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Newsletter October, 1991
Anesthesia History Association Newsletter Volume 9, Number 4
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October, 1991
Third International Symposium on The History of Anesthesia March 27-31, 1992 The Third International Symposium on the History of Anesthesia (T.I.S.H.A.), which will be held in Atlanta, Georgia, U.S.A. on March 27-31,1992, commemorates the 150th anniversary ofLong's administration of ether vapor to produce surgical anesthesia in 1842. Presentations by invited speakers at the opening plenary session on Saturday, March 28, will emphasize the mid-19th century society in which Long was educated, lived and practiced. Areas to be explored willinclude the general nature ofAmerican society at the mid-century, medical education in Long's time, social conditions and attitudes favorable to the acceptance of anesthesia at this stage in human history, and other related topics. On Saturday afternoon symposium participants willvisit Jefferson, Georgia, locale of Long's practice in 1842 and his first ether administrations and currently site of the Crawford W. Long Museum. On Saturday evening, following a cocktail buffet at the hotel, registrants and their guests willattend the premier ofan original drama on the first use of ether anesthesia. The general sessions ofthe Symposium will take place from Sunday morning, March 29, until mid-day on Tuesday, March 31. These will include oral presentations offree papers, poster presentations, and both historical and commercial exhibits. Additional features ofthese sessions will be panel discussions and papers by invited speakers. The opening reception will be on Friday evening, March 27, at the Carter Presidential Center. An additional cocktail buffet is planned for Monday evening, March 30, with entertainment. Special trips to permit accompanying guests to view famous attractions ofthe Atlanta area will be available on Sunday and Monday, March 29-30. The Symposium will be an unforgettable experience for everyone with an interest in the history and origins of anesthesia! The program committee solicits participation by all students of the history ofanesthesia in the symposium. Proposals for oral presentations (12 minutes duration), poster presentations and historical exhibits will be welcome. All submissions should be on special forms provided by the committee. Deadline for submissions has been extended to October 1. For the necessary forms, further details about the meeting and registration and hotel reservation materials, please write to: TISHA Attn: John E. Steinhaus, M.D. Department of Anesthesiology 1365 Clifton Road, N.E. Atlanta, GA 30322 -Norman Bergman, M.D.
CRAWFORD W LONG SIESQUllCIEN11ENNlIAIL MDCCCXLII MCMXCII r,l (,! =
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Emory Clinic, 1365 Clifton Road, Atlanta, GA 30322 ATLANTA, GEORGIA. U.S.A. - MARCH 27-31.1992 Also In This Issue: • More About Horace Wells • John Snow-An Early Intensivist • An Intricate Apparatus
More About Horace Wells "TheFather ofAnesthesia, Dr. Horace Wells, 11 isthetitle ofa 105-page monograph written by Dr. SenNakahara, Dean andProfessor oftheNippon Dental University, andjustpublished in theJapanese language. The textisbeautifUlly illustrated by 50 photographs, themajority of which are in color, which depict mementos andareas of Hartford with which Wells must have beenfamiliar orwhich are associated withhismemory. The final twopages of thetextare asummary of thework andare reprinted below, with thepermission of the author. Anesthesia is one of the greatest discoveries in.the history of the development ofmedical science, and it is very interesting to know how the Anesthetic method finally came to be used. Figuratively speaking, we have two leading actors named Dr. H. Wells and Dr. W.T.G. Morton, while we have Dr. J.c. Warren as a supporting actor. We also have Dr. C.T. Jackson who played a minor part in this drama. By these persons, the greatest performance in the field of medical science was played. The curtain was raised on December 10, 1844 at Hartford, Connecticut, in the east ofthe U.S.A., and was dosed on October 16, 1846 in Boston, Massachusetts. On December 11, 1844, Dr. Wells, a dental practitioner, tried using nitrous oxide (laughing gas) on himself, and without being subjected to any pain he had his mend Dr. J.M. Riggs extract a molar tooth. After this success he applied this particular method to 15 patients and succeeded in each case. In January ofthe next year, Wells went to Boston to recommend his painless inhalation method to the doctors there. Through the good offices of Dr. Warren, Professor of Surgery at Harvard University as well as the Director ofMassachusetts General Hospital (M.G.H.), he tried practising his operation publicly at the School ofMedicine, Harvard University. Unfortunately, however, Well's method wasjudged a failure, thus branding him a swindler. So it resulted that his developing of painless surgery by anesthesia suffered a setback. A year and nine months later, a dentist named Dr. Morton, who was Dr. Wells' junior, succeeded in practising painless extraction of teeth by using sulphur ether. (On this occasion he was given advice by Dr. Jackson, a chemistry doctor, in selecting ether for use in the operation.) Immediately he asked Dr. Warren to give him permission tooperate openly at Massachusetts General Hospital on October 16, 1846, and he admirably succeeded. The news of this marvelous achievement immediately spread throughout the world. The era ofAnesthesia began at that time. This means that Dr. Morton succeeded in opening the door of the Inhalation Anesthesia Method on which Dr. Wells had bravely knocked. If I can be allowed to call Dr. Wells a pioneer of the Anesthetic Method, Dr. Morton can be called a person who generalized this particular method. There was, however, another actor who appeared on the stage even after the curtain had fallen. In 1849, three years after Dr. Morton had succeeded, a person appeared who insisted that he was the person who had used this particular method ofanesthesia first. The extra actor was Dr. C.W. Long, a medical practitioner. He firmly insisted that he had already practised this ether method in 1842. It is nonsensical that someone, who had made a great discovery but had kept it a secret, should suddenly declare that he was the discoverer. If my metaphor can be admitted again, the difference between the leading actors and the extra is that the leading actors had become keenly aware ofthe importance oftheir own roles in their achievements, while they had had firm confidence in what they had performed. This is a decisive difference from the extra's performance. Though Dr. Long's
expostfacto report was admitted as a real one, he was criticized because he had not made any contribution to the development and progress of the method of anesthesia. Both the American Dental Association (A.D.A.) and the American Medical Association (A.M.A.) judged and authorized Dr. Wells as "The Discoverer of the Anesthesia," respectively In 1864 and 1870. Nevertheless even today between the United States and Japan, we have subtlely different views upon the achievements ofthese three doctors, because the two leading actors were dentists, while the other was a medical doctor. However, I believe that only those who bravely challenged and practised their own beliefs are entitled to be called pioneers. That entitlement depends upon the degree to which those influences contribute to their own generation as well as to future generations, rather than upon the priority of their invention.
History Panel at ASAMeeting As in past years at the ASAAnnual Meeting, a Workshop on the History ofAnesthesia will be presented on Tuesday afternoon, October 29, from 2 till 5:00 p.m. Dr. Maurice S. Albin will be moderator and he has assembled a distinguished group ofspeakers to discuss the development and use of a number of inhalation agents. The program is as follows:
Moderator Maurice S. Albin, M.D., Professor of Anesthesiology and Neurological Surgery, University of Texas Health Science Center at San Antonio, San Antonio.
Chloroform Richard O. Patterson, M.D., Professor ofAnesthesiology, U.C.L.A. School of Medicine, Los Angeles.
Cyclopropane Lucien E. Morris, M.D., Emeritus Professor of Anesthesiology, Medical College of Ohio, Toledo.
Trichloroethylene, Ethyl Chloride David Wilkinson, F.F.A.R.C.S., Consultant Anaesthetist, St. Bartholomew's Hospital, London, England.
Methoxyflurane, Ethylene Joseph F. Artusio, Jr., M.D., Emeritus Professor ofAnesthesiology, Cornell University Medical College, New York.
Halothane, Fluoroxene C. Ronald Stephen, M.D., Emeritus Professor of Anesthesiology, Washington University School of Medicine, St. Louis.
John Snow -
An Early Intensivist
Snowisregarded by many asbeing thefirstprofessional anaesthetist. Certainly, hecan be calledaphysician anaesthetist withabroadinterest in trying totreat anumber of maladies, astheJOllowing account indicates. j:# are much indebted to theauthor, Dr. R S. Atkinson andto theEditor of theProceedings of theHistory ifAnaesthesia SocietyJOr permission to reprint this somewhat different look atJohn Snow, as it appeared in Volume 3:1988, pp 31-35, of the Proceedings. John Snow lived in an era long before the invention ofintensive care units and by no stretch ofimagination can he be referred to as an intensivist. Why then do I choose the title? The aim that I had in mind was to draw your attention to how John Snow thought about medical treatment and how he was ahead ofhis time in applying some of the principles of anaesthesia as then understood, to the care of the ordinary medical patient. Some ofhis patients had near fatal conditions and there was nothing to lose, so why not try some anaesthetic principles and some cWoroform? In any case, he didn't have to worry about medicolegal considerations in those days. If! canjust refresh you a little about Snow, the man. We are indebted to Benjamin Ward Richardson for such bibliography details as we have.! Richardson was his friend and biographer and tells us that Snow was born in York on the 15th June, 1813 and he studied in Newcastle. As we all know, he treated cholera at Killingworth Colliery. After some time at Bumup Field in Newcastle and Pateley Bridge in Yorkshire, he came to London. He took a circuitous route through Liverpool, trudging on foot through Wales, visited an uncle in Bath and, finally, arrived in London in 1837. We know something about him as a person. He is said to have been of middle height and of somewhat slender build, of sedate expression, and had a reserved manner with strangers. In short, he was introverted and he was the sort ofchap who devoted himself to scientific experimentation and rational clinical work. In London, he proceeded to take the various examinations then available and joined the Westminster Medical Society (WMS) where he was an active participant at meetings. In 1841- we are now talking about some 5 years before the introduction of anaesthesia - he was also interested in the principles ofresuscitation. He gave a paper to the WMS entitled 'Asphyxia - on the resuscitation ofnewborn children' and his aim was to describe a double air pump invented by a Mr Read of Regents Circus, thereby foreshadowing his interest in resuscitation methods. He spoke at various meetings of the WMS and wrote papers on various subjects, for example - paracentesis of the thorax. Some of these were published in the Medical Gazette and when anaesthesia arrived in London at the end of 1846, Snow was quick to take an interest. He had a lively mind and was adaptable to new ideas.
