BULLETIN OF ESTHESIA 1ST RY - CiteSeerX

BULLETIN OF

ESTHESIA 1ST

VOLUME 14, NUMBER 1

William Thomas Green Morton as a Military Anesthetist during the Civil War Maurice S. Albin, M.D., M.Sc.(Anes.) Professor of Anesthesiology and Neurosurgery University of Texas Health Science Center at San Antonio

With the sesquicentennial celebration of the use of sulfuric ether by Morton at the Massachusetts General Hospital (October 1 6, 1 846) shortly upon us, it becomes fitting to examine a little known aspect of this pioneer-the dedicated military Anesthetist. Most of this information concerning Morton's venture into military anesthesia comes to us from a paper published in the JAMA in 1904 and furnished by his son, William J. Morton, M.D., then residing in New York City.l Apparently, it was written after the battle of the Wilderness in May, 1 864, in which Morton relates his Civil War experiences.

It appears that Morton's military anesthesia experiences started during the Battle of Fredericksburg on December 13 , 1 862, which was a definitive Confederate victory and which ended on December 15, 1 862, when the Commander-in-Chief of the Union Army, Major General Ambrose Burnside, ordered the Union Army to retreat to the eastern bank of the Rappahanock River. The battle was extraordinarily costly to the Union since their casualties numbered about 12,600 against 5,300 for the Confederates. More than 6,000 Union casualties occurred during the attack on Maryes Heights where the bodies were stacked so high that they had to be trod upon by the attacking Union soldiers2•3

It appears that Morton was notified by the Surgeon-General of the Union Army that his services would be required prior to the Ba ttle of the Wilderness which commenced on May 4, 1 8 64, and continued through May 6, 1 8 64. This battle resulted in more than 1 7,600 Union casualties and 7,500 Confederate ones.2•l Shortly thereafter, General Grant turned his Army of the Potomac southeast and tried to outflank the Army of Northern Virginia, commanded by General Robert E. Lee, beginning the battle of Spotsylvania which lasted from May 8 through May 18 , 1 864. This battle caused more than 17,500 Union dead and wounded while the Confederates suffered 1 0,000 losses. The combined casualties of the last two cited battles were 35, 100 for the Union and

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JANUARY, 1996

1 7,500 for the Confederation.2•l There is certainly no doubt that the talents and services of Morton were needed. In his article, Morton noted that many of the wounded from the Battle of the Wilderness were taken to Hospitals in Fredericksburg,

many of which had been churches, and he notes that "one of the principal hospitals was the Baptist Church which was l iterally packed with wounded. The tanks intended for immersion were used as a bathing tub, and the operations were performed in the pastor's small study back of the pulpit."

As can be imagined, the transport of the wounded over virtually nonexistent roads brought about unimaginable suffering to these poor souls. Morton writes that "The ambulances could not have brought one tenth part of them, and the rest were brought in wagons, eleven or twelve miles over the remains of a planked road, worn by war-travel. In places the larger wagons had to be pried out of the deep holes with trimmed trees . . . On such a highway, and in such a manner did these poor fellows, who stretch their hands out of these ambulances and army wagons for tin-cupfuls of water, painfully travel-some with arms off at the shoulders, some with legs off below the knee, some with an arm and leg both off, hundreds shot through the leg or arm, or the breast, some with horrible wounds of the face-even to the loss of the j aw and the destruction of speech-all presenting in the aggregate every

Continued on Page 23

1 BULLETIN OF ANESTHESIA HISTORY

Anesthesia History Association

The Annual Meeting and Dinner of the Anesthesia History Association was held on October 24, 1995, in the Milan and Strasbourg Rooms of the Atlanta Hilton and Towers Hotel. About 80 people attended and enjoyed an excellent buffet dinner.

At the business meeting, presided over by Lucien E. Morris, President, the several guests were introduced, the David M. Little, Jr., Prize was awarded to B. Raymond Fink, the reprinting of the first ten volumes of the AHA Newsletter was announced, the forthcoming Spring Meeting in Buffalo under the aegis of Douglas R. Bacon was stressed, and the recommendations of the Nominating Committee for the officers and council of the AHA for the forthcoming year were accepted by acclamation. They are:

Lucien B. Morris, President R. Raymond Fink, Vice-President John W. Severinghaus, Past President T.C. Smith, Secretary-Treasurer Council: Douglas R. Bacon, Donald Caton, Doris K. Cope, Burdett S . Dunbar, Will

iam D. Hammonds, Gerald L. Zeitlin Editors of the Bulletin: C. R. Stephen, Donald Caton, Doris K. Cope The program of the dinner suitably honored Roderick Kerns Calverley, M.D., 193 8-

1995, Co-Founder of the AHA with a photograph of Rod as we all knew him. His lovely widow, Mrs. Janeen Calverley, was a special guest at the dinner.

The speaker of the evening, Dr. Martin Moran, was introduced by Dr. Bill Hammonds, who was also local arrangements Chairman. Dr. Moran, an Atlanta pediatrician and also President of the Medical Association of Atlanta, presented a well-illustrated and engaging lecture on "The Medical History of Atlanta, Georgia."

Wood Library-Museum of Anesthesiology

Under the Chairmanship of Dr. Elliott V. Miller, President of the Wood Library-Museum of Anesthesiology (WLM), the third of its annual meetings was held in Atlanta on October 21, 1995. Various Committee Chairpersons discussed the ongoing activities of committees. Dr. Charles Tandy noted the several acquisitions to the library and museum since the last meeting. A special Fellowship is being organized to recognize the late Dr. Roderick Calverley, generous donations having been received from the University of San Diego and other friends of Dr. Calverley. The WLM Lewis H. Wright Memorial Lecture was presented this year on October 24 by Dr. B.S . Siker and in 1996 the lecture is to be presented by Dr. Joseph F. Artusio, Jr.

Liaison activities with other institutions (Anesthesia History Association, Arthur E. Guedel Anesthesia Center, Crawford W. Long Museum) were discussed by Drs. C.R. Stephen and Dr. William Hammonds. Dr. Frank McKechnie, Secretary-Treasurer, reported favorably on the financial status of the organization. Dr. Adolph (Buddy) Giesecke discussed the preparations for the September 1996 history issue of the ASA Newsletter. Mr. Patrick Sim; WLM Librarian, and his Assistant, Mrs. Sally S . Graham, reported that approximately 1 ,000 requests during the past year were received by the WLM from anesthesiologists and other interested parties asking for information which is housed in the library and museum. In addition, numerous visitors were welcomed to the WLM. Dr. George Bause, Curator of the Museum and WLM Trustee, designed and completed the WLM Exhibit at the 1995 ASA meeting, which was dedicated to Dr. Rod Calverley and which depicted various recent wars (World Wars I and II, the Korean conflict, hostilities in Viet Nam and Desert S torm) and the contributions of anesthesia to them.

At 5:00 P.M. the members of the WLM and guests boarded a bus and traveled to Jefferson, Georgia, to view the Crawford Long Museum and its many exhibits, and from there went to the Chateau Elan Winery and Resort to partake Dutch Treat to a sumptuous repast.

Call for Papers

The Spring Meeting of the Anesthesia History Association is being held on Thursday, May 9, 1996, at the Buffalo Hyatt Hotel, in conjunction with the annual meeting of the American Association of the History of Medicine. Anyone interested in the history of anesthesia is urged to participate by presenting a paper. Abstracts on one sheet of paper should be sent no later than January 31 , 1996, to:

Douglas R. Bacon, M.D., Anesthesiology Service / 128, Buffalo VAMC, 3495 Bailey Ave., Buffalo, NY 14215-1 199

Wood Library-Museum Fellowships

Each year the Wood Library-Museum of Anesthesiology (WLM) awards four Fellowships to worthy applicants interested in furthering their knowledge of the history of Anesthesiology.

Applications are invited from anesthesiologists, residents in training in anesthesiology, physicians in other disciplines, historians and others interested in library and museum research.

Fellows will receive a grant of $500.00 to support their work. If one lives more than 100 miles from the WLM, funds for airfare (economy class) equal to one round-trip fare will be provided. A per diem of $125 .00 is available for those requiring commercial lodging, not to exceed 15 working days, while pursuing their research at the WLM.

For the year 1996, all applications must be received by January 3 1, 1996. For application forms and further information please write to:

Mr. Patrick Sim, Librarian Wood Library-Museum of

Anesthesiology 5 10 N. Northwest Highway Park Ridge, IL 60068-2573

Resident Essay Contest

The Anesthesia History Association announces the first annual Resident Essay Award to be presented at the History Association Dinner in conjunction with the American Society of Anesthesiologists 1996 Annual Meeting in New Orleans, Louisiana.

The entrant must be in training or in the first year after completion of residency and must have performed the work as the primary investigator during residency or fellowship.

A 1 500-3000 word essay related to the history of anesthesia, pain management or critical care should be submitted to:

Doris K. Cope, M.D. University of South Alabama Department of Anesthesiology 245 1 Fillingim Street/MSTN 610 Mobile, Alabama 36617 USA The recipient of the Resident Essay

Award will receive an honorarium of $500 and the manuscript will be presented October 22, 1996, at the Dinner Meeting of the Anesthesia History Association and subsequently published in the Bulletin of Anesthesia History.

Entries must be received on or before September 1, 1996.

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Fourth International Symposium on the History of Anesthesia

Under the jo int cooperation of the History Association of Germany, the Anesthesia His tory Assoc ia t ion of the United States and the History of Anaesthes i a S oc i e ty of Great B r ita in, the Fourth International Symposium on the History of Anesthesia is being held in Hamburg, Germany, from April 26 to 29, 1997, at the Congress Center.

The Local Arrangements Committee consists of nine prominent German anesthesiologists, the Chairman being Dr. J . Schulte am Esch, the Co·Chairman being Dr. Michael Goerig and the Secretary being D r. J. S cholz. The International Committee consists of 23 representatives from Australia, Austria, Brazil, Canada, the Czechoslovakian Republic, France, Hungary, Italy, Japan, the Netherlands, Poland, Russia, Spain, Sweden, the United Kingdom and the United States.

The format for the meeting will encompass special lectures, plenary sessions and free p aper sessions. For abstract forms with instructions for authors, together with the second announcement of the meeting, one should write to:

M C N The History of Anesthesia Wielandstrasse 6 D-90419 Nurnberg, Germany. Everyone is urged to plan now to at

tend and participate in this meeting. Special events are being planned for spouses which will highlight cultural, artistic and sigh t-seeing activities in and around Hamburg.

The Bulletin of Anesthesia History is published four times a year as a joint effort of the Anesthesia History Association and the Wood-Library Museum of Anesthesiology.

C.R. Stephen, M.D., Editor Doris K. Cope, M.D.,

Associate Editor Donald Caton, M.D.,

Associate Editor Debra Lipscomb, Editorial Staff

Editorial, Reprint, and Circulation matters should be addressed to the Editor, 15801 Harris Ridge Court, Chesterfield, MO 63017 U.S.A.

Book Review

I Awaken to Glory

Here at last is a definitive biography of Horace Wells, often described as "volatile", "errant" and "wayward", which offers to the reader a true picture of this man and his associations with others during his life, which was brought up short by his unfortunate demise.

Edited by Richard J. Wolfe, Curator of Rare Books and Manuscripts in the Francis A. Countway Library of Medicine of Harvard University, and the late Leonard F.

Menczer, who before his death in 1994 served as Curator of the Historical Museum of Medicine and Dentistry in Hartford, the book consists of 12 essays defining the life and work of this extraordinary man and the Sesquicentennial of his discovery of anesthesia, December 1 1, 1 844 to December 1 1, 1 994.

In the first chapter Dr. Wolfe presents the premise that Horace Wells was indeed the discoverer of surgical anesthesia and one is hard put not to believe his story as he traces the research, use and development of nitrous oxide from Humphry Davy to the glorious proof shown by Wells on December 1 1, 1 844.

In the second and third chapters Dr. Menczer, himself an accomplished dentist and historian ofthe history of dentistry, establishes the reasons why Wells was considered to be one of the most competent

History of Anesthesia

BULLETIN OF ANESTHESIA HISTORY

dentists of the era. The remaining nine authors examine in

depth the external forces which helped to shape the character of Wells. Particularly outstanding was the help of his affectionate wife, Elizabeth, again written by Dr. Wolfe. Offundamental interest is the contribution of Christopher S tarr Brewster, an American dentist in Paris, as portrayed by Dr. Jacques Foure, and the recognition Wells achieved in Britain, as written by Dr. J.A.W, Wildsmith.

A full chapter written by Drs. Wolfe and Leroy D. Vandam traces the documentation underlying the Charles Noel Flagg portrait of Wells, painted some 20 years after his death.

Abundantly illustrated with 49 photographs and thoroughly documented throughou t its 417 pages, this book is a delight to read and is thoroughly recommended to those interested in the origins of anesthesia as a specialty. It was published in 1994 by the Francis A. Countway Library of Medicine, in association with the Historical Museum of Medicine and Dentistry, Hartford. Priced at $28.95, it may be obtained by writing to:

Francis Countway Medical Library 10 Shattuck St. Boston, MA 021 15 .

-C. R. Stephen, M.D.

and Related Fields in Philately

by Miguel Colon-Morales, M.D.

THE STETHOSCOPE The development of monitoring the vi

tal signs of respiratory and .cardiac functions in the practice of anesthesia has been without doubt most important in the evolution of the medical specialty of anesthesiology.

Beginning with the use of the stethoscope invented by Rene Laennec, circa 1 8 19, for the diagnosis of respiratory problems, its adoption in the practice of anesthesiology for monitoring both respiratory and cardiac function from its beginning has been instrumental in its progress.

In the last few decades electronic devices have complemented and improved monitoring of patients during anesthesia.

Nevertheless, the simplicity and reli-

ability of the stethoscope as a monitoring device has prevailed and fortunately never been surpassed.

The Stethoscope was honored during the celebration of the 7th International Congress of Bronchoesophagology in Japan in 1958 by issuing the stamp illustrated. Scott # A398.


WLM Laureate of the History of Anesthesia

Gwenifer C. M. Wilson, MD, MBBS, DA (Syd), FANZCA On October 24, 1 995, at the annual

meeting of the American Society of Anesthesiologists (ASA) in Atlanta, Georgia, Dr. Gwen Wilson was named the first Laureate of the History of Anesthesia awarded by the Wood Library-Museum of Anesthesiology. She will be suitably honored in 1996 at the ASA annual meeting in New Orleans, Louisiana.

Born in Australia in 1 9 1 6, Dr. Gwen graduated from medical school at Sydney University, M.B .B . S ., in 1 939. In 1945 she was awarded a Post-Graduate D iploma in Anaesthesia (D.A. Syd.) from Sydney University, the first woman to gain this Australian Diploma. In 1952 she became a Foundation Member of the Royal Australian College of Surgeons and in 1956 she became a Fellow of the Faculty of Anaesthetists of the Royal College. In 1992 she became a Fellow of the newlyformed Australian and New Zealand College of Anaesthetists (F.A.N.Z.C.A) . Finally, in 1 995 she was awarded the Doc-

torate of Medicine (M.D.) from the University of S ydney. Theses presented were "Fifty Years: The History of the Australian Society of Anaesthetists 1 9 34- 1 984," published in book form in 1 987, and "Bibliography of References to Anaesthesia and Related Subjects, Australian Medical Publications 1 846- 1 962." This was the first M.D. in Australia awarded purely for medical history.

Dr. Wilson is the author of no fewer than 43 contributions to the literature. S he has presented some 42 papers at various meetings which were not submitted for publication because they constitute sections of a large project on which she is at present working, called One Grand Chain, a two-volume book which includes information from hundreds of sources around the world.

S ince 1961 Dr. Wilson has devoted much of her energies to the history of anesthesia as it has evolved and her se-

The Boer War 1899-1902

lection as the first WLM laureate of the History of Anesthesia is well-deserved.

Dr. Gwenifer C. M. Wilson, named the first Laureate of the History of Anesthesia by the WOod Library-Museum of Anesthesiology on October 24, 1995, has graciously granted permission to publish an excerpt from her forthcoming book, One Grand Chain, which is an Australian account of that country's participation in the Boer War. � are much indebted to Dr. Wilson for her permission.

In 1 899 Australia was on its way to becoming a nation independent of Great Britain, but this did not prevent a wave of emotion and care for the mother-country when its welfare was threatened. Even before the Boer War commenced, Queensland, Victoria and New South Wales had offered assistance to Britain, and when war was declared in October, 1899, there was enthusiastic volunteering for service. For the first time lists of medical men serving in the army appeared in pages of the journals, together with accounts of medical aspects of battle, and decorations awarded to doctors (not enough, the editor considered).

