3 - History of Anaesthesia Society

Zhe History of Anaesthesia Society
Vice President
wil ad Officers June 1991
Honorary Treasurer &
Membershin Secretary
Honorary Secretary
Assistant Honorary Secretary
Council Members
Dr A.K Adams CBE
Dr D D C Hrnt
Dr A Padfield
Dr I McLellan
Dr D J Wilkirlson
Dr J A Bennett
Dr G W Hamlin
Dr J Hoe-on
Dr A F Naylor
Dr B Owen OBE
Dr J Rupreht
Dr T G C smith
Dr Barbara T)uncum
m mms Keys
Dr Ruth Mansfield
Dr H Rex Marrett
Dr Ole Secher
DrWDASmith

Prof D Vermuelen-Cranch
Dr C FIiemeqeers e t a1
Dr U Erhnn et al.
Dr A K Adams
Prof J Steinhalls
Prof C Oner et al
Prof J rle Lange et a1
Dr J M Horton
Prof H ReinhoLB
Dr M &rig et 31
Dr J Samarutel et a1
Pro£ H Rohrer et a1
Dr C Weissnr at a1
Dr J J3erlin et a1
Dr M Goerig et al
ProE H Rohrer et a1
Dr M Kul
Dr R Patterson
Dr M Goerig e t ill
Theodore Picnot: an English dentist
in the Netherlands
Janssen contrihtions to anaesthesia
Anaesthesia in Ajurveda medicine
Haydn, the Hunters and 'The Creation'
Pioneer American anaesthesioloqists,
Waters & Lundy, a contrast in styles
Early use of crrrare in tetanus patients
Fidel Paq?s Mirave: first lumbar epidural
anae~thesia
Denis Rrowne's 'Top Hat1
Creation of mcdern anaesthesia in Belqium
Excess gases: a historical review
Develpent of modern anaesthesia and
intensive care in Estonia
Tne role of George Washington Crile in the
developcent of anaesthesia
The first 135 ether anaesthetics in Spain
Henry Walter Featherstone; First President
of the Association of Anaesthetists of
Great Britain and Ireland
Cerebral anaemia for anaesthesia induction
Martin Kirschnerls spinal zone anaesthesia
The history of hypnosis in anaesthesiology
The contrilxltions of L Burckhardt and
H Kumnell to intravenous anaesthesia
Criminal confessions under the influence
of anaesthetic aqents
Cardiac resuscitation in Poland
Ewopean imprimatur of an American
discovery
Georg Hirschel and Dieijrich Kulenkampff:
pioneers of local anaesthesia
The early use of chloroform in Spain
Cbituaty - Professor A Hunter
An appreciation by Dr J M Horton

PARTICIPANTS AT TllE RO1TERDAM MEETING
Dr A K Adnms
Dr R S Atkinson
Dr B J Bamforth
Dr J A Bennett
Dr J H van Berkel
Dr J Borlin
Dr H Bohrer
Dr T B Boulton
Dr E C Bouvy-Bcrends
Dr A Carregal Rano
Dr I D Conacher
Dr C F Damstrea
Dr B Dworacek
Dr U Erdmann
Prof W Erdmann
Dr N S Faithful1
Dr C A Fuge
Dr E P Gibbs
Dr M Goerig
Dr P Goulden
Dr M B Gouth
Dr C Hall-Davies
Dr G W Hamlin
Dr I Hoffman
Dr J M Horton
Dr D D Howat
Dr J Kesecioglu
Dr E Kross
Dr M Kus
Prof J J de Lange
Dr C Nnllios
Jelle Bos
Tudy Drenth
Miso Dzoljic
Eric Eijking
Denise Haas
Hannie Kesecioglu
Marco Koenders
Locnl Mccting Aidos
Dr R E Mansfield
Dr H Marland
Dr J S Mather
Dr E T Mathews
Dr L Misuraca
Dr A F Naylor
Dr C Niemegeers
Dr B Owen
Dr A Padfield
Dr R W Patterson
Prof H Reinhold
Dr A-M Rollin
Dr H R Rollin
Dr J Ruprecht
Dr J Samarutel
Dr H J Schenck
Dr B H Smith
Dr T G Smith
Dr J Smits
Prof J E Steinhaus
Prof M K Sykes
Dr T H Taylor
Dr C )I Theunissen
Dr A Tutuncu
Dr M Valkenburg
Dr Vazquez Barreiro
Prof D Vermeulen Crnnch
Dr C Weisser
Dr C M White
Dr M van Wijhe
Dr D J Wilkinson
Yvette Lie
T Muetgeert
Marco Obree
Nies Verhagen
Bianca Verstecg
Larnine Visser

Professor D M E Vermeulen-Cranch (mterdam)
During my professional life in the Netherlands I have been struck by
cortai?~ differences in attitudes and practice between Britain and the
Netiierlands.
Dental anaesthesia
Dutch anaesthesiolcgists, unlike those in the IJK until recently, have
had no professianal connections with dentists. Also, general
anae~thesia for purely dental procedures has always been considered
unnecessary and even taboo in the Netherlands for a variety of reasons.
Firstly, the stoic Calvinistic conservative character of the Dutch
encouraqed them to accept pain or to be less sensitive to it and,
srcondly, in the Netherlands in the first half of the 19th century,
dentistry was carried out in the commmity by mstly Jewish, closed
families. They trained each other in the tradition of itinerant
dentists, accepted their rather lowly social status and mrking
conditions, rarely souqht anything better and were not, or chose not to
be, involved In the plitical and educational changes which were taking
place about that time. They failed to give a definition or work
description of dentistry, or to claim procedures and training proqrms
for dentistry.
There was a general belief that dentistry required nothing more than
manrlal dexterity which could easily be acquired by those with a medical
training. Because dentistry involved the human body it was considered
that it should he carried out by those with a medical training. There
was, in addition, a lack of interest in dentistry by doctors, who
therefore remained ignorant of, and untrained in, the advances taking
place in other countries.
Finally, when nitrous oxide was used by the dentist Horace Wells, ether
by lkxton and chloroform by Simpson, it made no Teat or lasting iqnct
on doctors or dentists irl the Netherlands. They were not inspired to
action and Eurther developments as John Snow and numerous others were.
With a Ee!i exceptions, it was caution, theorising and possible
alternatives to general anaesthesia which caught their attention.
Leg'blation on dentistry
A l3r.1 of 1923 offered hospital tr3ining to surqeons, lxlt not to
dentists, !+lose &]cation and status then lagged behind that of
stlr!.Teons. Surgeons performed the majority of tmth extractions, leaving
to the dentists t9e sale of muth washes and powders, and the filling
and filing of teeth before the fitting of artificial teeth. The
dentists w2re therefore less often concerned with the pain caused by
extract ions.
In 1865 a lsrg was p3ssocl which stated that dentistry would in future he
carried out only by doctors, because they were better able to deal with

haerrorrhage and the administration of an anaesthetic. The doctors would
require but little extra practical training, it was thought, to enable
them to perform dentistry. Only those dentists who were already
established would be all& to continue practising.
me first training school for diseases of the ear, nose and throat, for
skin diseases, children's diseases and dentistry was set up in IJtrecht
in 1865. It was to enable medical students to gain practical experience
in these branches of medicine and, at the same time, to serve the poor.
It was not a training school for dentists. The interest of the medical
profession in dentistry was minimal.
lheodare Picrurr's origins
This was the situation when meodore Pimot (1820-1910) began to
influence practice in tte Nether1ands.h the bptiml registers of the
parish of St Wrtin's in the Fields, Middlesex, Theodore Picnot1s name
can be found on September loth, 1826, being the son of Andre Marie

Practice m the omtbent
Tneodore may have travelled from the Hague to attend the wedding,
hecause in 1857 tile Hague City Register gives Theodore's address as
Zeestraat 55. However, he also had an address in Ixelles, near mssels
and it is believed that he moved there from Leeds in 1857. It was there
that his l3St 4 children were born. He practised dentistry at both
addresses, travelling between the two - quite an achievement. me
addressas remained the same until 1986. From 1886-1896 the address
changed to Laan Copes van Cattenbrg 36, !The Hague. It is thought that
after the birth of the last child in 1967, Picnot and his family came to
reside in the Hague. He is also registered in the first British dental
register of 1979 as having been !cnm to be a practising dental surgeon
before July 1878. His address was then given as Zeestraat 55, the
Hague, and it remined so each year until 1886, when it became Laan
Cops van Cattenhrg, the Hague. Then from the Dentists' Register of
1997 his address changes to Rue Crespel 4, Brussels. meodore rerrratned
on the British Register until 1910. He died in that year aged 90, in
Brussels. Interestingly, his brother Charles can also be found in the
Dentists' Register from 1879 until 1908, practising in Rochester, Kent.
Published viewa m dental training
Theodore Pinot never pblished in the British journals, but in 1875 he
wrote a snnll ?moL in French: 'L'Art Dentdire', in which he explains
that he came to the Netherlands at the invitation of certain
distinguished persons who wished to avail themselves of his professional
services. It was the understanding which he encountered and the
recognition of his personal professional standards which prompted and
encouraged him to write his treatise concerning his views on dentistry.
He describes how strongly he disagreed with the law of 1865, which
allowed only doctors to train in dentistzy. He considered the situation
to be critical because the remaining 60 dentists were doomed to
extinction. In the last 10 years only 4 medical students had followed
the additional training in Utrecht for dentistry. lba of them were sons
of dentists who had gained their experience Eran their fathers.
Furthemre, the teaching given in Utrecht was minimal, was not given by
dentists and was outdated.
Picnot advocated an official training for dentists, as was taking place
in America (1839) and in Britain (1855), where newer ways of teaching
dentistry were taking place. He did not consider that a complete
medical training was necessary. It muld be difficult, he wrote, to
arouse siifficient interest in dentistry after the long medical training.
Also, by that time, the students would have already lost the necessary
finger and hand agility required to becorne a skilled dentist. He did
advocate teaching physiology and anatomy and anomalies of the head and
neck. It wss imperative, he believed, that the dental school should be
adjacent to the medical schools, to allow interchange and
irkerdependence between dental and medical teachers.

Pimot did not believe that dentists should give general anaesthetics
themselves, and felt that a doctor should be called in. He was, in
contrast to many of his colleagues, in favour of pain control using
nitrous oxide. His eminent patients prohably agreed with him,
especially as at this time local anaesthesia was still unknown. He
advised against dentists using muth washes and powders, etc. mde up by
travelling salesmen, and said that such materials should be obtained
from the apothecary. Picnotls fees included: extraction of a tooth or
rwt - 5 Florins; extraction of a tooth or rmt under the influence of
nitrous oxide, including the attendance of a doctor - 15 Florins. Who
the medical doctor was, preslrmably one trained in the administration of
nitrous oxide, is not known. Could Picnot perhaps have instructed him?
Because Picnot had no dental diplaua fran either mgland or the
Netherlands, he was fined large suns of mney on several occasions for
practising dentistry illegally. Both he and his friend, meodore Dentz,
knm later as the father of Dutch dentistry, and who was a medically
qualified dentist, ?mt who had been trained in dentistry by his dentist
father, protested strongly against the disastrous restrictions of the
law of 1865. It was hinted by some doctors who did not want the law to
be changed, that the intention was only to enable the foreigner
practising dentistry in the Hague illegally to practice legally.
Picnot certainly had friends and patients in high places, who gave him
'protection'. It is known that the Regent Wen F~IM and her daughter,
who later became Queen Wilhelmina of the Netherlands, were atmng his
patients.
In 1876 the law was changed out of necessity, because of the shortage of
dentists. However, by this law, dental practice was limited to the
local treatment of teeth, sockets and gum, orthodontics and the fitting
of artificial teeth. Prescribing or achinistering any drugs which could
produce a generalised effect was forbidden. It was this facet which
clarifies the fact that dentists in the Netherlands were unable to use
any effective form of analgesia, including general anaesthesia.
Dentists would now be able to obtain a theoretical and practical
training with the medical students who were learning dentistry. They
wmld be required to pass a state examination giving a non-academic
qualification. No preliminary basic standard of education was required
before entering dental training. Theodore Dentz had, however, always
select& his non-medical students wishing to train in dentistry,
choosing those with a good general education, even though dentistry was
considered by most people to require mainly maniml dexterity, little
theoretical kxwledge and no prcwision for pain control. It was 1092
before the law required dental students to have successfully conclud& a
5-year period of secondary education before cannencing their specialist
training.

Dental anaesthesia at the end of the 19th century
At th? opening of the new dental clinic in Utrecht in 1895, lheodore
Dentz, who had been appointed as the Lecturer, described the prevailing
situation with regard to pain control as follows: 'Dentists may not use
nitrous oxide, but the doctors who may use it, do not know LW to use
it, and are not even interested to do so'.
It should be remembered that for extractions or painful dental
procedures in the Netherlands, there were really no effective means of
obtaining analgesia. The use of morphine or Richardson's local ether
spray or local ethyl chloride or local chloroform which produced cold
analqesia was limited to the few doctors who trained as dentists. This
remained so until Novocaine came into clinical practice after 1905 when
its use by dentists was tolerated.
It was 1947 before dentistry becarne an academic subject in the
Netherlands and the law of 1876 was repealed. Dentists were then
allowed to practise dentistry to the full extent which implied that they
could administer a general anaesthetic. However, they were never taught
to do so. With the introduction of lignocaine into dentistry in 1950,
the advantages were so great that very Eew dentists wished for anything
better to produce analgesia. Furthemre, at that time, general
anaesthesia usually want a nurse giving open drop ether under the
supervision of a surqeon and was therefore out of reach for dentists,
and also vas a technique quite unsuitable for dentistry.
The first school for anaesthesia for qualified dcctors was started in
Amsterdam in January 1947. The specialty of Anaesthesia was first
recolpis4 in 1948. Little wonder that there were no professional
connections btween dentists and anaesthesiologists. It is only now
that anaesthesiologists and dentists are beginning to realise the
advantaqes of general anaesthesia and sedation when treating the
handicar~ped and extremely anxious patients.
Picnot is also remembered because in 1801 he was, as was !Thedore Dentz,
a founder rilember and later on honorary member, of the first and most
highly esteemed dental scientific society in the Netherlands - The
Tandheelkundig Genootschap. Medical dentists and dentists of good
replte were invited to join the Society. The intention was to improve
knwnrledge and the social standing of dentists.
Picnot is also known for his dentist's cabinet, hilt especially to his
instructions by the famous furniture makers, Horrix of the Hague, in
1890 and for ~hich he is said to have paid 2,200 Florins. It is
functional and beautiful. It is carved with the letters T.P. in gold
leaf. Queen hma and WilheMna rere given dental treatment in front of
it. It can be seen on display in the reproduction of the Picnot dental
surgery in the University Phlseum at Utrecht.
He ranmined in practice at his Dutch address in the Hague. It is
recorded in the Dutch Dental Journal of 1895 that, on November 1st 1895,
Picnot celebrated the 50th anniversary of his becoming a dentist in 1845
(he did 3lS0 obtain his Dutch qualification by examination in 1877). He

was visited by mny friends, colleagues and patients. Reautiful floral
tributes were presented to him. Harever, the celebrations were
postponed temporarily, according to the report, while Picnot, then 75
years old, first finishe4 his sur'lery.
Iater life
In l896 Picnot left the Hague and went to live at Rue Crespel 4,
Bn~sels, with his wife. From letters which he wrote to Dr Pinkhof
living in the Hague, he was in poor health in 1900, yet racovere4
sufficiently by 1903 to treat some ptients. In the l905 Eenti~ts'
Rgister, at the British Dental Association's library, his add re.;^
changed to Rue de Joncker 54, Brussels. By 1909, his health did not
allow him to treat ptients any mre. His children remined well, but
his wife was tmubled with arthritis and had ear trouble, so that t'iey
were confined to the house. He writes that he was still in possession
of hi^ dental chair, other furniture appertaining to the prsctice and
also his dental instruments.
An appreciation of Theoclore Picnot, when he died in 1910, ms given by
the chairman of L\e Tandheelkundiq Genootschap. He said: 'I have never
heard patients spak with more respct and appreciation abut their
dentists than those of Picnot. All t'le rnembcrs of the Gencntsch~p who
knew our honorary member will remember him with great admiration, and
those who did not bow him with rmlch appreciation. me secrst Lay in
his character ard behaviour - he was always correct in his operating
technique, in his association with mtients and colleagues, in his
appearance and in. every other way. Although he was a moifest,
unassuming man, never seeking the limlight in his lmblic Aental
professional life he, through his character, personality and his work,
has contributed qreatly to raising the status of dentists and dentistry
in this country. He will always remain in our thankful rememhrances.'
van Wigyen, W. In meer eerbare banen. Amsterdam Wopi 1986, Academic
thesis.
de mar, m. Theorlore Picnot en zijn kast. Tandheelkudiye Studenten
A.nak 1976; 310-314.
van Wiggen, GJ.. Net Nederlandisch Tandheelkmdiq r~nootschan.
Ned.Tijdschr.Tankheelkd. 1991; 98: 287-293.
Vemelen-Cranch, DME. De geschi~lenis van de pijn bestrijdinq in de
Tandheelkunde in Nederland. Ned.Tijdschr.Tandhee1kd. 1991; 99: 778-292.