Snow and anaesthesia Richardson considered why he was attracted to anaesthesia. He suggested that Snow enjoyed the rational nature ofanaesthetic administration and its humane aspects and appreciated its basis in physiological knowledge. Snow started to design an improved ether inhaler and experimented with anaesthetics on animals and on himsel£ He attended outpatients of St George's Hospital where he used anaesthesia for tooth pulling. Eventually, the ether practice in London, Richardson tells us, came almost exclusive to Snow though, of course, ether soon gave way to chloroform. We know that Snow kept a diary of his clinical practice, from 17thJuly 1848 until the 5th June 1858, the last ten years before his untimely death. These diaries occupy three exercise books which on Snow's death came into the possession ofRichardson and his fanIily. Richardson's daughter-in-law, Mrs. Audrey Richardson,
presented them to the Royal College of Physicians of London where they now reside in the Library.I
Resnscitation I found it interesting to read some of the extracts from the diaries, and am now concerned with some which are quite unconnected with surgical operations. Snow attempted resuscitation ofthe newborn and in one ofhis entries he described his only case ofcardiac arrest during anaesthesia and what he did to.try to resuscitate the patient. It is interesting to discover that he also had several cases ofwhat we might describe today as 'near misses'. . He did a lot ofobstetrics and it is quite clear that practice was pretty crude in the mid 19th century. We all know that the maternal death rate and perinatal death rate were high and it is fascinating to read some of the descriptions of how obstetrics was done in those days, of how chloroform was administered and how, in the absence ofproper antenatal care and so forth the babies were often delivered in perilous states. Snow described several attempts to revive stillborn or lla'l:dly breathing newborn babies. For example, it seems that as a last resort he passed a gum elastic catheter into the larynx and made attempts to inflate the lungs by blowing down it. In another patient Snow described how he passed a female catheter into the glottis but he was clearly not satisfied with his attempts to resuscitate the patient because he took it out again, and he remarked that his fellow practitioners got much better results by blowing directly into the baby's mouth. Snow's one anaesthetic death was during administration ofamylene, a drug we don't know much about today but one which he used in a number of patients to produce anaesthesia. He gave a fairly honest description because he noted that his attention was distracted from the anaesthetic for a few seconds while he was watching the surgery and when he looked back he found the valve ofthe face piece had moved so as to occlude the apperture, presumably giving the patient a rather high concentration ofthe drug. He at once discontinued the anaesthetic and felt for the pulse which was not present in the left wrist and only a slight flutter in the right, and although the patient was breathing well, the respirations gradually became slower and deeper. Snow had to draw the surgeon's attention to the fact that all was not well. How did they treat this case?They threw cold water on his face and that didn't work very well. The patient was now becoming livid and gasping, and they began to perform artificial respiration according to the method of Marshall Hall. Then they pressed on the chest, the face being turned to one side and Snow was careful to note that at this time air could be heard going in and out of the lungs freely, in other words, he checked that the technique was actually working. He also noted that care was taken that the tongue did not fall back and he was very particular to note the timings 4.46 inhalation commenced, 4.48 unconsciousness, 4.49 surgery commenced, 4.54 called Mr Ferguson's attention to the fact that all was not well, 5.00 deep inspirations were still occurring and they apparently felt some kind ofpulsation. They went on for 1% hours before they gave up. At post mortem they didn't find very much to account for it all. This doesn't really surprise you but it is interesting to note that the patient is said to have drunk a pint ofbottled ale a quarter
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John Snow...
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ofan hour before the operation! The significance ofthat I don't know, the patient was only 33 and presumably healthy. What about these 'near misses'? I was quite interested to read that it was not too uncommon for a state ofsyncopy or fainting to occur. For instance, during the extraction of4 molar teeth which required immense force for their removal, Snow says, " .. .I felt the face was rather cold during the extraction ofthe second and subsequent teeth and at the end of the operation there was a little cold sweat on the forehead. He appeared faint and a minute or two afterwards the pulse could hardly be felt. He was laid on a sofa and recovered from the faintnessvery slowly. It was upwards often minutes before he became conscious, after which he felt very drowsy and it was more than halfan hour before he felt able to go." They kept the patient in for halfan hour if things went badly in those days! I think it is interesting that in the context of the times relatively detailed records were kept.
Tetanus But what about other medical diseases? If-you came across a patient who was dying, was about to die, was likely to die, or there was no other known therapy, why not try an inhalation of chloroform? For example, on the 7th March, 1858, Snow administered chloroform at St Mark's Hospital to a man aged 52 affected with tetanus. "He was operated on by Mr Salmon on Monday last for prolapsus ani and haemorrhoids by ligature, and the tetanus commenced on Friday evening. The patient was conscious and able to speak. He said he was not in pain but complained of twitchings. Spontaneous contractions came on almost every minute causing him to start and his muscles remained contracted between these. The abdomen was hard, he was able to show the tip of his tongue between his teeth. He had not been able to swallow anything since yesterday. His pulse was 148 full and strong and his breathing 30 in a minute." Snow commenced chloroform. "I had onlyjust placed the face piece on with the valve wide open (presumably to allow plenty of air to get in) when his breathing stopped, his lips became very blue and he became unconscious, the pulse becoming very slow and somewhat feeble. Mr Salmon said he thought the man was dying. The nurse, however, told us that he had had a similar attack before in the course of a morning. In a minute or two the muscles of the chest became relaxed and he made gasping inspirations at intervals and in about a minute his breathing was natural and his lips of a proper colour again and his pulse as quick as before." What did he do? "I now re-applied the chloroform." They removed a bit of sloughing tissue while the patient was asleep. "The patient slept for about 20 minutes after the operation, then he had a little spasm on his anus being touched, and the chloroform was repeated and he slept the same time as before. I endeavoured after he awoke to get him to take some egg and brandy but he spluttered it out after attempting to swallow and had a bad attack of spasm." Of course.. the patient subsequently died in St. Bartholomew's Hospital to where he had been transferred (even in those days the patients were transferred). Here's another case - 11th November 1853: "Administered chloroform at 10 Mansfield Street, to a son ofMr Morris, aged 10, who was affected with lockjaw. The jaws could only be opened sufficiently to get the tip ofa spoon between his teeth. Chloroform was administered so as to make him unconscious. He still couldn't open his jaw... The chloroform was repeated a second time and then a third time, no relaxation ofjaw was effected although I carried the
effect of chloroform to insensibility and as far as seems safe in such a subject".
Convulsions, mania, typhoid, cholera Snow administered chloroform to treat convuhions in a child aged 2 years 11 months who was presumably in status epilepticus. Chloroform was given which, of course, only had a temporary effect and the child later died. Viscount Hinton, aged 34, suffered from acute mania - "He could not be persuaded to breathe the chloroform so he was seized by three keepers and held while I administered it, first on a towel and afterwards with the inhaler. When he found he was gassed and the chloroform was beginning to take effect, he became somewhat tractable and desired that it might not be given too strong". Although he gave him several repeated dosesofchloforom this did not really, I am sure, do the patient much good ultimately. He used chloform to treat typhoid; presumably ifyou have typhoid you get some abdominal pain, and that was why the anaesthetic was given. After taking chloroform the delirium never became quite as violent as before. He even used it to treat a patient with cholera " ...She had severe cramps and almost constant vomiting. The pulse was small, feeble and frequent. The patient inhaled from a smallinhaler lithe extent ofbeing made just unconscious and when she woke up in a few minutes the inhalation was repeated to the same extent. Soon after I left she fell into a natural sleep which lasted 2lf2 hours and she continued afterwards to improve." These are just a few extracts from Snow's diaries and I thought it was interesting to report some which I find quite fascinating. They show, I think, that Snow was not afraid to try unconventional methods in those patients who really had very little hope of recovering otherwise. He wasn't afraid to try the effect of chloroform and see what it would do. References 1. Richardson, B.W., Snow J. A representative ofmedical science and art ofthe Victorian era. The Asclepiad, London, 1887, Vol. IV, 274-300. Reprinted in 'Snow on Cholera,' 1965, Hamer Publishing Company, New York and London. 2. Atkinson, R.S. The 'lost' diaries ofJohn Snow. Progress in Anaesthesiology, 1970, 197-199, Exerpta Medica Foundation, Amsterdam.
