, about a quarter ofthe Librarian's time was spent in searches, over 3,000 of them in the first four years of the Library's existence. The Library also sponsored the annual Dripps Conference, a three-day continuing education conference which still draws large numbers of participants. The Conference is now directed especially, but not exclusively, to Penn alumni. A further example of the leadership role taken by the Dripps Library is the Penn Anesthesia library List (PALL). This list, published in Allesthesiology (Atlesthesiology 62:81-785,1985) established criteria, based on usage patterns, for inclusion of texts and journals in a specialized anesthesia library. It was the first such list published, apart from the very brieflist for anesthesiology included in the Medical Library Association's Brandon List. Special care was taken, in developing PALL,to avoid the partial coverage ofsubjects which results when too few texts on a subject are chosen. Overlapping texts were included until a sufficiency ofinformation was achieved. This list remains a standard. The Dripps Library is not, strictly speaking, a memorial library, but we have a small and growing collection ofhistorical interest and value. These include a cabinet of early medical texts, some of which came from the personal library of Dr. Austin Lamont-some from Dr. Dripps' own collection. They include William Bromfield's Chimrgical ObservatiollS in two volumes, published in London in 1773, Sargent's Minor Slirgery published in Philadelphia in 1856, a Manual of Slirgery by Astley Cooper and J.H. Green published in London in 1832, and a first edition ofOliver Wendell Holmes' Homeopathy anditsKindred Delusions (Boston, 1842). More recent classicsinclude a copy ofWilliam Osler's Aequanimitas. Dr. Dripps' collection includes a series of reproductions ofearly books on ether, such asJohn C. Warren's Etherization (Boston, 1848), Snow's 011 the7iihalatioll o.fthe Vapor ofEther (1847) and Morton's Sulphuric Ether (1849). While these texts are perhaps moderately rare, they are not unique; however, the Library does contain some unique items. These include a carbon copy of the letter dated April 11, 1945,

from Dr. Dripps to Dr. James Eckenhoff, offering him a fellowship in the new Department at the University of Pennsylvania. We also hold the original letter from Leroy Vandam, M.D. to Dr. Dripps dated July 2, 1947, accepting a residency position in our department. We were recently very happy to add to this collection some original notebooks of lectures kept by Dr. Vandam during his residency. We have, ofcourse, several editions ofthe long-lived textbook later written by Dripps, Eckenhoff and Vandam, including a copy of the second edition, and a collection ofearly papers ofthe Department. The Dripps Library seeks to expand its archival collection, and would be especially pleased to receive documents and other memorabilia from alumni who trained in the department during its early years. We can accommodate some memorabilia in our secure display case in the Library-for more bulky material we plan to consult with the University Archivist to ensure that it is kept under the best possible conditions for permanence. Substantial changes are under way in the Dripps library this year as we endeavor to keep pace with the increase in computer literacy among physicians and the increasing availability of search and data services (such as Grateful Med) at the touch ofa computer key. Four electronic workstations will be installed in the Library for independent searching by residents and faculty in addition to routine word processing. The computer is changing not only research, but teaching, and we hope to add as they become available some of the computer-assisted learning software from which anesthesia techniques can be taught via computer. Facility with the computer is already becoming one of the basic skills required of our residents and fellows. In time, probably many journals and texts will be available on disk or over a service network, saving the time and space now spent in maintaining hardcopy editions. We will be very open to making use of these resources and are continually seeking funding for future computerization ofthe Library. We believe the direction towards electronic, rather than paper, archives is an inevitable trend and we are moving to establish the Dripps Library as an electronic resource for the next decade.

Anesthesia History Association Newsletter Printed and Distributed Courtesy of Becton Dickinson Vascular Access Excellence in Vascular Access Products

Before the Days of Simpson The women o/this world are etemallv grat~(zll toSirJames YOllng Simpson (1811-1870)/or introdudno atedmique ofaUwiating thepain ~rchildbirth. A concept ~r howthispain was borne in thecenturies b~rore has been preset/ted by Dr. Audrey Eccles who atpresent istheLibrarian/Archivist ~r theAssociation ~rAnaesthetists ~r Great Britain andIreland. T# are milch indebted toDr.Eccles andtoDr.David Wilkinson, Editor ~rthe Proceedings ~rthe History ~rAnaesthesia SocietyJor their permissions to reprint this paper which appeared in the Proceedings, Volume 8a, pp. 36-41, 1990.