Drs C.J.Niemegeers & F Awouters (~eerse, ~elgium)
Janss~~n Reaea~xh has contri'xltsd t.r, anaesthesia mainly by introdllcing
ptent and safe analqesics and neuroleptics. T'le developnent
of tllesa corrrpou~ds started 37 years ago, when Paul Janssen evaluated the
ph3m~coloqical activity of new mlscules chemically related to
pethidine. It w.3~ t+ Stdrt of extensive studies on structure-activity
relationship which led to very rptent and selective camp3unds providhq
gieater clinical efficacy and safety (Figure 1).
Figure 1. Pethidine-related ilevelopnent of potent ,Janssen
narcotics and neuroleptics
Early developtent of drugs
Via the rmich base, th? propioah..nune R951 was synthesised and further
elaborated to very ptent and specific narcotics and neuroleptics. When
the 3-carbn bridge wss shortend to an ethyl group, narcotic activity
increased; .3ul3?tituents on carbon 4 of the pipxidine ring were varied
extensively to end up for optimal activity with the propioanilide group
of fentanyl. Men tne 3-carbon bridge was length~n~rl by one methylene
group as in the first butyrophznone, RllS7, neuroleptic activity

increased. In haloperidol the neuroleptic specificity was further
enhanced by the 4-hydroxy substitution and markedly consolidated as a
result of tm tenninal halogen substit~rents. The introduction of a
benzimidazolinone ring in the 4 position of the piperidine was a mjor
step to droperidol. Among the series of narcotics, the
diphenylpropylamine, piritramide was selected for postoperative
analqesia, mainly because of itsl ?metic action in doqs was much less
pronounced than that of mryhine. I-
?he narcotic phenoperidine R1406 and the butyromenone haloperidol R1625
were the original components of the neurolyt-analgesia technique,
introduced by De Castro and Mundeleer in 1959. !The rapid evolution in
new active compmds, however. led very soon to the combination of
fentanyl and droperidol, two compounds with the same basic activity as
menoperidine and halope idol, tut more potent, shorter acting, and with
a higher safety margin.' The selection of fentanyl was based on the
results obtained in the tail withdram1 test in rats, in which rmter at
55' is applied as a pinful stimulus. Blockade of the tail withdrawal
reflex injection of narcotic analgesics reflects surgical
analges~fprmllowing intravenous injection the lowest effective dose
of pethidine in the tail withdrawal test is 6.04mg/kg, the lethal dose
29.@/kg. Tne safety mrgin in rats, that is the ratio of the lethal to
the lowest effective dose is nearly 5. The corresponding v3lues for
Menoperidhe are 0.12 and 4.69mg/kq. Thus phenoperidine is 50 times
rmre ptent than pethidine and has a safety margin of 39. Fentanyl
(~50:0.011mg/kg) is a t least 500 times as potent as pethidine and the
safety ratio increases to 277. Fethidine, phenoperidine and fentanyl,
induce, at equianalgesic doses, similar levels of respiratory
depression,generated by their carmon action on mu-opiate receptors.
Rats, however, survive unassisted respiratory depression and following a
narcotic overdose, die from a widespread disturbance of general body
functions, prbrily cardiovascular collapse. In anaesthesia, with
adequate ventilation of the patient, a higher safety margin therefore
means a reduced risk of avoidable haemdynamic and other harmful
effects, that are unrelated to the desired analgesic action. This
general view has been well dccumented by De Castro et a16 in curarised
and mechanically ventilated dogs, under conditions which mimic the
clinical situation.
At the time fentanyl was studied for use in anaesthesia, the neuroleptic
droperidol was found to have an activity profile of interest for
preoperative application. Droperidol has a mrkedly shorter duiration of
action than haloperidol and a characteristic receptor binding profile
with virtually equal high affini y for the dopamine D2, serotonin 5KP2
and al@ml-adrenergic receptors.' Clinical correlates of these three
receptors include moderate to intensive protection from nausea and
en-esis, protection of the microcirculation from semtonin-inrh~ced vessel
contractions and platelet activation, and attenuation of adrenerqic
hypertension and autonomic reflexes. me serotonin commnent has Further
been clarified by studies with ketanserin. Blockade of 5K$ receptors in
surgery reduces vascular resistance and is of Teat imcnrtance in the
lung, where pulmnary hypertension S corrected without a decrease in
omen saturation of the blood .Q me classical combination of
droperidol and fentanyl is used for preoperative sedation and for the

oriqinal neuroleptanalqesia. For. postoperative requirements, the
separate components and newer mlacules siich as Icetanserin hake their
spscific application.
In 1978, Stanley and 1Vetwter9 evaluated fentanyl as a mnoanaesthstic in
cardinc ;urqery. T7e distinct advantages of the fentanyl-oxygen
techni,que agai? were car~liovascul=ir stability, no signs of relensed
histamine and a shorter duration of postoperative respiratory
depr~jsion. llany other investigators contributed to establish fentanyl
as the analgesic of choice for ccmplete anaest'lesia in man. With (graving
clinical experienc;. however, the requirement Eor maxim1 safety and
coanfort of the ptient, as well as for minim31 pstoperative
complications, cslled for a m extend4 range of potent and safe
anslgosics in order -to increase the flexibility of use and to cover the
wide range of of surqical interventions from vgry short and .minor to
very long and severe. To satisfy these clinical requirements, hul
Janss~n initiated mle~lular redesiqn of the fentanyl molecule. Numerous
cl~emical mxlifications resulted finally in the selection of sufentanil
and alfentanil. (Figure 2)
0
I I
C-CHl-CH3
~ c H l - c H l - N ~ ~ o Fentanyl 1960
/ \
-
CH,-O-CH,
~ C H * - C H ~ -3 N Fi
d
N-C-CHl-CH,
Sufentanil 1974
0 CH2-O-CH3
CH~-CH,-~~~-C~~-CH~-N
a
N=N N-c-CH,-CH~
3 Alfentanil 1976
figure 2. ~Tanssen narcotics used in anaesthesia
Sufentanil 1s a sllective liga? to mu-opiate recsptors with a 16-times
higher affinity than fentanyl. As an analgesic in rats, sufentanil is

9000 times as potent as pethidine and 15 times as potent as fentanyl.
Tests in several anim?l species indicated a very large ~ fety margin in
comparison with the comnly used narcotic anlagesics. In clinical
studie. when compared with fentanyl, sufentanil is about 10 times as
potentq1, its onset of action is fas-ter, analgesia is deeper and the
postoperative recovery period shorter and less hindered by
renarphinisation. Those conclusions were also re ched following a
double-blind s I y of 4 analqesics by Flacke et 31.' and confirmed by
Sanford et aLJP Analysis of the mleculir properties of fentanyl and
sufentanil clarifies these differences.
In comparison with fentanyl, a larger fraction of sufentanil is in the
unionised transportable form at body pH of 7.4, and the higher
lipophilicity further contributes to fast transport. me calcul~ttd rate
for penetration into tissue fluid is hence about 3.5 times faster for
sufentanil than for fentanyl. According to the distribution volumes,
4.4L/l:g for fentanyl and only 2.7L/kg for sufentanil, fast transprt is
not followed by considerable acc~unulation of sufentanil in tissues and
at equal hepatic clearance , the half-life o f tion of sufentanil
1. '
is mrkedly shorter than that of fentanyl. 4: ?he pharmamkinotic
comparison favcurs sufentanil over fentanyl for most anaesthesia
requirements. However in mjor operations such as cardiac surgery, the
selection of sufentanil is most suitable, whereas for minor and short
operations another mre appropriate analgesic is required. T'1e reason is
that the available narcotics have potential for respiratory depression
that lasts longer than the surgical procedure and c m t s to prolonged
supervision of the patient.
hng the fentanyl analogues, the tetrazolinone alfentanil (Figure 2)
has a virtually iate onset, a very short duration of action and a
high safety margin? Alfentanil is virtually completely unionised at
body pH and is correspndingly transported at very high rates in and out
of tissues. Together with its small distrihtion volume thesa high
transport rates mre than compensate for the lower hepatic clearance, so
that the half-life of elimination is three times shorter than that of
fentanyl. As is predictable from pharmacolgical studies in anhls and
m, alfentanil can be used in surgery of short duration , mainly
because of rapid induction of, and fast recovery from analqesia.
Usually within half an hour noml respiration and response to comnands
are restored. In fact, the use of m alEentani1 bolus plus infusion is
now considered equally appropriate in longer intementions, especially
because unexpected re flg~7;~~ponses can be rapidly suppressed with an
a1fent.mil supplement.
Finally, the analgesics of the fentanyl series are also being studiecl
extensiv y in recent new pproaches for the rnanagement of pain.
Fentanyl''.20 and sufentani12' have Lxen used in epidural analgesia. A
lipophilic molecule like sufentanil rms found to act quite differently
f m
the hydrophilic morphine, at least in terms of duration-activity
relationships. Within a few minutes, sufentanil in doses ranging from
7.5-100ug provides excellent postoperati35 relief of pin that lasts up
to 6h and causes only minim31 sedation. In comparison with that of

wrphine, the analgesic effect of sufent.mil is much faster and superior
during the first hours; it is less long-acting and side-effects are less
frequent. The clinical profile of epidural sufentanil inspired studies
in 13bw pain, where the need fo a limited duration of action and
relative safety are ~elf-evident.~~'~~ Meanwhile, the transdemnl
amroach, with skin patches containing fentanyl for alnost constant
delivery during three days has been shown to improve pstoperative pain
relief. It is imprtant to note that removal of the patch is not
equivalent to a naloxone injec since receptor occupation outlasts
the end of fentanyl Another non-invasive technique,
intranasal administration, has also been explored and preinduction of
iatric and adult patients by this route has been
found valuable.
To conclude, since the introduction of phenoperidine about 5000 studies
have been published on Janssen products in anaesthesia. The close
collaboration of basic scientists and anaesthetists resulted in the
introduction of a series of new compomds that can be used in widely
varying conditions of surgery. These compounds were important tools h
the developnent of a safer and more comfortable anaesthesia over the
past 35 years.
References
Janssen PA. Piritramide (R3365), a potent analgesic with unusual
chemical structure. J. marm. and Pharmacol. 1961; 13: 513-530.
Same H. Clinical evaluation of the new analgesic piritramide.
Acta Anaesth.Scand. 1969; 13: 11-19.
De Castro J, Mundeleer P. Anesthesie sans barbituriques: la
neuroleptanalgesie (R14-06,R1625,Hydergine, Ptocaine).
Anesthesie,Analg.Reanh. 1959; 16: 1022-1056.
De Castro J,Mundeleer P. Die Neuroleptanalgesie. Auswahl der
Preperate. Bedeutung der Analgesic und der Neurolepsie.
Anaesthasist 1961; 11: 1-10.
Janssen PA, Niemegeers C1,Dony JG. The inhibitory effect of
fentanyl and other wrphine-like analgesics on the warm water
induced tail withdrawal reflex in rats. Armeimittel-Forschung
1963; 13: 502-507.
De Castro J et a1 Comparative study of cardiovascular,
neurological and metabolic side effects of 8 narcotics in dogs.
Acta Anesth.Belg. 1979; 30: 5-99.
Tntsen JE, Gomneren W. Drug receptor dissociation time, new tool
for drug research. Drug Developnt Research 1986; 8: 119-131.
Van der Starre PJ et al. Ketanserin in the treatment of prlmonary
hypertension after vascular surgery. Critical Care Medicine
1989; 17: 613-8.
Stanley TH, Webster LR. Anesthetic requirements and cardiovascular
effects of fentanyl-oxygen and fentanyl-diazepamoxyqen
anesthesia in man. Anesth.Analg. 1978; 57: 411-426.
Niemegeers CJ et al. Sllfentanil, a very potent and extremely safe
intravenous morphine-like compund in mice, rats and dogs.
Armiemittel-Forschung 1976; 26: 1551-1556.
De Lange S et al.Cornparison of sufentanil-0 and fentanyl-02 for
coronary artery surqery. Anesthesiology 1988; 56: 112-118.