Annual Meeting of the Anesthesia History Association The Annual Meeting ofthe Anesthesia History Association will take place on Saturday, October 26, 1991, at the Four Seas Restaurant, 731 Grant St., San Francisco. Social hour will begin at 6:30 p.m., followed by the business meeting and dinner at 7:15, and the lecture at 8:30. Lecturer this year will be Ralph Kellogg, M.D., Ph.D., Professor Emeritus, Department ofthe History ofHealth Sciences,University of California, San Francisco. His topic will be "Historical Links between Physiology and Anesthesia." Reservations and checks for $32.00 per person should be forwarded by October 1 to: J.W. Severinghaus, M.D., 1386 HSE, U.C.S.F., San Francisco, CA 94143.
An Intricate Apparatus Mr.Patrick Sim,Curator ofthefiVood Library-Museum ofAllesthesiology, has brought toour attention all article by Dr. E. fiVood which describes all apparatus desiglled by Dr. M. Duroy of Paris for the administration of chlorofoml. This article is reprinted from the Pharmaceutical Journal alld Transactions 16:274-277, 1856-57. T# thanl: Mr. Sim for his continuing interest ill the Newsletter. -Editor
.Duroy's Anaesthesimeter DUROY'S ANlESTHESIMETER.
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enumerated thirty-seven casesof death, resulting from the inhalation of chloroform, which he found recorded in the Lancet and Medical Gazette up to the middle of 1855, in the greater number ofwhich casesan inhaler had not been used. It was important that the best means ofobviating such accidents should be adopted, and he thought M. Duroy's apparatus gave the operator more control over the anaesthetic agent than any other that he knew of. He was anxious that the instrument should be fairly tried in one of the large hospitals. The following is a description of the apparatus:DESCRIPTION OF THE APPARATUS.
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Mr. E. Wood, ofBrighton, directed the attention ofthe meeting to the apparatus ofM. Duroy, ofParis, for the administration ofchloroform. He referred to the difference ofopinion expressed by authors as to the importance of employing suitable apparatus for regulating the amount of vapour inhaled in the administration of anaesthetics, and
M M (fig. 1), a glassjar, where chloroform vapour, mixed with air, is generated. M', ebony lid, lined in the interior with cork, hermetically closing the jar. M", ebony foot. R R, two elastic metal uprights, rising from the foot ofthe apparatus, and fitting by means of a protuberance into a moulding on the lid. A (figs. 1 and 2), reservoir or kind ofdisplacement vase, bearing divisions each corresponding to 1 gramme (15.4 grains) of chloroform. A', stoppered mouth. C, stop-cock, pierced transversely. A" (fig. 2), tubulated socket, or inferior extremity of the reservoir. K (figs. 1, 3, and 4), small graduated vase, into which are introduced-1st, the socketA" ofthe reservoir; 2nd, the shorter branches ofthe two syphons FF; the interior of which is filled with filaments of cotton. JJ' (figs. 1 and 7), two tubes, intended for the introduction ofair into the apparatus. These tubes rise at the side of the transparent reservoir to protect it, penetrate to the interior of the vase M, and nearly touch the tray V. I (fig. 1), flexible breathing-tube, screwed on to the lid and terminated by a mouth-piece I'; six centimetres from this mouth-piece are two valves Q, whose alternate play permits inhalation and exhalation outof theapparatus. V (figs. 1 and 2), metal tray, slightly concave, furrowed with small concentric circular grooves, whence arises the chloroform vapour; the centre V' is perforated, so as to permit the flowing ofthe unevaporated liquid into the cup V. V (figs. 1 and 6), crystal cup, graduated and on a wooden foot, supporting the tray V, and intended for the reception of the excess of chloroform. D (fig. 1), regulator, giving horizontal and vertical movement to the Continued 011 Page 6
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Duroy's Anaesthesimeter. . .
Continued from Pages
two syphons; it is composed of axis YY', fig. 3, the superior extremity ofwhich is screwed into a nut, D', fig. 1. The middle portion ofthe axis passes through a copperjacket, Z', fig. 1, and its lower extremity, after having passed through the lid, is caught in a copper ring, soldered to the anterior face ofthe small vessel K. The jacket Z is slit in Z', to allow a small index fixed at a right angle upon the axis, to pass as seen in Y' (fig. 2). The course ofthe needle is limited by the slit Z'; it stops, consequently at the two extremities numbered 1 and 5. Going downwards, this small scale, 1, 2, 3, 4, 5, engraved on the rim of the slit, marks the degrees of theAnaesthesimeter. XX (fig. 3), two diverging guards, between which are clasped the long branches of the syphons. MANAGEMENT OF THE APPARATUS. The Anaesthesimeter being put together according to the plan No. 1, and its stop-cock C closed, the liquid is introduced by the orificeA ofthe reservoir, and the stopper immediately replaced. Now suppose chloroform poured in up to the 16th division (say 16 grammes), and the pressure ofthe air observed to be exerted thoroughly in the interior of the jar M M', just as in the little vase with the syphons K, by means of the communication which exists between the atmosphere and the air in the interior by the tubes]. As soon asweopen thestop-cock C, several bubbles of air will be introduced at the bottom by the aperture A", will be seen traversing the liquid in the reservoir, and an equivalent quantity of chloroform will immediately descend into the little vase K, yet the flow of chloroform will always stop as soon as its level in K touches the extremity A" of the orifice, for then the simple atmospheric pressure, which is exerted upon the surface of the liquid in K, will sustain the column ofchloroform in the superior vesselA. But ason the other hand the small syphons, furnished in the interior with filaments of cotton, dipping into K, have the property of absorbing by capillarity, the chloroform will ascend in the tubes, follow their course, and fall guttarim on the tray U; the level ofthe liquid will instantly sinkin the vase K till the extremity of the channel A" is uncovered, and allows the entrance of air again into the reservoir; then the level will re-establish itself incessantly, until all the liquid in the great reservoir is exhausted. The above detailed arrangement constitutes, we see, an apparatus in which the distribution ofthe chloroform is regular and successive, and takes place only by a drop at a time. But, as it was further desirable to be able to obtain an appropriate estimation for different ages and various idiosyncrasies ofsubjects, and asfor that purpose it is necessary that one should be able atpleasure to augment or diminish the number ofdrops, and if possible, also to enlarge or contract proportionally the surface upon which these drops fall (evaporation being relative to surface), the regulator YX (fig. 3) andD (fig. 1) has been added. For understanding the office of this appliance, it will suffice to state that the long branches of the syphons F F' are held between two guides X X', fig. 3, and that the bends ofthe syphons articulate with the arm ofthe lever T, which is itselfattached to the axis Y, fig. 3. Consequently, if the nutD is turned to the left, the axis descends, and the syphons, in obedience to this motion, dip deeper into vase K, at the same rime that their long branches, following the oblique direction of the guards, recede from each other. On the contrary, when the nut D is turned to the right, the branches approach each other, because the axis lifts the syphons up. In the former case the drops of chloroform fall plentifully on the circles farthest from the centre ofthe tray U, and, becoming evaporated on a greater surface, produce a greater quantity ofvapour. In the latter case, the branches being very near one another, and the drops less
numerous, falling very near the centre, and having but a small distance to run to reach the orifice of the tray, form but very little vapour. The different degrees ofthe instrument indicated by the needle Z', fig. 1, present for evaporation the following number of drops:No. 1 gave about 4 drops of chloroform per minute. No.2 gave about 10 drops of chloroform per minute. No.3 gave about 25 drops of chloroform per minute. No.4 gave about 40 drops of chloroform per minute. No. 5 gave about 60 drops of chloroform per minute. The use of the Anaesthesimeter is subject to the following simple rules:1st. Before the experiment, note the weight ofchloroform poured into the reservoir. 2nd. Apply a nose clasp, so that the patient may breathe only by the mouth. 3rd. To begin with, turn the nut D, so as to bring the index Z to No. 1. 4th. Alwaysstarting from No.1, let respiration go on for two or three minutes before increasing the drops of chloroform; pass progressively and slowly from a weaker to a stronger degree. In proceeding thus, the idiosyncrasy of the patient is ascertained, and the phases of chloroformisation succeed each other gradually and regul;rrlyup to complete anaesthesia, without producing a period of intolerance called reaction. 5th. To sustain anaesthesia without danger during long operations, it is sufficient to bring the index to No.1, and to continue inhalation at short intervals. 6th. At the close ofthe operation the stop-cock is closed, and ifit is required to know the quantity of chloroform employed, nothing is more easy. The three vessels, A, R, and V, being transparent, and graduated by grammes, the weight ofthe chloroform used may be seen by what remains. (Two grammes may be allowed for the liquid retained by the syphon cottons.) Lastly, the chloroform which has fallen into the little cup must be emptied out before commencing a fresh application.
The Chairman thought the fatal results which had been referred to by Mr. Wood, might be ascribed to peculiarities in the constitutions of the patients more than to differences in the modes ofadministering the anaesthetic. As he observed an operative surgeon present, the gentleman would probably favour the meeting with his opinion. Mr. Alexander Ure quite agreed with what the Chairman had just stated. He thought there were some points about the apparatus before the meeting which might offer advantages in its use, and he would be very happy to give it a trial at St. Mary's Hospital.