Pain in Childbirthbefore Simpson: Perceptions and Responses by Dr. Alldrey Eccles In the pre-Simpson period, pain in childbirth was viewed as an inevitable part of childbearing, and indeed occasionally (but very occasionally) specifically referred to as 'the curse of Eve.' All denominations of the Christian church accepted the interpretation ofGenesis Simpson was later so concerned to refute, but it does not seem that before his time this led to any proscription ofpain relief, though it may have favoured approaches other than the medical. Some ofthese earlier approaches persisted alongside the medical anaesthetic model and have indeed been re-emphasized in competition with it in recent times. Until very recently however pain was labour; and even though authors from the 17th century onwards explained that the muscular movements ofthe uterus caused the pains, they nevertheless universally referred to them as 'pains.' So early as the 'Birth of Mankind' in 1540 midwives were urged to distinguish between colicky pains, which called for treatment, and the pains oftrue labour, which did not, and also to distinguish between the pains before the head was visible, which simply had to be endured, and those after, when bearing down was called for. However, authors were aware that pain in childbirth was very variable, and that even in normal labours it was much more severe for some women than for others. The French surgeon Jacques Guillemeau (1612) noted that all women had pain, but referred to Aristotle's statement that the women ofLigustria 'doe bring forth without paine, and that they return to their businesse as soone as they are delivered.'! This idea that barbarians have less pain than civilised races was to be curiously long-lived and was frequently prayed in aid to condemn 'unnatural' and luxurious behaviour. William Sermon in 'The Ladies' Companion' (1671) recounted a personal observation of what appeared to be a painless labour as follows: 'it would be almost a miracle to see a woman delivered without pain; though I am apt to believe, that the wife of Thomas James did enjoy that happiness, whom I saw delivered ofa lusty Child in a Wood by her self, which presently after she took the Child and put it into her apron with some Oaken leaves, and marched stoutly with it almost half a mile, to an Uncles house ofmine... and within two hours, her Child and her self being refreshed... took her journey a long mile further, not in the least discouraged, and the next day came and returned hearty thanks. This accident happened as she was walking homeward from a Market Town, in the year 1644, the manner of which I saw, being accidentally placed under a hedge (purposely) to shoot a Hare that I knew frequented the very place where she was delivered. '2 An even more heroic episode was recounted by William Harvey who heard it from Lord George Carew, formerly President ofMunster in Ireland: 'There was a Woman bigge with Child, which followed her Husband, who was a Souldier in the Army; and the Army being daily in motion, was it seemes forced to make a Halt, by reason ofa little River than run cross the place whether they intended to March: whereupon the poor woman finding her labour come upon her, retired to the next thicket, and alone by her self, without any Midwife, or other preparation, brought forth Twins: which she presently carried to the River, and

there washed both her selfand them: which done, she wrapt her Infants into a course cloth, and tied them to her back, and that very day, marched along with the Army twelve mile together, bare-footed: and was never the worse for the matter.'! There seemed to be general agreement however that not only were painless births a great rarity, but they only happened to the poor and labouring classes. Sometimes the hardy Scots, sometimes the wild Irish, were mentioned as having painless labours; sometimes it was said that whores and doxies had less pain than others - Defoe made Moll Flanders comment after one ofher numerous labours that she was'as well as I always am on these occasions.' It was a'fact, and generally known, that women who had concealed illegitimate pregnancies often seemed able to give birth without any screaming or groaning, quietly smothering the child and returning to work immediately as if nothing had happenecl. Read was expressing a widely accepted view in 1687 that: 'poor Women, Hirelings, Rusticks, and others us'd to hard Labours, also Viragoes and Whores, who are clandestinely delivered, bring forth without great difficulty, and in a short time after, rising from their Bed, return to their wonted Labours: but Women that are rich, tender and beautiful, and many living a sedentary Life, bring forth in Pain, and presently after their delivery lye in an uneasie and dangerous condition. '4 Hence painful and difficult labours were a sign of social status, and much solicitous attendance by men-midwives plainly became essential for upper class women. Dionis indeed declared that quick painless birth might cause gossip: 'An easy and sudden Delivery is not so much for a Woman's Reputation, especially in her first Child; for People are apt to conclude, that the Parts have been open'd and relax'd before, and therefore most Women are proud of being long in Labour." Thus, cultural and religious influences fostered the idea that childbirth, especially for those above the lowest social ranks, was always painful. Abnormal labour was usually even more so. This perception did not mean that nothing could be done about the pain of childbirth however, and several strategies were employed to cope with it. These could be divided into two types, the religious, psychological and cultural in one group, which for convenience we may call social, and the practical, medical and surgical in the other, though these approaches were in practice by no means mutually exclusive and any combination or all might be adopted in a single case. The social approaches, like-the various natural childbirth schools of our day, addressed the woman's frame of mind, whereas the medical approaches, like the anaesthetic approach pioneered by Simpson, addressed the body. In contrast with Simpson's solution of removing the pain by obliterating consciousness, the medical approach before his time was essentially to get the labour over as soon as possible, since pain and labour were the same thing. Religious approaches to dealing with pain did not feature prominently in the textbooks for midwives and surgeons, although penitential and devotional literature exemplifies this approach. The Book ofCommon