Flacke JW et al. Comparison of morphine, meperidine, fentanyl and
sufentanil in balanced anesthesia. Anesth.Analg.1985; 64: 897-910.
Sanford TJ et al.Comprison of morphine, fentanyl and sufentanil
anesthesia for cardiac surgery. Anesth.Analg.l986;65:259-266.
Heykants J et al. Selection criteria of intravenous narcotic
analgesics in anesthesia. In Pmc. of the International Congress
Anesthesiology - Feedback & Feedforward. G.M.Nykens Ed. Nijmegen
1988; 127-140.
Halliturton JR. me phanmmkinetics of fentany1,sufentanil and
alfentanil. J.Am.Assn.Nurse Anesth.1988; 56: 229-233.
Niemegeers CJ, Janssen PA. Alfentanil (R39 209), a particularly
short acting intravenous narcotic analgesic in rats. Drug
Devpt.Research 1981; 1: 83-88.
Patric M et al. Alfentanil supplemented anaesthesia for short
procedures. l3r.J. Anaesth.1984; 56: 861-866.
Ausans ME et al. Variable rate infusion of alfentanil as a
supplement to nitrous oxide anesthesia for general surgery.
Anesth.Analg. 1983; 62: 982-986.
Rutter W et al.Extradura1 opioids for postoperative analgesia.
Br.J.Anaesth. 1981; 53: 915-920.
Justins CM et al. A controlled trial of extradural fentanyl in
labour. Br.J.Anaesth.1982; 54: 409-414.
Rosseel FM et al.Epidura1 sufentanil for intra-and postoperative
analgesia in thoracic surgery: Acta Anaesth.Scand.l988;32:193-198.
bbllmn M et al. Sufentanil for postoperative analgesia. The
European Journal of Bin 1990; 11: 72-75.
Van Steenberye A et al. Ektradural bupivacaine with sufentanil for
vaginal delivery. l3r.J.Anaesth. 1987; 59: 1518-1522.
Vertomnen JD et al.The effects of the addition of sufentanil to
0.125% bpivacaine on quality of analgesia during labr and on the
incidence of instrumental delivery.Anesthesiology 1991;74:in press
Hill FH. Clinical pianmcology of transdenml fentanyl. The
mopean Journal of Pain. 1990; 11: 81-91.
MLeskey CH.Fentany1 TTS for postoperative analgesia. The European
Journal of Win 1990; 11: 92-97.
Henderson JM et al. Preinduction of anesthesia in pediatric
patients with nasally administered sufentanil. Anesthesiology
1988;68: 671-675.
Helmers JH et al. Canparison of intravenous and intranasal
sufentani.1 absorption and sedation. Can.J.Anaesth 1989;36:494-497.

Drs U Erdmm, G Janssen, M Bhatia, J Sepaar (Rotterdam)
'k.3 begi;mings of medici~e date b3c'; to the ori-~ins of Ayurveda medicine
- 5,000BC. Historians w'no have been accustomed to trace all medical
sciencis t,> ancient Greece have sh:mn that a well-ad
exiited mng the Hindus prior to that of the Greeks.
Most of the ancient medical texts have for years remained a closely
warded secrat of tne families of the Vaidyas . It c.ms not until around
1900 that this old rne,jizal knowledge was rediscovered. The earliest
m4icsl utterancm which have 'wen preserved in the literature are Vedic
hymns which wcre writtsn in Sans'crit abut 1500BC. There are four known
TJedas ( ioly writings) : Rigveda, Samveda, Ya jurveda and Atharvaveda.
'Tn,? Atharvdvela is th- first al~thentic record now available of the state
of 1n~?dic,31. knoiiledge r-king the Vedic period.
A s~~:>plement to Atharvaveda is Ayurveqa. Ayur means life, Veda means
!a~owl?dqe: Veda of Ayur - knowledge of life. In the Arsha period (around
the 9t:1 Century BC) Ayurve:la me9icine was taught at two great
universities in India, one at Benares on the River Ganges in the east,
here the h?sd of the medical section was Sushruta, the other at
'bkshashila in the 1ve.3t on the &elm river, where medicine was taught
under Charaka. The most outstanding represlntations of the Ayurveda are
the Charaka Sarnhita and the Sushruta Samhita, ?nth available in English
transns7ation. Suuhruta, the authority on surqery, tells us explicitly
abut his techniques and even provides pictures of his tools which look
almst exactly like the scalpels of modern surgeons.
In that early pricd of mdicine, mjor invasive surgery was already
being extensively undertaken; surgery of the head and neck including
aspcts of neurosurqery, ophthalmic, otorhinoloqic, aMominal and
pllstic sur.rery ware perforne3. To Sushruta is attributed the glory of
discovering t\e owration for c;ltaract which was unknown to the surgeons
of ancient Greecz and Fgypt. Sushruta possessed the skill to rebuild
damaged or even lost noses. Rhinoplasty does not appear again lmtil
W3rn plastic surqery. Sush~uta's reputation still runs so high that
American plastic rmrqeons have a society that is bown by his mm.
Little is known of the kind of anaesthesia prformecl to make these
operations pssible. In general, it is thought that the peat majority
were done without anaesthesia under t'ne strong persuasive influence of
the oprating physician, and other patients vino could not be operated on
uiidnr psycho-anaesthesia were just given alcohol as the anaesthetic
agent .
It was said that before any surqery the patient should be given a proper
diet of nutritious and enjoyable food followed by a strong alcoholic
drink. This procedure wss adopted because the effect of the food
prevented t ~ ,atient e from becoming fully senseless and the effect of
the alcohol prevented him from £=ling the pain of the operation. In the
third stage of intoxicdtion 'the patient &comes inactive like broken
wood, his senses overcone by Mada [intoxication] and in the living state

he seems as dead'. It is clear from this that a highly controlled munt
of alcohol was consum3d so as to intoxicate the mtient up to the third
h&. Only at this stage was the operation carried out-Nevertheless,
because of the shortcomings of these practices, anaesthstic sc:iames .{ere
developed in Ayurverla rne.jicine. Theso anaesthetics were generally
described as Sarmrahinis. However, t3e descriptions of tCle anaesthetics
used has never been explicitly reported in the respctive Sanskr~t
literature. Our information has to be gathered Erom an,xdotal llookv such
as Bhoja-Pram which is a collection of material abut the reign of
Bhoja Raja.
King Rhoja, son OF King Sudhul of Dhara (situated near the present city
of Ujjain in the State of Madhya Pradesh) ruled in the 10th Century AD.
Details are given of an interesting surgical operation which w?s
performed on the Raja who rms suffering from an excruciating win in the
head. A11 available help was applied but in vain and his condition
became critical. Just then, two brother physicians arrive? in nhar and
they were duly called in. After carefully examining the mtient, thrty
held that, unless surqic.~lly treated, no relief could be ~ssibly
afforded to the royal ptient. They adninistsred an anaesthetic
(Samhini) called Mohchuran to render him insemsitive, and when !ie was
caplet.ely under the influence of the drug, they trephined his skull,
rmved t9e mlignant portion of the brain which was the origin of t%e
problem, closed and stitched up the incision and awlied a h?alinq tz3l.m
to the rmund. Then they administered an antidote, Sanjiwini, to t4e
patient who thereupn regain& consciousness and felt quit5 at ease.
fie b k of Ballala Pandit, written in Sanskrit abut ,327AD was
translated by Kedannath Sham into Hindi in 1970. ?he author knew ahout
chloroform and indicated that the sleep pwder Mohchuran is a
chlorofom-like agent. Sanjiwani is still well-buwn in India tcday.
According to ancient stories, it was fist brought by Hanuman Erom the
Himalayan mountains to resuscitate King Lawran who was injure? in the
battle of Ramyana which took place about 2000BC in Sri Lanka.
In current times, extensive efforts are king made in tha West to
rediscover the old knowledge of Ayurveda medicine by mans of the
ancient literature mentioned abve and from the Vaidyas, who are
Ayunredic physicians in India. We are fortunate to have t'7e Ayurveda
Health Centre for Europe in the Netherlands. We recantly asked a Vaidyan
physician at this centre about ansesthesia in Ayurvedan mdicine. He
confirmed what we had discovered: one techniclue is psychoanaesthesia
which involves talking to the ptients and telling t'lem that the
operation will not be painful; another form is alcohol anaesthesia. The
Vaidya also knew about the sleeppowder mentioned above lxlt said that
the correct name was not Mohchuran, as written i.l the ancient text, but
Mohchuma.
-a
H.Schelenz. Geschichte der Phamzie. 1704
H.H.Wilson. On the Medical and Surgical Sciences of the Hindils. 1823.
J.F.Royle. Rn Essay on the Antiquity of Hindu medicine. 1.737.
T.A.Wi.se. A Camnentary on the Hindu System of Medicine. lr145.
Stenzler. Zur Geschichte der Indischen Melizin. 1946.

John Iiunter (1729-1793), scientist, naturalist and surgeon has been adopted
by the Royal College of Surgeons of &gland (RCS) in the role ahmst of a
patron saint. His collection of specimens forms the basis of the Hunterian
Museum and a large number of his writings and drawings are held in the
College Library, whilst the research and educational function of the
College constitutes the Hunterian Institute.
John Hunter met his future wife Anne (1742-1921) whilst he and her father
Robert Home were serving as army surgeons during the military campaigns in
Portugal. Though very different in character and personality, their
mrriaqe oms a happy and successful one. John was outspken irascible and
wholeheartedly devoted to his studies of natural history and human disease
whilst Anne was intellectual, full of delicacy and charm and noted b3th for
her poetry and as a society hostess.
Joseph Haydn (1732-1809) was for mst of his life court composer to the
Comts of Esterhazy whose estates

1 Landon, H.C.Robbins Ed. The Collected Correspondence and bndon
Notebooks of Jose* Haydn. London: Barrie and Rockcliff 1959
pp 253-254.
2 Dr Haydn's VI. OrigL~al Canzonettas. London.Corri and Lhxseck 1791
3 Palmr R, Taylor J. The Wrnterian Society. Catalogue of Its
Records and Collections. Iondon: I-hmterian Society. 1993
pp 118-119, and 196-197.
4 Plarr. Qtalogue of Manuscripts in the Royal Colleqe of Surqeons
of England, 1928.p 40.

Professor J Steinhaus (~tlanta)
The grcnvth and develo~mnt of the specialty of anaesthesiology in the
United States beyan in a somewhat unusual pattern in that its early Start
was in the ?lidwe-st instead of the larger and more sophisticated medical
centres on t'?e East coast. Tne pioneer anaest!!esiologists, Ralph Waters and
John Lundy buiLt their prqamnes in mdison, Wisconsin and Rochester,
Minnesota respectively, in the 1920's and 1930's. They were approximately
150 miles aprt located in m11 cities that, ccmbined, my have had a
population Of 100,000 people. The Lhiversity of Wisconsin at Madison was a
large state university with a medical school that had just added two years
clinical instruction to Wcome a four year school. Mayo Clinic was a
successful surgical clinic with no direct academic relation.
mmly's early life
Job LUIKIY ~ 13s brn in 1894, and reared in North Wota. His father was a
physician and ha \=S acqaahted with anaesthetic administration in kis
early years. He administered anaesthesia in dentists' and physicians'
offices while he was a teenager and attended a dmnstration of the
Heidbrink Anaesthetic Machine at the age of 16. He attended college at the
University of North Dakota and graduated from Rush Medical College in
Chicago. He practised his early a~esthesia with the aid of a Gwathmey No.1
gas mchine which he transported between hospitals. In 1924, as the newly
elected secretary of the King County Medical Society, he met William Mayo,
the guest speaker at a society meeting. Having arranged to sit across from
the invited speaker, their conversation led to Lundyls vitation to c m
to the Mayo Clinic and organise a Section of Anaesthesia. P'
W3ters' fozlmtive years
Ralph Waters w3s reared and educated in Ohio and graduated from Western
Reserve University Medical School in 1912. He began medical practice h
Sioux City, Iowa and in the early years decided to limit himself to
obstetrics and anaesthesia. Although it was c m n for medical colleagues
to exchange the administration of anaesthetics for each others' patients he
agreed to give all the anaesthetics for a well established surgeon in
exchange for the use of a new nitrous oxide machine which the surgeon had
pchasecf in ~oledo.~ With his mornings filled with hospital practice,
Water organised an ambulatory anaesthesia clinic in downtown Sioux City in
1916. 3
He moved t:, Kansas City in 1923 and continued outpatient anaesthesia with
its m recovery rooms with his hospital practice until he left for
Madison, Wisconsin in 1927. Curing this interval, his interest often
Focuss.d on physiological and pharmacological problems. He reported a case
of resuscitatio which was essentially cardiac compression with high
presstrrs oxyqen? a prredure substantiated at a much later date by Jacoby
in the laboratory. He developed a major interest in carbn dioxide and
correspnderl with the pharrmcologist Dennis Jackson who had anaesthetised

dogs with a cl system. His reprt of carbon dioxide absorption and the
Waters canisteywas a major charge in the practice of anaesthesioloqy
since mst anaesthesia mchines of that period provided for the
administration of carbon dioxide.
kyn and Wisansin
The institutions at which Lundy (1924) and Waters (1927) acce?ted positions
as directors of anaesthesia coloured and influenced thefr careers in
anaesthesiology. The Mayo Clinic, a large and dominant private surgical
practice of medicine, contrasted significantly with a clinical educational
programne in a state university with modest clinical facilities both in
size and reptation.
Cm the other hand, the University of Wisconsin had a qrhq reputation as
an outstanding university in tile United States with a secura reputation in
research. Both men were cdtted to the specialty of anaesthesiolcqy in
both its growth and developnent. Lundy had a sizable sc11ool of nurse
anaesthetists, due in part to the large clinical load and, on the other
hand, Waters had a major ecfucational respnsibility which he defined in
terms of medical student and resident training. Waters adopted a set of
objectives listed below; after anaest'netics, care of mtients, medical
school education and resident training were the next important objectives.
1. To provide the best pssible service to the ptients of the
institution.
2. To teach what is hown of the principles of anaesthesiology
to all candidates for the medical deqee.
3. Ta help long-term graduate students not only to gain a
f-tal knwledge of the subject and to master the art
of administration, ht also to learn as much as possible of
effective methods of teaching.
4. lb accompany these efforts with the encouragement of as much
cooperative investigations as is consistent with achieving
the first three objectives.
Rs a matter of reflection, the objectives would serve well for our
specialty tcday. His concept of the specialty was kilt on basic sciences
and was concerned with inhalation theraw, pain and resuscitation, as well
as surgical anaesthesia as is shown in Figure 1. Mged by Lundy's
plblications, new techniques and agents were mjor topics. The
correspondence between these two anaesthesiologists (over 60 letters) is
largely preserved in the archives at the University of Wisconsin and begins
with a congrat atory letter £m Dr Lundy to Dr Waters on the assumption
of his duties. F