The surge of patriotism during the war is reflected in the description in the Australasian Medical Gazette of the "Special Burroughs Well come and Co Medicine Chest" for the American Ladies' Hospital Ship Maine, fitted with "Tabloid" and "Soloid" Products. If the reader will sit back and let a mental picture of this chest form, there will not only be a laugh but an appreciation of the aura of the era.

This specially designed chest is equipped with medicines in accordance with the latest and most scientific methods.

The chest bears the following designs-

On the top panel appear the Union Jack and Stars and Stripes entwined; portraits of George Washington, Queen Victoria, and President McKinley, and representation of the American Eagle and British Lion.

The front panel bears portraits of Lady Randolph Churchill (President), Mrs. Ronalds (Hon. Treasurer), and Mrs. Blow (Hon. Secretary of the American Ladies' Hospital Ship Committee); a picture of the hospital ship Maine; a scene representing the British Lion wounded by an arrow (which lies broken at his side), being administered to by Britannia and Columbia-Columbia pouring a healing balm upon the wound whilst Britannia bandages the paw. A frieze is formed by a representation of American Indian wampum, upon

which are depicted Brother Jonathan and John Bull grasping hands.

The panel at each end of the chest represents Britannia and Columbia supporting a banner bearing the Red Cross. These panels also contain representations of the national emblems-the English Oak and American Corn.

.

The panel at the back of the chest depicts a charge of the British Regular and Colonial Lancers, and a Highland Brigade. The Boers hold their ground sheltered behind rocks and boulders. The young Bugler boy who felled three Boers is noticeable in the scene.

Prominently inscribed on the chest are Keble's line, "No distance breaks the lie of blood"; and Ambassador Bayard's notable phrase, "Our kin across the sea".

The chest is made of oak and covered with Carthaginian cow-hide, upon which the designs are tooled by hand.

Designed by Henry S. Wellcome. Wrought by Burroughs, �llcome & Co.

Continued on Next Page

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War of Ideas The following treatise, "Wilr of Ideas," reveals the problems encountered in medical care during the Boer War, the interim between, and during the First World War in the British Army. The part played by Dr. George Crile in aiding anesthesia development is outlined and the birth of the Boyle anaesthesia machine is described. we are indebted to Dr. J.A. Bennett and the Proceedings of the History of Anaesthesia Society (Proc HAS 15 : 59-64, 1994) for their permissions to reprint this pap!"l'. - Editor

WAR OF IDEAS

by Dr J A Bennett Consultant Anaesthetist, Bristol; Hon Secretary, History of Anaesthesia Society

Outstanding achievements in surgery and anaesthesia in the First World War evolved not from good planning, but from the presence of English and American men and women of outstanding talents who came together in an almost random and totally unplanned way. Very importantly, they were in the main volunteers occupying the most senior posts in civilian life. Such surgeons, anaesthetists, physiologists and nurses were to benefit surgery, anaesthesia and resuscitation in a way which is only now being fully realised.

Influence of Sir Frederick Treves In terms of its general organisation, the

Army Medical Service was perhaps most profoundly influenced by Sir Frederick Treves ( 1 857-1923), the eminent surgeon from the

Boer War . . . Continued from Page 4

The whole of the medical equipment of the Maine has been contributed by Burroughs wellcome & Co.

Laugh we may, but the description of the contents shows that intravenous saline for restoration of blood volume went to war for the first time; "Soloid" tablets were Burroughs Wellcome's new contribution for the rapid and simple preparation of intravenous solutions of sodium chloride, sodium chloride and sodium sulphate, and sodium chloride and sodium carbonate.

So far as medical treatment and organisation was concerned, the Boer War was the first of the modern wars. In previous wars of the nineteenth century casualties had had the boon of anaesthesia, but first aid and ambulance services (developed at this time), antisepsis, advances in pathology and bacteriology, in resuscitation, and above all, according to reports in the Australian journals, in radiology (introduced in 1896) revolutionised the recovery rate and prognosis of the wounded. The surgeons' reports, giving vivid descriptions of

London Hospital. Treves had witnessed at first hand the capabilities of the Army Medical Service in 1899 when, at the age of 46, he volunteered to lead a civilian surgical team to participate in the South African War. As consulting surgeon to the Field Force he took with him not only his own field surgical equipment but his own nurses as well.

The tactical conduct of the South African war was the object of fierce (albeit initially suppressed) criticism. A young journalist, Winston Churchill, complained that General Sir Redvers Buller plodded from blunder to blunder and from one disaster to another without losing either the regard of his country or the trust of his troops, to whose feeling, as well as his own, he paid little attention.

The tenor of this criticism spread to the

work in the field and in the hospitals, indicate profound satisfaction and relief that so much more could now be offered. To be able to locate bullets, shell splinters and visualise fractures, to be able to treat wounds aseptically and so save many amputations, to be able to give adequate aseptic first aid and wait while intravenous fluids dripped the patient into stable condition for operation; all these were sources of gratification to the hard-pressed army medical officers. Those who gave the anaesthetics were also highly pra i sed, chloroformists to a man though they were. They did not, however, have the civilian problems with this agent. Presumably, as with chloroform in obstetrics, there was not nervousness and apprehension (with accompanying adrenaline secretion), and raised adrenaline at the outset of the operation; there would have been, as in obstetrics, simple acceptance and gratitude for oblivion from pain, and thus the dangerous induction period was safely surmounted. The organisation of the Red Cross developed during this period, with

conduct of the RAMC. Treves, whilst being totally patriotic and supportive during the campaign, was later able to redress his opinions and became scathingly critical of many aspects of the medical conduct of the war. It took two Royal Commission Enquiries to fully reveal these problems. In his evidence, Treves stated: ''Any success of the work in Natal depended on the fact that the military medical organisation was entirely thrown aside. Regulations, petty bureaucracy, paperwork and general red tape, made it virtually impossible to act in medical emergencies without total disregard of official procedures. Senior medical officers spent more time working as junior administrators than doctors." He then listed the many defects that he had observed, the chief among which were the


increased organisation of retrieval of the wounded and ambulance transport to field hospitals. The foregoing paragraphs, prepared after study of the journals of the period, in Australasia, present this formal view of medical service in the African war.

The transactions of the Intercolonial Congresses of the years following the war give a very different picture. As will emerge from that reading, a number of services mentioned above developed from dire and urgent necessities. Predictions made at the Congress of 1 899 were, at the Congress of 1908, realised to have been all too accurate.

Nevertheless, as with later wars, the experience so rapidly gained by medical officers and the advances resulting from treatment of large numbers over a short period were reflected in civilian life postwar. The beginning of organisation of ambulance services in Australia really dates from this period, and, far removed from the rivalries of civilian life, there was a new rapport between surgeons and anaesthetists who had battled together on a bloodier field.


Ideas . . . Continued from Page 4

totally inadequate transport facilities and delay in the evacuation of casualties to ambulance field hospitals; antique surgical equipment; field hospital outfits too elaborate, half of which could be thrown away; and the English military hospitals at home which did not come up to the standards of the workhouse infirmaries in terms of conditions, equipment and staff training. Most of these observations, together with many others, were acted upon and incorporated into updated Army medical regulations, and the revised RAMC Training Book, published in 1911 , gives ample evidence of Treves' influence.

Anaesthetists had, in England at that time, no awareness of managing the particular problems of the war wounded, shocked and hypovolaemic patient. Physiological research was confined to animal laboratories and involved enormously cumbersome equipment. Few, if any, anaesthetists concerned themselves with the clinical physiological aspects of their subject. Hewitt, as early as 1893, in

. his bookAnaesthetics and their Administration, had directed the attention of anaesthetists to the intravenous injection of saline solutions as a method of raising the blood pressure, but this suggestion failed to attract interest. Indeed, Charles Hadfield, a contemporary medical student at St Bartholomew's Hospital, wrote later: " . . . anaesthesia at the beginning of this century was in a static condition, was tacitly assumed to have reached its zenith, and no further improvements were expected or even sought." Conditions remained much the same until shortly before the war.

Although aware of the chloroform controversy emanating from the Hyderabad deliberations, Treves' knowledge of and sympathy for anaesthesia was probably limited to those observations made by Dr Frederic Hewitt, his anaesthetic colleague at the London Hospital, together with those he had witnessed during the Boer War when morphine and chloroform would have been given concurrently. He supposedly (according to his bibliography) wrote a paper on chloroform anaesthesia, but no trace can be found of its whereabouts and his authority in this respect remains unproven. Indeed, in the RAMC Training Book, so much influenced by Treves, no reference is made to anaesthesia in the surgical management of patients, except to say: "Before an operation of any magnitude, the patient should go to bed for a day or two," and elsewhere: ''A small table is available for the anaesthetist's use." The extent of the anaesthetic equipment in the surgical field pannier was a chloroform drop bottle, gauze, and ampoules of chloroform to a total of3 lbs (approximately 1 .5 litres).

It is therefore difficult to evaluate Treves'

estimation of anaesthesia as a specialty or of anaesthetists as colleagues. A somewhat enlightening story is told ofthe occasion in June 1902, in connection with King Edward VII's appendicitis, when Treves telegraphed Lord Knutsford, the then Chairman of the London Hospital, instructing him: " . . . to tell the anaesthetist (Dr Hewitt) and Nurse Haines that they would be wanted next morning at the Palace" for what turned out to be a drainage operation of an appendix abscess-an operation somewhat less stormy than the anaesthetic.

An opportunity arose in 1908 for anaesthetists to draw attention to the prevailing lack of interest in anaesthesia as a specialty in military surgery. With the establishment of general hospital units within the newly formed Territorial Army, Treves wrote an open letter to the British Medical Journal. J Robert James Probyn-Williams, Senior Consulting Anaesthetist and Instructor in Anaesthetics at the London Hospital and the then President of the London Society of Anaesthetists, entered into correspondence with Treves and the War Office. He received the following reply:

Dear Dr Williams, July 2, 1908

There is no such post as Anaesthetist in the Army Medical Service, nor does an Anaesthetist figure among the staff of a General Hospital.

This applies to the Regular Service. In the Territorial Force there will be four General Hospitals in London and there can be no doubt whatever but that Anaesthetists will be required for these Hospitals and that their services will be very highly appreciated. The Territorial Force is being mobilised on the lines of the Regular Army and therefore no such post as Anaesthetist appears.

I think you would do well to join one of the General Hospitals as a Physician or Surgeon, it being understood that in the event ofinvasion you would act in your usual capacity as an Anaesthetist.

Very slow progress is being made in the actual details of the organization although the medical service is perhaps ahead of any other branch in the matter of completeness.

Yours very truly, Frederick Iteves

The consequence ofthese somewhat final pronouncements was that no anaesthetists were available at the beginning of World War I to supervise or advise on the conduct of anaesthesia to the wounded in the western

front. The Territorial Army General Hospital units in and around London were staffed by eminent instructors such as Probyn-Williams and administrators in anaesthetics, such as H E G Boyle and Trewby, who were shortly to deal with wounded soldiers being shipped from the battlefield.

Although the particular anaesthetic and surgical needs of the wounded seemed poorly provided for, greater attention was paid to the physiological needs of gas-stricken casualties a particularly threatening hazard on a mass scale. Consequently, teams of chemists and physiologists were sent to Europe, together with plentiful supplies of oxygen, a commodity which was to prove of value in the development of anaesthetic techniques.

The American Hospital in Paris England declared war on Germany on 1

August 1914 and within one month the Germans had advanced and were within reach of the northeast of Paris. The American community in Paris, feeling a sense of impending isolation, were anxious to establish an American Civilian Hospital in the city and requisitioned a high school for this purposethe Lycee Pasteur at Neuilly sur Seine in the west of the city. An approach for manpower was made to George Crile, the eminent surgeon at Lakeside Hospital, Cleveland, Ohio, and he enthusiastically volunteered to head a surgical, anaesthetic and nursing team to staff and run one surgical unit at the Paris Hospital of 80-100 beds complete with operating theatre. Lakeside Hospital would furnish all instruments, anaesthetics, dressings, surgeons, nurses etc. for a period of three months. Thereafter, the plan would be for other American centres (for example, Johns Hopkins) to send their teams on a three monthly rotational basis. In addition, Crile would undertake to do research: "Observing the effects of fear and exhaustion on the human body, opportunities for which were abundant, might never be available again and would be of the highest scientific and practical value." These were the avenues of research in which Crile excelled. His experience in clinical and academic medicine had made him a pioneer and world authority in the field of surgery, anaesthesia, resuscitation and clinical management of shock. The physiological control of blood pressure had been the object of six years' research. He was early to recognise the value of adrenaline in the management of asystole and to clinically prove the value of blood transfusion in the management, amongst other things, of haemorrhage and shock-even before the classic work of Landsteiner on the grouping of blood.

One month after his 50th birthday, CriIe set sail in December 1914 with a team con-

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sisting of two anaesthetists (Miss Agatha Hodgkins and Miss Mabel Littleton), two operating room nurses, himself, three surgeons, neurologist, clinical pathologist and three special researchers, together with equipment for the management of nitrous oxide anaesthesia. The machine favoured at this time was the Ohio Monovalve introduced in 1912. The team sailed via England where they encountered problems with the steel cylinders of nitrous oxide which were marked Tkry Inflammable. One of the staff with a Germansounding name was responsible for the custody of the cylinders. He was immediately placed under suspicion and had a hard time convincing the authorities. After a long explanation by Cri1e himself, the officer concerned said: "Well, I don't know you or anything about you, but you look good to me and I am going to let you and your gas pass."

Awaiting Crile's arrival was a characteristic and friendly letter of welcome from Berkeley Lord Moynihan (then aged 50). At the height of his civilian surgical career he had volunteered for and was appointed Consulting Surgeon to the British Army. His renowned reputation, his commanding personality, and ability as a public orator, were all qualities which were likely to impress the Army Generals, and his views would be greatly respected.

Moynihan arrived in France in December 1914 with his assistant from Leeds, Captain Braithwaite. They were based in Rouen and with the aid of a Daimler car were able to inspect the work of the RAMC close to enemy lines. He had already made many professional contacts with Crile at conferences in America and in London prior to the war, and he was a great admirer of his work. In 1913, his revised textbook on abdominal operations referred in great detail to Crile's technique of Anoci Anaesthesia, which consisted oflocal and regional blockade with light general anaesthesia using nitrous oxide and oxygen. In the wartime circumstances in which they both found themselves, Moynihan sought immediately to meet Cri1e, who was anxious to demonstrate the value of his nitrous oxide-oxygen techniques for the war wounded.

Nitrous Oxide Anaesthesia There is no clear evidence, however, that

such techniques were immediately adopted by the British Army at that time. Indeed, Moynihan and Crile both returned home in 1915 and, whilst the teams of Americans following Crile to Paris would presumably have used s imilar anaesthetic techniques, Moynihan's influence and enthusiasm may not have been heeded by the War Office and its medical hierarchy. A similar fate befell the introduction of blood transfusion which Crile

had promoted actively during his 1915 tour of duty.

In 1917, with the United States now officially engaged in hostilities, Crile again returned to France to find that, two years on, no plans whatever had been made for the use of transfusion in the English or French armies. There had, however, been a recent sudden awakening of interest in nitrous oxide anaesthesia, and demands for its use were outstripping the supply by its English manufacturers. This revival may have been triggered by the observations of Surgeon General Sir Anthony Bowlby, an eminent Bart's surgeon who, with others, had been very concerned by the large number of deaths occurring during the course of ether and chloroform anaesthesia.

In order to pursue this matter, he had commissioned a young Guy's Hospital physiologist turned temporary Army anaesthetist, Captain George Marshall, to investigate and, hopefully, remedy the situation. This he did in valuable work carried out in the casualty clearing stations some eight miles behind the front line near Ypres in 1916. As a result, he was able to pioneer the use of nitrous oxide anaesthesia as a means of reducing mortality in the British Army as well as to investigate the effects of the other agents and techniques then currently available.

These results were embodied in Marshall's classic paper2 devoted to anaesthesia for battle casualties which appeared in the British Medical Journal in 1917. The utilisation of oxygen, as part of the method, proved of little difficulty as it was in plentiful supply for the management of gas casualties. In order to administer nitrous oxide he set about designing and constructing a locally-made apparatus which was the forerunner ofthe more sophisticated equipment being developed and used by Boyle and Trewby, two assistant administrators in anaesthetics at St Bartholomew's Hospital, who were engaged as medical officers and anaesthetists to the Territorial Army Hospital a t Camberwell in England. Boyle had, additionally, acquired a Gwathmey nitrous oxide-oxygen apparatus in 1916 and was freely able to extemporise-leading to the Boyle machines that were presented3 at the Royal Society of Medicine in 1918.

It is more than likely that Marshall was aware of the details of the Gwathmey apparatus in France . Indeed, James T. Gwathmey had, at the age of 54, volunteered his services in France in 1917 and brought with him the apparatus he had introduced in 1912.