Anesthesia History Association Newsletter Printed and Distributed Courtesy of Becton Dickinson Vascular Access Excellence in Vascular Access Products
From the Literature A.J. Wright, Librarian Department of Anesthesiology, University of Alabama at Birmingham Brown BRJr. Classical file. SurvAnesthesiol1990; 34(3):196-199. This edition of the "Classical File" reprints part of a deposition given by Dr. John Mason Warren in Suffolk County, Massachusetts, on January 6, 1852, concerning the discovery of anesthesia.
- - - . Classical file. SurvAnesthesioI1991; 34(4):275-276. Thisedition of"Classical File" reprints an excerpt from William T. G. Morton's book, "Anaesthesia" (Washington, 1853), that "reflects Morton's downplaying of the concept that Horace Wells was the actual inventor of inhalation anes. " th esia,
Calverley RK. Classical file. SurvAnesthesiol1990; 34(6):428-438. In this edition ofthe "Classical File" Dr. Calverley reprints and comments upon an important article by Henry J.Bigelow, "Anaesthetic Agents, Their Mode of Exhibition and Physiological Effects," first published in 1848. 2 references.
- - - . WLM Fellowship program gains international interest. ASA Newsletter 1990; 54(9):21-24. .
Di Giandomenico M, ed. Claude Bernard: Scienza, Filosofia, Letteratura: Verona: Bertain, 1982. This Italian language monograph has not been examined.
Dick W. In memoriam: Zum Tode von Herrn Professor Dr. W.E. Spoerel. Anaesthesist 1989; 38:706. Briefnotice about the death of Dr. Spoerel (1923~1989). See also Can] Anaesth 36:738-739, 1989, which includes a portrait.
Donabedian A. Ernest A. Codman, MD, the end result idea and The Product of a Hospital. A commentary. Arch Pathol Lab Med 1990; 114(11):1105. This editorial has not been examined.
Donovan MI. An historical view ofpain: how we got to where we are! Cancer Nuts 1989; 12(4):257-261.
Describes the Wood Library-Museum Fellowship progtam initiated in 1987.
Superficial review ofhistorical views ofpain and ofthe "problem ofcancer pain in the world." 2 tables, 24 references.
Canale DJ, Longo ill. Harvey Cushing and pediatric neurosurgery. Neurosurgery 1990; 27(4):602-611.
Doughty A. Walter Stoeckel (1871-1961): A pioneer of regional analgesia in obstetrics. Anaesthesia 1990; 45:468-471.
This article has not been examined.
Carlsson C, Cooper S. One hundred thirty-six years ofether anesthesia. AnesthAnalg 1990; 70:339-340. This letter briefly describes what the authors believe to be the last ether anesthetic administered to a human in the United States. This anesthetic was given on October 20, 1982 in Temple University Hospital in Philadelphia. Strangely, no reason for the choice of this anesthetic agent is given. 1 reference.
Conn AW. Dr. C.H. Robson (1884-1969). Can] Anaesth 1990; 37(5):579. Briefbiography ofthe man "considered to have been the first full-time paediatric anaesthetist in Canada." Portrait.
Corssen G. Historical aspects ofketamine-fust clinical experience. In: Domino EF, ed. Status of Ketamine in Anesthesiology. Ann Arbor, Michigan: NPP Books, 1990:1-5.
Most of the article consists of an English translation of Stoeckel's 1909 paper describing 141 cases of obstetric epidural analgesia, Stoeckel, Was the leading German gynecologist of his era. 5 references.
Dudziak R, Arndt O. Dr. M. Zindler - 70 years old. Anaesthesist 1990; 39(5):288-291. This German language article has not been examined.
Dundee JW. Early British experience with ketamine. In: Domino EF, ed. Status of Ketamine in Anesthesiology. Ann Arbor, Michigan: NPP Books, 1990:7-10. Very brief overview. 2 tables, 12 references.
- - - . The taming of ketamine. In: Domino EF, ed. Status of Ketamine in Atlesthesiology. Ann Arbor, Michigan: NPP Books, 1990: 11-16. Describes early British studies that "were aimed at minimizing the side effects of the drug, while retaining its desirable properties." 7 tables, 8 references.
Briefly describes the initial clinical studies completed in the 1960s and early 19705 at the University ofMichigan and University ofAlabama in Birmingham. A more personal account from the late Dr. Corssen would have been valuable. 1 illustration, 16 references.
Dwyer B. Douglas Joseph (1925-1990): An appreciation of his life. Anaesth Intens Care 1990; 18:420-421.
Craig DB. The evolution ofanaesthesia as a specialty in Canada. Can] Anaestn 1990; 37:712-714.
El-Ansary MM. History ofpain reliefby ancient Egyptians. Mid East] Anesth 1989; 10(2):99-105.
Thisletter was written in response to an article ofthe same title (Shephard DAB, Can] Anaesth 37: 134-142, 1990). Dr. Craig discusses"...what I consider to be a number ofmajor omissions in his description ofPhase 6 (1972-1989)." Includes reply by Dr. Shephard. 6 references.
Cramond T. "A transient popularity": Queensland's early anaesthetists. Anaesth Intern Care 1990; 18-252-264. This lengthy article was delivered in October 1989 as the fifty-sixth Bancroft Oration. Reviews early development ofanesthesia after Priestly and describes its use after 1847 in Queensland.
Crankshaw DP. Inhalation anaesthetics and invertebrates. BrJ Anaesth 1990; 64(5):649. This letter describes experiments just after World War II in which he experimented with halogenated hydrocarbons as a method ofdealing with weevils in stored grain. 2 references.
Cunningham AJ. Anaesthesia - its coming ofage and the road not yet taken. ] Ir Coll PhysidallS Surg 1987: 16(2):61-67. This article has not been examined.
Personal remembrance of the Sydney anaesthetist.
Sections include theory of pain, descriptions of painful conditions and procedures used for pain relief. 4 illustrations, 27 references.
Epstein RM. The American Board ofAnesthesiology: Thoughts on the occasion of its fiftieth anniversary. ] CUn Anesth 1990; 2:3-6. Brief overview of the ABA. 3 references.
Erich D. Professor Dr. med. Heinz Oehmig zum 70. Geburtstag. Anaesthesist 1989; 38. A congratulatory note on the occasion of Dr. Oehmig's seventieth birthday. 1 reference.
Ferrante FM, Covino BG. Patient-controlled analgesia: a historical perspective. In: Ferrante FM, Covino BG, ed. Patient-Controlled Analgesia. Boston: Blackwell, 1990:3-9. Describes the development of modem PCA. 2 illustrations, 1 table, 30 references.
Continued on Page 8
History of Anesthesia and Related Fields in Stamps by
From the Literature. . .
Continuedfrom Page 7
Ferrari A, Sternieri E. Dietary headaches through the centuries. Funet Neurol1990; 5:79-84. This article has not been examined.
Miguel Colen-Morales, M.D, Fine E. Separate but integrated: Bertha Van Hoosen and the founding of AMWA.J Am Med f#Jm Assoc 1990; 45(5):181-190. Thisarticle about the early 20th century proponent of "twilight sleep" has not been examined.
Foldes FF. The impact of neuromuscular blocking agents on the development ofanaesthesiaand surgery. In: Agoston S,Bowman WC. Muscle Relaxants. Amsterdam: Elsevier, 1990:1-17. Excellent overview of the topic. 1 illustration, 6 tables, 69 references.
Franco Grande A, Banos Rodriguez G. Spanish pioneers in the technics oflaryngotracheal intubation. RevEspAnestesiol Reanim 1989; 36(6):344-349. This Spanish language article has not been examined.
Karl Landsteiner was born in Vienna, Austria, onJune 14, 1868. He graduated from the University ofVienna Medical School in 1891 at 23 years of age. Mter studying chemistry with Professor Emil Fischer for five years, he moved to the Pathologic Anatomy Institute at the University. Later he traveled to Holland and then in 1922 went to the Rockefeller Institute for Medical Research in New York. In 1900 he discovered the concept ofiso-agglutination and the four .types of human blood. For this work he received the Nobel Prize in Medicine in 1930. He also introduced dark-field microscopy for the diagnosis of primary syphilis, and participated with Wiener in the discovery ofthe Rh factor in human blood. He died suddenly in New York City from a heart attack on June 26, 1943. He has been honored on stamps by two countries, Austria (Scott #813), reproduced here, and East Germany (Scott #1025).
Anesthesia History Association C. Ronald Stephen, M.D., Newsletter Editor 15801 Harris Ridge Court Chesterfield, MO 63017 U.S.A.
Fromm GH, Sessle BJ. Trigeminal neuralgia - Current concepts regarding pathogenesis and treatment - Introduction and historical review. In: Trigeminal Neuralgia. 1991:1-26. This book chapter has not been examined.
Frost EAM. The contributions of Sir William Macewen, a pioneer neurosurgeon, to an early quality assurance survey in anesthesia. J Neurosurg Anesthesiol1991; 3(1):28-33. "A series ofevents in Glasgow toward the end ofthe nineteenth century focused public attention on anesthetic administration. The presence at that time of an educator and clinician, Sir William Macewen... was enough to launch what was probably the first organized survey of anesthetic teaching, administration, and operating room reporting." 2 illustrations, 1 table, 8 references.
Gavrilov OK. Blood transfusion service during World War II. Gematol Transjuziol1990; 335(5):3-6. This Russian language article has not been examined.