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Before Simpson. . . Continued jrom Page 14 Prayer referred in the service for the churching ofwomen to 'the great perils and dangers' of childbirth, and the fear ofdeath was a powerful component in the mental suffering ofwomen, not unreasonably when maternal mortality might reach some 25 per 1000 births." Especially where the labour seemed likely to be difficult, recourse to prayer might be explicitly advised. The anonymous author of 'A rich closet of physical secrets' (1652) wrote: 'Therefore 'when there appeareth difficulty in bringing forth the Child, Jesus Christ, the only preserver and saver in danger, is heartily to be called upon.' The seventeenth century man-midwife Percivall Willughby more than once consulted ministers ofreligion, who were apparently present, on the ethics of destroying a living child with the crochet to save the mother, and it seems to have been normal for women thought likely to die in childbirth to put their affairs in order and make spiritual preparation, as it was for those dying of illness. Midwives were urged to maintain a godly atmosphere in the lying-in room rather than tell gossips' tales, and the chief rationale for the licensing ofmidwives by the bishops, instituted in the 16th century, was to ensure proper Christian conduct and to avoid superstition and witchcraft. Superstition and witchcraft were of course other possible strategies for coping with pain and danger in childbirth, and in some social groups, especially earlier in the period, may have been very commonly resorted to. Superstitious means in use in medieval times included birth-girdles and amulets. Even in the seventeenth century much faith was placed in the eagle stone to draw forth the birth, although by then 'scientific' explanation was given that the stone worked by 'magnetic virtue.' Histories of anaesthesia often refer to the execution of Eufame McCalzane in 1591 in terms that suggest her crime, and that ofher midwife Agnes Sampson, was the avoiding ofpain in childbirth, but I think it much more probable that it was the use ofwitchcraft for the purpose that led to their execution. The accusation was the Eufame caused her 'narurall kindelie payne' to be transferred to a cat and a dog by witchcraft. Certainly the numerous clauses ofthe midwife's oath in the extant versions include several against witchcraft but none at all against pain relief. It would not seem, therefore, that the Church was particularly opposed to the reliefofpain in childbirth by means other than witchcraft in the 16th and 17th centuries. Psychological aspects oflabour were well recognized at a very early date. The 'Birth ofMankind' mentions a fearful or unruly temperament in the mother among factors causing difficult labour, and advises the midwife to support the labouring woman with 'swete wordes, geuynge her good hope ofa spedefull delyueraunce, encouragyng and enstomacking her to pacience and tolleraunce.' Guillemeau suggests the midwife should promise her a quick delivery and a fair son or goodly daughter, whichever she knows the mother would prefer, and several authors caution against tactless reference to bad labours by the women present, although this advice never seems to have been much heeded. It was customary until quite late in the 18th century for large numbers of female friends and relatives to be present at labours, and although some feminist historians portray this as a support system of great benefit to the mother, it seems equally possible that not only the noise and crowding, but often the conflicting advice and tales of woe that surrounded the mother might have been the reverse of constructive. It may however be true that the relatively public way in which childbirth was conducted, with certain expectations as to behaviour, may have helped the labouring woman support the ordeal, much as anthropologists tell us the candidate in painful initiation ceremonies