Thus it was that, two-thirds of the way through the First Great War, with the combined skills of pioneer American anaesthetists, surgeons, English physiologists, and

BULLETIN OF ANESTHESIA H ISTORY

History of Anesthesia and Related Fields in Philately

by Miguel CoI6n-Morales, M.D.

DR. JOAQUIN COTO Born in the City of San Salvador, Re

public of San Salvador, in Central America, on 28 April, 1 9 14. Graduated from the School of Medicine, University of San Salvador in 1939.

Training in Anesthesiology was taken at the Mayo Foundation, University of Minnesota, and at the University of Chicago Clinics in Chicago, Illinois.

Returned to Republic of El Salvador as its first formally trained and Board Certified Anesthesiologist.

Dr. Coto was much concerned with the training and development of anesthesiology in his country, playing an important role in providing professional anesthesiologists in El Salvador. He was considered a brilliant clinician and contributed over 16 publications related to scientific research in the field of anesthesiology.

Dr. Coto died in 198 1 . He was honored by the Postal Service of the Republic of El Salvador together with three other physicians in a Special Emission of "Distinguished Physicians" in 1992.

eminent and perceptive English surgeons, the specialty of anaesthesia rapidly advanced in a way which had been totally unforeseen at the outbreak of war. "The best talent," said Crile, "had been concentrating on the battle line, for this was not a war of men but a war of ideas."

References I. Treves F. Correspondence. British MedicalJour

nal1908; 1:653. 2. Marshall G. T he administration of anaesthet

ics at the front. British MedicalJournal 1917; 1 :722-725.

3. Boyle HEG. Nitrous oxide-oxygen-ether outfit. Proceedings of the Royal Society of Medicine 1918; Anaesthetics Section:30.


An Eyewitness Account of D-Day The following living account of the preparation for, the landing of, and the care by the 21 st Field Dressing Station of the Royal Army Medical Corps I

before, during and after D-day on June 6, 1944, is graphically described by Dr. Leslie Rendell-Baker, known to many of us. This paper was presented at the June 24-25, 1994, meeting of the History of Anaesthesia Society in Guernsey and is reprinted with the kind permission of Dr. Rendell-Baker and the History of Anaesthesia Society.

The charcoal sketch, made by Corporal Hatswell, a commercial artist who was a nursing orderly in the 21st Field Dressing Station, shows the 60 members of the 21st Field Dressing Station disembarking from Infantry Landing Craft #423 on Queen Red Beach at Hermanville-LaBreche at H-hour plus 230 minutes (approximately 12 noon on D-day June 6, 1944).

THE ORGANISATION & SETTING UP OF

DRESSING STATIONS FORD-DAY

by Dr L Rendell-Baker Professor of Anesthesiology, Lama Linda University, California, USA

Preparation of a Beach Group For operation "Overlord," the invasion

of continental Europe planned for June 1 944, 5,000-man beach groups were formed in 1 943. Their function was to handle up to 2,000 tons of supplies across each beach per day to support the assault troops. Nos. 20 and 21 Field Dressing Stations with attached surgical and transfusion units were to form forward surgical centres as part of No. 5 Beach Group. The surgical centres would operate on urgent abdominal and chest cases. The others would be evacuated to Britain. The FDS staff consisted of 4 medical officers, 1 dental officer, 1 nonmedical officer, a quartermaster and 95 other ranks.

Training for the Beach Group's role in the invasion started at the Combined Operations Centre north of Ayrshire. From Spring 1943, beach landing exercises took place every two weeks, at first along the Ayrshire coast. Later the Group travelled to Amroth on the Pendine S ands in Pembroke shire to experiment with offloading beached coastal steamers. After 7 days a storm tore up the beach and brought the exercise to an abrupt halt. The surgeon in charge of our surgical unit for this exercise fortunately didn't believe in window dressing. His unit was ready to operate at a moment's notice with all instruments, gowns and dressings sterile. This was just as well as we had a soldier who collapsed after a fall from a truck and was rushed to the surgical unit with a diagnosis of ruptured spleen. The surgeon had identified some universal donors amongst our soldiers so they were bled while the patient was given plasma. The splenectomy went

quite satisfactorily and the patient was resuscitated with the blood from our donors and plasma. This case greatly impressed the inspecting "top brass" who seemed astounded that we really could operate.

By December 1943 the required figure of 2,000 tons per day had not been achieved so the Beach Group spent Christmas in bitterly cold weather on the cliffs above Gultane Sands, just south of Edinburgh, until finally we achieved the magic figure, l argely due to the fact that by then we had DUKWs. These amphibious lorries could drive down to the beach, enter the water, go out to the ship, load up with supplies and then come back and unload at the supply dump.

At this time German intelligence had been fed the false information that we were training to invade Norway. Later, when our Division left Scotland, special signal units remained there to maintain the same radio traffic so that the enemy would not be aware of our movement south. A phantom US army group was also created in East Anglia with General Patton said to be in command and planning to launch an assault in the Pas de Calais, while our 3rd British Infantry Division and 5th Beach Group were sta-

tioned at Waterlooville behind Portsmouth. For our final exercise we embarked on

transport ships in Portsmouth which took us to the beaches off Littlehampton where we climbed down netting on the sides of the ships into Landing Craft Assault for the beach landing. Apart from getting very wet when we landed in quite deep water, the exercise went off faultlessly. We were then transferred to a barbed-wire secured holding camp behind Brighton where we were issued with French invasion francs and briefed as follows:

Queen Red Beach, where we would land was better than those we had encountered on exercise. It would vary between 400 yards deep at low tide and 20 yards at high tide. It was expected that 22,000 troops would be landed on the first tide and that there would be 3,000 casualties on our sector during the assault. Each Field Transfusion Unit would embark with 100 bottles of blood and would receive afurther 450 bottles daily thereafter.

The Real Thing At 1 500 hrs on 5th June at Newhaven

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we boarded Landing Craft No. 534 which had previously been used for the landings in Sicily and Anzio. Before we set sail we were served a meal of potato salad and corned beef which I didn't feel was very suitable before a sea voyage. At 1 700 hrs we sailed. The sea became quite rough as we passed the Seven Sisters Cliffs which we saw through the haze and I wondered if I would see these familiar sights again as an 80% casualty rate had been predicted. Very soon most of the troops were being sick. I began to feel nauseated and went up on deck to find we had turned south and I realised that this must be the assault we had planned for. At 0600 hrs maps and charts were issued indicating that the target was Caen in Normandy. At 0800 hrs we received a radio message that the assault had been successful. We were then passing through shipping lanes marked by flagged buoys. As far as the eye could see there were ships of all types. It was rather like traffic going three abreast down a motorway. The noise was incredible, as the Navy had all possible ships firing at the shore batteries and softening up the assault areas. When the British battleship Warspite fired its salvos from IS" guns over our heads it wasn't so much the noise as the concussion which was quite unnerving.

From the aerial photo handed out at the briefing session it was clear that there was a strong point very close to our beach landing site at Queen Red. The map showed our route about a mile inland to establish a Field Dressing Station close to Hermanville church. H-hour for the assault on our beach was 0725 hrs. Our Commanding Officer, Lieutenant Coombes, and 14 men were to land 60 minutes after H-hour to set up the beach dressing station. I was to bring in the main party about 1 1 . 1 5 .

Our party consisted of 6 officers and 54 men. The Navy provided us wi th one of the driest of landings in only 2 feet of water as compared with waist deep on our British disembarkations. There was a great deal of urgency to get off the ship as a German 88 mm gun was firing along the beach in our direction from Ouistreham and the ship next to ours was hit. Once off the beach we struck inland through the remains of seaside cottages which had been fortified by the Germans with tunnels connecting each house with its neighbour. By the time we arrived there was no sign of small arms fire from these buildings. Unfortunately, not all the German defenders were eliminated. That evening the Beach Group Commander was killed by machine gun fire from one of the ruined houses.

Once through the cottages we turned

west along the lateral connecting road and soon began to notice heavy machine gun fire coming from a strongpoint further down the road. I had some difficulty identifying the small side road turning off for Hermanville. The Germans had cut down the woods shown on our map along this road. My colleagues later reported that qui te a lot of mortar fire was landing in our vicinity. However I was too preoccupied trying to locate the correct turning to pay much attention to it. Once we found the correct road we went inland about a mile towards Hermanville church and set up the dressing station in orchards close by. The preliminary aerial bombing, unfortunately, had missed the targets along the beach and landed inland on the farm fields where we were to set up our dressing station. Injured cows on the site had to be put out of their misery with a .38 calibre shot through the head.

At the eastern end of Sword Sector the 1 st Commando Brigade under Brigadier Lord Lovat landed at H-hour to capture the guns at Ouistreham and to link up with the British 6th Airborne Division along the bridges over the River Orne. A Free French Commando Battalion was included with these forces. The French inhabitants of Ouistreham and Riva Bella came out to welcome their Free French liberators like long-lost heroes. By the time we arrived, 3Yz hours later, the Free French were well advanced in their celebration and were decidedly inebriated. The Commandos who came back through our unit reported they had captured the villages overlooking the city of Caen, so we anticipated that our 1 85th Brigade which had landed that afternoon would be able to capture Caen that evening as planned. Unfortunately, their Brigadier was non-aggressive by nature and was reported to have ordered his troops to dig in well short of their objective. Warren Tute, in his book on D-day, says that the British infantry, lacking tank support, were stopped 2Yz miles from Caen by the 21st Panzer Division's tanks. The Germans had launched a counter attack which almost reached the coast very close to our location. Happily, we knew nothing about this. The 250 gliders bringing in reinforcements flew over this armoured thrust and so unnerved its commander that he pulled back, fearing to be cut off.

We soon began to get a trickle of wounded and by the evening things were fairly hectic with lots of stretcher patients on the ground. Unfortunately, the surgical team failed to appear. We found later that their landing craft was stuck on a sandbar offshore, under fire from the beach shell-

BULLETIN OF ANESTHESIA HISTORY 9

ing of the Germans, while the British naval vessels were firing over their heads onto the German batteries. The back-up surgeon and anaesthetist arrived later that evening with their instruments in their rucksacks. The FDS had an operating tent and a folding operating table with a canvas top together with a pan to boil the instruments for sterilisation. The Army didn't provide us with any sterilised dressings so while we had been waiting in Britain to embark, we collected gauze rolls from the Army supply and had the local hospital's volunteers fold them into abdominal mops which were then packed in large biscuit tins and autoclaved and sealed. This supply of dressings saved the day when the main surgical team failed to arrive. We had also collected a large supply of Pentothal as we had few other anaesthetics available.

The initial medical supplies we had consisted of the 26 Ibs we were able to carry in our rucksacks. Fortunately, by late afternoon all our vehicles, consisting of three 3-ton trucks, one of IS cwt, the water truck and an ambulance had arrived. Only an amphibious jeep had sunk on leaving the LCT. When this transport arrived we were able to set up our tents and function quite satisfactorily. A medical problem arose on the first day when we received memberS of the 5 1st Highland Division who had tecently been transferred from Egypt. Many of these soldiers became incapacitated with high fever due to a resurgence of malaria precipitated by the strain of battle. Fortunately, we found quinine tablets in our standard wicker British Army medical supply baskets which were fitted with rings on each side so that they could be carried by mules in India. We'd never had cause to open these before but they proved a godsend.

Surgical Unit Activity When our surgical team, consisting of a

surgeon, an anaesthetist and assistants arrived, they set up their operating room in a tent attached to the rear oftheir truck. They sterilised their instruments by boiling them in a pan over a Primus stove on the tailgate of the truck. As anaesthesia equipment they had an Oxford Vaporiser which gave precise percentages of ether in air. Hot water was poured into the central container and melted the calcium chloride crystals. When the temperature rose on the thermometer, they knew that the vaporiser was ready for service. It was fitted with a bellows so that one could assist the ventilation with ease. For induction, ethyl chloride could be squirted into an induction bag to obtund


1 0 BULLETIN OF ANESTHESIA HISTORY

Eyewitness . . . Continued from Page 9

the patient's cough reflex before commencing with ether from the main vaporiser. They also had Pentothal but of course, no muscle relaxants. The only cases the surgical unit operated upon were those which couldn't tolerate further delay. Lord Lovat came into our unit with a through and through gunshot wound on one flank and the exit on the other. Laparotomy showed that the bullet had coursed through the muscle planes and never entered the abdominal cavity. Early on we were pleased to receive a visit from the Army's consultant surgeon, Arthur Porritt, the famous New Zealander, and former Olympic athlete. He recommended that our unit be given four nurses to handle the postoperative nursing. They arrived in short order, making a tremendous difference to the care provided.

After about ten days, the postoperative patients were moved down to the beach for return to Britain on a landing craft. One evening we sent a postoperative abdominal case to be evacuated to Britain, only to receive him back about 0800 hrs the next morning. The landing craft had been torpedoed and he ended up swimming in the water for some time before being rescued and brought back to us, apparently little the worse for his experience. The first use of penicillin I ever saw was on a soldier with gas gangrene in the posterior compartment of his thigh. I expected it would be necessary to amputate his leg. However, after the wound was opened widely and penicillin had been given, his leg and his life were saved. By Dday plus 1 we had the Field Ambulance Surgical Unit and the Field Transfusion Unit and everything was going full blast. In the first three days we handled 1,025 patients between the 20th and 21st FDSs. We evacuated a total of 1,700 injured back to Britain in the first week.

After a month, with Caen stilI not captured, Montgomery called for a massive air attack on 7th July. Lancaster and Halifax aircraft dropped 2,573 tons of bombs as a preliminary to a three-sided assault on the city. As we were situated only six miles away from the target zone we had an awe-inspiringview of the raid. On 9th July, after fierce fighting, in which the British and Canadians suffered almost 5,000 casualties and 3,000 civilians were killed, the city of Caen and its nearby airfield were at last in British and Canadian hands.

Management of Battle Fatigue General Montgomery's battle plan was

to draw German strength to the eastern end

of the front near Caen so that an armoured breakout might be made through St Lo, outflanking the Germans and forcing them back over the River Seine. Though this did in fact work in the long run the British soldiers who were opposite Caen took a tremendous pounding. Even the best troops have their l imits of endurance. After a soldier had been confined in a slit trench for four days under continuous bombardment, his ability to function or resist could be lost.

When our job as a forward surgical centre in the Hermanville area was completed early in July our unit was moved west of Caen. Here we became a Corps psychiatric centre. We had attached to us a Corps psychiatrist who guided our care of these patients. They came to us in large numbers, stuporous or unable to focus their attention on their immediate problems. The psychiatrist's plan of treatment was as follows: first the men received a hot meal, then they were given a large oral dose of a barbiturate to produce sound sleep. When they awoke they received a second meal and a second dose of barbiturate. Upon waking after this they were seen by the psychiatrist to determine those who could be sent back to their units after further treatment and those who would probably never recover enough to return to the battle.

Another feature of the treatment was strenuous exercise, playing soccer to vent their feelings of frustration and anger. Unfortunately, gaps in the teams had to be made up by RAMC orderlies who were usually somewhat less robust than the infantry soldiers. One of our problems was to keep our own staff sufficiently patched up so they could continue playing football. Generally, about half the patients were returned to their units and the other half were sent back to Britain.

German Surgery As the German Army fell back through

northern France, 2 1 FDS was sent to Amiens to take over a French civilian hospital which held over 700 German casualties. They had no German medical officers and no surgeons. To solve this problem our commanding officer went down to the prisoner of war cage and called for all German medical officers who claimed to be surgeons to report for duty. He returned with six alleged surgeons. They were each sent up to the wards to choose a patient to operate upon and watched to see how they performed. From these trials we selected three competent surgeons. The anaesthesia was provided by a German orderly who used open drop ethyl chloride on a mask large enough to cover the whole face. His idea of

anaesthesia was that, providing the patient ' was not moving, itwas satisfactory. He liked , to have them phonating throughout most I of the procedure, for that way he knew they :

were stilI breathing. A few days later a British mine disposal

officer was brought in having lost both feet to a land mine. We took him straight to the operating theatre and called for the German surgeons to come quickly. Meanwhile, a dispatch rider was sent to obtain supplies of blood. Fortunately, we had plenty of freeze-dried plasma, so we set up an Lv. line and commenced pumping in plasma as fast as possible until the blood arrived. We got four units of blood which was given rapidly. Meanwhile, the surgeons arrested the bleeding and cleaned up the two stumps. They looked extremely concerned about the amount of fluid being pumped into the patient but at the end of surgery, when they asked how the patient was, and we reported that the blood pressure was 1 20/70 they couldn't believe it. They had never seen such a blood transfusion given in the whole of their military careers. The German Army did not have a blood transfusion service. In place of plasma and blood they had Periston. This was a 3 Yz% solution of polyvinyl pyrolidine in normal saline. It was supplied in 200 ml ampoules. We did not come across any giving sets in the German Army medical stores we depended upon to treat our 700 German POW patients. It was our impression that this plasma substitute was given in 200 ml doses.