Structure of the Science of A~~estlicsi;l
ANESTHESIA
. TIAIHIHG AIESlHCTISTS
Many of these letters were three pages, singly spced, in length. Plans for
the Travel Club were frequently mentioned and mst of the other problems
facing the young specialty of anaesthssioloyy were disctlssed at Wisconsin
in 1927. Although there was some cmpetition between the two institutions,
and at least to sane degree between their leaders, they were equally
comnitted to developing anaesthesiology as a specialty.
Ideas on carbon dioxide
Cne difference between the two in anaesthet'c management related to carbon
dioxide. In Lundyls letter of August 4,1327,' he wrote:
'In answer to your letter of Auqwt second, the advantage of carbon dioxid
added from a tank over that of properly conducted rebreathing is that at

the times when carbon dioxid is mst needed the carbn dioxid content of
the bag is too low. '
Waters, having initiated the c&n dioxide absorption technique, held
strong views abut it elimiriation frcm anaesthetic atrrospheres. In his
letter of my 23, 1930) he wrote:
'Of course to me, personally, it would seem quite ridiculoua that the
carbon dioxide ranoval technique was not mentioned because that, to me, is
the one absolutely safe way to use inflamnable and explosive anesthetic
mixtures. I realise that you muld not aqree with m, ht I do kelieve that
it should be mentioned in such articles as Hendersons.'
An even more vigorous statement s made by Waters in his letter of January
15, 1937 to Lundy when he stated?
'Now then, I must make a comnent in regard to carbon dioxide since
everyb3dy seem to be sort of kidding me about it. In the first place, if
you think I did not mean what I said when I assured you in Rochester that I
did not have you in mind in the slightest in regard to the abuse of carbn
dioxide, you are mistaken. There is, hcwever, a crazy use of carbon dioxide
therapeutically throughout the world which I think you do run into and do
not know anything about. It is against that aort of use of carbon dioxide
that I started to harp.'
Apparently, up to his retirement, Laxly felt the addition of carbon dioxide
was a valuable technique. Both men were self -trained anaesthes iologists .
Lmdy focused on clinical management. Waters raised questions often of a
mysiological nature concerning the effects of anaesthetic agents.
A tribute to m y by J W Pender is expressed in the following statement:''
'His greatest contrihtions were his talents and untiring efforts taward
the formation of active and effective organizations.'
His early efforts were expended at the American Medical Assxiation,
getting anaesthesiology aWtted as a specialty. During the 192OVs, papers
on anaesthesiology muld be placed in the Miscellaneous Section of the
progrm. When Board Certification was in its early years it :as spmsored
by the AMA and consequently recoqnition of the specialty was required.
'Anesthesia and Analgesia', edited by Francis McMechan, was the only
journal devoted to the specialty in the United States during this early
period. With the death of its editor, McMechan's widow decided to continue
the journal and serve as its editor. Both Lundy and Waters agreed that a
new journal was needed. In a letter of August 1, 1939 from Lundy to Waters,
he expressed his op8ion that the new journal should be through the
m i c s of the AMA:
'Fbr example, I think anyone waild prefer to have his article published in
the journal of the AMA than any other journal.'
In answering the letter, Waters expresses a different aPproach.l2

l Now from the standpoint of conduct of such a magazine, I balieve it can be
kept in the hands of the ASA with advantage and possibly with profit to the
Society. That is, I feel that the subscription to the journal should be
included in the dues of the Society and that it should not be turned over
to the AMA.'
The American Board of Anesthesiology started as a sub-spcialty under the
American Board of Surgery in 1938 with Ralph Waters as a founding member
and second president. The Anesthesia Section of the AMA began in 1940 with
Lundy as its secretary, a psition which he held for 17 years.
The Travel Club was organised and managed by John Lundy until the begbning
of World War 2. Ralph Waters enthusiastically supported the fomtion of
this o ganisation, as shown in the comnents in his letter of March 3,
197.9: 16
'He told me rather hurriedly last night something of your scheme for a
travel club, and the idea strikes me as a good one, except that I am sure I
muld enjoy it more to be altraveller' rather than a 'host' at the first
meeting. '
'The first meeting was held in Rochester in December 1929 and the second in
Madison in 1930. Waters, however, 'iias less than enthusias 'c in later years
due to its * heavy social e@asiel and 'exclusiveness1& In his letter
of November 5, 1937, he expresses his reservations:
'Then, I think I should add a frank statement of my attitude toward such
meetings. I have suggested in the past that I was afraid that sticking in
the same goup each year would develop a feeling of snootiness on the part
of some of the men, or rather I probably should say would develop a
repitation of snootiness among other anesthetists. I still feel that way,
and I even feel that the usefulness of gatherings of that particular group
mre frequently than once in five years or so has probably been mm out.'
The personalities of these two leaders were in marked contrast. As Pender
expresses his opinion of Lundy: 'Aggressiveness was both an asset and a
detraction. .... he stepped on many toes.' However, he concludes that
problems facing 15he specialty henefited by these tactics. EclaMn writes
abut John Lundy : 'Adversity may have deterred, ht never ended, his
mrch toward the objectives he set himself; disap~ointments did scarcely
mre than whet the keen edge of his determination; opposition, far frm
persuading him to retreat, in each instance taught him to circumvent even
mre formidable impediments to advancement in the future.'
Alt.hough Ralph Waters xms driven in his desire to luild anaesthesiology, he
used a Tom Sawyer approach in that he enlisted well-established
physiologists and phamcolor~is s to accmrplish the research needed for the
specialty of anaesthesioloqy." He had the unique talent of attracting
young physicians into anaesthesiolqy and persuading them that education
and training in anaesthesiology should become their medical careers. The
Aqua Alumni Tree designed by L M3n-is illustrates the unusual talent that
came from the faniLy of residents established by Waters.
A new and fitting trihte to Waters rias made by Geoffrey Kaye:

'The salient characteristic of the man (Ralph Waters) is his uncanpranising
scientific honesty. To subnit one's work to his criticism is to emerge
naked and ashamed, yet inspired to do better. He is a man of yygin31 mind;
one meets few people to whom that description my be applied.'
In conclusion, these pioneers in anaesthesioloqy respected each other and
worked effectively to establish anaesthesioloqy as a medical spcialty in
the United States. Although they were quite different in talent and
approaches, they each made contritxtions to the specialty which benefited
the succeeding generations of anaesthesiologists and provided much of the
foundation upon which anaesthesiology is hilt.
Iamdy JS. From this point in time; some menories of my part in
the history of anesthesia.J.Am.Assn.Nurse Anesth.1966; 95: 95-102.
Waters RM. Ihe developnent of anesthesiology in the United States.
J.History of Medical & Allied Sciences 1946; 1: 595-607.
Waters RM. The down-town anesthesia clinic. Am.J.Surg.1919;33:71-4
Waters RM. Resuscitation. Artificial circulation by mans of
intermittent high pressure chest inflation with oxygen. Selected
scientific papers and addresses of Ralph Milton Waters MD.
Cleveland Western Reserve University 1957.
Waters RM.Clinica1 scope and utility of carban dioxide filtration
in inhalation anesthesia. Anesth.Analg.(Curr Res)1924; 3: 20-22.
Letter fran John S Lundy MD to Ralph M Waters MD January 1927.
Ibid. August 1927.
Letter fran Ralph M Waters MD to John S MD Mey 1930
Ibid. January 1937
Pender JW. CSA Bulletin 1985. September 4-8.
Letter fran John S Lundy MD to Ralph M Waters MD. August 1939.
Letter fran Ralph M Waters MD to John S Lundy MD. August 1939.
Ibid March 1929.
Ibid November 1937.
[Note these letters are preserved in the archives of the University of
Wisconsin, Dept. of Anesthesiology, Madison, Wisconsh.1
15. Eclm J, Iundy S. In: Volpitto P, Vandam L. ?he Genesis of
Contemporary Mrican Anesthesiology, Springfield, Illinois 1982:
35-47.
16. Steinhaus J. Anesthesiolafl and Phamcology at Wisconsin in the
30's. In Rupreht J et a1 Eds. Anesthesia- Essays on its History.
Berlin; Springer Verlag 1985: 198-202.
17. Gillespie N. Ralph Milton Waters: a brief biqphy. Br.J.Anaesth.
1949; 198-215.

Professor C Oner, l Drs J Kesecioglu,lf2 L Telci,' A Tutunci, lf2
( '~stanbul, 2~otterdam)
me history of curare dates back to 1595 when Sir Iialter Raleigh published
an account of his emition in search of Eldorado in South America. He
reported the use of poisoned a r m by the Indians in m e . * This poison
was eventually analysed after many technical difficulties. In 1601, Herrera
ohserved the existence of at least 20 different su3stances constituting
this poison.
Charles-Marie La Condamine reported the results of animal experiments with
'brut' curare in 1747. Herrisant performed similar experiments and observed
respiratory depression snd paralysis after the use of the same substance.
In 1779, Waterton saved an animal victim of poisoning by means of
artificial ventilation. This result was confinned by Eirdie in loll with
further anh3l experiments. Finally, the well-)olawn experiments by Claud
Bemrd were carried out and presented during a lecture on 7th May 1856. f
In the last century, Fontana observed that the vapour of heated curare was
ineffective. After Claude Rernard, Tillie demnstrated that rabbits
intoxicated with curare could sirrvive twenty-Five times the lethal dose if
they were artificially ventilated.
In 1839 the Schcanburgk brothers postulated that Strychnos toxifera produced
a pison. This was confirmed by Appm in 1870, who slso observed that
different types of the plant must be used in different regions. The final
product cms a mste, obtained after a few days of premration. mis paste
ms kept in pots, bamboos and calabashes. The poison in the calahshes was
used for large game h~mting, or during war. The poison in pots was used for
birds and hunting m11 animals. The bamboo tubes - the 'tubocurare', had
an intermediary prpae between the other two.
Contemporary research on tuboclxarine began with King's work in 1935,
leading to the preparation of crystaLised d-tubocurarine by Wintersteiner
and Dutcher in 1943. Uncertainty concerning the composition and the doss of
the drug explains the failure in therapeutic trials in the 19th century am3
the beginning of the 20th century.
The introduction by Squibb of Intarcostrin in 1941 - a product standardism-f
for biological use - permitted Griffith to introduce curare in anaesthesia.
Lawen1s early trial in 1912 had failed due to the lack of a reproducible
product. In fact, the difference was due to the conflicting anaesthetic
conceptions of the two men. Furthennor?, a low dose could be iqcreased and
a high dose was no longer n danijer since respiratory depression and arrest
could be treated. The maesthetist,
* This is an unprdven anecdotal account which persists in quoted
litersture, 23leigh's acco~rnt bing mre suggestive of wound infection and
tetanus. See also Carman J, I-listocy of Curare. Anaesthesia 1968; 23: 706-
707. Mitor.

Griffith, well imderstood the imprtance of respiratory assistance and even
controlled ventilation. The surgeon, bwen, insisted on refusing to
achwledge anaesthesia as a medical subspeciaIty until after the second
lJorld War.
Clinical manifestations of tetanus were described by FLippocratss, and for
centuries after him only a Few new ideas about this disease were
introduced. Dcninique Larrey observed different ~OLTLIS of the disease but
its origin remined unknown; it ms generslly accepted as being a muscle
disease. Vulpian and his successors proposed a nervous system origin for
tetanic crises, but it iuas Simpson (1354) who established this. Carle and
Ratton (1F!G4) induced the first tetanic infection ln laboratory animals.,
In 1885 Nicolaier showed that the injection of earth provoked tetanus and
establishfd that this was due to a bacillus.
The action of curare on respiratory muscles and the survival of
artificially ventilated animals were observed by Sir Benjamin Collins
Brodie and Edward Bancroft in 1811. Subsequently, Brodie informed the
Academy of Sciences in Paris of his proposal to treat animals with tetanus
with curare. He mentioned his plans tpo_gllse curare for a tetanus patient in
a latter he sent to Flourens in 1811.
Guyane Indians blew air into birds injured with arrow poisons in order to
keep Cnem alive. Knowing this, Charles lrlaterton successfully used
artificial ventilation to keep curarised an 1s alive. His friend Francis
Bilron later used the same method on horse2 he same technique was also
used by Snell, an hglish veterinary practitioner, in 1837.~ In 1856, the
analogy between strychnine intoxication and tetanus was made by George
Harley. Working on this hypothesis, he performed exper nts with horses
using strychnine and mare for tile treatment of tetanus.pTherapeutic use
of curare in a patient with facial paralysis was reported by Thibaut de
Nantes in 'LVUnion Medicale', in 1856. The same author was one of the first
to use curare in the treatment of tetanus, referring, as did others, to the
article by Vulpian on: 'The use of curare as strychnine antidote and as
treatment of tetanusg published in 1857.' (h?e year later, Manec and
Vulpian used curare in a tetanus ptient at the Charite Hospital, Paris.
The drug was first applied to the mund as a solution and therafter us4
subcutan~o -1y. No improvement was ohserved and the patient died of
tetanus. 4f' Sayres and surul applied civare to the wound of a tetanus
patient in the same year in New York, ht without success.
Although early arplications failed, French doctors persisted with trials.
They had more occasions for its use during the war in Italy. Vella used
curare on three wounded sol-liers with tatanus in the French Hospital in
Turin. He reported cossation of the convulsions after 45 minutes. The
treatment ryls repeated many times as the convulsions reapared shortly
aftenuards. Rvo of the ,utients died but the thlrd one W o had been
seriously wounded u, the battle of Magenta, rec~vered.~~~~~-'~ Mother
success wis reported by Slr Thonns awncar in 1863. He treated twelve
patients the same way and three of them surv~ved.~

In France, the trials conducted by Follin in Paris and Gintrac in Bordeaux
failed. A discussion took place at the Academy of Sciences in Paris.
Another discussion followed at the Academy of Medicine. Velpeau especially
criticised the reports of Vella and Gintrac, copring the results obtained
with the llorrnal evolution of the disease. In othsr words, he was looking at
a control group. Claude Bernard w3s especially astonished by the hypothesis
of an eventual refractory state to the action of cutare. In 1959, 13
comnunications on this s~ibject were published in French journals, four in
Anglo-Saxon literature and four in Germany. nuenty-one patients were
treated in hospitals in Milan and Pavia by Parravicino, Gherini, Monti,
Cuesta, Moroni, dell8Acqua and Gualla between 1859 and 1861. Four of these
patients survived. meso data were published in 1864 in the French language
in 'Gazette Medicd d'Orientl(I~t?nbul), Vella's work tms also published in
the same journal and referred to in an article on the same subject in
'L'Union Medicale'(Paris). Retween 1853 and 1873 Wme reported D
mng 22 cases and Busch reprted 6 survivals mng 11 patients. 4, 5':"fi"-PS
From 1880 on, no publications apared abut the use of curare in tetanus
patients tmtil 1925 when West, from Scotland, started experiments with a
plrified product. The turning point was in 1952, when Lassen ventiLated for
prolonged periods patients with respiratory muscle paralysis during a
poliomyelitis epidemic. This made the administration of a paralysing dose
of curare possible in the treatment of tetanus. Final*, rlollarst from the
Claude Bernard Hospital, Paris, first reported successful results with d-
tubocurarine.
The early use of curare more than a century ago ia tetanus patients, both
subcutaneously and as locally spplied solutions, is interesting. This
method had little effect in improving the prcgnosis of the disease but was
successful in some cases in stopping convulsions for a limited period.
References
Bernard C. Etudes physiologiques sur quelcpes poisons americains.
Revue de Deax Wmdes 1864; 53: 164-190.
Bevan DR. ett al. Muscle relx~ants in clinical anesthesia.
Year Book Med. Pub. 1988; 1-2.
Davidson I.W. The Evolution of Anaesthesia. John Sherratt & Son
1965; 154-158.
Gazette Medical dlOrient. Istanbul. 1860; 10: 178-190.
Lee JA, Atkinson RS. A Synopsis of Anaesthesia. John Wright 1973.
Vellard. Les curares indiens. Anesth.Analg.Reanim.1973; 20:2.
Vulpian EF. De llemploi du mare come antidote de la strychnine
et come traitmnt du tetanou. LrUnion Itedicale 1357; 11: 25-26.
Cazette Mdic41 de Orient. Istanhl 1864; 2: 17-22.
Gazette iMiz,3le doOrient. Istanbul 1859; 7: 143.
Kern E. TR 'curare en anesthesie. I.Qsson 1950.
LILhion :,ledicale 1959; 49: 817-825.
Sykes !E. Essays on the First Himdred Years of Anaesthesia.
John Wright 1973.
L'Union Medic3le 1859; 140: 401-404.