More From the Literature in the Next Issue
'
October, 1991
Third International Symposium on The History of Anesthesia March 27-31, 1992 The Third International Symposium on the History of Anesthesia (T.I.S.H.A.), which will be held in Atlanta, Georgia, U.S.A. on March 27-31,1992, commemorates the 150th anniversary ofLong's administration of ether vapor to produce surgical anesthesia in 1842. Presentations by invited speakers at the opening plenary session on Saturday, March 28, will emphasize the mid-19th century society in which Long was educated, lived and practiced. Areas to be explored willinclude the general nature ofAmerican society at the mid-century, medical education in Long's time, social conditions and attitudes favorable to the acceptance of anesthesia at this stage in human history, and other related topics. On Saturday afternoon symposium participants willvisit Jefferson, Georgia, locale of Long's practice in 1842 and his first ether administrations and currently site of the Crawford W. Long Museum. On Saturday evening, following a cocktail buffet at the hotel, registrants and their guests willattend the premier ofan original drama on the first use of ether anesthesia. The general sessions ofthe Symposium will take place from Sunday morning, March 29, until mid-day on Tuesday, March 31. These will include oral presentations offree papers, poster presentations, and both historical and commercial exhibits. Additional features ofthese sessions will be panel discussions and papers by invited speakers. The opening reception will be on Friday evening, March 27, at the Carter Presidential Center. An additional cocktail buffet is planned for Monday evening, March 30, with entertainment. Special trips to permit accompanying guests to view famous attractions ofthe Atlanta area will be available on Sunday and Monday, March 29-30. The Symposium will be an unforgettable experience for everyone with an interest in the history and origins of anesthesia! The program committee solicits participation by all students of the history ofanesthesia in the symposium. Proposals for oral presentations (12 minutes duration), poster presentations and historical exhibits will be welcome. All submissions should be on special forms provided by the committee. Deadline for submissions has been extended to October 1. For the necessary forms, further details about the meeting and registration and hotel reservation materials, please write to: TISHA Attn: John E. Steinhaus, M.D. Department of Anesthesiology 1365 Clifton Road, N.E. Atlanta, GA 30322 -Norman Bergman, M.D.
CRAWFORD W LONG SIESQUllCIEN11ENNlIAIL MDCCCXLII MCMXCII r,l (,! =
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E HI RYOF ANE SIA ~ ANESTHESIA HISTORY ASSOCIATION Symposium Committee: Chairman, John E. Steinhaus,
M. D.
Emory Clinic, 1365 Clifton Road, Atlanta, GA 30322 ATLANTA, GEORGIA. U.S.A. - MARCH 27-31.1992 Also In This Issue: • More About Horace Wells • John Snow-An Early Intensivist • An Intricate Apparatus
More About Horace Wells "TheFather ofAnesthesia, Dr. Horace Wells, 11 isthetitle ofa 105-page monograph written by Dr. SenNakahara, Dean andProfessor oftheNippon Dental University, andjustpublished in theJapanese language. The textisbeautifUlly illustrated by 50 photographs, themajority of which are in color, which depict mementos andareas of Hartford with which Wells must have beenfamiliar orwhich are associated withhismemory. The final twopages of thetextare asummary of thework andare reprinted below, with thepermission of the author. Anesthesia is one of the greatest discoveries in.the history of the development ofmedical science, and it is very interesting to know how the Anesthetic method finally came to be used. Figuratively speaking, we have two leading actors named Dr. H. Wells and Dr. W.T.G. Morton, while we have Dr. J.c. Warren as a supporting actor. We also have Dr. C.T. Jackson who played a minor part in this drama. By these persons, the greatest performance in the field of medical science was played. The curtain was raised on December 10, 1844 at Hartford, Connecticut, in the east ofthe U.S.A., and was dosed on October 16, 1846 in Boston, Massachusetts. On December 11, 1844, Dr. Wells, a dental practitioner, tried using nitrous oxide (laughing gas) on himself, and without being subjected to any pain he had his mend Dr. J.M. Riggs extract a molar tooth. After this success he applied this particular method to 15 patients and succeeded in each case. In January ofthe next year, Wells went to Boston to recommend his painless inhalation method to the doctors there. Through the good offices of Dr. Warren, Professor of Surgery at Harvard University as well as the Director ofMassachusetts General Hospital (M.G.H.), he tried practising his operation publicly at the School ofMedicine, Harvard University. Unfortunately, however, Well's method wasjudged a failure, thus branding him a swindler. So it resulted that his developing of painless surgery by anesthesia suffered a setback. A year and nine months later, a dentist named Dr. Morton, who was Dr. Wells' junior, succeeded in practising painless extraction of teeth by using sulphur ether. (On this occasion he was given advice by Dr. Jackson, a chemistry doctor, in selecting ether for use in the operation.) Immediately he asked Dr. Warren to give him permission tooperate openly at Massachusetts General Hospital on October 16, 1846, and he admirably succeeded. The news of this marvelous achievement immediately spread throughout the world. The era ofAnesthesia began at that time. This means that Dr. Morton succeeded in opening the door of the Inhalation Anesthesia Method on which Dr. Wells had bravely knocked. If I can be allowed to call Dr. Wells a pioneer of the Anesthetic Method, Dr. Morton can be called a person who generalized this particular method. There was, however, another actor who appeared on the stage even after the curtain had fallen. In 1849, three years after Dr. Morton had succeeded, a person appeared who insisted that he was the person who had used this particular method ofanesthesia first. The extra actor was Dr. C.W. Long, a medical practitioner. He firmly insisted that he had already practised this ether method in 1842. It is nonsensical that someone, who had made a great discovery but had kept it a secret, should suddenly declare that he was the discoverer. If my metaphor can be admitted again, the difference between the leading actors and the extra is that the leading actors had become keenly aware ofthe importance oftheir own roles in their achievements, while they had had firm confidence in what they had performed. This is a decisive difference from the extra's performance. Though Dr. Long's
expostfacto report was admitted as a real one, he was criticized because he had not made any contribution to the development and progress of the method of anesthesia. Both the American Dental Association (A.D.A.) and the American Medical Association (A.M.A.) judged and authorized Dr. Wells as "The Discoverer of the Anesthesia," respectively In 1864 and 1870. Nevertheless even today between the United States and Japan, we have subtlely different views upon the achievements ofthese three doctors, because the two leading actors were dentists, while the other was a medical doctor. However, I believe that only those who bravely challenged and practised their own beliefs are entitled to be called pioneers. That entitlement depends upon the degree to which those influences contribute to their own generation as well as to future generations, rather than upon the priority of their invention.
History Panel at ASAMeeting As in past years at the ASAAnnual Meeting, a Workshop on the History ofAnesthesia will be presented on Tuesday afternoon, October 29, from 2 till 5:00 p.m. Dr. Maurice S. Albin will be moderator and he has assembled a distinguished group ofspeakers to discuss the development and use of a number of inhalation agents. The program is as follows:
Moderator Maurice S. Albin, M.D., Professor of Anesthesiology and Neurological Surgery, University of Texas Health Science Center at San Antonio, San Antonio.
Chloroform Richard O. Patterson, M.D., Professor ofAnesthesiology, U.C.L.A. School of Medicine, Los Angeles.
Cyclopropane Lucien E. Morris, M.D., Emeritus Professor of Anesthesiology, Medical College of Ohio, Toledo.
Trichloroethylene, Ethyl Chloride David Wilkinson, F.F.A.R.C.S., Consultant Anaesthetist, St. Bartholomew's Hospital, London, England.
Methoxyflurane, Ethylene Joseph F. Artusio, Jr., M.D., Emeritus Professor ofAnesthesiology, Cornell University Medical College, New York.
Halothane, Fluoroxene C. Ronald Stephen, M.D., Emeritus Professor of Anesthesiology, Washington University School of Medicine, St. Louis.
John Snow -
An Early Intensivist
Snowisregarded by many asbeing thefirstprofessional anaesthetist. Certainly, hecan be calledaphysician anaesthetist withabroadinterest in trying totreat anumber of maladies, astheJOllowing account indicates. j:# are much indebted to theauthor, Dr. R S. Atkinson andto theEditor of theProceedings of theHistory ifAnaesthesia SocietyJOr permission to reprint this somewhat different look atJohn Snow, as it appeared in Volume 3:1988, pp 31-35, of the Proceedings. John Snow lived in an era long before the invention ofintensive care units and by no stretch ofimagination can he be referred to as an intensivist. Why then do I choose the title? The aim that I had in mind was to draw your attention to how John Snow thought about medical treatment and how he was ahead ofhis time in applying some of the principles of anaesthesia as then understood, to the care of the ordinary medical patient. Some ofhis patients had near fatal conditions and there was nothing to lose, so why not try some anaesthetic principles and some cWoroform? In any case, he didn't have to worry about medicolegal considerations in those days. If! canjust refresh you a little about Snow, the man. We are indebted to Benjamin Ward Richardson for such bibliography details as we have.! Richardson was his friend and biographer and tells us that Snow was born in York on the 15th June, 1813 and he studied in Newcastle. As we all know, he treated cholera at Killingworth Colliery. After some time at Bumup Field in Newcastle and Pateley Bridge in Yorkshire, he came to London. He took a circuitous route through Liverpool, trudging on foot through Wales, visited an uncle in Bath and, finally, arrived in London in 1837. We know something about him as a person. He is said to have been of middle height and of somewhat slender build, of sedate expression, and had a reserved manner with strangers. In short, he was introverted and he was the sort ofchap who devoted himself to scientific experimentation and rational clinical work. In London, he proceeded to take the various examinations then available and joined the Westminster Medical Society (WMS) where he was an active participant at meetings. In 1841- we are now talking about some 5 years before the introduction of anaesthesia - he was also interested in the principles ofresuscitation. He gave a paper to the WMS entitled 'Asphyxia - on the resuscitation ofnewborn children' and his aim was to describe a double air pump invented by a Mr Read of Regents Circus, thereby foreshadowing his interest in resuscitation methods. He spoke at various meetings of the WMS and wrote papers on various subjects, for example - paracentesis of the thorax. Some of these were published in the Medical Gazette and when anaesthesia arrived in London at the end of 1846, Snow was quick to take an interest. He had a lively mind and was adaptable to new ideas.