In April 1 945 it was clear that the war in Europe was drawing to a close. Our FDS had not sustained any casualties at all . However, in the Pacific, Japan was still fighting doggedly and the prospects of participating in the invasion of the Islands of Japan was far from appealing. So on 1st April I replied to an HQ invitation and volunteered for anaesthetic training.

Conclusion It is clear to me that the concept of the

FDS worked well in the Normandy campaign, forming a good basic unit to which specialist functions could easily and effectively be grafted. However, this was a relatively static camp'aign by comparison with the Persian Gulf war where tank divisions moved forward so rapidly that they ran out of helicopter transport range. Casualties, had they occurred, would have been difficult to collect from the forward forces. Maybe in future one should think in terms of helicopter-borne medical u nits that could be advanced rapidly to the scene of the engagement.

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An Inventive Mind:

The Career of James O. Elam, M.D. by Robert R Sands, Jr., M.D. and Douglas R. Bacon, M.D., M.A. Department of Anesthesiology, S UNY at Buffalo, NY

Introduction Genius, it is often said, is more perspira

tion than inspiration. The career of James Otis Elam exemplifies this statement. Ever striving to improve the quality of care given to patients, his inventive and ingenious mind has devised many new modifications of anesthetic equipment and techniques that have revolutionized anesthesiology and medicine. Perhaps best known for popularizing mouthto-mouth resuscitation in the 1950s, Elam has had a greater range and diversity than that one bright and shining moment. His work can be broadly categorized into several divisions. He made significant contributions in carbon dioxide homeostasis and absorption, mechanical ventilation, rescue breathing and airway management. Several of his inventions are used daily in the operating room, while others, fixtures for decades, have slowly been replaced by different techniques. Over the 40 years of his career, and up to this very moment, Elam typifies the hard working anesthesiologist working to improve patient outcome.

Carbon Dioxide Homeostasis and Absorption

One of Elam's earliest successes was the development of a carbon dioxide (C02) absorbent system. The impetus for this work was provided by the introduction of closed circuit anesthesia in 1930 by Brian Sword, a New Haven anesthesiologist which reduced the amount of anesthetic gas needed to anes-thetize a patient.l

.

Elam had studied human respiratory physiology while an anesthesiologist at Barnes Hospital and Washington University in St. Louis, Missouri, in the early 1950s, using money he was receiving from an Army contract. At that time, the Department of Anesthesiology at the University was under the auspices of the Department of Surgery. That in itselfwas not a problem until the University hired a new chairman of the Surgery Department. He decreed that the bulk of the research performed by the anesthesiology department would be performed using animal instead of human subjects.2 This change would, of course, place Elam's Army funding in jeopardy, so he relocated to Roswell Park Memorial Institute in Buffalo in 1953 to continue his research. He was able to bring with him his two major collaborators from Barnes Hospital, Elwyn Brown and Raymond Ten Pas.

The three investigators arrived in Buffalo

with two trailers stocked with research equipment from their laboratory in St. Louis.3 Among the more esoteric pieces of equipment was a new Liston-Becker model 16 CO2 analyzer which measured the concentration of CO2 in a gas sample by infrared spectral analysis.4 Although the device was quite easy to use, it did first need to be calibrated with a known concentration of CO2•5 This analyzer was used in many ofElam's research projects through the years, and he needed it to measure how well different materials absorbed CO2,

The groundwork for the development of a system that would absorb CO2 had already been laid by Adriani and Rovenstine in 1941 .6 Extrapolating on this information, Elam and his colleagues were able to prove that the interstitial space within the CO2 absorption canister should closely approximate tidal volume.7 Furthermore, for CO2 absorption to be maximally efficient, the soda lime should contain 20-25 percent water.8 The physical property of the CO2 canister, channeling, was discovered. Channeling, where expired gas flowed directly through the canisters and bypassed any interaction with soda lime, depended on how tightly the granules were packed. By placing baffles in the canister, channeling was minimized.9 With these modifications of Adriani's original work, Elam was able to introduce a soda lime canister that provided prolonged and more efficient CO2 absorption than had previously been available. His design has been used in one form or another on anesthesia machines in the United States for the last 35 years.

The Ventilator Each question that Elam strived to answer

caused a multitude of new queries to be raised. A case in point was the soda lime research. To obtain reproducible results, it was necessary to construct a machine that could simulate human respiration. His first working model was akin to the first computer, large and unwieldy, but still useful because it was able to provide data 24 hours a day for almost five years. This permitted Elam and his colleagues to test multiple breathing circuits and CO2 canisters to ascertain the optimal design with minimal airway resistance.

The prototype ventilator was invaluable in assisting with calculations of both physiologic and anatomic dead space and furthermore, with minute adjustments, it could simulate different human respiratory pat-

BULLETIN OF ANESTHESIA HISTORY "

terns. Elam reasoned that, if the machine could be "programmed" to breathe like a human being, maybe it could be further modified to breathe fur a human being.

Idea became reality. The ventilator he constructed, dubbed the Roswell Park ventilator, was multifunctional. 10 It was able to work in either volume or pressure modes, and could cycle in a positive-negative, positive-zero and positive pressure manner. Application to human subjects validated previous work with the respiratory simulator used in the soda lime research, demonstrating that CO2 homeostasis was adequate.ll This device, initially the Roswell Park ventilator, continued to be used for many years as the Air Shields Ventimeter Ventilator, slowly replaced by more "advanced" technology.

Rescue Breathing The ventilator that Elam designed was

invaluable in providing assistance to hospitalized patients with respiratory insufficiency. He also knew that it was next to useless for patients who experienced a respiratory arrest outside of the hospital setting. This lent further impetus to study another area of respiratory physiology known as rescue breathing, which already was a lifelong interest of his. He had performed mouth-to-endotracheal tube breathing for patients during the poliomyelitis epidemic in Minnesota in 1946 in an effort to save these young peoples' livesY That effort led him to further ponder the feasibility of mouth-to-mouth ventilation.

Again using the Liston-Becker CO2 analyzer and with a blood gas analyzer, Elam had demonstrated that mouth-to-mask respiration could maintain normal gas exchange in patients experiencing residual muscle paralysis in the recovery room at Barnes Hospital. Further proof of the success of this method had been curtailed by the aforementioned new chairman of the Department of Surgery at Barnes. This forced Elam to attempt to construct a face mask that would fit a dog. He was not successful. More than likely, however, had he succeeded, it might have led to withdrawal of his Army fundingY

Elam's first study on rescue breathing was published in the New England Journal of Medicine soon after his arrival in Buffalo.14 The success of rescue breathing was directly dependent on a patent airway as proven by



Dr. E1am. . . Continued from Page 11

Elam and corroborated by many other investigators throughout the world. The easiest way to assure airway patency was to extend the neck and displace the mandible anteriorly. This new "chin lift and jaw thrust" technique was infinitely more easily performed than the previously accepted method of chest pressure and arm lift. Without a patent airway, it was not possible to deliver large enough tidal volumes to the lungs of the patients to sustain life.ls

Elam knew that this technique, with the proper support, could save hundreds of lives per year. To further popularize this life-saving technique, he enlisted the assistance of the New York Health Commissioner, Herman Hilliboe. Suitably impressed with this technique, Hilliboe asked Elam to write the instructional booklet, "Rescue Breathing", which was distributed nationally in 1959.16

The booklet's success spurred Elam to produce films demonstrating this method of rescue breathing. He produced two different versions of the film dependent upon the target audience, either the general public or his fellow health care professionals.17 The take home message being the same in either case, this technique WOULD save lives. The United States Army became the distributor of the film. Elam was sought after as a lecturer because groups knew that, during his speaking engagements, he would invariably show one of his films.18

Elam's technique of rescue breathing slowly gained acceptance and by 1960 it had been adopted by the National Academy of Science, the American Society of Anesthesiologists, the Medical Society of the State of New York and the American Red Cross as the preferred method of rescue breathing. By forever changing the face of emergency medicine, Elam was recognized by the United States Army with a Certificate of Achievement, and in 1962 the Medical Society of the State of New York presented him with its highest honor, the Albert O. Bernstein Award.

The Binasal Pharyngeal Airway Some of Elam's ideas, regardless of their

clinical soundness, were not accepted into mainstream practice. One such concept was the use of the binasal pharyngeal airway for patient ventilation. Over one thousand patients had this airway placed during a fouryear clinical trial in the operating rooms at the Lying-In Hospital in Chicago, Illinois.19

The binasal pharyngeal airway consisted of two Rusch nasopharyngeal tubes attached to a Puritan rubber adapter, which was then in turn attached to an anesthesia breathing circuit. This airway was placed nasally after anesthesia was induced either by mask or by

intravenous injection. Mter being passed distal to the base of the tongue via the nares, the tips of the airway would come to rest near the larynx just below the tip of the epiglottis. The patient was then placed on a ventilator and any excess pressure generated could be vented through the mouth.19

Elam's research revealed this to be a safe and easy method to ventilate patients with an anticipated difficult airway. It also had the added benefit of not causing any edema of the larynx, so rarely did a patient complain of postoperative hoarseness or sore throat. This became the ventilatory technique of choice for most ambulatory dental and eye surgery cases at his hospitaI,19

Although this technique was proven to be safe and effective in well over 1000 patients, it was never widely accepted, the main reason being that most practitioners did not like the idea of having an unprotected airway during a prolonged surgical procedure, in spite of the fact that not one of the patients in the study developed any signs or symptoms attributable to aspiration.

Another concern the practitioners may have had was that the stomach migh t distend if inspiratory pressures were too high. This was unlikely, however, because the opening pressure of the non intubated adult esophagus ranged between 15 to 25 centimeters of water, whereas the pressure necessary to expel air via the mouth was 10 to 20 centimeters of water, depending on the size of the patient's tongue and lips and the state of re1axation.20 To most practicing anesthesiologists, there was not a large enough safety margin to warrant use of this new airway and it never became accepted as a standard of practice.

Elam also used the binasal pharyngeal airway to successfully ventilate patients who had suffered a cardiac arrest. Theoretically, there was an increased risk of aspiration in this group of patients, but again no aspiration was reported. The idea of an airway that could be easily placed by a medical professional or a layman continued to interest Elam throughout his career.

The Next Great Invention? At the age of 77, having been retired for

over 10 years, Elam continues to tinker with equipment to help improve patient care. Currently he is working on two different problems which have their roots back in the 1950s and 1960s. The first invention addresses the problem of an easily placed device by trained or untrained personnel to protect the airway. Using human cadavers to ascertain proper anatomical distances, he has designed a double-barreled plastic tube to be placed blindly into the person's mouth. Through one barrel of the tube, an endotracheal tube can be placed which, due to the

curvature of his invention, will pass through the vocal cords and protect the airway. The other barrel of the tube is designed to accept a nasogastric tube to decompress the stomach. The plastic tube can then be removed by sliding it over the endotracheal tube and the nasogastric tube. The system is designed so that no medical knowledge is required to place the plastic tube. Clinical trials are scheduled to begin shortly and, if successful, the use of this device may resul t in decreased mortality for out-of-hospital cardiac arrests.

Another invention on which Elam is working is a modification of the Air Shields Ventimeter Ventilator. One of the advantages of that ventilator was its ability to be set in assist or control modes. In assist mode, the sensitivity could be adjusted to detect even the most minute attempt at respiration by the patient. Sometimes the ventilator was too sensitive and it would pick up artifactual movement causing hyperventilation by the patient. Elam has been able to overcome this shortcoming of the ventilator by interposing another sensor in the inspiratory limb of the ventilator.

Using this combination ventilatory technique, he has been able to demonstrate that patients receiving halothane anesthesia were able to regulate their own breathing. Unfortunately, this data was lost through the years and not published.21 His ultimate goal at this time is to incorporate the flexibility of the Air Shields Ventimeter with his sensor into one of the present day anesthesia machines to permit patients to regulate their own breathing without need for the anesthesiologist to intermittently provide ventilation via the bag.

Conclusions J ames Otis Elam has had a profound ef

fect on the practice of anesthesiology, as an inventor and clinician. From his early work on CO2 homeostasis, leading to the first human capnograph tracing, to his present day work on an airway that laymen can use to intubate victims of cardiac arrest outside the hospital, Elam has always strived to improve the quality of life of his fellow man. Battling through hardships of his own, both emotional and financial, he has always exemplified what a true anesthesiologist should be. Now in the twilight years of his life, Elam is as devoted to his ideals as he was as a young practitioner. He is a physician who should be a role model for all physicians for his unwavering dedication to his patients.

References I. Sword BC. The closed circle method of ad

ministration of gas anesthesi a . Anesth Analg 1930;9:198.

2. Personal communication, Elwyn S. Brown, MD.


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BULLETIN OF ANESTHESIA HISTORY 1 3

The Evolution of Nitrous Oxide Dr. D. J. Wilkinson, a well-known anaesthetist and historian, recently published the following article in the PrQceedings 'Of the HistQry 'Of Anaesthesia 16:81-84, 1994. Wil thank Dr. Wilkinson and the Editor of the Proceedings for their kind permission to reprint this paper in the Bulletin.

NITROUS OXIDE IN THE 1920s AND 1930s

by Dr D J Wilkinson Consultant Anaesthetist, St. Bartholomew 's Hospital, London Curator of Charles King Collection of Historical Anaesthetic Apparatus

The '20s and '30s were a time 'Of cQnsiderable sQcial and PQlitical change in the Western WQrld. NitrQus 'Oxide anaesthesia did nQt suddenly spring intQ prQminence during these tWQ decades; there had been a steady develQpment in the art and science 'Of its use since its inceptiQn SQme 80 years previQusly. HQwever, it was in this era that SQme 'Of the mQre impQrtant develQpments 'Occurred.

Pre- I 920s Crile and LQwer had published their

WQrk 'On AnQci-assQciatiQn in 1 9 141 in which they described their technique 'Of nitrQus 'Oxide anaesthesia fQllQwing heavy premedicatiQn tQgether with the liberal use Qflocal anaesthetic infiltratiQn. When Crile set up his Lakeside HQspital in France during the First WQrld War, these techniques prQved very effective in shocked trauma cases. Also at this time Marshall, Boyle and Shipway were wQrking with nitrQUS oxide anaesthesia in cQmbinatiQn with ether. The military anaesthetists thus returned tQ civilian life with a new perspective 'On an old drug, but withQut the apparatus with which tQ administer it.

Apparatus in the 1 920s In 'Operating theatres there were few ni

trQUS 'Oxide machines. There was usually an anaesthetic table with masks and drQPper bQttles tQgether with bottles of ether, chlQrQfQrm and ethyl chlQride. Gradually the BQyle's machine began tQ be intrQduced, initially with a simple water sight flQW meter and an ether vapQriser, then mQdified by the additiQn 'Of a chlQrQfQrm bottle. In 'Outpatient and in dental practices there WQuid be a simple nitrQus 'Oxide apparatus cQmprising a cQuple 'Of cylinders 'Of gas, withQut reducing valves. CQntrQl was by a fQQt key, the cylinders were connected tQ a Cattlin bag which was, in turn, cQnnected tQ a stopcQck and mask and the apparatus WQuid then be used to prQvide a pure nitrQus oxide anaesthetic fQr shQrt dental extractiQns 'Or minQr QperatiQns.

Charles King, Francis de Caux and Elmer McKessQn

Charles King 'Opened his shQP at 34 Devonshire Street tQ sell general medical instruments in the early 1920s.2 Francis de Caux, an anaesthetist frQm the NQrth Middlesex Hospital, had recently visited McKessQn in ToledQ, OhiQ, when he came intQ King's shQP with a McKesson machine. The mid-west 'Of America was the birthplace 'Of a wealth 'Of nitrQus 'Oxide apparatus, frQm manufacturers such as Heidbrink, Teter, White, Gatch and McKesson. Examples 'Of their equipment can be seen by thQse whQ visit the WQod Library-Museum of Anesthesiology in Park Ridge, Chicago.

At that time, de Caux was the "dQyen" 'Of nitrQus 'Oxide anaesthetists in LQndon and had written CQpiously 'On the subject.l He had developed SQme special endQtracheal tubes for nitrous oxide anaesthesia and these were intrQduced during the use 'Of McKessQn's technique of secQndary saturatiQn. This invQlved a pure nitrQus 'Oxide inductiQn fQllQwed by the additiQn 'Of about 10% 'Oxygen; this was primary saturation. Once the patient was breathing satisfactorily with this mixture the oxygen was turned 'Off and 1 00% nitrQus 'Oxide was given. When the patient was d eeply cyanQsed a "burst" 'Of 'Oxygen was given, preferably "under pressure" and the patient would then become apnoeic and tQtally relaxed, and intubatiQn CQuid take place. The patient whQ had undergQne this "secQndary saturation" WQuid then restart breathing 10% oxygen in nitrQus 'Oxide.