Professor J J de 'Lange, Drs M A Cuesta, A Cuesta de Pedro.(Amsterdam)
In 1865 Faulconer and Keys wrote abut Pages in 'Foundations of
Anesthesiolq': 'NT)~ much can be found out aborit the life of thi
imprtant Swish surgeon'. They did not even know t'ie date of his birth. 9
But Pages still achieved a plxe in these excellent books &cause he was
the first to carry out epidur.31 anaesth?sia by the lmhr mute. For a long
time this fact was l.ittle known; prohbly the main reason was h t he
plblished his work in 1921 in mish nations1 surgical journals. $PS In
1331 the Italian sturgeon AchiLe rQrio Dogliotti cla'med to be the first to
carry out epidural anaesthesia by the imr mute.' Became we had access
to the archives of his son, we are now able to complete the personal and
scientific bioyraphy of Fidel Pages.
mly life rmd military career
Fidel was 'mm on 25th Janlmt-y 1886, the son of Juan Pages and Conception
Xirave, at Ifuesca in Sixin. He studied medicine at the University of
Zaragoza, where he gained his licence (cum laude) in Medicine and Surgery
on 17th June 1908. On 30th September of that year he started training as a
~Wqical Of ficer at the MiLitary Medical Academy in Madrid and after a year
kcame Surgeon to the Military Hospital of CaraMchel in Madrid. At that
time. Spain ms engaged in a bloody war against the Rerbers in North Pfrica
and in July 1909 Pages was sent to a military hospital in Mellila, where he
treated many wound4 brought irl from the httlefields. He stayed there for
two years, of which severe1 months were spent in the front line, and was
honoured for his work by the award of a Military Cross, First Class.
In August 1911 he returned to the mainland, was prmted to Capt;am and
viurked at a n&r of military centres - Tarragona, Toledo and then the
Deprtment of War at Madr~d. In 1913 '~e mrrled Concepclon Rergem y
Nros, whose father was Gemn, and mtll 1914 thp couple l~ved at Cludad
Real Ware Pages carrled orit med~cal examnatlons on nulltary recmlts.
From there he was s?nt to the mil~tary hhosp~tal on Menorca, then to
Allcante and flnally m Iby 1915 to tne Central Mxlltary Centre m Madrid
there he would stay untll January 1920.
Mluence of the First World Wm
In 1915 he was almintd Surgeon to the Provincial Hospital of Madrid
(I+ospital de la Eenificiencia), and b c m Associate Professor of Practical
Suryery in the Mdical Faculty of San Carlos and also General Practitioner
to the Royal I-Iousshold. In February 1917, the third year of the First World
War during wkich Spin was neutral, Pages was comnissioned by a Royal Order
to go to Vienna and acccmpany, as medic3l expert, the Spanish Ambassador in
inspections of prisoner-of-war camps in Austria-Hqary. In addition to his
reptation as a good military surgeon, he was selected for this task
becausa of his knowledge of French and G e m . On April 11th he arrived in
Vienna and from there inspected camps; during the months of July and August

he also worked in the Military Hospital, where he performed a number of
operations. On 8th September that year he returned to lQdrid.
On return to duty as general surgeon in the Madrid Provincial Hospital, he
was appointed co-ordinator for the organisation of medical units in the
Swish Army, for which he was honoured in 1919, and was then comnissioned
to prepare a classification of wounds and injuries for use during military
campaigns. In the same year he became co-founder of 'Revista Espanola de
Cirurgia', today, still the official orqan of the Spnish Surgical Society.
At the same time he continued his mrk in t'le Military Hospital td?ere he
taught the nurses with swcial courses on emergency surgery, wri-operative
care, local and general anaesthesia, wound healing, sterilisation and the
preparation of all kinds of material for the care of wounds.
In September 1921 he was ssnt again to Melilla, to the Hospital Doecker. He
was chief of 3urqic3l staff in the city during the terrible disaster of
Annual, when rebels headed by .4M el Krim, charged and destroyed all the
Spanish military psts up to the streets of the city during the battles of
Tissa in September, Atlaton and Segangan in October, and Tarrenda in
November. He remained in the operating room for several days and as
subsequently honoured for his treatment of the wounded and his skills in
medical organisation. In Decemher 1921 he returned to his post in Madrid.
In August 1923 he went on holiday to San Sebastian in northern Spain, to
tne spa at Cestona (for treatment by the medicinal waters) and was present
at the inauguration of an operating room at the Military Fbspital in San
Sebastian. After performing his last operation there he started Mck to
mdrid by car on 21st September, but died in a car crash at Quintanaplla
in the northern province of brgos at the age of 34.
Pages published pxrs about many different subjects; frequently
discussed his exprience in the treatment of Mttle injuri~s~'-~ one paper
a prlze by the Swish Vilitary academy in 1914. Other
*' papers revealed a special interest in the treatment of cancer.
C i ~ i l i ~ ~ _ ~ ~ was ~ i also e n ct%e e basis of papers on aspects of general
surgery including the surgical treatment of con~ti~t~on~~, his lsst
paper.
J.m&m epidural anaesthesia
And finally there was his great contrihtion to anaesthesia, his 'Metameric
Anaesthesia' which was pblished simultaneously in Flax 921 in 'Revista
Fspanola de Cirurgia' and 'Reviata de Sanidad Militar'. Ihile he was
carrying out a spinal anaesthetic he had the ides of halting the progress
of the tip of the needle in the spinal canal befare it pierced the d m
mter, and then blxking the roots outside the theca after the needle had
~ssed through the ligamenturn flavun. He abandoned the Stovaine he had
prepared, and dissolved three tablets of Suprerenin Novocain in 2-
physiological saline in a sterilised container, proceeding to inject the
solution through the needle which had been inserted between the second and
third 1-r vertebrae.

Mter twenty mnuted he carried out a radical repair of a right inguinal
hern~a without the least discomfort to tha patient. He named the method'
lietameric anaesthesia' because, while sensation is lost in one segment of
the body, it was retained in prts above and below that portion of the
spinal cord from which the blocked routs arise. His papr presents the
anatonucal prmciples, instruments, phamcology, physiology of different
levels, indications, contraindications and ccmplications of epidural
anaesthesia in the first forty three patients who underwent the technique.
Personal comications suggest that ?ages had a very superficisl knowledge
of French paprs on sacral epidural anaesthesia, but -was well awdre of
Kappis's work in Germany on pravertebral anaesthesia. Pages knew that
after wravertehral injection the solution will spread through the
intervertebral formnae into the epidural spce, causing anaesthesia.
Because of his great experience with spinal anaesthesia he used the median
intervertebral route to produce the same effect, as described above.
Uthough Dogliotti, in Italy in 1931, 'rediscovered1 this techni~ue without
knowing of Pages' pblication, he later achowledged that Pages .was first
and gave him all credit for it publicly.
We wish to exprsss our thanks to Dr Fidel Pages Sergem, retired medical
doctor in Barcelona, Dr Rami.ro de la Mata Pag*s, millo-facial surgeon in
Madrid and Dr Matilde Faura, anaesthesiologist of the Hospital de la
Princess, ~Yaclrid for their valuable contrihtions to this study.
1 b'aulconer A, Keys TE. Foundations of Anesthesiology. Charles
C Thms, Springfield, Ill. 1965; 927.
2 Pages F.Anestesia Metamerica. Revista de la Sanidad Militar,
Madrid 1921; 11: 351-356, 385-396.
3 Pages F. Anestesia Metamerica. Revista Espanola de Ciruryia
1922; 3-30.
4 Dogliotti M. Un promenttente metdo di anestesia tronculare in
studio: La rachianestesia peridur.ale sementaria. Boll.Soc.
Piementosa di Chirurgia 1931.
5 Pages F. Trataniento de las fracturas diafisiaris de 10s huesos
largos. Revista Sanidad Militar; 1914.
6 Pages F. El shock traumtim. Revista Eswnola de Cirurgia; 1921.
7 Pages F.Sobre 13 existencia de un espacio pravertebral
hlprsonoro en 10s pneurootorax a tension. Revista Espanola de
Ciwqia 1921;3:1-13.

Pages F. Heridas abdaninsles de querra. Mi exparienca personal.
Revista Espanol de Cirurqia 1923.
Pages F. Drenaja transcerebral. Revista Espanola de Cirurgia 1923
Pages F. El tramiento incruento de 10s tmres. Revista Sanidad
Militar 1913; 3:215-232.
Pages F. Cbntritucion a1 estudio de la cirugia plastica de la
mejilla. Revista Espanola de Cirurgia 1919; 1:l-28.
Pages F. El tratamiento de 13s fracturas del olecranon por el
enclavijamiento y la extension continua. Revista Espanola de
Cirurgia 1919; 1:486-495.
Pages F. Arteritis de la arteria subclavid. Revista Espanola de
Cirurgia 1921.
Pages F. La gastroenterostmua con collar epiploico. Revista
ffipanola Je Cirurgia 1922.
Pages F. Aspecto quirurgico del estre nimiento. Revista Espanola
de Cirurgia 1923.

Dr J M Hot-ton (Cambridge)
Denis Browne's lbp Hat was the name given by successive generations of
anaesthetists at the Hospital for Sick Children, Great Omnd Street,
(GOS), London, to the ether inhaler devised by the ~ediatric surgeon
Sir Denis Brame.
Denis John Wolko Bruwne, KCVD, W3 BS (~ydney), FRCS, ADn FRACS, 1892-
1967, was a pioneer of wediatric surgery who spent his mrking life at
the Hospital for Sick Children. He was the first strgeon in 'hgland to
devote all his time to children, and was affectionately !mown to all who
worked with him as 'DB' .
A great original thinker and innovator, he developed many ingenious
instruments for techniques specifically suited to children. Of inter st
to the anaesthetist are an ether inhaler (the Denis l3r-e 'bp Hat).' a
mth tube for delivering anaesthetic gases, a mouth gag for edentulous
children, an endotracheal tube, a blood transfusion apgziratus for
children (modified from that described in 1927 by R R Macint~sh)~ and a
cruciform supp3rt far use when operating on infant^.^
Lknis Brawne was born in Melbourne, Ustralia in 1892, the son of an
Australian pioneer in mining and sheep farming, and educated at Kings'
Schaol, Pararmtta and the University of Sydney. Both at school and
university he was very mch an individualist and, as well as being
academically able, he excelled at tennis, shooting athletics and
billiards. He graduated in 1914 and Wiately joined the 13th Light
Horse Regiment of the Australian Imperial Force as a medical officer and
served at Gallipoli and in France with the ANZACS. After denmbilisation
he elected to live, train, succeed am3 then die in England. After
training in Liverpool and London and taking the FRCS in 1922 he became a
casualty officer, then resident Medical Superintendent at GQS and was
appointed to the consultant staff in 1928, serving the hospital until
1957, when he was electerl emeritus surgeon. He was appoint& KCVO in
1961. He was also interested in history and in 1960 gave a paper at the
Royal Society of Medicine on Byron's 1 ~ness, based on a careful study
of the leg appliance that the poet mre.
amune-S ether inhaler ('lbp mt)
Vhen Derljis Brme was casualty officer and then Resident Medical Officer
at ?AS, one of his duties was to deal with the enormous tonsil and
adenoid waiting list which the hospital had acquired as a legacy of the
work of the ENT surgeon George Waugh who had propounded the need for the
operation to be done by carem dissection rather than by the generally
accept4 guillotine rnethd. DB was a demon for work and organised
oprating sessions of 25 tonsils and adenoids a day and 10 on Saturdays.
Ckl Sundays, according to James Crooks his EWl' surgeon colleague a t GOS,
DB would think about tonsils and adenoids! !

He described a tortuous vein
lying between the tonsil and
posterior pillar of the fauces
(thought to be the cause of the
bleeding tonsil), developed
suitable surgical instruments for
the operation and for
anaesthesia, an ether inhaler and
a muth gag for delivering the
anaesthetic gases and ether.
These instnnwnts were fomd in
all the mjor anaesthetic
catalogues of the day. He
attxhed his name to all the
instruments he devised, so using
one of the few advertising
channels open to the medical
proEession.
In a letter1 to the Sritish
Medical Journal of 6th &to&
1928, DB comnented on an article fi
in the Et of 28th July 1928 by a
P4r Sandiford (an surgeon) and
a Dr Cl3yt0n (an anaesthetist)
from Sneen Nary's Hospital,
Stratford, landon who had
described the use of ethyl
chloride and the millotine for
tonsillectomy. DB's letter pints
out that the operation for
Ether Inhaler (1928)
tonsillectomy should be unhurried
and that the best anaesthetic was
ether, and proceeded to describe
his m inhaler which he said had
Rlotoqr;lph m*?e from sIi:9e no. 71 been used in mny thousands of
Aysn.of .bae.ithetisrs c~lle;tion cases. Ilis description of his
of photoqr-iphs of ether inhaler shors he was
Charle.; King Collection familiar with, and understood the
workings of, other ether inhalers
avaiL3ble at the time, and their
disadvantages. In DB's own words: 'The main difficulty in giving ether
is to vary the concentr+tion of the vapour from the very weak at the
start to very strong when deep anaesthesia is needed. With the open
methd a high concentration can only be obtained by muffling the mask
with towels etc. - a crude rvasteful and inexact proceeding. Also the
ordinary Sckimnel~ch msk has the fatal defect for ether that as soon
as the fluid is poured onto the convex gmze pd it runs down to its
brders, leaving a dry patch throuqh which the patient breathes. The
Clover inhaler, well used, gives a mst excellent anaesthetic, h t it is
expnsive, fragile, and difficult to clean, while its proper handling is
a rare accomplishment. Silk's inhaler has the sound principle of
retaining the heavy ether vapour where it must be braathed by the

-mtient, by mans of a cylinder fitting belaw, closely to the face. The
sponge, however, when soaked in ether, is almost impenetrable to air,
and tends to clrip from its 1-r surface.
'My own pattern (mde by Allen and Hanixry) is an aluminium 'cylinder' 7
inches in height, and shaped to fit tine face, with a Sorbo sponqy r ubr
pad at the lower end.
'The ether is held by an oval game pd, 7 inches by 5, and at least 8
layers thick, preferably hemned so that it can 'be rvashed and used again.
This is placed on top of the cylinder, and thrust down into it, on to
the bars across the 1mer end, by a mller cylinder munted on a
handle. This gives a flat gauze surface, down which all ether poured
into the inh3ler nms, so that the ptient's breath rmlst pass through
it; while owing to its flatness, there is no tendency to driming.'
DR consirlered that his inhaler had the following advantages:
'1. It w ill give a very high concentration of ether with a percentage
of CO2 much as in tFle Clover inhaler.
2. It is very economical, its consqtion being only one
third of that of the open method. In on lent alone at GK~ilt
Omond Street this difference meant a s £50 a year.
3. It is sinple, cheap, easily cleaned between anaesthetics, and has
that priceless quality for 'nospit31 equipnt of surviving after
being d rom on a stone floor.
4. It does not cover tile yes, thus avoiding what I think to ke one of
the main causes of panic in children.'
DB then described his main points on how to use his inhaler:
' 1. Start the induction with a single drop of sther in the inhaler.
Anyone who thinks this is too little is recmded to experiment
on himself.
2. Keep the mask closely on the face, and as soon as the patient is
breathing one strength of the ether easily, increase it. A fairly
wide experience of inducing all types of cases with ether has
convinced me that the main causes of failure are starting with too
strong a vawur, and taking the mask off for no particular reason
except to see if the patient is still underneath it.
3. As soon as the patient is deeply anaesthetisd, with dilated
ppils and easy breathing, hang a weighted hooked imuthpiece on
the top of the inhaler and puntp ether vapour through it. If this
provokes coughinq, gag t3e muth open and hang the tube in
it to continue the anaesthetic, again carefully avoiding giving
one breath of etherless air.
DB then corrmented that he found this method quicker and better than
inducing with ethyl chloride and charging to ether, as it avoided the
'no-MS-landr when thn pltient is clxning out of deep ethyl chloride
into sha1101~ ether, and an expsrt surgeon and anaesthetist team could do
almut eight cases an hour.