Snow and anaesthesia Richardson considered why he was attracted to anaesthesia. He suggested that Snow enjoyed the rational nature ofanaesthetic administration and its humane aspects and appreciated its basis in physiological knowledge. Snow started to design an improved ether inhaler and experimented with anaesthetics on animals and on himsel£ He attended outpatients of St George's Hospital where he used anaesthesia for tooth pulling. Eventually, the ether practice in London, Richardson tells us, came almost exclusive to Snow though, of course, ether soon gave way to chloroform. We know that Snow kept a diary of his clinical practice, from 17thJuly 1848 until the 5th June 1858, the last ten years before his untimely death. These diaries occupy three exercise books which on Snow's death came into the possession ofRichardson and his fanIily. Richardson's daughter-in-law, Mrs. Audrey Richardson,
presented them to the Royal College of Physicians of London where they now reside in the Library.I
Resnscitation I found it interesting to read some of the extracts from the diaries, and am now concerned with some which are quite unconnected with surgical operations. Snow attempted resuscitation ofthe newborn and in one ofhis entries he described his only case ofcardiac arrest during anaesthesia and what he did to.try to resuscitate the patient. It is interesting to discover that he also had several cases ofwhat we might describe today as 'near misses'. . He did a lot ofobstetrics and it is quite clear that practice was pretty crude in the mid 19th century. We all know that the maternal death rate and perinatal death rate were high and it is fascinating to read some of the descriptions of how obstetrics was done in those days, of how chloroform was administered and how, in the absence ofproper antenatal care and so forth the babies were often delivered in perilous states. Snow described several attempts to revive stillborn or lla'l:dly breathing newborn babies. For example, it seems that as a last resort he passed a gum elastic catheter into the larynx and made attempts to inflate the lungs by blowing down it. In another patient Snow described how he passed a female catheter into the glottis but he was clearly not satisfied with his attempts to resuscitate the patient because he took it out again, and he remarked that his fellow practitioners got much better results by blowing directly into the baby's mouth. Snow's one anaesthetic death was during administration ofamylene, a drug we don't know much about today but one which he used in a number of patients to produce anaesthesia. He gave a fairly honest description because he noted that his attention was distracted from the anaesthetic for a few seconds while he was watching the surgery and when he looked back he found the valve ofthe face piece had moved so as to occlude the apperture, presumably giving the patient a rather high concentration ofthe drug. He at once discontinued the anaesthetic and felt for the pulse which was not present in the left wrist and only a slight flutter in the right, and although the patient was breathing well, the respirations gradually became slower and deeper. Snow had to draw the surgeon's attention to the fact that all was not well. How did they treat this case?They threw cold water on his face and that didn't work very well. The patient was now becoming livid and gasping, and they began to perform artificial respiration according to the method of Marshall Hall. Then they pressed on the chest, the face being turned to one side and Snow was careful to note that at this time air could be heard going in and out of the lungs freely, in other words, he checked that the technique was actually working. He also noted that care was taken that the tongue did not fall back and he was very particular to note the timings 4.46 inhalation commenced, 4.48 unconsciousness, 4.49 surgery commenced, 4.54 called Mr Ferguson's attention to the fact that all was not well, 5.00 deep inspirations were still occurring and they apparently felt some kind ofpulsation. They went on for 1% hours before they gave up. At post mortem they didn't find very much to account for it all. This doesn't really surprise you but it is interesting to note that the patient is said to have drunk a pint ofbottled ale a quarter
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John Snow...
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ofan hour before the operation! The significance ofthat I don't know, the patient was only 33 and presumably healthy. What about these 'near misses'? I was quite interested to read that it was not too uncommon for a state ofsyncopy or fainting to occur. For instance, during the extraction of4 molar teeth which required immense force for their removal, Snow says, " .. .I felt the face was rather cold during the extraction ofthe second and subsequent teeth and at the end of the operation there was a little cold sweat on the forehead. He appeared faint and a minute or two afterwards the pulse could hardly be felt. He was laid on a sofa and recovered from the faintnessvery slowly. It was upwards often minutes before he became conscious, after which he felt very drowsy and it was more than halfan hour before he felt able to go." They kept the patient in for halfan hour if things went badly in those days! I think it is interesting that in the context of the times relatively detailed records were kept.
Tetanus But what about other medical diseases? If-you came across a patient who was dying, was about to die, was likely to die, or there was no other known therapy, why not try an inhalation of chloroform? For example, on the 7th March, 1858, Snow administered chloroform at St Mark's Hospital to a man aged 52 affected with tetanus. "He was operated on by Mr Salmon on Monday last for prolapsus ani and haemorrhoids by ligature, and the tetanus commenced on Friday evening. The patient was conscious and able to speak. He said he was not in pain but complained of twitchings. Spontaneous contractions came on almost every minute causing him to start and his muscles remained contracted between these. The abdomen was hard, he was able to show the tip of his tongue between his teeth. He had not been able to swallow anything since yesterday. His pulse was 148 full and strong and his breathing 30 in a minute." Snow commenced chloroform. "I had onlyjust placed the face piece on with the valve wide open (presumably to allow plenty of air to get in) when his breathing stopped, his lips became very blue and he became unconscious, the pulse becoming very slow and somewhat feeble. Mr Salmon said he thought the man was dying. The nurse, however, told us that he had had a similar attack before in the course of a morning. In a minute or two the muscles of the chest became relaxed and he made gasping inspirations at intervals and in about a minute his breathing was natural and his lips of a proper colour again and his pulse as quick as before." What did he do? "I now re-applied the chloroform." They removed a bit of sloughing tissue while the patient was asleep. "The patient slept for about 20 minutes after the operation, then he had a little spasm on his anus being touched, and the chloroform was repeated and he slept the same time as before. I endeavoured after he awoke to get him to take some egg and brandy but he spluttered it out after attempting to swallow and had a bad attack of spasm." Of course.. the patient subsequently died in St. Bartholomew's Hospital to where he had been transferred (even in those days the patients were transferred). Here's another case - 11th November 1853: "Administered chloroform at 10 Mansfield Street, to a son ofMr Morris, aged 10, who was affected with lockjaw. The jaws could only be opened sufficiently to get the tip ofa spoon between his teeth. Chloroform was administered so as to make him unconscious. He still couldn't open his jaw... The chloroform was repeated a second time and then a third time, no relaxation ofjaw was effected although I carried the
effect of chloroform to insensibility and as far as seems safe in such a subject".
Convulsions, mania, typhoid, cholera Snow administered chloroform to treat convuhions in a child aged 2 years 11 months who was presumably in status epilepticus. Chloroform was given which, of course, only had a temporary effect and the child later died. Viscount Hinton, aged 34, suffered from acute mania - "He could not be persuaded to breathe the chloroform so he was seized by three keepers and held while I administered it, first on a towel and afterwards with the inhaler. When he found he was gassed and the chloroform was beginning to take effect, he became somewhat tractable and desired that it might not be given too strong". Although he gave him several repeated dosesofchloforom this did not really, I am sure, do the patient much good ultimately. He used chloform to treat typhoid; presumably ifyou have typhoid you get some abdominal pain, and that was why the anaesthetic was given. After taking chloroform the delirium never became quite as violent as before. He even used it to treat a patient with cholera " ...She had severe cramps and almost constant vomiting. The pulse was small, feeble and frequent. The patient inhaled from a smallinhaler lithe extent ofbeing made just unconscious and when she woke up in a few minutes the inhalation was repeated to the same extent. Soon after I left she fell into a natural sleep which lasted 2lf2 hours and she continued afterwards to improve." These are just a few extracts from Snow's diaries and I thought it was interesting to report some which I find quite fascinating. They show, I think, that Snow was not afraid to try unconventional methods in those patients who really had very little hope of recovering otherwise. He wasn't afraid to try the effect of chloroform and see what it would do. References 1. Richardson, B.W., Snow J. A representative ofmedical science and art ofthe Victorian era. The Asclepiad, London, 1887, Vol. IV, 274-300. Reprinted in 'Snow on Cholera,' 1965, Hamer Publishing Company, New York and London. 2. Atkinson, R.S. The 'lost' diaries ofJohn Snow. Progress in Anaesthesiology, 1970, 197-199, Exerpta Medica Foundation, Amsterdam.