and suchlike rites of passage is supported by having definite cultural expectations and an assigned role to play. Several authors recounting difficult cases comment on the fortitude shown by the women, and iri the Victorian period comparisons were made between the woman going into labour and a soldier going into battle, suggesting that it was seen as a personal moral test. Medical approaches to pain in childbirth on the other hand were directed at expediting the labour rather than enabling the woman to tolerate the pain. Some direct attempts at alleviatingpain were alsomade however. The 'Birth of Mankind' for example, has a recipe for: 'certayine pylles the which make the labour easye and without payne' (68v) containing myrrh and opium. The advertisement in 'Dr. Chamberlain's midwives practice' (1668) for 'An excellent powder to procure easie delivery in Childe-bearing women, being a secret of the Authors to be had ofMr Thomas Rooks at the Holy Lamb at the east end ofSt Pauls' might equally well be an analgesic, or something similar to the wellknown 'pulvis parturiens' 'the midwife's powder,' in common use for stirring up ineffective pains. Indeed, a staggering array of medicines, fumigations, poultices and so forth featured in the midwifery textbooks up to the end ofthe seventeenth century, when they seem to have been largely given up. The administration of these substances satisfied the need of both patient and attendants for some action to be taken, and authors frequently assert that these remedies produced the lookedfor effect. Many of these medicines were administered in ~'a1cohol, and a woman in labour for several days, which was not uncommon, might be much under the influence by then. Although no textbook proposes the deliberate use of alcohol as an analgesic, it is possible that midwives' alleged over-use of cordials? was partly an attempt to dull pain. Charles White of Manchester remarked that alcohol was often freely given by the women: 'If the woman's pains are not strong enough, her friends are generally pouring into her large quantities of strong liquors, mixed with warm water, and ifher pains are very strong, the same kind ofremedy is made use ofto support her.'8 William Giffard commented on a case he attended: 'What in some measure occasioned the difficulty, was the Woman's being stupified and senseless from the quantity of strong liquors that was given her, and her smoaking Tobacco, so that she was very drunk, and no ways capable of pursuing directions, nor ofassisting me by bearing down at the time of my extracting the Child.'9 Giffard, however, almost alone among authors before 1750,favoured opiates in labour, which he declared did more good than all the forcing medicines generally recommended. Other authors, however, although they prescribed laudanum for after-pains, and for numerous other conditions from hysteria to cancer, seem to have felt opiates inappropriate during labour because they concentrated on expediting the delivery rather than on relieving the pain directly. Practical manual methods of hurrying on the birth advised by the earlier authors from the 'Birth ofMankind' to the end ofthe 17th century included greasing the passages, manually dilating and stretching the vagina and cervix, and pressing down externally on the belly. Many midwives followed this advice,and later 17th and 18th century authors devoted much attention to pointing out the ill consequences of such efforts to hurry the birth. Harvey wrote; 'Therefore the younger, more giddy, and officious Midwives are to be rebuked; which, when they hear the woman in travaile cry out for paine, and call for help; lest they should seem unskilful in their trade and less busie then comes to their share, by daubing over their hands with oyles, and distending the parts of the Uterus, do mightily bestirre themselves, and provoke the expulsive faculty by medicinal potions: so that... by their desire to has-

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Before Simpson...