In Allen and Hankury's &t;ilogue of Surqical Instruments for 1930, the
ether inhaler was priced at one pound two shillings and sixpence
(C1.2.a) and the double r~eighted muth tube at eight shillings and
sixnence (8 .a) .
Working with DB the 'Top F&tl
DB ms an outstanding five of a van, well over six foot, having
in'lerited from his forefathers rtronq cpalities of physical stature,
adventlre, leadxshin, courdge and scholarship. 'I\iolko1, his third naw,
in abriginal language mans 'Big Win', appropriate to this man who
probably contributd more tc pdiatric sxrgery over a wider range of
conditions than any other surgeon.
He was an ~ntellect~~l adventurer, a rebel, and a cynic who took nothlng
at ~ts face value. Altgetl~er a formidable character.
I was a s.znior House Officer in anaesthztics at GOS from 1951-195?, and
privileged to have given anaesthetics for DB, who taught me how to use
his 'Top Hat'. In thos? days a senior house officer would give
anaesthetics for him vit:iout aqy condtant supervision, and I went once
a week to the cou~try branch at Tadmrth Court in Surrey to give
anaesthetics €or an operation list F%- DR. Providing that you did what
he ask4 a d used his techniques 0.- ones of wrich he approveli, he was
very kind and tolerant with a junior and ineprienc~ed ana.?sti~i?tist. If
one sxnt too long over an induction, he would offer to holp, saying
that he knew a thing or two abut anaesthesia and tracheal intuhation!
mere 1s no longer a need for the 'Ton Hat1 ln ppsdlatr~c anaesthesia,
but ~t a s one of knis Browne's in~onio~ls and 11seFul gadqets, md 'ie
ra&s mng tho5e fa~nous slrqeons who have contr~butec! to t h ~
developnent of anaestk~asra,
References
1 Rrome DR. Annest:~esia for tonsillectomy and remvsL of adenoids.
2
British Wdic31 Journal 1928; 2:532.
'lacintosh W. 4 simple methcd of blood transfusion. Lancet 1927;
ii:22.
3 Brome RB. .?n aid to o:xr;ltions on infants. British ?Mica1
Journal 1930; 1:54'7.
4 Uoituary. Sir Denis Rr3wne. British N4ical Journal 1967; 1: 50'3.
5 Stepliens D. 0'7ituar-y. Sir Wnis Srowne. British Medicll Journal
1967; 1:509.
6 Rruwne RB.The prol-~lem of Ryron's lameness. Prxeedi.lqs of the
Royal Wiety of Medicine 1963; 53:440-442.
7 Crcm'rs J. Denis Br,me : Colleague. In: Nixon HH, r,iat.?rs ton D and
ifink CAS eds. Selected VJritings of Sir Wnis Rrowne. London.
Trujtees of the Sir &nis Rrme Xemria7 Furld 1983; 1-2.
8 Sandiford CR. CLay'on JC. The quillotine and ethyl c'llorirle.
British rwicsl Journal 1928; 2: 149-157.

Professor H Reinhold (73nlssels)
History is larqely conditioned by detanniniw factors. Those concerning
the developnent of anaesthesia \ere mlch alike in mst of continental
Europe. So, events similar to those reported here for Belgium also
probably took plxe in nearby co~mtries.
To fully explain this pyxr I mst first d~fine 'mdern anaesthesia'.
What is modern today will obviously he oSsolete in 20 years. I mean
hers, our specialty as practised by physicians devoting themselves
exclusively, or nearly so, to this brmch of mwicine. Anaesthesia,
concordant with this definition, did not exist in Flelqi~m until after
the 2nd World War. It was t'len introduced by young doctors who had
received their tr9ining mainly in the United Kingdom, but also in
American and Swadish hospitals. Oelgian anaest'?etists of the first
generation thus have a debt of gratitude to their British colleagues.
?here is an old sayinq, that to him from wllom you acquired merely one
single item of knowledge, you mie thankfulness For life.
Before 1946
\+hat was the situation hefore modern anaesthesia in Belgium ? Surqery
rms of course, widely practised in its vario~ls fields with the exception
of intra-thoracic operations. The anaesthesia was either local or
general. For lmal anazst!lesia the rmst imp3rtant type was spinal
performed by our sixgical colleagues. Several Belgian surqeons had a
deep interest in this. In 1934 .Joseph Sebrechts (1895-19481 described an
original and rational. technique of spinal anaesthesia conprising
repeated injections of 5ml light Nuprcaine 1/1500, with the ytient
lying in the prone position until the required level of analgesia w3s
obtained. l The technique became widespread in Belgium and France.
bngton Hewer descrilrd it in his well-'mown 'Recent Advances in
Anaesthesia and Analgesia' .2 In that era, some surgeons who were
impatient to start operating carried out t\e spinal anaesthesia without
due care. During surqery the patient was unsupervised and if they
complained of inadequate anaesthesia they were smthes rebuked. Severe
hptension of ten remained undetacted. To explain uniisml results f rrxo
these spinal anaesthesia methods, which &re often due to technical
failure, Sebrecht concocted a theory of a variable reactivity of
ptients, who were thus either too resistant or too sensitive to spinal
anaesthesia. He assartd he could prsdict the patient's type according
to their response to premedication. Spinal anaesthesia was highly
favoured by the surgeons, but, according to what they had heard ahout
it, wtients often expressed fear of what they called the 'prick in the
back.
For major operations the alternative was general anaesthssia. It mstly
consisted of $he administration of ether by means of the 'appareil
d'anbredanne' . This was a semi-own inhaler (Fiq.1) invented in 1908,
having some similsrity to Clover's inhaler. Ether anaesthesia from this
apparatus was necessarily associated with hypoxia and hypercapnia. A few
generll practitioners acquired wide e:tperience in its use and obtained

Figure. aahrdame Apparatus. Metal sphere, containing pieces of
felt, to be filled with ether. Pig's bladder for reservoir bag.
Handle to set concentration on the right.
satisfactory results. mt for mst cases genenl anaest%esia was
administered by a nurse, medical student a junior surqical assistant or
the referring physician; they usually had the comn Eeature of hating
to give the anasqtiietic. After the o~ration these ptients were nearly
al~mys p3le, had a moist or cyanotic skin and were examples of the
classic picture of shoc'c. This w3s regar94 as the noLm1 and
~mavoidable aftemth of sur9et-y. It '.ms believed that t:~e patient w11ld
be helped by tonic dru(jsV. For that p~upos-, injections were prescribed
four-hourly . for example cam@?or oil, caffeine, ephadrine, nikethamj.de
ad even digitalis ~rewrations given in succession. Survival without
lasting sequelae \EIS regarded as a g& result From surgery.
Specialists in anaesthesia rho ware appointed after the war had to
rssolve a Larqe n-r of problems: obtain 3uppLies of apwrat~ls,
instruments and drugs, improve the standard of anaesthesia, attain
profassion?l stat~ls and satisfactory my, and train doctors to meet the
growing demd for &ern anaesthesia. These tasks were accompl.ished
'cetween 1946 and 1954 w5en t'le present stnicture of our specialty in the
country was cmpleted. Tho progre:?sive steps are best descriw in
chronolqic~l order.

In the early pst-mr perid the necessary drugs and volatile
anaesthetics rapidly became available. Tnis :ms not the case for
compressed gases. Initially the simplest app-ratus were used. For ether
it was the Oxford vaoorisor4 which w.as used for ocen thoracic
operations. Tric'7loroethylene was administered with a mst elementary
air draw-over bottle, fittail with one-way valves as designed by H R
~tarrztt.~
Anaesthetics were usually given in the deprtments of surylery, but in
th-se deprtments doctors were apyinted to do surgery. The only work
available for an anae5thstist was voluntary work. The ansesthetist was
needed hlt not b~md by any contract. Nevert5eless. recplations and a
sense of responsibility ensured that an anaesthesia assistant was
reqularly employed. This proved unsatisfactory as the departments of
El?'l', gvnaecoloq.] and others which had surqicsl activity, were dependent
for anaesthesia on t'le qoodwill of the department of surgery.
As only a handful of anaesthetists existed, mst sllrOery continued to be
done in t'le 'tradition31 my1. Difficult or imprtant cases were pupd
in special sessions for which an anaesthetist was requested. Rs an
example of a 'difficult case' the follaqing may be renortd. A strong
muscular stevedore had a tumour on the na,p of his neck, of the size of
a fist, lying ?elm a canpletely bld, shiny scalp. Abut ten years
previously the scalp had been irradiated for depilstion to treat a
refractory skin condition. The demtolgical condition had been cured
but the man had remind totally bald. The twour also seemed to be the
result of an excess of X-rays. In addition, wor'c in the harbour was
mostly mnual at the time, causing sustained dehydration. The patient
attentively canpensated for this loss of fluid with cool refreshing
beer. Excision of the tumour by electrocautery had to be performed with
the patient in the prone position. A junior assistant in surgery was
entrusted to give intravenous anaesthesia with Evip (hexobarbitone).
l3e drug prhced ~lnconsciousness as expzted. l3ut when the electrocautery
was applied the st2vedore ros? frighteningly on the table.
Repeated injections and further attempts at surgery brought the saw
result. After a total dose of 1G had been injected in vain, it was
decided to postpne t5e case for a 'special session'. Wen this took
plqce, the faces of several members of staEE could be seen peering into
the t'leatre from behind a dindow. Tile look on the faces could be
described as that of Wnrcins in the amphitheatre watching fighters facing
wi-ld teas ts, ' quaerens quem devoritl , wondering w'lo will .#in against
\++a>. The pWient, a known alcoholic, had now received an appropriats
premedication. '~e ;gas given a fair dose of the lruch mre powerful
Pentothal, follov~~? by trichloroet!iylens in air. He then had a blind
naso-tracheal inttihation, was turncd on his stomach and had the tumur
renoved in a qudrter of an hour.
Aprt from prlctical demonstrations to hosi>itals, the advantages of
modern ana~?st:~esia 3ls0 ne?d to be rep~rted to medical societies. Since
1940, surtsi.~eJ progress in me;licine had been interrupt,-4 in occupied
Europe. Advances in the treatment of inf~xtion, in anti-thymid drugs
and in parenteral nutrition were poorly known on the Continent; this

also applied to anaesthesia. Wartime had been difficult for members of
t!!e medical profession as well as for other citizens. All had to give
much time and energy to the basic needs of daily life. During 1946 most
activities returned to noml in Belgium. Meetings of t:he Societe Belge
de Chiruryie startu:l again. Three pprs dealing with anaesthesia were
read. One was by a surgeon reporting 50 cases of intrasternal
anaesthesia, two were by an ansesthatist who dsalt with Pentothal -
still unknown in Belgium - and gave a description of the Oxford
vaporiser.
The Wiete Beige de Chirur:lie (SW) decidecl to hold its first post-war
congress. Traditionally two topics rvere chosen and select.?d nethrs were
appointed to write mnoyra,*s. One of the subjects was 'Indications for
the various methcds of anaesthesia' and a surgeon and n anaest!ietist
were delegated to de3l with it In the plblished reprt' the following
subjects werz discussed: ~.3l,intravenous, inhalational and
endotracheal anae:;tk?sia, the use of curare and problem of
intrathoracic oprations. It was explained that, contrary to the title
chosen by the Societv, clearcut indications for anaesthetic drugs or
methods did not exist 3nd that clinical results were reflected, not by
their choice, but by the ccnn,wtence of the physician giving the
anaesthetic. The Congress was attanded by slxqeons £ran all over
Belgim, as well as from neigwmuring countries. John Halton from
Liverpm1 was one of the guest speakers. The message about modem
anaesthesia got through. Posts for anaesthetists were created in
university and other hospitals.
The first arm11 group of Belqian anaesthetists still had many problems
to solve. t5ey decided to discuss t\em and met replarly at a brasserie
in Brussals. In Belgium there is a rule that professional matters are
kept seFrate from scientific activities. Papers on anaest'lesia were
read at meetings 3E the society, but the sixqeons could not be
relied uwn to deEenA tile material interests of the ana?st?etists and a
professional organisation ms required for the m s e . At the time,
there were only about a dozen who regarded themselvzs as qualified
anaesthetists. To create a professional bocly with so few amare5
presmptuous. Nevertheless, the Association Professionelle des
Specialistes en Anestl~esiolqie' (%?SA) was founded. It was a bold step
which proved highly beneficial as it provided an official existence. In
meetings to disc~~as awqistrative and financial matters there coulrt now
be representation from anaestl~~sia.
As consequence of the 1947 Congress and with an increasing number of
papers by anaest~etists, the Board of the ,%C deci-led to create a
Section of Aneathesio1o:~y and t;~ hold ssssions dealing solely with
anaest\esia. Meetings rmre still chaired by the President of the
Society. Surljmns attxde3 the meetings and they were in the majority
but they qradually seemed to feel less at home during the discilssion
periods.