Annual Meeting of the Anesthesia History Association The Annual Meeting ofthe Anesthesia History Association will take place on Saturday, October 26, 1991, at the Four Seas Restaurant, 731 Grant St., San Francisco. Social hour will begin at 6:30 p.m., followed by the business meeting and dinner at 7:15, and the lecture at 8:30. Lecturer this year will be Ralph Kellogg, M.D., Ph.D., Professor Emeritus, Department ofthe History ofHealth Sciences,University of California, San Francisco. His topic will be "Historical Links between Physiology and Anesthesia." Reservations and checks for $32.00 per person should be forwarded by October 1 to: J.W. Severinghaus, M.D., 1386 HSE, U.C.S.F., San Francisco, CA 94143.
An Intricate Apparatus Mr.Patrick Sim,Curator ofthefiVood Library-Museum ofAllesthesiology, has brought toour attention all article by Dr. E. fiVood which describes all apparatus desiglled by Dr. M. Duroy of Paris for the administration of chlorofoml. This article is reprinted from the Pharmaceutical Journal alld Transactions 16:274-277, 1856-57. T# thanl: Mr. Sim for his continuing interest ill the Newsletter. -Editor
.Duroy's Anaesthesimeter DUROY'S ANlESTHESIMETER.
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enumerated thirty-seven casesof death, resulting from the inhalation of chloroform, which he found recorded in the Lancet and Medical Gazette up to the middle of 1855, in the greater number ofwhich casesan inhaler had not been used. It was important that the best means ofobviating such accidents should be adopted, and he thought M. Duroy's apparatus gave the operator more control over the anaesthetic agent than any other that he knew of. He was anxious that the instrument should be fairly tried in one of the large hospitals. The following is a description of the apparatus:DESCRIPTION OF THE APPARATUS.
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Mr. E. Wood, ofBrighton, directed the attention ofthe meeting to the apparatus ofM. Duroy, ofParis, for the administration ofchloroform. He referred to the difference ofopinion expressed by authors as to the importance of employing suitable apparatus for regulating the amount of vapour inhaled in the administration of anaesthetics, and
M M (fig. 1), a glassjar, where chloroform vapour, mixed with air, is generated. M', ebony lid, lined in the interior with cork, hermetically closing the jar. M", ebony foot. R R, two elastic metal uprights, rising from the foot ofthe apparatus, and fitting by means of a protuberance into a moulding on the lid. A (figs. 1 and 2), reservoir or kind ofdisplacement vase, bearing divisions each corresponding to 1 gramme (15.4 grains) of chloroform. A', stoppered mouth. C, stop-cock, pierced transversely. A" (fig. 2), tubulated socket, or inferior extremity of the reservoir. K (figs. 1, 3, and 4), small graduated vase, into which are introduced-1st, the socketA" ofthe reservoir; 2nd, the shorter branches ofthe two syphons FF; the interior of which is filled with filaments of cotton. JJ' (figs. 1 and 7), two tubes, intended for the introduction ofair into the apparatus. These tubes rise at the side of the transparent reservoir to protect it, penetrate to the interior of the vase M, and nearly touch the tray V. I (fig. 1), flexible breathing-tube, screwed on to the lid and terminated by a mouth-piece I'; six centimetres from this mouth-piece are two valves Q, whose alternate play permits inhalation and exhalation outof theapparatus. V (figs. 1 and 2), metal tray, slightly concave, furrowed with small concentric circular grooves, whence arises the chloroform vapour; the centre V' is perforated, so as to permit the flowing ofthe unevaporated liquid into the cup V. V (figs. 1 and 6), crystal cup, graduated and on a wooden foot, supporting the tray V, and intended for the reception of the excess of chloroform. D (fig. 1), regulator, giving horizontal and vertical movement to the Continued 011 Page 6
I
Duroy's Anaesthesimeter. . .
Continued from Pages
two syphons; it is composed of axis YY', fig. 3, the superior extremity ofwhich is screwed into a nut, D', fig. 1. The middle portion ofthe axis passes through a copperjacket, Z', fig. 1, and its lower extremity, after having passed through the lid, is caught in a copper ring, soldered to the anterior face ofthe small vessel K. The jacket Z is slit in Z', to allow a small index fixed at a right angle upon the axis, to pass as seen in Y' (fig. 2). The course ofthe needle is limited by the slit Z'; it stops, consequently at the two extremities numbered 1 and 5. Going downwards, this small scale, 1, 2, 3, 4, 5, engraved on the rim of the slit, marks the degrees of theAnaesthesimeter. XX (fig. 3), two diverging guards, between which are clasped the long branches of the syphons. MANAGEMENT OF THE APPARATUS. The Anaesthesimeter being put together according to the plan No. 1, and its stop-cock C closed, the liquid is introduced by the orificeA ofthe reservoir, and the stopper immediately replaced. Now suppose chloroform poured in up to the 16th division (say 16 grammes), and the pressure ofthe air observed to be exerted thoroughly in the interior of the jar M M', just as in the little vase with the syphons K, by means of the communication which exists between the atmosphere and the air in the interior by the tubes]. As soon asweopen thestop-cock C, several bubbles of air will be introduced at the bottom by the aperture A", will be seen traversing the liquid in the reservoir, and an equivalent quantity of chloroform will immediately descend into the little vase K, yet the flow of chloroform will always stop as soon as its level in K touches the extremity A" of the orifice, for then the simple atmospheric pressure, which is exerted upon the surface of the liquid in K, will sustain the column ofchloroform in the superior vesselA. But ason the other hand the small syphons, furnished in the interior with filaments of cotton, dipping into K, have the property of absorbing by capillarity, the chloroform will ascend in the tubes, follow their course, and fall guttarim on the tray U; the level ofthe liquid will instantly sinkin the vase K till the extremity of the channel A" is uncovered, and allows the entrance of air again into the reservoir; then the level will re-establish itself incessantly, until all the liquid in the great reservoir is exhausted. The above detailed arrangement constitutes, we see, an apparatus in which the distribution ofthe chloroform is regular and successive, and takes place only by a drop at a time. But, as it was further desirable to be able to obtain an appropriate estimation for different ages and various idiosyncrasies ofsubjects, and asfor that purpose it is necessary that one should be able atpleasure to augment or diminish the number ofdrops, and if possible, also to enlarge or contract proportionally the surface upon which these drops fall (evaporation being relative to surface), the regulator YX (fig. 3) andD (fig. 1) has been added. For understanding the office of this appliance, it will suffice to state that the long branches of the syphons F F' are held between two guides X X', fig. 3, and that the bends ofthe syphons articulate with the arm ofthe lever T, which is itselfattached to the axis Y, fig. 3. Consequently, if the nutD is turned to the left, the axis descends, and the syphons, in obedience to this motion, dip deeper into vase K, at the same rime that their long branches, following the oblique direction of the guards, recede from each other. On the contrary, when the nut D is turned to the right, the branches approach each other, because the axis lifts the syphons up. In the former case the drops of chloroform fall plentifully on the circles farthest from the centre ofthe tray U, and, becoming evaporated on a greater surface, produce a greater quantity ofvapour. In the latter case, the branches being very near one another, and the drops less
numerous, falling very near the centre, and having but a small distance to run to reach the orifice of the tray, form but very little vapour. The different degrees ofthe instrument indicated by the needle Z', fig. 1, present for evaporation the following number of drops:No. 1 gave about 4 drops of chloroform per minute. No.2 gave about 10 drops of chloroform per minute. No.3 gave about 25 drops of chloroform per minute. No.4 gave about 40 drops of chloroform per minute. No. 5 gave about 60 drops of chloroform per minute. The use of the Anaesthesimeter is subject to the following simple rules:1st. Before the experiment, note the weight ofchloroform poured into the reservoir. 2nd. Apply a nose clasp, so that the patient may breathe only by the mouth. 3rd. To begin with, turn the nut D, so as to bring the index Z to No. 1. 4th. Alwaysstarting from No.1, let respiration go on for two or three minutes before increasing the drops of chloroform; pass progressively and slowly from a weaker to a stronger degree. In proceeding thus, the idiosyncrasy of the patient is ascertained, and the phases of chloroformisation succeed each other gradually and regul;rrlyup to complete anaesthesia, without producing a period of intolerance called reaction. 5th. To sustain anaesthesia without danger during long operations, it is sufficient to bring the index to No.1, and to continue inhalation at short intervals. 6th. At the close ofthe operation the stop-cock is closed, and ifit is required to know the quantity of chloroform employed, nothing is more easy. The three vessels, A, R, and V, being transparent, and graduated by grammes, the weight ofthe chloroform used may be seen by what remains. (Two grammes may be allowed for the liquid retained by the syphon cottons.) Lastly, the chloroform which has fallen into the little cup must be emptied out before commencing a fresh application.
The Chairman thought the fatal results which had been referred to by Mr. Wood, might be ascribed to peculiarities in the constitutions of the patients more than to differences in the modes ofadministering the anaesthetic. As he observed an operative surgeon present, the gentleman would probably favour the meeting with his opinion. Mr. Alexander Ure quite agreed with what the Chairman had just stated. He thought there were some points about the apparatus before the meeting which might offer advantages in its use, and he would be very happy to give it a trial at St. Mary's Hospital.