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ten and provoke the Birth, they do rather retard and pervert it... and bring them in danger of their lives.'!" The men-midwives who became increasingly prominent in obstetrics from the early 17th century onwards, used surgical means to shorten the labour, at first only destructive operations in cases of danger, later podalic version for malpresentations and such emergencies as ante-partum haemorrhage, and from the 1730sthe forceps for normal presentations which proved tedious or obstructed. The same pressures to show their skill and to rescue the woman from her pain often tempted them to over-use these techniques, and much debate about the improper use of the forceps ensued. It is however not unreasonable to suppose that both the meddlesome midwifery of the 17th century and the frequent recourse to the forceps ofthe 18th were not only responses to obstetric difficulties, but responses to the appeals ofwomen in pain and their friends and relatives. Interestingly, it seems that (except for witchcraft early in the period) the only one ofthe approaches outlined in this paper which provoked much moral or religious opposition was the use of the forceps. It is significant that surgical texts ofthe pre-anaesthetic era reveal the same approach to pain as do texts on midwifery; pain is noted and deplored, but the answer is sought in shortening the procedure by the fastest possible technique. Direct attack on the phenomenon of pain itself by the adoption of anaesthesia required not only the discovery of certain technical facts but a real revolution in philosophy, and it is for this leap ofimagination even more than the technical discovery ofanaesthesia that Simpson and the other pioneers of anaesthesia are to be honored. References 1. Guillemeau]. Childbirth. Or The Happie Deliverie Of Women. 1612.90. 2. Sermon W. The LadiesCompanion. 1671.96-7. 3. Harvey W. AnatomicalExercirarions. 1659.509. 4. Read A. Chirurgorurn Comes. 1687.631. 5. Dionis P. A General Treatise of Midwifery. 1719. 166. 6. Eccles A. Obstetricsin the 17thand 18thcenturies and its implications formaternal andinfant mortality. Bull. Soc Hi". Med. 1977: 20:8-11. 7. AvelingJ.H. English Midwives. Their History And Prospects. 1872. 125. 8. White C. A Treatise On The Management OfPregnanr And Lying-in Women. 1773.6. 9. Giffard W. Cases In Midwifery. 1734. 152. 10. Harvey W. Anatomical Exercirarions. 1659. 488.

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

Nitrous Oxide-Oxygen...

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ventilated bag. Although the inventor demonstrated his apparatus at several anaesthesia meetings, anaesthetists ignored it and so Jackson used it on the dogs in his laboratory. In 1918, he offered a prototype military circle carbon dioxide absorption apparatus to the U.S. army. Consultant surgeons felt it would be too complicated for their anaesthetists to manage. It remained for Ralph Waters, in Sioux City, Iowa, to introduce carbon dioxide absorption into everyday anaesthesia. Waters' patients breathed to and fro from the bag, through the absorbent. Many anaesthetists found the absorber rather clumsy and it'was only widely used after Waters introduced cyclopropane, which was both expensive and explosive, in 1930. As a result, Brian Sword's more convenient circle absorption apparatus was rapidly adopted as a standard breathing system in the USA to facilitate the use of cyclopropane. Studies on carbon dioxide absorbers led James Elam and colleagues of Roswell Park, New York, to complete this saga by introducing the present-day large capacity absorber which has been universally adopted. The absorber has two compartments, each of which is more than adequate to accommodate a patient's SOOml tidal volume. Elam reported that with minute volume fresh gas flow, each chamber of the apparatus had capacity to absorb for 60-90 hours. This resulted from the components of the system being correctly arranged so that expired carbon dioxide was preferentially eliminated and tresh gas was conserved to be delivered to the patient.

How It All Began... Continued from Page 10 104. Woodward C.S.: 111e MallWI,aConquered Pain: A Biograpltyo{Wllliam 11lOmas CreenMortall. Boston: Beacon Press. p. 50, 1962. 105. Tirer S.: Rivalries and controversies during early ether anaesthesia. Call. j. Allestlt. 35:605-611, 1988. 106. Pernick M.S.: A Calculus of S'~fferillg: Paill, Pr~{essiollalism, alldAllestltesia ill NineteenthCenturyAmerica. New York: Columbia University Press, p. 124-167,234, 1985. 107. Goodwin C.S. and CoodwinJ.M.: The tomato effeet: Rejection of highly efficacious therapies. JA.MA. 251:2387-2390, 1984. 108. Forman R.: Medical Resistance to innovation. Med. Hypotheses 7:1009-1017,1981. 109. Whitehill W.M.: Early learned societies in Boston and vicinity. In: Oleson A., Brown S.c., eds.: 111e Pursuit ~{K1lowledge ill the EarlyAmericall &pllblic. Baltimore: Johns Hopkins University Press, p. 151-173, 1976. 110. Churchill E.D., ed.: To /¥ork ill the Villeyard ~{SlIrgery: Reminiscences ~{j. Collins /¥orrell (1842-1927). Cambridge, Massachusetts: Harvard University Press, p. 238-239, 1958.