The best (if nQt the 'Only) apparatus for this technique was the McKessQn. The tQP 'Of the range mQdel 'Of this line was the Indicating and Recording Nargraf. This was a truly sQphisticated apparatus capable 'Of cQntinually recording the patient's respired vQlumes, blQod pressure and inspired gas mixtures. de Caux persuaded King tQ import these machines and thus started him 'On his career related to anaesthetic apparatus. McKessQn machines were SQon tQ be fQund in almQst all dental surgeries in the UK. McKessQn cQntinued tQ lecture and teach hQW tQ use his apparatus and pub-

lished many bQQks and mQnQgraphs 'On the subject. de Caux modified the McKesson machine tQ his 'Own specificatiQn and 'Other practitiQners develQped a series 'Of nasal and 'Oral masks fQr dental anaesthesia. McKessQn's influence 'On British anaesthesia can be seen in the preface to the 3rd editiQn 'Of BQyle's Practical Anaesthetics (which was cQ-authQred by Langton Hewer) i n which they p ay recQgnitiQn tQ McKessQn's cQntributiQn of a complete chapter 'On mQnitQring during anaesthesia.4

Meanwhile, in Germany, Drager had intrQduced their highly sQphisticated MQdel A machine which incQrpQrated a circle soda lime absQrber. This was utilised because nitrQUS 'Oxide was considered tQ be relatively expensive. At the same time, Ralph Waters was wQrking 'On his "tQ and frQ" clQsed system and, with Lundy and Guedel prQduced a cuffed tracheal tube which was SQ elegantly demonstrated at the American SQciety 'Of AnesthesiolQgists Meeting when they perfQrmed their "drQwning dQg" experiment. In this, they wheeled 'On tQ the stage a dQg suspended underwater in a large tank. The dQg, knQwn as ''Airway'' in their subsequent cQrresPQndence, was anaesthetised and breathing thrQugh a clQsed system via the cuffed tracheal tube. The dQg was remQved frQm the tank, the anaesthetic was stQPped, the dQg was extubated and made a cQmplete reCQvery.

Other DevelQpments This was the periQd when Ivan Magill

and Stanley RQwbQtham perfected their techniques 'Of intubatiQn. Magill, wQrking with the engineering skills 'Of King, produced a whQle range 'Of apparatus relating tQ nitrQus 'Oxide anaesthesia. There was a special reducing valve, and an endQtracheal anaesthetic machine which incQrpQrated Siebe-Gorman RQtameter-type flow meters, as well as the Magil l tubes and laryngQscQpe. Magill alsQ develQped a special gas and 'Oxygen apparatus at this time althQugh this did nQt prQve tQ be particularly PQPular.


1 4 BULLETIN O F ANESTHESIA HISTORY

Obesity in the Middle Ages � are indebted to Ms. Erica Hershey and to the Editor of Old News, ltVl. 6, No. 11 for their permissions to reprint this vignette of Henry II and his attempt to combat what is still a problem of humanity. Old News is published nine times a year, subscription $15.00 per year, by Susquehanna Times & Magazine, Inc., 400 Stacks town Road, Marietta, PA 17547-9300. -Editor

Medieval Exercise Program Menaces Health of Monarch, Says Archdeacon of Brecknock

by Erica Hershey

When Henry II ascended to the throne of England in 1 154, he was determined to enlarge his kingdom and to shrink his waistline.

He was successful in achieving his first goal, swelling his kingdom to include most of the British Isles and half of France. Reducing his own girth proved to be a more difficult task for the naturally chubby monarch.

The archdeacon of Brecknock, Giraldus Cambrensis, described the king's physical appearance as follows:

"King Henry II of England had a reddish complexion, rather dark, and a large, round head. His eyes were gray and bloodshot; they flashed when he was angry. He had a fiery countenance, his voice was tremulous, and his neck a little bent forward. His chest was broad and his arms were muscular, but his body was fatty, and he had an enormous paunch.

"His obesity was not the result of gross over-eating. Considering that he was a prince, Henry ate moderately-in fact, he was so moderate in everything that some people called him a miser.

"Trying to change his natural shape, Henry waged a continual battle, so to speak, with his own belly. His weapon in this contest was physical exercise.

"In wartime-and he was usually at war-Henry m arched without rest. In peacetime he exercised by going hunting.

"Henry was such an enthusiastic hunter that he changed the sport into hard work. At the first dawn of day he would mount a swift horse, and then he would tirelessly spend the whole day riding through the woods, penetrating the depths of the forests, and crossing the ridges of the hills. In the evening, when he came home for supper, he seldom sat down. Instead, he would weary himself and all his court by staying constantly on his legs, before and after dinner."

According to Giraldus Cambrensis, all this exercise failed to shrink the King's belly. In his History of the Conquest of Ireland, Giraldus Cambrensis expressed his

personal opinion that King Henry's calisthenics succeeded only in demonstrating the foolishness of physical exercise.

The. archdeacon wrote, '�ll of his exertions wore the King down. He suffered from swellings in his legs and feet, which got worse every time he tried to slim himself by taking a violent horseback ride. Such physical exercise is unhealthy: at best it hastens the onset of old age; at worst it causes serious disorders. . . Would to God he had been as zealous in his devotions as he was in his sports."

SOURCE History of the Conquest of Ireland. by

Giraldus Cambrensis. c. 1 1 89.

N20 . . . Continued from Page 13

In 1932 Robert Minnitt was asked to investigate the possibility of developing a nitrous oxide apparatus for use in obstetric analgesia by midwives. He, too, was a friend of Charles King and they developed the Minnitt's apparatus, which was a bisected McKesson machine with some air entrainment holes added. A whole series evolved. Each was designed to give nitrous oxide analgesia using a mixture of 50% gas in air, i.e., about 10% oxygen. There was the added refinement of the CM attachment for the Hospital model which allowed the use of 100% nitrous oxide for about six breaths before reverting to 10% oxygen. Despite their shortcomings, obvious in this day and age, Minnitt's apparatus was used to great effect from the '30s to the mid 1960s.

In surgical practice, the Boyle's machine continued to evolve. The water sight flowmeter was replaced by the Coxeter dry bobbin flowmeter which, in turn was replaced by the Rotameter. The Walton 1 machine was designed for use in dental surgeries as a replacement for the McKesson and, in Europe, a new form of anaesthesia was being developed with the

introduction of the intravenous barbiturate induction agents like Evipan.

In 1932 Langton Hewer produced the first edition of what would prove to be a long running series: Recent Advances in Anaesthesia. This edition referred to recent problems abroad with contamination of nitrous oxide cylinders with nitric oxide and noted the high purity of UK supplies. He also noted that secondary saturation techniques were regarded in the UK as causing considerable strain on the right side of the heart and not advisable for inexperienced anaesthetists.5 In the second edition, the presence of nitrogen in nitrous oxide was mentioned. This was more evident at the beginning of use of a cylinder when the inspired concentration might reach 8%. By 1939 Hewer was writing about recent reports of destruction of the cerebral cortex in patients who had received pure nitrous oxide and oxygen anaesthetics in tl:).e USA. He believed that this was most likely to be due to hypoxia rather than a direct effect of the nitrous oxide.6

Clement's book on nitrous oxide anaesthesia was published at this time, with its dedication to his mentor McKesson, who had recently died. This book reviewed the full pharmacology and application of nitrous oxide anaesthesia from a US perspective.7 It is interesting that "secondary saturation" was still recommended.

The decade thus ended with nitrous oxide anaesthesia firmly established. There were two basic forms of use. Firstly, as a sole agent for rapid procedures such as dental extractions or as an induction agent; secondly, as an adjuvant or even a carrier gas with a Boyle's type machine. The use of "secondary saturation" in the UK was rare and generally considered to be dangerous. The forthcoming world war would provide even greater impetus to the development and refinement of both techniques and apparatus for the use of nitrous oxide ana e s t h e s i a .

References 1. Crile Gw, Lower WE.Anoci-association. WB

Saunders Company. Philadelphia, 1 9 1 4. 2. Wilkinson DJ. A. Charles King: a unique

contribution to anaesthesia.Journal o/the Royal Society 0/ Medicine 1 987; 80:5 1 0-514.

3. Wilkinson DJ. Francis Percival de Caux (1 892-1965). An anaesthetist at odds with social convention and the law. Anaesthesia 1 991; 46:300-305.

4. Boyle HEG, Hewer CL.PracticaIAnaesthetics. 3rd Edition. Henry Frowde and Hodder & Stoughton. London, 1 923.

5 . Hewer CL. Recent Advances in Anaesthesia and Analgesia. J & A Churchill. London, 1 932.

6. Hewer CL. Recent Advances in Anaesthesta and Analgesia. 3rd Edition. J & A Churchill. London, 1939.

7. Clement FW, Nitrous Oxide-oxygen Anesthesia. Lea & Febiger. Philadelphia, 1 939.

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"I fill three quarters of immensity! " Satires of Early Nitrous Oxide Research A.J. wright, MLS

BULLETIN OF ANESTHESIA HISTORY I S

Department of Anesthesiology Library, School of Medicine, University of Alabama at Birmingham

In early 1799 the twenty-year-old scientist Humphry Davy published a brief letter announcing his discovery that nitrous oxide gas could safely be respired by humans; a full account of this research appeared in the summer of 1 800, 102 During this period Davy worked in Clifton, just outside the English seaport of Bristol, under the tutelage of Thomas Beddoes, a physician who for many years had researched the possible therapeutic uses of gas inhalation. In addition to patients who appeared at Beddoes' clinic and research facility, the Pneumatic Institution, Davy and his mentor were joined in their research by more than forty healthy individuals, including Samuel Taylor Coleridge, Robert Southey, Peter Mark Roget, Thomas Poole, J ames Mackintosh, Anna Laetitia Barbauld and James Watt.3 This work by Beddoes and Davy was quickly replicated elsewhere in England and within a few years in the United States.4

For the past several years I have been investigating aspects of nitrous oxide research between 1 799 and 1 844:

• Beddoes/Davy research in England • Woodhouse/Barton replications in

America • Dispan replication in Toulouse,

France (ca. 1 806) • Nitrous oxide in chemistry/medical

textbooks • Public and classroom demonstrations

of nitrous oxide inhalation • Satiric attacks on this research Although Davy suggested nitrous oxide

inhalation as a possible surgical anesthetic, he never attempted such a use. Neither did anyone else until Horace Wells successfully anesthetized several of his dental patients using the gas in December 1 844. I am thus investigating popular and professional knowledge of nitrous oxide in the four and a half decades between Davy and Wells in an attempt to understand why knowledge of the gas was so widespread and yet anesthesia was not attempted. A similar situation existed with ether-an agent known for many years and in its gaseous state used for recreational purposes in the early nineteenth century. Yet no one attempted to produce an anesthetic state with ether gas until Crawford Long and William Morton did so successfully in the early and mid-1 840s.5

Chemist Joseph Priestley first isolated nitrous oxide in 1774 or 1775 in the midst of his extensive research on a series of gases.6 He noted a few basic characteristics about nitrous oxide, but did not attempt to respire it himself. By the mid-1790s, American physician/scientist Samuel Latham Mitchell was proclaiming nitrous oxide to be the source of all contagious diseases.7,8 At the same time Beddoes' career was on a collision course with nitrous oxide.

Thomas Beddoes' life and work have been admirably explored by Stansfield and Porter.9,IO Beddoes trained as a physician in Edinburgh; and by the late 1780s he was teaching chemistry at Oxford. Beddoes was apparently popular as a lecturer, but his penchant for supporting radical political movements forced him to leave Oxford in the early 1790s. While at Oxford Beddoes developed an interest in possible medicinal applications of the gases, or "factitious airs," that were the subject of extensive experimentation and writing by Priestley, Lavoisier and many others.

Beddoes rightly decided he could build a lucrative medical practice in Bristol, then a center of British intellectual life as weU as trade. Wealthy Irish landowner Richard Lovell Edgeworth, a frequent visitor to Bristol, provided Beddoes with introductions into the city's society and a wife in daughter Anna.

Beddoes' activities in Bristol during the 1790s faU into three main areas: his clinical practice as a physician, political activity and research on gases. Industrialist James Watt helped Beddoes with his gas research by designing both stationary and portable equipment patients could use to inhale the gasesY-12 And Beddoes worked tirelessly to raise money for a Medical Pneumatic Institution, where a clinic for administering gases could be combined with teaching and research-the three elements, of course, of a modern academic medical center.13 By 1796, Beddoes' scheme had attracted almost 200 subscribers from all over the British Isles, including 44 physicians, 19 surgeons and 14 clergymen.14 In the fall of 1798 Humphry Davy was hired as Research Director and the Institution opened. Within two and a half years the research effort had sputtered to a halt, unsuccessful in effecting disease cures with

gas inhalation. Davy left Bristol in March 1 80 1 for the fledgling Royal Institution, where his career as a chemist flourished over the next decade. IS

In London Davy continued to give demonstrations of nitrous oxide's effects for a year or so. Over the next decade several successful attempts were made in England, America and continental Europe to replicate Davy and Beddoes' work with nitrous oxide. One of the most elaborate attempts was made in 1 807 by William P.C. Barton, a University of Pennsylvania medical student. By 1 8 10 knowledge of nitrous oxide and its effects was available in public and classroom demonstrations, and chemistry and medical textbooks, a situation that continued for over three decades.4 Satires of nitrous oxide effects and research quickly became another way in which this .knowledge was transmitted.

Beddoes had been the subject of a comic attack long before his research on nitrous oxide. Erasmus Darwin, poet, successful physician and member of the Lunar Society, read Beddoes' writings on gases and disease and recommended Beddoes to James Watt when his own treatment of Watt's tubercular child proved unsuccessful . In 1 793 Beddoes published A Letter to Dr. Darwin in which he outlined his new treatment for consumption patients. 16 An anonymous wag, perhaps someone who knew Beddoes from his Oxford days, responded the following year with The Golden Age, a Poetical Epistle from Erasmus D N. M.D., to Thomas Beddoes, M.D. 1 7 This parody, written in the style of Darwin's own poetry, attacked some of Beddoes' more outlandish scientific ideas-such as the notion that animal products like butter and tallow could be produced from vegetables. In the opening lines the poem announces:

Eternal war with Dulness born to wage, Thou Paracelsus of this wondrous age; Beddoes, the philosophic Chymist's

Guide; The Bigot's Scourge, of Democrats the

Pride; Although meant to denounce Beddoes,

whose political pamphleteering had made him notorious, these lines accurately describe the thinker who attacked the politi-



S atires . . . Continued/rom Page 15

cal and medical status quo of this "wondrous age." The Golden Age also managed to skewer Darwin and his popular poem Botanic Garden, with its obvious sympathy for the French Revolution.18

Later in the decade Beddoes and Darwin were also pilloried by writers George Canning and Benjamin Frere in the Tory publication to which they contributed, the Anti-Jacobin Review. In a mock account of a voyage to the Far East, the two physicians are mentioned in a l ist of passengers, including other political and social radicals like William Godwin. On board is a stench and

. . . Beddoes and Darwin engage to repair This slight inconvenience with �

air, A mock Latin poem by Frere notes in

the i ntroduction, " The subject is Dr. Beddoes' Factitious Air applied to the case of Consumption."19

In December 1799, Beddoes published a pamphlet describing the first few months' research on nitrous oxide inhalation in humans, which had begun in March.2° This item contains accounts by some of the earliest participants describing their own reactions to nitrous oxide inhalation. Davy's massive S80-page report on the basic, animal and human research appeared the following summer.2 In the same year the first two satiric accounts of the Pneumatic Institution work also were published. The mechanism of this speedy response by antiJacobin writers is unclear, unless we assume that supporters of the Crown kept track of Bed does' every movement. Indeed, some of his political activities in Bristol were reported to London. 21 However, Beddoes' tireless promotion of his gas research and the involvement of so many intellectuals in the nitrous oxide research, as well as what many observers saw as the comic effects of nitrous inhalation upon humans, may have kept Beddoes' Institution more in the public eye than the published record would indicate.

One of the first poetic satires was "The Pneumatic Revellers: An Ecologue," which appeared in the Anti-Jacobin Review and Magazine in 1 800.22 Although published anonymously, the poem is known to have been written by the prol ific Richard Polwhele, a frequent contributor to that journal. Polwhele was "a country clergyman and well-known Cornish poet and historian", remembered today for "his blatantly anti·.feminist poem, The Unsex'd Females . . .