Anesthesia History Association Newsletter Printed and Distributed Courtesy of Becton Dickinson Vascular Access Excellence in Vascular Access Products
From the Literature A.J. Wright, Librarian Department of Anesthesiology, University of Alabama at Birmingham Brown BRJr. Classical file. SurvAnesthesiol1990; 34(3):196-199. This edition of the "Classical File" reprints part of a deposition given by Dr. John Mason Warren in Suffolk County, Massachusetts, on January 6, 1852, concerning the discovery of anesthesia.
- - - . Classical file. SurvAnesthesioI1991; 34(4):275-276. Thisedition of"Classical File" reprints an excerpt from William T. G. Morton's book, "Anaesthesia" (Washington, 1853), that "reflects Morton's downplaying of the concept that Horace Wells was the actual inventor of inhalation anes. " th esia,
Calverley RK. Classical file. SurvAnesthesiol1990; 34(6):428-438. In this edition ofthe "Classical File" Dr. Calverley reprints and comments upon an important article by Henry J.Bigelow, "Anaesthetic Agents, Their Mode of Exhibition and Physiological Effects," first published in 1848. 2 references.
- - - . WLM Fellowship program gains international interest. ASA Newsletter 1990; 54(9):21-24. .
Di Giandomenico M, ed. Claude Bernard: Scienza, Filosofia, Letteratura: Verona: Bertain, 1982. This Italian language monograph has not been examined.
Dick W. In memoriam: Zum Tode von Herrn Professor Dr. W.E. Spoerel. Anaesthesist 1989; 38:706. Briefnotice about the death of Dr. Spoerel (1923~1989). See also Can] Anaesth 36:738-739, 1989, which includes a portrait.
Donabedian A. Ernest A. Codman, MD, the end result idea and The Product of a Hospital. A commentary. Arch Pathol Lab Med 1990; 114(11):1105. This editorial has not been examined.
Donovan MI. An historical view ofpain: how we got to where we are! Cancer Nuts 1989; 12(4):257-261.
Describes the Wood Library-Museum Fellowship progtam initiated in 1987.
Superficial review ofhistorical views ofpain and ofthe "problem ofcancer pain in the world." 2 tables, 24 references.
Canale DJ, Longo ill. Harvey Cushing and pediatric neurosurgery. Neurosurgery 1990; 27(4):602-611.
Doughty A. Walter Stoeckel (1871-1961): A pioneer of regional analgesia in obstetrics. Anaesthesia 1990; 45:468-471.
This article has not been examined.
Carlsson C, Cooper S. One hundred thirty-six years ofether anesthesia. AnesthAnalg 1990; 70:339-340. This letter briefly describes what the authors believe to be the last ether anesthetic administered to a human in the United States. This anesthetic was given on October 20, 1982 in Temple University Hospital in Philadelphia. Strangely, no reason for the choice of this anesthetic agent is given. 1 reference.
Conn AW. Dr. C.H. Robson (1884-1969). Can] Anaesth 1990; 37(5):579. Briefbiography ofthe man "considered to have been the first full-time paediatric anaesthetist in Canada." Portrait.
Corssen G. Historical aspects ofketamine-fust clinical experience. In: Domino EF, ed. Status of Ketamine in Anesthesiology. Ann Arbor, Michigan: NPP Books, 1990:1-5.
Most of the article consists of an English translation of Stoeckel's 1909 paper describing 141 cases of obstetric epidural analgesia, Stoeckel, Was the leading German gynecologist of his era. 5 references.
Dudziak R, Arndt O. Dr. M. Zindler - 70 years old. Anaesthesist 1990; 39(5):288-291. This German language article has not been examined.
Dundee JW. Early British experience with ketamine. In: Domino EF, ed. Status of Ketamine in Anesthesiology. Ann Arbor, Michigan: NPP Books, 1990:7-10. Very brief overview. 2 tables, 12 references.
- - - . The taming of ketamine. In: Domino EF, ed. Status of Ketamine in Atlesthesiology. Ann Arbor, Michigan: NPP Books, 1990: 11-16. Describes early British studies that "were aimed at minimizing the side effects of the drug, while retaining its desirable properties." 7 tables, 8 references.
Briefly describes the initial clinical studies completed in the 1960s and early 19705 at the University ofMichigan and University ofAlabama in Birmingham. A more personal account from the late Dr. Corssen would have been valuable. 1 illustration, 16 references.
Dwyer B. Douglas Joseph (1925-1990): An appreciation of his life. Anaesth Intens Care 1990; 18:420-421.
Craig DB. The evolution ofanaesthesia as a specialty in Canada. Can] Anaestn 1990; 37:712-714.
El-Ansary MM. History ofpain reliefby ancient Egyptians. Mid East] Anesth 1989; 10(2):99-105.
Thisletter was written in response to an article ofthe same title (Shephard DAB, Can] Anaesth 37: 134-142, 1990). Dr. Craig discusses"...what I consider to be a number ofmajor omissions in his description ofPhase 6 (1972-1989)." Includes reply by Dr. Shephard. 6 references.
Cramond T. "A transient popularity": Queensland's early anaesthetists. Anaesth Intern Care 1990; 18-252-264. This lengthy article was delivered in October 1989 as the fifty-sixth Bancroft Oration. Reviews early development ofanesthesia after Priestly and describes its use after 1847 in Queensland.
Crankshaw DP. Inhalation anaesthetics and invertebrates. BrJ Anaesth 1990; 64(5):649. This letter describes experiments just after World War II in which he experimented with halogenated hydrocarbons as a method ofdealing with weevils in stored grain. 2 references.
Cunningham AJ. Anaesthesia - its coming ofage and the road not yet taken. ] Ir Coll PhysidallS Surg 1987: 16(2):61-67. This article has not been examined.
Personal remembrance of the Sydney anaesthetist.
Sections include theory of pain, descriptions of painful conditions and procedures used for pain relief. 4 illustrations, 27 references.
Epstein RM. The American Board ofAnesthesiology: Thoughts on the occasion of its fiftieth anniversary. ] CUn Anesth 1990; 2:3-6. Brief overview of the ABA. 3 references.
Erich D. Professor Dr. med. Heinz Oehmig zum 70. Geburtstag. Anaesthesist 1989; 38. A congratulatory note on the occasion of Dr. Oehmig's seventieth birthday. 1 reference.
Ferrante FM, Covino BG. Patient-controlled analgesia: a historical perspective. In: Ferrante FM, Covino BG, ed. Patient-Controlled Analgesia. Boston: Blackwell, 1990:3-9. Describes the development of modem PCA. 2 illustrations, 1 table, 30 references.
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History of Anesthesia and Related Fields in Stamps by
From the Literature. . .
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Ferrari A, Sternieri E. Dietary headaches through the centuries. Funet Neurol1990; 5:79-84. This article has not been examined.
Miguel Colen-Morales, M.D, Fine E. Separate but integrated: Bertha Van Hoosen and the founding of AMWA.J Am Med f#Jm Assoc 1990; 45(5):181-190. Thisarticle about the early 20th century proponent of "twilight sleep" has not been examined.
Foldes FF. The impact of neuromuscular blocking agents on the development ofanaesthesiaand surgery. In: Agoston S,Bowman WC. Muscle Relaxants. Amsterdam: Elsevier, 1990:1-17. Excellent overview of the topic. 1 illustration, 6 tables, 69 references.
Franco Grande A, Banos Rodriguez G. Spanish pioneers in the technics oflaryngotracheal intubation. RevEspAnestesiol Reanim 1989; 36(6):344-349. This Spanish language article has not been examined.
Karl Landsteiner was born in Vienna, Austria, onJune 14, 1868. He graduated from the University ofVienna Medical School in 1891 at 23 years of age. Mter studying chemistry with Professor Emil Fischer for five years, he moved to the Pathologic Anatomy Institute at the University. Later he traveled to Holland and then in 1922 went to the Rockefeller Institute for Medical Research in New York. In 1900 he discovered the concept ofiso-agglutination and the four .types of human blood. For this work he received the Nobel Prize in Medicine in 1930. He also introduced dark-field microscopy for the diagnosis of primary syphilis, and participated with Wiener in the discovery ofthe Rh factor in human blood. He died suddenly in New York City from a heart attack on June 26, 1943. He has been honored on stamps by two countries, Austria (Scott #813), reproduced here, and East Germany (Scott #1025).
Anesthesia History Association C. Ronald Stephen, M.D., Newsletter Editor 15801 Harris Ridge Court Chesterfield, MO 63017 U.S.A.
Fromm GH, Sessle BJ. Trigeminal neuralgia - Current concepts regarding pathogenesis and treatment - Introduction and historical review. In: Trigeminal Neuralgia. 1991:1-26. This book chapter has not been examined.
Frost EAM. The contributions of Sir William Macewen, a pioneer neurosurgeon, to an early quality assurance survey in anesthesia. J Neurosurg Anesthesiol1991; 3(1):28-33. "A series ofevents in Glasgow toward the end ofthe nineteenth century focused public attention on anesthetic administration. The presence at that time of an educator and clinician, Sir William Macewen... was enough to launch what was probably the first organized survey of anesthetic teaching, administration, and operating room reporting." 2 illustrations, 1 table, 8 references.
Gavrilov OK. Blood transfusion service during World War II. Gematol Transjuziol1990; 335(5):3-6. This Russian language article has not been examined.
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