Most anaesthetics were still given in the old style and the demand for
specialists had km pressing. The mall 11umber of qualified
specialists was ovemr'ced and often asked to do cssea on the same day
in several llospitals and sometires in ~rnprepred surro~mdings. This
would occasionally generate Aiffic~iLt and hazardous situations, but
fortunately teaching in anaesthesiology gradually appeared in the
university prqranmes.
llle same year reform were undertaken in the mediml profession. The
developnent of spcislised medicine had created the need to define the
relative position of general practitioners and soecialists. Social
security mdicine had bcme general in the country and specialists
claimed priviLeged fees within its orpisation. .%ny doctors h3d an
undiscuted canpetence as specialists in a variety of branchzs of
medicine, but some were ju~t sslf-awinted or had obtained a certain
notoriety without havinq undergone a training progrannne or passed an
examination.
In anaesthesia, some general practitioners were still regularly giving
'old style' anaesthesia. They believed the only technique of the
spcial-ist they were unable to manage was tracheal intubation. Many
applied to be dccepted in demrtments of surgery, displacing an
anaesthetist, so that they could learn 'how to pass a tube1. The
qislified anaest:~etists had to insist that hospital authorities only
admit candidates for training for a €1111 course.
In 311 specislties, it had hem necessary to set rip a system for
granting recognised qualifications. this ms the task of a new union of
all spxialties: 'Groupnent des Unions bfsssionelles Belges de
Medicins Specialistes' (GBS). As the anaesthetists had started their
union in 1947, they were one of the founding unions of the GHS. This was
highly gratifying to our young qroup.
'[he nlnnber of anaesthetists had increased and so had the nmhr of their
whlicatims. Their ppers had t~come rather abqtruse to surgeons. In an
attempt to further incrsasz ti?~ status of our spcialty, and to make it
prfectly clear to the m~dical profession as well as to the authorities,
that clinical anaesthesia wss neither part of surqery nor of
pharnucolay, it appeared that an independent scientific journal was
necessary. 'Acta Anaesthesiologica Wlgica' was foundeft. For a small
colrntry like Bel9ium it was a daring initiative which contriktcd to the
slxzialtyf s pre.3tiye.
Pie National Health Insurance then dacided to re-examine the
nomenclature of the various medical services and their sc4e of fees.
The clment system had heen introduced in 1344 when specialised
iinaest!~esia did not exist. Py tradition, the anaesthesia fees were 10%
of the surgeon's. Cur proEessiona1 union decided to clsim 30% with the
hope of obtaining 20%. It !ms a plcasant surprise that the 30% was

g-ranted ! 'he monetary success was the confirmation of the new status of
our profession.
In the Section of Anaesthesiologie of the SOC a function of Chaim of
t'le Section was created. me sessions rere from then on presi4ed over by
an anaesthetist. In 1954, postgraduate teaching of anaesthnsioloqy,
already existing in all universities, was established by law. This had
no particular consequenca, but was another step fonuard.
Anaesthesia was now autonomus in hospital work, in professional status
and in pstqraduate teaching. Since 1946, scientific activity had taken
plxe at meetings of the SIX. Acta Anaesthesiologica Belgica waa a
seprate publication managed by the 'Societe' and a good relationship
had been establishd. With changes of membership of the Board, financial
difficulties arose over the plblication expenses ancl a new format
appeared actvisahle. The 'Societ~ Bel~e dgAnesthesie et Reanimation' was
then formed.
me creation of modern anaesthesia start4 in Belgium in 1946 and its
present structure was cornplated in 1964. At its introduction, it was
highly welcomed and w~nnly supprtr?d. But its birth represented a move
army fro .surgery, a branch which had originally been prt of it. As
anaesthesia improved its status in the hospital situation, omsition to
its developnent from less eminent surgical colleagues appeared
spradically. Its growth to a major specialty was the result of combined
efforts in l-iospital and academic work, and in research. The audacioous
decision to create early in 1947 a professional union was crucial to
later success. All these ss-s are interlocked. Better material
conditions enhanced clinical and academic work and the latter helped to
improve materirll conditions., 'Audentes fortuna juvat' (Virgil: Aeneid,
X, 284). Fortune hel,ns those who dare. Now in Belgium, like in many
other countries, !Xpartments of Anaesthesia are amongst the largest in
m y hospitals.
1 Sebrechts J. La rachianesthssia. Revue &l?e des Sciences
Iledicales 1934; 6: 311-334.
2 Hewer CL. Recent Advances in Anaesthesia and Analgesia. 7th Edn.
p236, Loncfon,: J & A Churchill, 1953.
3 Qnbredanne L. Un aLp3reil pour l'anestheeuie plr l'ether.
fazette des Hopitaux 1909; R1 S: 1095.
4 Epstein HG et al. Theoxford Va{mrisnr. Lancet 1941; 2: 62-64.
5 llarrett HR. Apparanls for obtaining general analgesia and
anaesthesia. British :Mica1 Journal 1942; 1: 643.
6 Laduron E,Reinhold H. Indications r~spectives
+-.S diverses
anasthesies. kta Chimgica Rel:).ica 1747;46:151-21lO(Sugpl.a1m 5).

Drs M Goerig, W Pothmann, H Polcar
Estcess anaesthetic gave3 polluting the air in oprating rooms may result
n detrimental effects for ,311, worlcers in that In rzcent
years renewed efforts have been made both to develop new scavenging
app~atus, and to let everyone involved with inhalat'o a1 anaesthetics
!mow abut the pssible side-effects of their vapours. 2-3
The first ~nentian of the existence of excess gases and associated sideeffacts
occurred in 1889 when h-0f.G van Overbeek de Meyer, a
microhioluqist at the Reichsuniversitat of Utrecht, pointed out the
~ssibility of an interactio 'ktween chlorofon and incident gas light
if us-ci at the same the.'' He discr,~ssed the quality of air in the
theatre, adding that he had never noticed this phenomenon when
chloroform or ether was used alone. His ohsewation initi t~
disc~lssion about the problem, which has yet to be fully resolved. 3-fkl a
A few weks latx, an ophthalmlogist at the University of Fxlangen,
near Nursmburg, Prof.von Eversbusch gave a more detailed description of
slde-effect5. He had observed symptoms: coughing, headache and mucous
secretmn of the nose and eyes, men h and his colleagues had worked
longer than wll?~l Ln such pLlut?d airJ7 He s13w pollution as the main
calise of these symptorits and recmendwl intensive ventilation of
theatr?s as the best method of prevention. Another preventive mathod, he
felt, was the prnduction of hi7h humidity, to absorb the polluting
rmlecules .
Intrnslve research followd to identify the toxic gases. In 1891,
P~wf.von Pettenkover, Chairman of the Institute of Microbiology of the
UnLverslty of Mun~ch, pblished his ~esults in a review article.'' In
hls laboratory, the main toxic substances were identified as chlorine
and hydrochlor~c acld. mth gasas were well-known at the time for their
toxic praperties which could produce symptoms comparable to those
reported in the medical journals.
During the following years, few publisheA articles dealt with excess
gases, probably as a r~sult of modernisation, such as he use of
electricity in hospitlls, and especially in theatres.' Another
explmation may lie in the rediscwery of ether for anaesthe~ia which
led to a more intensive use of this agent. Degradation by gas light of
this agent has never been descril~d as its explosive proprties prevent
it being used in t'le presence of an open flame.
With the tremendous progress of locsL anaeqthetic techniques during the
next decades the problem seemed to receje. Wen mentioned, the problems
of excess gases wpre considered as minor. Wor'cers s~lfficiently concerned
to recognise the rnssible hazards includd two EerLin surgeons, Unger
and ~ettmann.~O When rewrting t:-e results of their experience with the
apnoeic insufflation technique of anaesthesia, they noted problems,
esp-iaLly for the anaesthetist, from atmus&eric pollution. Similar

effects were noted during the use of the Sauerbruch chamber for thoracic
=gery.
In 1918 a Dresden surgeon, Kelling, reprted in a surgical journal on
the various problems caused by excess g ses and the intolerable
situation they caused for all affected staff .'l He designed a specially
sham anaesthetic mask for effective removal of the vapur. During
suhjequent years, Kelling published sev a articles reprting some of
his methais for overcoming the (Figure 1) in retrospect,
his developcents were highly effective and his contributions to the
field deserve wider recognition.
Just when Kelling was drawing
attention to the existence of excess
gases, the American pioneer in
anaesthesia, Francis Mctlechan,
pointed out in an obituary the
detrimental effects of ch nic
inhalation of excess gases. 38 *
colleague was said to have died of
cRronic inhalation of narcotics. -
PlcMechan wrote: 'We know what ,
protective measures mist be used by
radiologists, but so far medical I
science has not forced the
protection required for those who --- . --.
give anesthetics'.
The next to ccnnnent on pollution was
the Gemn Perthes, (of Rrthes'
dissase) ad well-known for his
method of localising peripheral
nerves the use of an electric
current. 't28 In 1925, he described
a specially designad exhaust fan
with an inlet close ta the patient's
head. (Figure 2) Within five
minutes, the air in the theatre
could be ccmpletely renewed,
resulting in improved well-being in
his staff.
K,
In the sm year, Kirschner
suggested the advantageous use of
fans to dissipate the anaesthetic
away f r m the surgeon within the
theatre?' In retrospect, this w3s a
step backrvards as t\e gases were not
eliminated, in contrast to the

Figure 2. E@rthegs Device (1925)
methods of Kelling and Perthas. Even in the 1940j8 the use of fans was
recmended in &m textbxks of surgery. Another way of
eliminating he anaesthetic was su.3gestd by Wielxh, an obstetrician in
Ronigskrc~.~' Bzaring in mind that the vamurs of ether and other
inhalational agents are of higher density than air and tend to sink, he
designed a specially sham box in which the patient's h~ad was
positioned during anaesthesia. By a sophisticated exhaust ss$tem, all
excess gases were removed and eliminated outside tha theatre. During
the early 19301s, this apratus was produced by the Braun Company and
its use ims 31jec~nded in the first edition of Killian's textbook of
anaesthesia.
'Ihe advantages of absorption of gases ch rcoal filters were seen by
the surgeon, Holsc'ier, of Cologne. q4r " ~ilter systems were
incorporated wit41i1 the expirdtory alves of a,3pilratus or fitted to the
top of a spzially designed mask.3x A remrkahle re~~uction of excess
gases was noted and interpreted by him as an improved theatre
enviroru.lent. He said that changing used charcoal filter systems for the
removal of excess gases s!iould become a daily practice like the
st.erilisation of irs-trunentq. In the rnid 1940'8, Epstein, a colleague
of Professor Macintosh in Oxford, yublished an article in fjty I Tancet l
and emphasised the use of charco-1 filters for this Fpse.
A new indication for charcoal filters was s?en with the clinical
introduction of Narcylen as an anaesthetic. The first enthusiastic
reports of its narcotic proparties were 0vers'nadOv~ed by several injuries
due to its explosive nature. To minimise this, a filter system bcame
widely accepted as an effective protection, as the gas is rapidly
aSsorkd. This finally bcame an integml part of some anaesthetic

apparatus. Moreover, the quality of air within the theatre was
imnensely improvd. 'Ihis effect was dnscritxd by the Gem
obstetrician, Ga~lss, y8,!~ll as by the surgeon Tiegel, a colleague of
Sauerbruch at Fheslsu. Tiegel had designed a special anaesthetic
apF*cra 1s for heated etner to improve the anaesthetic proprties of this
agent. "140 Toreduc,? the explosive hazard he also included charcoal
filters in his machine. Ebth the Narcylen and the heated ether
appratus were produced by the Drager Company in ~ubeck.~~ Acceptance
of filter system in those days rvas based more on the reduction of
explosions than on providing an effective scavTFflg system to minimise
side effects like cough, headache or dizziness.
Wern methods
me technical solution, well-known to every anaesthetist nowadays, w=is
described in the late 1920's - the ~ip' g system. One of tine first was
that of the surgeon Zaaijer of Leiden.' Tne reate gas dispossl system
led to a hall in the theatre suite. A sinilar mthcd was used in the
surgical deprtwnt of the mivers' y Clinic of Freilxlrg where Hans
Killian started his medical career.i' lumnq others, he suggested the
use of water-power4 extraction system with a minimum performance of 40
litres per minute. Even tday this value is generally acceptd. During
the following years the pro3lens of excess gases were almost totally
ignored. The first to revive this concept was the remn surgeon
~ertmann.~~ In 1946 he called once more for a definitive technical
solution arcping that the costs muld be minimal in compwison with
thos- of the side effects for all involved. He c421ed for a solution at
a time when many mr-damaged hos~itals were bing reconstructed.
It seem that his proposals fell on deaf ears as the same hazards were
again discl~ssed Cqirty years later in a Russian plblication by Vaia
entitled in translation: 'Work.yg&onditions in surqery and their effect
on the health of anaesthetists . She specified once rmre the effects
of chronic inhalation of anaesthetics such as headaches, cough, reduced
a;-tite, etc. All this had been dencrihec-1 in the 1930's and even the
title was nearly the same: 'Die chronische Aethervergift~mq der
Chirurqen und Mitts1 zu deren Ve hutunq' (Chronic intoxication by ether
md nethods for its prevention). 35
As Vaimn was the first to report an increased rate of prem3ture
births, abortions and m=~lfo~tions in the newhorn of anaesthetists, the
article re-initiated a worl:kide dis 11-s'o ! e risks associatei-l with
chro-nic inhalation of anaesthetics. 'li, 3-8r''1i' Reniwed efforts r;.2re
mde t3 find a satisfactory solution, fmm tha theoretical as well as
the technical pint of view. All over the world various national
scxieties of ansest!lesia worked on recomnendstions for when inhalstional
anaesthetics yvrJ to be used.' A ramrkable reduction of excess gases
was achieved. 'Ia9 Neverthele~s, due to improved technical methods of
analysis, high concentr,3tions of tile differin7 vamurs can still be
found. E£ forts to solve the excess gas problem man one hundrecl years
aqo but much work remains to be done before the problem is solved.