23 Polwhele's poem seems to be based on

Beddoes' pamphlet. Five characters de-

scribe their reactions as they "drink" nitrous oxide; although identified only by initials, their identity is obvious and the accounts of all but one were included in B eddoes ' 1 799 publ icat ion . B esides B eddoes himself, there i s Reverend Rochemont Barbauld, the Unitarian minister, and his wife Anna Laetitia, the poet and "children's friend." Also appearing are poets Robert Southey and George Dyer. Dyer's presence is interesting. Although an associate of Coleridge's, Dyer is not known to have either participated in or observed activities at the Pneumatic Institution. He does not appear in either Beddoes' pamphlet or Davy's account, nor in such reminiscences of the events as those by observers Joseph Cottle and Maria Edgeworth.24-25 D avy does tantalize us with the observation, "Many other persons have respired the gas, but as their accounts contain nothing unnoticed in the details, it is useless to particularize them."26 Did Polwhele know something about attendance at the gas respirations that we don't?

The poem consists of a prose introduction, an opening monologue by Beddoes, and statements by the five characters while under the influence of nitrous oxide. The introduction links Beddoes with Darwin and Godwin. Beddoes is "combining in his own great and comprehensive mind, the theories of Darwin and Godwin; and applying his dephlogisticated nitrous gas to the purposes of both these phi losophers . . . " Not only is Beddoes tainted by this association with radicals; he is also depicted as undermining serious intellects. In his monologue, Beddoes says he tried the gas "on a learned society.";

. . . . each was as light as a feather: And they, every one, cried it was a plea

sure exta tic To drink deep draughts of the mighty

pneumatic. As if by a wizard entranced, How wildly they shouted, and gambol'd

and danc'd Such behavior was apparently associ

ated by contemporaries with the research taking place at the Pneumatic Institution, and is entirely probable, given the light levels of gas patients and volunteers were inhaling.

S tatements in the poem by the other participants reinforce this portrait of silliness and loss of control being developed by the author. Dyer notes, "I have drawn the nitrous gas / O! I know not where I am! / Sure, I am not what I was." Reverend Barbauld proclaims, "My frisky spirits are all spent at once,/ And in the sad residuum leave-a dance!" His wife Anna declares that breathing nitrous oxide is "sweeter far

that inhalation, / Sweeter than the breath of fame." Robert Southey is depicted as ascending to the stars:

. . . I spurn, I spurn This cumbrous clod of earth. .

. . . and from star to star still gliding. . . Ingulph the dephlogisticated floods of life and riot in immortal Gas! Beddoes himself is depicted as an ego-

maniac: "And in me, with loud plaudits, the people shall own/ A discovery to shame the Philosopher's Stone . . . "

Thus Polwhele has depicted a group of radical thinkers making themselves ridiculous by nitrous oxide inhalation. This supposed scientific advance, promoted by Beddoes for years, is also explicitly associated with political radicalism near the end of the poem. After all the participants inhale and dance again, they sing:

Then hail, happy days! when the high and the low,

All nourish'd alike, from this air-hospitality

Shall together with Gas-born benevolence glow,

And prove, that true bliss must arise from equality.

In order to depict these events, Polwhele must have had inside information about events at the Pneumatic Ins t i tution . Beddoes' pamphlet naturally portrays the research in a serious tone. Interestingly, Davy, Coleridge and others are discussed in Beddoes' work, but not in the poem. Perhaps Polwhele chose the best known participants for his characters, although that could still not explain Dyer's presence.

Another relevant work also appeared in 1 800, the anonymous The ScepticY This item is a meditation on "The Birth of Wonders!" in which the author declares, "I have no doubt of being able to convince you that this is a day of great things! - an Era big with wonders; - Some of which are already brought to light!. . . The most redoubtable of this birth was baptis'd Reyolution . . . " Further attacks are made on the work of Franz Mesmer, Antoine Lavoisier, and the "Quacks-Pneumatic." Those "bladder conjurers" are branded pimps whose female patients, "if certain innuendo's have foundation", have become pregnant. One of these characters is a Dr. Thistleton, whose lengthy medical publications are plagiarized extracts from other authors-a clear attack on Beddoes, whose numerous medical publications in the 179.os contained extensive extracts of letters from fellow physicians describing their cases of gas inhalation treatment. Dr. Thistleton was a member of the group that "brew quantities of air, or gase£ as they call them. . . which

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they retail by the bladder-full; and like the quacks of the old school. . . they publish wonderful accounts of wonderful cures, effected by breathing so many bladders full of air a day." The anonymous author does concede that gas inhalation may have some benefit, but "With respect to their speculations and their theories; so long as they are devoid of principles, and abundant in inconsistencies and absurdities, I must beg leave to remain as usual, a sceptic." The only real individuals from the nitrous oxide story who appear in this account are Davy and Count Rumford. Rumford, who had founded the Royal Institution in 1799, invited Davy to join him in London, which Davy did in March 1 801 . Rumford was apparently impressed with Davy's published account of the Bristol experiments.

One of the most biting attacks on the nitrous oxide experiments of this period is James Gillray's famous caricature. This 1 802 engraving depicts a nitrous oxide demonstration at the Royal Institution and is entitled, "Scientific Researches! New Discoveries in Pneumaticksl or, an Experimental Lecture on the Powers of Air." A satanic-looking Davy holds a bellows and presides over the scene. Dr. Garnet administers the gas to Sir J.C. Hippesley, who is suffering a monstrous case of flatulence as a result . Visible in the room are Count Rumford, D'Israeli , Earl Gower, Lord Stanhope, Earl Pomfret and Sir Henry Englefield.28 This depiction must have been especially painful to Davy, who was just beginning his rise to incredible fame and scientific success at the Institution; and may have been the reason why Davy ceased nitrous oxide demonstrations within a year or so after moving to London in March 1 801 .

In the first decade of the nineteenth century, American poet and author Thomas Green Fessenden (1771-1837) spent several years in London. During his stay he published a long poem satirizing many of the medical and scientific advances of the day. First published asA Poetical Petition Against Tractorixing Trumpery, Fessenden's poem has a tortured publication history through numerous editions and under various titles, but was still being issued in 1837, the year he died. It is this work attacking the nitrous oxide experiments that Philadelphian William Barton, who attempted in 1 806 to replicate Davy's experiments, mentions in his medical school dissertation.28

Fessenden's poem contains a long prose introduction that is primarily an attack on Perkinism, a medical fad of the day involving metallic tractors-thus Fessenden's original title. The first of four cantos in the poem is a sustained attack on Beddoes'

work, featuring lengthy footnotes that often occupy most of the page. The narrator of the poem declares, "I've found a substitute for wit. . . Beddoes (bless the good doctor) has / sent me a bag full of his gas, / which, snuff'd the nose up, makes with brighter, / And eke a dance an airy writer."

This precious gas, sirs, is the pink Of pure philosophy,-the link With which great metaphysicians bind To worlds of matter worlds of mind. The narrator declares he will "follow

Southey's bold example" and breathe the gas. The effects in this satiric context are predictable:

Inflated with supreme intensity, I fill three quarters of immensity! Should Phebus come this way, no doubt, But I could blow his candle out!

This earth's a little dirty planet, And I'll no longer help to man it. 30 In his footnotes Fessenden refers to

Priestley and Darwin several times and quotes extensively from Davy's book.

These three publications and Gillray's caricature constitute a sustained contemporary attack on efforts at political, medical and scientific progress. In his brilliant account of British chemistry during this period, Golinski describes the situation. "In a climate that was increasingly unfavorable to Beddoes' enlightened aspirations, the experiences of the Bristol group appeared to many as the shared delusions of an isolated religious sect. . . in the three decades thereafter, nitrous oxide became the material of public entertainment, rather than of serious medical research."3! Public knowledge of nitrous oxide did not have an auspicious beginning.

In 18 14, Philadelphian Moses Thomas published a pamphlet in which he used events at a public nitrous oxide demonstration to poke fun at political events in the United S tates. Thomas' work contains lengthy descriptions of the preparation and chemistry of nitrous oxide, as well as a long account that may be the first published reference to such a demonstration in the United States. The ending of Thomas' pamphlet makes explicit his concerns. "It appeared to me as though the United States of America, in congress assembled, had inhaled an imprudent portion of the exhilarating gas . . . It grieves me to expose the nakedness of my country-in a state of political intoxication . . . "32 Linking political conditions to the state of mind produced by nitrous oxide inhalation was a useful tactic in America, too.

One of the strangest appearances of nitrous oxide in a satiric work was published in 1 820. Doctor Syntax in Paris was one of


m any imitations using the peripatetic schoolmaster created in 1 809 by William Combe and others.33 The work includes an illustration and a long poem depicting the usual antics induced by nitrous oxide inhalation. However, this account also describes the relief of a toothache by the gas inhalation, a phenomenon also noted by Davy. This poem has been reprinted and extensively analyzed by Smith.34

Beginning in the 1 830s, other types of satire appeared. "Laughing Gas" is a comic song written by W.H. Freeman.35 The song lyrics describe "Poor Jeremy Jones," a man racked with grief, who "swallowed a bladder of laughing gas . . . [and] convulsed with Laughter, he homeward goes ! " A comic engraving by George Cruikshank depicting a public demonstration of gas inhalation appeared as the frontispiece of an 1 839 monograph; why this image is the only illustration in John Scoffern's serious chemistry text remains a mystery.36 In the 1 860s another song appeared, "Laughing Gas, or, A Night at the Polytechnic." Written by John Nash, the song tells the story of "Young Humphrey Brown" who falls asleep in the lecture hall, awakes to find himself alone and sees a glass beaker marked "Improved Laughing Gas. "37 Depiction of nitrous oxide inhalation for comedic effect has continued in modern times in the form of L. Todd's "underground' comic, "Dr. Atomic Tells How to Make and Use Nitrous Oxide."38

S atiric portrayals of physicians and medical practice h ave been a staple of popular culture for centuries. The long eighteenth century is particularly rich in such materials, ranging from Swift in Gulliver's Travels to Voltaire in Candide, Glyster in A Dose for Doctors and the caricatures of Hogarth and Rowlandson.3942 In this context the satiric portrayals involving nitrous oxide are embedded.

By the spring of 1 800 the gas trials in Bristol had ceased. The research seemed to be leading nowhere; consumptive and other patients were not getting better and the experiments attracted increasing ridicule from Beddoes' political opponents. In the summer Davy's book appeared, but after a few more months at the Institution he fled to London and over two decades of increasing fame and fortune. Beddoes kept the facili ty open a few more years as a clinic and even published two more articles on nitrous oxide.4344 His political radicalism ceased, and he spent the few remaining years of his life primarily in public health areas. A few attempts were made in London to replicate the nitrous oxide work, and



Satires. . . Continued from Page 1 7

James Woodhouse and Wil liam Barton pursued the matter in America later in the decade.4

Knowledge of nitrous oxide slipped into a sort of suspended animation. The Bristol group had established that inhalation of the gas by humans was safe and had designed and tested elaborate equipment for that purpose. Davy speculated on the relief of surgical pain by gas inhalation. The next leap never occurred; however, a wall of rid icule stood in the way.

Yet the information about the manufacture and psychological effects of nitrous oxide survived in subsequent decades in a variety of ways. Chemistry professors gave classroom demonstrations; and itinerant showmen toured America and England providing entertainment and information to local audiences. Medical and chemistry textbooks usually included some information about nitrous oxide, and often mentioned Davy's work.4 These forms of popular and professional knowledge thus provided a bridge over the satires, and brought nitrous oxide to Hartford, Connecticut, on that fateful night in December 1 844, when young dentist Horace Wells attended just such a public demonstration and had a brilliant idea-the same one Davy had expressed four-and-a-half decades earlier.

References 1. Davy H. Respirability of the gaseous oxyd of

azote. Nicholson's Journal of Natural, Philosophical and Chemical Arts 3:93, 1799.

2. Davy H. Researches, Chemical and Philosophical: Chiefly concerning Nitrous Oxide . . . London: J. Johnson, 1 800.

3. Wright AJ. Humphry Davy's small circle of Bristol friends. Middle East J Anesthesiol (in press).

4. Wright AJ. D avy comes to America: Woodhouse, Barton and the nitrous oxide crossing. J Clin Anesth 7:347-355, 1995.

5. Wright AJ. Diffusion of an innovation: the first public demonstrations of ether anesthesia. Middle East J Anesthesiol 1 1 :93-1 18, 1991.

6. Priestley J. Experiments and Observations on Different Kinds of Air. 6 vols. London: J. Johnson, 1 774-1786.

7. Mitchell SL. Remarks on the Gaseous Oxyd of Azote or of Nitrogene, etc. New York: T. & J. Swords, 1795.

8. Mitchell SL. T he doctrine of Septon. Medical Repository 1: 1 83-186, 1797.

9. Stansfield DA. T homas Beddoes, M.D., 1 760-1 808. Dordrecht: D. Reidel, 1984.

1 0. Porter R. Doctor of Society: T homas Beddoes and the Sick Trade in Late-Enlightenment England. London: Routledge, 1992.

1 1 . Beddoes T, Watt J. Considerations on the Medicinal Use of factitious Airs and on the Manner of Obtaining T hem in Large Quantities. London: J. Johnson, 1794.

12. Watt J. Supplement to the Description of a Pneumatic Apparatus, for Preparing Factitious Airs; Containing a Description of a Simplified Apparatus, and of a Portable Apparatus. Birmingham: T. Pearson, 1 796.

13 . Beddoes T. Suggestions Towards Setting on

Foot the Projected Establishment for Pneumatic Medicine. Bristol: Biggs and Cottle, 1 797.

14. Beddoes T, Watt J. Considerations on the Medicinal Use and Production of Factitious Airs. Part III. Second Edition, Corrected and Enlarged. London, J. Johnson, 1796, 177-178.

15. Knight D. Humphry Davy: Science and Power. Oxford: Blackwell, 1992.

16. Beddoes T. A Letter to Dr. Darwin, on a New Method of Treating Pulmonary Consumption and Some Other Diseases Hitherto found Incurable . . . Bristol: Bulgin and Rosser, 1793.

17. Anon. T he Golden Age, a Poetical Epistle from Erasmus D N, M. D ., to T homas Beddoes, M.D. London: Rivrngton and Cooke, 1794.

18 . King-Hele D. Doctor of Revolution: T he Life and Genius of Erasmus Darwin. London: Faber and Faber, 1 977, p. 250.

19. Edmonds C, ed. Poetry of the Anti-Jacobin. New York: G.P. Putnam's Sons, 1890, 242-243, 247.

20. Beddoes T. Notice of Some Observations Made at the Medical Pneumatic Institution. Bristol: Longman and Rees, 1799.

2 1 . Stansfield DA. T homas Beddoes, M.D., 1 76 0 - 1 808: Chemist, Physician, Democrat. Dordrecht: D. Reidel, 1984, p. 130.

22. Polwhele R. T he pneumatic revellers: an ecologue. Anti-Jacobin Review and Magazine 6:109-1 1 8, 1 800.

2 3 . Lorraine de Montluzin E. T he AntiJacobins, 1798-1800: T he Early Contributors to the Anti-Jacobin Review. New York: St. Martin's Press, 1988, pp. 129-132.

24. Cottle J. Reminiscences of Samuel Taylor Coleridge and Robert Southey. New York: Wiley and Putnam, 1 847, p. 243.

25. Barry FV. Maria Edgeworth: Chosen Letters. Boston: Houghton Mifflin, 1931, pp. 152, 360-364.

26. Davy H. Researches . . . op. cit., p. 536. 27. T he Sceptic. Retfordi E. Peart, 1 800, pp. I

l l, 57-67. 28. Wright T, Evans RN. Account of the carica

tures of James Gillray. New York: Benjamin Blom, 1968, pp. 468-469.

2 9 . Barton WPC. A D issertation on the Chymical Properties and Exhilarating Effects of Nitrous Oxide Gas; and Its Application to Pneumatick Medicine. Philadelphia, Lorenzo Press, 1 808; xiii-xiv.

30. Fessenden T G. T he Modern Philosopher: Or, Terrible Tractorationl 2nd American ed., rev., cor., and much enlarged. Philadelphia: Lorenzo Press/E. Bronson, 1 806, pp. 3-6, 12-13.

31 . Golinski J. Science as Public Culture: Chemistry and Enlightenment in Britain, 1760-1820. Cambridge & Cambridge University Press, 1 992, pp. 1 70 and 175.

32. T homas M. A Cursory Glimpse of the State of the Nation: On the Twenty Second of February, 1 814 . . . or, a Physio-Politico-Theologico, Lucubration Upon the Wonderful Properties of Nitrous Oxide. Philadelphia, J Maxwell, 1 8 14. Rep. Shedlin M, Wallachinsky D (eds): Laughing Gas. San Francisco. And/Or Press, 1973;82-89.

33. Hamilton HW. Doctor Syntax: A Silhouette of William Comb, Esq. (1742-1823). Kent State University Press, 1969.

34. Smith WDA. Under the Influence: A History of Nitrous Oxide and Oxygen Anaesthesia. London: Macmillan, 1982, pp. 43-5 1 .

35. Freeman WA. Laughing Gas. Words and music. Wellcome Institute for the History of Medicine. Different cover sheets reprinted in Smith WDA, Under the Influence, p. 36 and Melin BW, Discovery of Anesthesia. J Colorado Dent Assoc 72(2):16-18, October 1993.

36. Scoffern J. Chemistry No Mystery; or a lecturer's bequest. London, 1 839. Reproduced in Smith WDA, Under the Influence, p . 36.

37. Nash J. Laughing Gas, or, A Night at the Polytechnic. Wellcome Institute for the History of Medicine. Cover reproduced in Smith WDA, Under the Influence, p. 38.

38. Shedlin M, Wallechinsky D, eds. Laughing

GaslNitrous Oxide. San Francisco: And/or Press, . 1973, pp. 48-51.

39. Papper EM. Satire of medicine: the 1 8th century and beyond. J Roy Soc Med 83:524-528, 1 990.

40. Glyster G. A Dose for Doctors. London, 1 789.

41. Wagner P. T he satire on doctors in Hogarth's graphic works. In: Roberts MM, Porter R, eds. Literature and Medicine during the Eighteenth Century. London: Routledge, 1993, pp. 200-225.

42. Butterfield WC. T he medical caricatures of T homas Rowlandson. JAMA 224:113-117, 1973.

43. Beddoes T. On the experiments made at the Royal Institution with the nitrous oxide. Nicholson's Journal of Natural, Philosophical and Chemical Arts 4:75-76, 1 80 1 .

44. Beddoes T. Facts and observations on the medical respiration of gaseous oxide of azote. Nicholson's Journal of Natural, Philosophical and Chemical Arts 13:1 1-16, 1 806.

Dr. Elam . . . Continued from Page 12

3. Personal communication, Elwyn S. Brown, MD.

4. Flower RC. Rapid infrared gas analyzer. Rev Sci Instrum 1 949;20:175.

5. Luft K Methode der registrieren gas Analyse mit Hilfe der Absorption ultraroten Strahlen ohne spectrale Zerlegung. Z Tech Phys 1 943;24:97.

6. Adriani J, Rovenstine EA. Experimental studies on carbon dioxide absorption for anesthesia. Anesthesiology 1941;2:1 .

7. Brown ES. Factors affecting the performance of absorbents. Anesthesiology 1959;20:198.

8. Brown ES, Bakamjian V, Seniff AM. Performance of absorbents: effects of moisture. Anesthesiology 1959;20:613.

9. Elam JO. Channeling and overpacking in carbon dioxide absorbers. Anesthesiology 1958;19:403.

10. Personal communication, James O. Elam, MD.

1 1 . Elam JO, Brown ES, Janney CS. Ventilator. Anesthesiology 1956;17:504-517.

12. Jude JA. Origins and evolvement of cardiopulmonary resuscitation. In: Atkinson RS,Boulton T B, eds. T he history of anesthesia. New York: T he Parthenon Publishing Group, 1989:452.

13 . Personal communication, James O. Elam, MD, and Elwyn S. Brown, MD.

14. Elam JO, Brown ES, Elder JD. Artificial respiration by mouth to mask method, a study of the respiratory gas exchange of paralyzed patients ventilated by operator's expired air. N Engl J Med 1 954;259:1954.

15. Elam JO, Greene DG, Brown ES, Clements JA. Oxygen and carbon dioxide exchange and the energy cost of expired air resuscitation. JAMA 1958;167:328.

16. Rescue breathing: Albany, N.Y: New York State Department of Health, Health Education Services, N.Y

17. Personal communication, PS Klein. 18 . Letter from James 0. Elam to PauIM. Wood,

July 14,1959. In: T he collected papers of Paul M. Wood, M.D. T he collection of the Wood Library Museum of Anesthesiology, Park Ridge, Ill.

19. Elam JO, T itel JH, Feingold A, et al. Simplified airway management during anesthesia or resuscitation: A binasal pharyngeal system. Anesth Analg 1969;48:307.

20. Ruben HM, Knudsen EJ, Carugati G. Gastric inflation in relation to airway pressure. Acta Anaesth Scand 1961;5:107.

2 1 . Personal communication, James O. Elam, MD.

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Sir Humphry Davy The following delightful paper is a brief story of Sir Humphry Davy and his numerous contributions to medicine, chemistry and agriculture. Having just read I Awaken to Glory, a series of essays celebrating Horace Wflils and the Sesquicentennial of his discovery of Anaesthesia, edited by Richard J. Wolfe and the late Leonard R Menczer, one recognizes the important role which Davy played in promoting thoughts about the abolition of pain during surgery. Wfl are much indebted to Dr. Pring and to the Editor of the Proceedings of the History of Anaesthesia (15: 24-27, 1 994) for permission to reprint this paper. -Editor

Davy and the Blue Gas - or gases, vapours, and lots of hot air! by Dr. J. Pring Consultant Anaesthetist, Penzance

Let me start my talk by introducing you to Penzance-8 miles from Lands End, and 5 hours by train from London! Whether one approaches from the west-or the eastone would eventually notice the large dome above Lloyds Bank, and if one walks up Market Jew Street towards the bank, one will soon reach the statue of Penzance's most famous son, S ir Humphry Davy. Davy was born in Penzance on 17th. December 1778, but a stone's throw from his statuein fact, if one looks over the shoulder, the plaque which commemorates his birthplace can be seen. Davy left school near his 16th birthday. His father died soon afterwards, leaving a number of debts, and Davy, as eldest son, had to choose a profession to help support the family. He was duly apprenticed to John Bingham Borlase, surgeon/apothecary and later physician in Penzance.

Just opposite Davy's statue is Peasgoods pharmacy, where that apprenticeship took place. According to Jim Saulter, the current owner of Peasgoods, Davy is reported to have blown up the cellar during the time he was there! On one of the windows in the lane at the side of the shop, one can see a picture of Davy hard at work I This may not be an accurate representation of fact, but it interests the tourists and is good for business, so Jim Saulter's happy!

At 17 years of age Davy began seriously to educate himself-theology, geography, languages, physics, mathematics, and at 19 chemistry, reading Lavoisier's Traite Elementaire in French. As B ingham Borlase's apprentice, Davy undertook "not to play any unlawful games whereby his said master may have any loss, nor haunt Taverns and Playhouses . . . "

However, just round the corner from Peasgoods, in the Green Market, is the S ir Humphry Davy pub, where Davy and his friend Albert Einstein put the finishing touches to the Theory of Relativity-and if you believe that you'll believe everything else I have to tell! In any case, I'm led to believe that the name of the pub only changed to the Sir Humphry Davy about

12 years ago (previously the St. John's House), and that it was built for the St. Austell brewery in the 1930s. More tourist folklore! Had Davy, who lived in what he called the dawn of modern chemistry-"the greatest chemist of his age" as the Swedish chemist Berzelius described him-been an anaesthetist, he would have shared John Snow's honour (as any Part 3 FRCA candidate will tell youl) of having a pub called after him . . . Anyway, look more closely at the pub sign, and one will see four itemsthe gear at the head of a pit, a miners lamp, some chemical apparatus, and a book. Now this is where the story really begins!

Joseph Priestley had i so la ted dephlogisticated air (later named oxygen by Lavoisier) in 1771, and nitrous oxide in 1772. In 1794, Thomas Beddoes founded the Pneumatic Institute in Bristol for the treatment of pulmonary tuberculosis and experimented with the therapeutic inhalation of gases and vapours. Davy's work on nitrous oxide had begun after reading a paper on it by Dr. Samuel Latham Mitchell, an American physician, who believed it to be the principle of contagion (i.e., a poison). Davy, by a "few coarse experiments", proved that this theory was incorrect. Dr. Beddoes had been reader in Chemistry at Oxford, and had read Davy's essays and thought he recognised in Davy's experiments on heat and light and in his experiments on nitrous oxide, signs of an uncommon talent-he was soon convinced that here was a young man who could be of service to and who could be served by, the Pneumatic Medical Institution which he was seeking, with the aid of various subscribers, to establish in Clifton, to provide a laboratory for research, a theatre for lecturing and a hospital for patients. The whole scheme was experimental, of course. Davy was appointed superintendent in 1798. As Denis Smith states, if Davy ever made vital practical contributions towards the inhalational anaesthesia that was to come, they were his demonstration of nitrous oxide's respirability, his attention to its purity and his discovery of its analgesic

effect, having himself experienced the relief the gas gave to dental pain. Nitrous oxide's name, "laughing gas", is attributed to Davy.

Beddoes had established his clinic to investigate the curative powers of the newly-discovered gases, and it was fortunate that he first studied their effects on animals. He had been able to prepare and store oxygen, hydrogen, carbon dioxide, and hydrocarbonate or water gas, and had found that water gas (a mixture of hydrogen and carbon monoxide) killed a pigeon very quickly when mixed with one-third its volume of air. Used in dilution, patients complained of vertigo. Later, when Davy inhaled it undiluted, he had a narrow escape from death and gave a graphic description of how ill he felt. Davy produced his nitrous oxide by heating ammonium nitrate, as it is still manufactured nowadays, but even in 1 800 he was aware that at high temperatures water, nitrous acid, nitric oxide and nitrogen could be formed. He inhaled nitrous oxide in its pure form on a number of occasions and experienced a "fullness of the heart accompanied by loss of distinct sensation and of voluntary power". Recovery was swift " . . . in 10 minutes he had recovered his natural state of mind". In January, 1 800, he published a 580-page volume titled Researches chemical and philosophical, chiefly concerning NP, or dephlogisticated nitrous air, and its respiration.

The poet Southey described Davy's gas as that " . . . which excites all possible mental and muscular energy, and ;l1duces almost a delirium of pleasurable sensrtions without any subsequent dejection . . . Davy has invented a new pleasure for which language has no name. I am going for more this evening, it makes me strong and happy." Davy and his colleagues experimented by breathing the gases themselves, and his conclusions on the use of inhaling nitrous oxide are temperately stated: ''As nitrous oxide in its extensive operation appears capable of destroying physical pain, it may probably be used with advan-



Blue Gas . . . Continued from Page 1 9

tage during surgical operations in which no great effusion of blood takes place."

Henry Hill Hickman in 1 824 had the idea of respiring a gas to render the individual insensible-he used animals-to enable an operation to be performed. Unfortunately he chose the wrong gas-carbon dioxide! Davy on the other hand chose the right gas, but did not make the most of it.

It was a pity that a practical means of anaesthesia was not what Beddoes and Davy were seeking, and that it was left to Horace Wells to introduce nitrous oxide inhalation to produce anaesthesia during dental extraction. In 1 844, when Wells was laughed out of the Harvard Medical School after the patient complained of pain during a demonstration with nitrous oxide, it may be that Wells' misfortunes stemmed as much from the use of impure nitrous oxide (prepared and used in strange surroundings) or from the use of an ill-fitting mask, as from having removed the mask too soon.

The year 1 801 marked the beginning of a major phase in Davy's life when he was appointed to the Royal Institution in London. He conducted original research in galvanism and electrochemistry, which resulted in the discovery of sodium and potassium, a discovery which he announced in his Second Bakerian Lecture to the Royal Society in 1 807. The lecture caused a great sensation, and his next new course on electrochemistry was crowded. By further experimentation Davy showed that four more metals existed-calcium, barium, strontium and magnesium. One of the attendees at Davy's lectures was a young Michael Faraday. In 1 8 1 3 Davy's eye had been inj ured by an explosion of nitrogen chloride, and Faraday acted as Davy's secretary for some days. A few weeks later, following the dismissal of a lab assistant, D avy sent for Faraday and offered him the post. It has been said that Michael Faraday was Davy's greatest discovery. A course of Davy's lectures for the Board of Agriculture-on the connection of chemistry with vegetable physiology, part of a wide effort to convert farming "from a mere art of blind processes into a rational system of science"-was eventually published in 1 8 13 under the title Elements of Agricultural Chemistry (Pub sign again). The book dealt with plant physiology, soils and soil analysis, as well as with the improvement of land by burning, irrigation, fallowing, rotation of crops, and with grassland.

On the left of the sign is what most people associate with Davy-his lamp-

and immediately we are back onto gases and vapours! One of the problems with gases ( Cl2 and N02 excepted) is that they're invisible-and just such gases are methane (fire-damp or marsh gas) and its aftermath "choke damp" or CO2, Methane was not found in the Cornish tin mines, but it was-and is-a problem in coal mines. For flammability or an explosion one needs a fuel, an oxidant, and a source of ignition (the miners' lamps or candles). The steel flint mill invented by Charles Spedding around 1 740 produced a feeble shower of sparks, and not much light, but insufficient heat to explode fire-damp as a rule. If there was a reason in a pit to believe fire-damp was a problem, a "fireman" was sent in-some lucky miner swathed in damp sacking as protective clothing, with a candle on the end of a very long pole to push cautiously around corners! Better ventilation was not the answer, and as demand for coal increased so the mines were going deeper, and the dark galleries became longer. Explosions became increasingly frequent and caused considerable loss of life. It was some three years after an explosion at Felling Colliery, near Sunderland, in 1 8 12, when 92 pitmen were killed, that Davy's aid was positively invited to help solve this problem. Davy found that the flame of an explosive mixture of coal gas and air would pass along a tube 1/4" in diameter, but when the diameter of the tube was decreased to 1/7" he could not make the mixture explode, even though coal gas was more explosive than fire-damp. He also found that flames passed more readily through glass than metal tubes of the same diameter, due to the cooling effect of the metal. He found too that the explosion would not pass through fine wire gauze (which is in effect a bundle of narrow bore tubes of extremely short length) . S afety depended too on the fineness of the meshwith less than 576 apertures/square inch (24 squared-shades of 4 and 8 mesh soda lime!), an explosion occurred when the gauze became red hot towards the top. I visited the Camborne School of Mines recently, and photographed a later modification of "a Davy". When the explosive mixture is entering at the lower end of the gauze cylinder, the metal is not hot enough to cause inflammation, whilst at the top an inert mixture of burnt gases is passing out.

In On the Safety Lamp; with some Researches on Flame, Davy had stated : "In plunging a light surrounded by a cylinder of fine wire-gauze onto an explosive mixture, I saw the whole cylinder become quietly and gradually filled with flame; the upper part of it soon appeared red hot; yet

no explosion occurred". The wire gauze lamps, which were ready by January 1 8 1 6, not only gave protection, but acted as de- I

tect9rs, for they burned more brightly at the approach of danger. You could also see to work by them! Davy had warned that there was no hazard except in exposing the lamp to a strong current, when there was a risk of passing the flame through the gauze. The remedy?-a tin screen, which slides upon the frame-wires of the lamp, and encircles the circumference of the gauze cylinder to an extent of about 1/2 to 1/3 of its circumference. There were still explosions-lamps might be damaged in a rock fall, and sometimes proper care of the lamps was not taken and damaged wire gauzes were not replaced.

The Cornish tin miners risked being i killed by underground explosions (gunpowder or dynamite), roof and rock falls, falling miners (as in "down the mine shaft" ! !), breaching flooded workings, and machinery accidents-as well as from fire. The tin miners used to carry naked candles on their helmets for illumination. Carelessly discarded candle ends-or a candle holder stuck into a piece of timber, occasionally caused fires, and the added hazard of smoke and oxygen lack. A rare type of gas explosion in Cornwall was caused by the accumulation of pockets of fire-damp in underground workings, produced by the decay of old timbers. At Ding Dong mine in 1 868, workmen were reopening a section which had been abandoned about 20 years before, when a violent explosion accompanied by a blue flame threw two of them down and severely scalded them. Three days later a managing agent caused a second explosion by inserting a candle fixed to the end of a long pole (nowadays of course we'd send an SHO in . . . 1) After a third explosion (fast learners!) when somebody carrying a naked candle entered the mine, no one was allowed to enter until Davy lamps had been procured-"whose flames were elongated and surrounded by flickering blue haloes".

Miners used the term "foul air" to describe polluted atmospheres encountered underground and this has led to a number of casualties. The introduction of the compressed air drill in the 1 870s and the 1880s was the mining equivalent of the Sander's injector! Prior to that, ventilation of mines left much to be desired, and there were many "ends" where a candle would not burn and a man could easily be rendered unconscious or even die through lack of oxygen. In blind tunnels there might be raised carbon dioxide levels-a School of


As We May Sleep : Anesthesia and the Popular Imagination

A.J. wright, MLS

Clinical Librarian, Department of Anesthesiology, University of Alabama at Birmingham

Introduction The Bulletin editorial team of Drs. C.R.

Stephen and Doris K. Cope have offered me the opportunity to indulge an obsession. For a number of years I have collected material from that rather strange intersection between anesthetic practice and popular culture-a place where a muscle relaxant becomes the murder weapon in a mystery novel; where an anesthesiologist can be a major fictional character; and where a cute robot is one movie's futuristic vision of computer-controlled anesthesia.

Over the past twelve years as librarian in a large academic department, I have learned more than most "laymen" can about late twentieth-century anesthetic practice. The tutelage of chairmen Drs. Ed Ernst, Simon Gelman, Paul Samuelson and David Chestnut has provided a window on the clinical day-to-day, the technical jargon, medical specialty education and the research environment. Yet what also fascinates me about the specialty and its history are the fringe areas that might interest any layman-the eccentric characters, from Humphry Davy to Benjamin Paul Blood;1,2 the eye-popping variety of equipment from past to present;3 the penchant for self-experimentation among anesthesia researchers;4,s and the cross-pollination between an almost-invisible-to-the-public medical specialty and popular culture.6,7

What is popular culture? Over the past four decades the term has characterized an academic growth industry. From his base at the Center for the Study of Popular Culture at Ohio's Bowling Green State University, Ray Browne has almost singlehandedly created a legitimacy to the search for meaning in everything from Mickey Mouse to dime novel portrayals of nineteenth-century train robbers.8 Browne's efforts have spawned national and regional organizations, numerous journals, a publishing house and a grudging respect among many outsiders for this sort of academic study. What is popular culture? The answer seems to be at the junction of folk culture and industrialization-i.e. , where the "common" man's activities meet the mass meJia.

In his classic dissertation of the late 1940s, sociologist Dan Lortie described anesthesiologists as "doctors without pa-

tients".9 He noted the efforts of the specialty to organize and gain legitimacy in the eyes of other physicians. Today the specialty is both a highly organized and legitimate one within medicine, but for the most part anesthesiologists remain little-known to the general public. Yet the presence of anesthetic administration, its pharmacologic agents and practitioners has a rich history in the popular culture of both the previous and current centuries. As we approach the 150th anniversary of Morton's first public demonstration in October 1 846, as well as the start of a new century and millennium, perhaps it is time to take a reading of anesthesia's presence in the public sphere.

In a series of columns over the next several years, I propose to examine aspects of this subject in some detail. In the next column I will attempt an overview of popular culture and medicine generally to give this discussion some context and background. Then I would like to examine how anesthesia has made the "news" during this century-everything from the late 1940s New Yorker profile of Dr. Emory Rovenstine to the appearance of ASA President Dr. Bernard Wetchler on the "Phil Donahue" syndicated television program and the "Day One" expose of anesthesia's dangers. From that base I will move on to such genres as film, television, fiction, drama and so forth.

The title for this series of columns is a transmutation of the famous essay published in the Atlantic Monthly just after World War II. In that work, ''As We May Think", Vannever Bush outlined what has become the field of artificial intelligence. Since much of the general public views general anesthesia as a sort of artificial sleep, I think this title is appropriate. I look forward to the comments of readers as this series develops, and again thank Drs. Stephen and Cope for this chance to indulge myself.

References 1 . Wright AJ. Humphry Davy's small circle

of Bristol friends. Middle East J Anesthesiol (in press).

2. Wright AJ. Benj a m i n Paul B l o od: anesthesia's philosopher-mystic. In: Fink BR, Morris LE, Stephen CR, eds. The History of Anaesthesia: Proceedings of the Third International Symposium. Park Ridge, III.: Wood Library Museum of Anesthesiology, 1993, pp 447-456.


3 . T homas KB. The Development of Anaesthetic Apparatus. Oxford: Blackwell, 1 975.

4. Wright AJ . Self-experimentation in anesthesia: a preliminary inventory. Middle East J Anesthesiol 1 2:43 1 -442, 1 994.

5. Wright AJ. Self-experimentation in anesthesia: an update. ASA Newsletter (in press).

6. Wright AJ. Anesthesia and the popular imagination: a preliminary inquiry. Anesthesiology 79:AI032, 1 993.

7. Wright AJ. Anesthesia and the popular imagination: a preliminary inquiry. Presented at the Anesthesia History Association annual meeting, May 1 993.

8 . Wright AJ. "The Alabama wolf ": Rube Burrow's appearance in three dime novels. Quarterly of the National Association for Outlaw and Lawman History 1 6(2) :25-33, 1992.

9. Lortie DC. Doctors without Patients: T he Anesthesiologist-A New Medical Specialist. Masters thesis, University of Chicago, 1 949.

10. Bush V. As we may think.Atlantic Montllly 1 76: 1 0 1 -1 08, 1 945.

Blue Gas. . . Continued from Page 20

Mines student was killed like this in recent times. There was an interesting article in the British Medical Journal last year on the " S tythe gas" or "choke damp" in Nottinghamshire-a lady moved into a new house on a rainy day and found neither her gas fire nor cigarette lighter would work. With changes in atmospheric pressure mines "breathe", releasing carbon dioxide produced by decomposing timber underground-in this case maximum ambient CO2 concentrations of 7 .05 %-and 02 down to 8-9% (in the cupboard under the lady's kitchen sink!)-were recorded.

Let's finish with a final glimpse of Humphry Davy again-the plaque at the base of his statue sums it all up, doesn't i t?-outstanding scien tist and electrochemistwho discovered a number of important elements, made a major contribution to miners' safety when he invented the lamp-which he refused to patent incidentally, initiated work on the "blue gas" (NP), presented a major treatise on agricultural chemistry, refuted the myth that all acids contained oxygen, more than helped the fortunes of the Royal Institution, and "discovered" Michael Faraday. However, one ends with a mild criticism of Davy-pictured next to his statue is a man selling balloons, filled with helium, isolated by Ramsey in 1 895. Davy should have called THAT "laughing gas"! !

22 BUllETIN OF ANESTHESIA HISTORY

A General Practitioner Uses His Head An early application of oxygen therapy is described in the following article by Mr. Rick Bromer, Editor of Old News, to whom we are indebted for permission to reprint it (UJI. 6, No. 11). Old News, published nine times per year, may be obtained ($15.00 annually) by writing to 400 Stacks town Road, Marietta, PA 17547-9300. -Editor

Oxygen Therapy Tested by Rick Bramer

In March of 1 885, a sixteen-year-old boy named Fred Gable fell ill. "I can't breathe," he told his parents. Fred began panting at the rate of eighty breaths per minute, but he fel t that he was suffocating. His complexion turned blue. His body was wracked by chi l ls, and his spit t le was sta ined with rust-colored blood.

Fred lived with his parents on a small farm in York County, Pennsylvania. The only physician in the neighborhood was D r. George E. Holtza p p l e , who was twenty-two years old, and so new to his p rofession that he had not yet saved enough money to buy a satchel . Summoned to the Gable farm on March 6, Dr. Holtzapple diagnosed Fred's disease as lobar pneumonia.

Because antibiotics had not yet been discovered in 1 8 85, there was no effective treatment for pneumonia. Fred Gable was suffering from a bacterial form of pneumonia which causes the lungs to bleed, literally drowning the patient in his own blood. Fred's only hope of survival therefore lay in will -power and lungpower. H e had to somehow find the s trength to keep breathing until the disease ran its course, a process that took anywhere from a week to thirty days.

Dr. Holtzapple was a modest, straightforward young man. He told Fred's parents that there was no cure for pneumonia, that he expected their son to die, and that any treatment he attempted might cause Fred more suffering than it was worth. Mr. and Mrs. Gable asked him to simply do his best.

Having no other gravely ill patients to attend that day, Dr. Holtzapple decided to spend the rest of March 6 at Fred's bedside, giving the boy whatever psychological encouragement he could. He knew that Fred's state of mind would become vitally important at the "crisis" of the illness, the moment when the effort of breathing through blood-clogged lungs became so unbearable that most patients simply quit trying.

But any hope that Fred might fight his way through the crisis seemed to vanish

when the boy said, "Doctor, if you d on' t g i v e me something to breathe, I'm going to stop."

Fred's request for "something to breathe" set Dr. Hol tzapple to th inking about c h e m i s try. (He had not learned any chemistry in medica l school, because anatomy was the only science that physic i a n s were required to study in 1 885, but chemistry was one of Dr. H o l t z a p p l e ' s many hobbies. He h a d s tudied chemistry in h is spare time, for the fun o f i t . ) Dr . Hol tzapple rec a l l e d reading about the experiments of Joseph Priestley, the discoverer of oxygen. Pr ies t l ey h a d found t h a t a mouse could survive for half an hour in a sealed jar full of oxygen-enriched air, although a mouse would die after five minutes in a sealed j ar containing ordinary air.

It occurred to Dr. Holtzapple that, if he contrived to give Fred Gable a dose of pure oxygen, the boy might be able to breathe more easily. On the other hand, the doctor knew of no experiments testing the effect of pure oxygen on humans.

Dr. Holtzapple explained his idea to Fred's parents, telling them that oxygen might ease Fred's suffering, allowing him to die more peacefully. He also warned Fred's parents that his idea was untested and dangerous: that oxygen might prove

poisonous in high concentration. The Gables, certain that their son was dying in any case, told the doctor to go ahead with his experiment.

After promising to give Fred "somet h i n g to b r e a th e , " Dr. H o l t z a p p l e hitched up a buggy a n d drove several m il e s to o b t a i n t h e e q u i p m e n t h e needed. When he returned, Fred was just barely alive.

What happened next was described in a report Dr. Holtzapple submitted to the Medical Society of York, Pennsylvania:

My patient begging me to relieve him from his labored respiration, I


.....

for wn tor

eIe al l e as

in �e

'ge

F

02 Therapy . . . Continued from Page 22

resolved to administer the very element he craved . . . I generated oxygen from chlorate of potassium and black oxide of manganese in large test tubes over a spirit l amp, and with rubber tubing I conducted the gas to the bottom of a b ucket fil l ed with water which I had placed beside the patient 's bed. Then, with a fan, the gas was wafted i nto the patient's face . . . The effects on the respiration and his color were distinctly appreciated by the parents and those around the bedside of the young man. I repeated the administration a number of times during the day until i t was no l onger needed . The pat ient

Dr. Morton. . . Continued from Page 1

possible variety of gunshot wound . . . " Morton also speaks of the wounded

soldiers going to the rear area and says "it is the most sickening sight of the war, this tide of the wounded flowing back. One has a shattered arm, and the sling in which he carried it is the same bloody rag the surgeon gave him the day of the battle; another has his head seamed and bandaged so you can scarcely see it, as he weaves like a drunken man as he drags along through the hot sun. . . "

Morton describes his involvement as an anesthetist and the organization of the triage system and the field hospital service, put in place by the Medical Director of the Army of the Potomac, Major Jonathan Letterman. Morton states that "On Saturday morning, May 14, I was awakened by the booming of cannon and learned that the enemy were endeavoring to regain their lost position . . . On the arrival of a train of ambulances at a field hospital the wounds were h astily examined, and those who could bear the j ourney were sent a t once to Fredericksburg. The nature of the operations to be performed on the others was then decided on and noted on a bit of paper pinned to the pillow or blanket under each patient's head. When this had

recovered rapidly.

Rather to h i s own astonishment , George E. Holtzapple, barely out of medical school, had disc-overed the first effective treatment for pneumoni a . Until Alexander Fleming's discovery of penicillin in 1 928, oxygen therapy remained the only effective treatment.

Among the thousands of l ives that were saved by Dr. Holtzapple's discovery was that of his own sister, Mrs. Mary S tover. When she caught pneumonia, he put her into an oxygen tent.

During World War I, portable oxygen tents at the front proved effective not only in treating pneumonia, but also in saving victims of poison gas attacks. Today, oxygen therapy is still used to save victims of shock, including surgical shock. It is also used to treat heart disease, se-

been done I prepared the patients for the knife,producing perfect anesthesia in an average time of 3 minutes [emphasis MSA], and the operators followed, performing operations with dexterous skill, while the dressers in their turn bound up the stumps. It is surprising to see with what dexterity and rapidity surgical operations were performed by scores in the same time really taken up with one case in peaceful regions. When I had finished my professional duties a t one hospital, I would ride to another, first arranging at what hour I would next return."

While there is no historical certainty as to the number of patients that Morton anesthetized during the Civil War, Rene Fulop-Miller states that Morton " . . . was able to save more than two thousand wounded so ldiers from the terr ib le agency of the knife."4 This therapy i s also echoed by Rachel Baker who said that "Following at the edge of battle, Morton gave ether to more than two thousand wounded men."5 There is a clue as to the potential number of patients anesthetized by Morton when he states in the introduction to his paper that "How little did I think, however, when originally experimenting with the properties of sulfuric ether on my own person, that I should


vere migraine, and a variety of other ailments.

Dr. Holtzapple made no money from his discovery, but he received a note of congratulations from King George V of England, and an honorary doctorate from S usquehanna Univers ity. The doc tor spent the rest of his life practicing medicine in rural York County, Pennsylvania. He was remembered there as a churchgoing family man who played a variety of musical instruments.

Dr. Holtzapple was nearly eighty-four when he died in York, Pennsylvania, on February 22, 1946. Standing at his bedside during the final days was Fred Gable, aged seventy-seven . Fred lived to be n inety-one . H e d ied i n 1 960 a t the Lutheran Home for the Aged in Washington, D.C.

ever successfully administer it to hundreds in one day, and thus prevent an amount of agony fearful to contemplate."

At the conclusion of Morton's paper he proclaims, "For myself, I am repaid for the anxiety and often wretchedness which I have experienced since I first discovered and introduced the anesthetic qualities of sulfuric ether by the consciousness that I h ave thus been the instrument of averting pain from thousands and thousands of maimed and lacerated heroes, who have calmly rested in a state of anesthesia while undergoing surgical operations, which would otherwise have given them intense torture. They are worthy of a nation's gratitude-happy I am to have alleviated their sufferings."

BIBLIOGRAPHY I. Morton WT G: T he first use of ether as

an anesthetic at the battle of the Wilderness in the Civil War. JAMA 42: 1 068-1 073, 1904.

2. Graham M, Skoch G, Davis WC: Great Battles of the Civil War. Beekman House, New York, 1978, pp 66.

3. McPherson JM: Battle Cry of Freedom. Ballantine, New York, 1 988, pp 904.

4. Fulop-Miller R: Triumph Over Pain. T he Literary Guild of America, New York, 1 938, pp 438 .

5 . Baker R: D r. Morton: Pioneer in the Use of Ether: Julian Messner, Inc., 1 946, pp 224.


WLM History Review: Spirits of Anesthesia SUBJECT: Anesthesia Organizations

The formation of a specialty depends on development of a clearly identified body of scientific and clinical material related to its practice. However, it also depends on the formation of organizations and societies where its members may meet to discuss medical, scientific and political issues. The references cited here describe some of the pe()ple and problems encountered during the early years of anesthesia, when it ceased being a branch of surgery and began to gain recognition as a specialty in its own right.

Books *Volpitto Pp, Vandam LD. The Genesis

of Contemporary American Anesthesiology. Springfield, Illinois: Charles C Thomas, 1982.

(See particularly Chapter 1 "Francis Hoeffer McMechan" [Seldon TH), Chapter 14 "Historical Development of the American Society of Anesthesiologists, Inc. " [Betcher AM}, and Chapter 15 "The American Board of Anesthesiology, Inc. " [Haugen FPJ)

*Wilson G. Fifty Years: The Australian

Bulletin of Anesthesia History

Society of Anaesthetists. Edgecliff, NSW: Australian Society of Anaesthetists, 1987.

Other Resources Several papers, some of them "classics,"

deal with the history of organizations dedicated to anesthesiology.

*Betcher AM, Ciliberti BJ, Wood PM, Wright LH. The jubilee year of organized anesthesia. Anesthesiology. 1 956; 1 7:226-264.

Betcher AM, Wright LH, Wood PM, Ciliberti BJ. The New York State story of anesthesiology, 1 807-1957. New York State Journal of Medicine. 195 8;58: 1,5661-572.

*Griffith HR. History of the World Federation of Anesthesiologists. Anesthesia and Analgesia. 1963;42:389-397.

*Bacon DR, Lema MJ. To define a specialty: a brief history of the American Board of Anesthesiology's first written examination. Journal of Clinical Anesthesiology.

C. Ronald Stephen, M.D., C.M., Newsletter Editor 1 5801 Harris Ridge Court Chesterfield, MO 6301 7 U.S .A.

1 992;4:489-497.

*Bacon DR. The promise of one great anesthesia society: the proposed merger of the American Society of Anesthetists and the International Anesthesia Research Society. Anesthesiology. 1994;80:929-935.

*Loan or photocopy available from i WLM. Compiled by Douglas R. Bacon, M.D.; Edited by Donald Caton, M.D.

"From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same. . . good Lord deliver us."

-Sir Robert Hutchison 1871-1 960

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