Cohen EN et al. Occupational disease amng oprating room
personnel. 4 nations1 study. Anesthzsioloqy 1974; 41:321-340.
Dorsch J, Dorsch S. In: mcyclomdia of Medical Devices and
Instrumentation. Vol.1. M: Tiebster J. New York, Wiley 1988, 72-
Operderbecke W. Das Mutterschutzqesetz und seine Auswirkungen
auf den Personsleinsatz...Anasth. U Intensivmd 1989; G-11.
Lauven RI, Stoec'kel H. Der Eiifluss von Schutrmassnahmen. Anaesth
U Intensivmed 1982; 1:l-9.
Obel D. et al. Efficiency of the ejector flow meter. A scavenging
device for anaesti~etic gases. Acta Anaesth. Scand. 1985; %9:125-9
Reiz S. et al. The double mask - a new local scavenging system for
anaestlietic gases.... Acta Anaesth.Scand 1986; 30-260-265.
Gilly H. et al. Sicherhoit durch Uberwachung von Narkosegaskonzentration
volatiler Anasthetika. Anaesthesist(S) 1989;30:113
farsen W et al. Rerroval of halolpnated anesthetics from a closed
circle system. Acta Anaesth Scand 1989; 33:374-379.
Pottunann W. et al.Bslsst~mg des Arbeitsplatzes durch IJarokosegase.
Ursachen M Fravention. Anaesthesist 1991: in press.
Goerig Y, War H. Narkos~aseEortleitung-70 Jahre Benuh~ingen urn
eine ProbleiLosung. An3esthesist Suppl 1989; 30:682.
Goerig V. Remerkungen zur Arbeit von ,l P Jantzen et al.
Rnaesthesist 1989; 39: 639-641. Anaesthesist 1990; 39:537-633.
Meyer 0. !Zrwidemg zu dem AuFsatz d e Herrn ~ Dr Ostmlt. Bln
klin Wochensc!ir 1889; 8:165-166.
bony Praktische hlotizen. Bln klin {Jochenschr 1789; 10:219.
Anonym Praktisclie Notizen. Rln tlin Wochenschr 1889; 15:340.
Stobwassor Ue-r Zersatzung des verdunsteten Chlorofom in der
Ceuchtflamne. Rln 'clin Woc'lenschr 1889; 34:769.
Zwoifel ukr Lungenentmdung nach bj-~ratden in Mlge von
Zersetzung des Chloroforms Fm caslicht. Bln klin Wochenschr.
lM9; 15:311-320.
Eversbusch 0. Ueber den nachtheiligen Einfluss des Leuchtgases
Munch Med blochensc5r 1889; 13: 212-213.
Pettsnkofer 1.2. Ueher Gaslxleuchtung und elektrische Releuchtung
votn hyqienischen Stsnd[xln!kte am. Munch Med Whtr. lR90; 7 : 101-7.
Martens M. Ueber den %U wld die Einrichtung moderner Operationsram.
Bln klin Wochenschr 1906; 42:1372-1380,
Unger E, Bettmnn M. Reitrag zu S: J Eleltzer's Insuffl3tionsnsrkose.
Bln klin Vklienschr 19x0; 21:957-051.
Kelling G. W r die Relaitigung AY^ NarkosedanpEe aus dem
Operationssaale. Zlb f Chir 1918; 35: 602-606.
Kelling G. Narkosztmske zur selbvttatiqen Abf~~htung der
C:iloroform und Atherdampfe. Zlb f Chir 1422; 35: 1061-1066.
Kelling G. Zur Beseitiyjng der Narkosdedampfe arls dem
Operationssaal. Zlb f Chir 1325; 29:1586.
Kelling G. Nachtr?q zur 'Beseitiqung der Narkosdcdampfe aus den
Operationsa,3le.' Zlb f Chir 1919; 50:307.
Kelling G. Demonstration einer Narkosemske. Berlin, Springer
Verlag 17?6; 176-177.
Zkiechan Fr. Obituary. Anesth.Ana1g.Cleveland 1922; 1:19.
Perthes G.Schutz der am O-wrationstisch Beschaftigten vor
Schadigung durch die Narkosegas. Z13 f Chir 1925; 16:852-854.

43.
44.
45.
46.
47.
CA.
Goerig M, Schulte AM, Esch J. Georg Perthas - ein Pionier
n-cderner Regionnlanesthesie-Techniken. Reg-Anaesth. 1990;13:1-5
Kirschner M. Zur Hygiene rles Oprationssaales. Zlh f Chir 1925;
39-2162-2164.
Kirscher M. Algemeine und Spezielle Chirurgische Gprationsleher.
Vo1.3, Pt. 3, Springer Verlag 1940; 45R.
Wieloch J. Zur Beseitigunq der Narkosdampfe als dern
Operationssaill. Zbl f Gyn 1925; 49:2768-2770.
Sclmfer A. Die chronische Aethemeqiftung der Chinmqen und
Mittel zu deren Vertiutunq. Mels~ulger-Med Pham Mit. 1928; 695-7.
Killian H. Narkose zu olxrativen Zwecken. Springer Verl=ig, Berlin
1934; 372-374.
Fblscher Fr. Zur Beseitiguug der ausqeatmeten Narkosogase.
Zlb f Chir 1927; 25:1559-1589.
Holscher R. Zm Schutze des Operateurs. Deutsch rned 'iWhsnschr
1928; 48:794-795.
Erremer H. Bekanpfung der Narkoseschadlichkeiten fur kzt lmd
Kranke. Munch cled 1Jokenschr 1329; 16:2177-2178.
Epstein HG. Removal of ether vapur during an2esthesia.
Lancet 1944; i:114-116.
Gauss Cl. Die Narcylenbeta~llxulg mit dem Kreisatmer. Zbl f r;yn
1975; 23:1218-1226.
Tieqel Y. Narkose nit hochgespanntem Athet-rlampf. 11. Technik
der Narkose. Zlb f Chir 1934; 40:2313-2330.
Lauer F. Narkose mit hochgenpnnten Atherdampf.111. Zlb f Chir
1928; 40:2330-2336.
Haupt J. Der Drager Narkosea~~rat - historisch qesehen.
Dragerrerk Lubck, Medizintechnik, Sonderdruck 1970; rfP 105.
Van Wijhe M , Beukers H. The 7aaijer nitrous oxide anaesthetic
appziratus. Frls: Atkinson, bulton: me History of Anaesthesia.
Parthenon Camforth. 1989; 287-295.
Killian H. Narkoseeinrichtungen an der neuen Freihrqer
Chirurqischen Klinik. Chirurq. 1931; 23-917-921.
Wer?hm H. Reittag zu chronisc:~en Atherintoxikation der
Chirurqen. Bms Beitr z klin chir. 1949; 178:149-154.
Vasimn AI. Working conditions in surgery and their effect on
health of anaesth?~. Eksp Khir Anaestheziol 1967;3: 430-437.
Deutsche Chlsellschaft fur Anaesthesie und Wiieiferbelebmg.
Betufsverband L)eutscher Anaest'lesisten. 197A; 15:292-294.
Cudziak R. Nekenwirk~mgen von fl~uchtigen Anasthetika auf das
Anasthesieprsonal.. . Anaesth U Intansivwd 1981; 4:91-89.
Nat Inst &c Safety and Health. C~cu~tional expme to tmste
anesthetic gases and vacours.. . . Washington: US Govern
Printing Office DrEW pblication No (PIIOSH) 1977; 77-140.
Swedish National Roar3 of Ccc~qxtional Safety E; Hsalth 1381;
Rubln. AFS.

Drs J Samarutel, A Yivic, E Kross, B Le+tepm, R Talvic, A Tikk
(Tartu, Tallinn)
General inhalation anosthesis with dietnyl ethnr was intrduced in Tartu
University Hospital in 1347. Unfortunately, iye have no exact data about
the first admin~stration, but fnm the reports of G Adel,mnn, kofessor
of Surqery, and P Ihltllur, Professor of Obstetrics, it is known that in
1@47 ether anaesthesia was used S? time-;. Until the beginniig of the
Second World War and the ocmytion of Estonia by t'le Soviet Union,
sur.;ical and anaerthetic practice did not differ very much from that of
the rest of cmtlnental Europe.
The introdrrction of modem methods of anaesthesia and iitqnsive care in
EsLania began in the 1150's. Up to t'lis time surgery was performed with
open-drop ether-air anaesthesia awnistered by nurses, or with local
infiltration of 0.5 3r 0.25% prccaine injected by the surgeons. l3eca1ise
of the danqers of general anaesthzsia administered by unskilled people,
the technique of local infiltration which ws associated in t5e Soviet
Ihion with the names of its great prownents, the father and son team of
Vischnevesky, enjoyed imnense p!ularity. Local infiltration anassthesia
was used in Estonia as l?te as 1973 in 52.75% of all operations. In the
1950's thoracoplasties and extensive laparotomies riere often performed
with solely local anaesthesia. Sanetimes the operations becm
unbarable for the mtients, bit these occasional failures did not
disguise the valuable features of the methd. Operating under locsl
anaesthesia virtually excluded rough handling of tissues and demanded
reasonable operating speed. Surgeons so trained, often retained these
v3luable features in their oprating techniques and so obtained
uncomplicated postoprati-~e recovery for tlleir patients. Unfortunately,
lmrestricted availability of anaesthetists' servicas today, limits
sur!leons' exprience with local anaesthesia. In elderly wtients with
intercurrent disease, this lack of familiarity with local techniques
often leads to requests for general anaesthesia for relatively minor
procedures in which the risks of anaesthesia are weater than those of
the proposed surqery.
Euly genera2 anaesthesia
The basis for the intror3uction of Mern anaesthesia in Estonia was the
discovery of three ri~nlsed American Heidbrink anaesthesia rmchines which
had beer1 sent to the Soviet Union und,?r 'lend-lease' aid during the war,
and then left to tale Estonian ?ldicll Services in 1950. Tm of these
mchines were sent to Tartu and tqe other to Tallinn. In hrtu a
Heizrin': rmchine ins first used in 1353 to give N Ot and, later,
diethyl et'ler-oxygen by a face mask. The use of an ar?ae$&esia mchine
of such complexity attracted doctors, students and young surqeons to
anaesthetic practice. Tqe first endotraclie~~l anaesthetic in Tartu was
given in 1955 by one of these young sur:geons, Dr J Seeder. The patient,
with a ~nediastinal teratana, was blindly intuhted under deep etlier
anaesthesia without a laryngoscope. She was then cooled down in a water

ath as a protzction frm n-.uroreflectory 'shock' and sublectd to
thoracotomy and evnloration of the mss. Rscovery was uneventful.
FTM 1956, general endotrdcheal anaesthesia took place more regularly in
Tartu and Tallinn. At tnis time tCle first full-time professionals
ent?rd anaesth,_?tic practice. Three names deserve special mention -
Doctors A Xivik, B Leheplu and L VeeSer. Tney dere sll young medical
graduates with some surqical training, who devoted their professional
careers w5olly to anaesthesia and who intrccl~lced completely new
tachnicpe:; - such as endotracheal intubation, the use of muscle
relaxants, and controlled ventildtion of the lungs - into daily
practice. They themelve; had received very little practical anaesthesia
training in Mosc~cw or Lenin~ad but, beside their reslmnsibilitiss in
ptient c;tre, they devoted much enern to taching anaesthesia to other
doctors and to rlurse-anaesthetists.
Mficially, anae?t.h~+siology was recoqnis,+d as a distinct spcialty by
the medical authorities in Estonia in 1961. This meant the establishment
of 3 so-called 'chief specialist' ~s.t at the Plinistry of Health (Dr ND
Leileyxru) for the caxdination of dctivities of the snecialty. Manpower
in this year consisted of some 14 anaesthetists of whom only 4 had
received a little training (up to 3 mnths) outside Estonia. In a
country with a population of 12.5 nillion, general anaesthesia was used
in 1961 for 30.3% of 25,552 oprations perf~rmed. Endotrachesl
intubtion was used in a little less than one third of 311 anae3thetics.
4t t'le present time thase I-lumkrs have increased up to 53,000 general
anaesthetics a year with more than 80% of all operations king performed
tmder general anaesthesia.
Folio ad ICU devel-t
The impetus for the development of darn intensive care in Estonia w3s
provided by the pl.ioayelitis epidemic. Tile need for long tern
ventilator treatment led to the establistunent in 1959 of the first
rr~spiratory ILW at t!?e Neurolgical and Neurosurgic~l Dep~rtment of
Tartu kiversity. Amng the 70 victims of poliomyelitis treated in this
ICU, 35 needed long term rnechanic-il ventilation of the lungs. Soon this
unit !&came a centre for intensive care for all critically iL1 patients
with neurolo~icsl disease or injury and, indeed, until the second half
of the 1960's it served as the only place for long term respiratory
treatment in the Rewblic. Patients in critic31 condition from all over
Estonia werz transprt5d to this 'Respiratory Centre' by the unit's
dile r.-suscitstion texti, often using mechanical ventilation and
infusion ther.33 during trans~rt. Wensive exixrience in the
management of comatose patients ena'bled the staff of the unit to
establish a set of clinical and him1ical criteria for brain death in
1969 (Dr M Magi).
AMesthetic societies
In 1967 thz Estonlan An~e~the~ioloq~s~~-P,pnn~~~t01~~sts
Soclety (W)
I ~ S fmmded. Its wmlxrsh~p has qrown from 412 orl.jul?l members to more

than 170 in 1991. TCIe EARS holds reqular meetings and conferences and
has p-lrticipated in scientific events in th? USSR and also abroad. me
first direct international contacts were establis'lsd with the Finnish
Anae~thesiologists Society i~ 1958, but after the first two joint
meetings, the plitical insistence on cultural isolation from the
western world stow contacts until 1988. Closa contact.^ have always
been maintained with the btvian and Lithl~nian Anaesthesiolgists-
Reanimatoloyists Societies. lie have held regular weekend Smmer meetings
t:~roughout our country from 1969 to the present time. In 1969 sane of
the leading anaesthetists in Estonia organised a systemtic study of the
'state of the art' of intensive care in surgical hospitals,. This led to
the setting up of a regul~ postgraduate course in hsic elements of
intensive care given to doctors of all speci?lties at Tartu University.
Since 1975, advanced training and specialisation in anaesthesia and
intensive care has been provided by Tartu University Hospital within the
framewrk of an internship proqramne consisting of one year for
specialisation after six years at medical school. Up to this time the
official requirement for anaesthesia training was only five months.
Teaching anaesthasia and intensive care to medical underqraduat?s by
specialists in Tartu University dates back to the end of the 1950's but
official recognition of our specialty was not received until 1976, when
the Department of General Surgery a t the rledical Faculty was reorqanised
into Depilrtments of Anaest!lesiology, Reanimatoloqy and General !jurqery.
Ihe influ?me of basic anaesthetic textboaks
mis reimrkhle era of establishment of a new medical spcialty in
Estonia began in conditions of strict cultural isolation from all
Western influences .in the beqinrling of the 1350's. It is of interest to
follow some lines of medical thouqht which influenced this developnent.
In t!!e 50's an extensive overeqhasis on neuroreflectory theories
occurred in virtually every branch of mwicine due to the great
poplarity in t!e Soviot Union of H Labrit and 0 Huguenard's
publications abut hibrnothera.~ and the need for autonanic protection
and stabilisation. mis lead to the widespread use of p'lenothiazines
inllytic cocktails', aid the popllarity of so-called 'ptentiation' in
anaesthesia. A high canplication rate, which followed this deep
depression of autoregulstory mechanisms soon led to its abandonwnt.
Pco'wbly as some form of rnental colmteraction, there folloi~ed a brief
pried of popularity in the middle 60'3, of very li-qht levels of general
endotrac'7eal anaesthesia ilenoting t!~e stage of analgesia, as ppularised
by J F Wtusio. .h unacceptable number of patients complsining of
awareness and r?collection of events in t!?e operating room soon
tenninatd this em. FYm the second half of the 601s, ~ith the more
refplar deliveries of =stern anaest:~etic literature, the practice of
anaesthesia and intensive care berme more in line with contemporary
world practice. Unfort~lnately, there still remain severe restrictions in
the choice of snaezthetic dmgs and there is a lack of cont,mpo-rary
equipnent which continues to hamper our specialty's developnent.
Hopefully, in th.2 plitically new climate now emerging in Furr~e, there
are prs&xctives for radical changes to take pl~ice.

CRAWFORD W LONG
SESQUIICENTENNM
MDCCCXLII - M CWI
' THE HISTOWOF
:
i AN'ESEIESIA
I ANESTHESIA HI!ZORY ASSOCIATION
I
Symposium Committee: Chairman, John E. Steinhaus, M. D.
i Emory Clinic, 1365 Clifton Rmd, Atlanta, CA 30322
1 NUNTA. GEORGIA. U.S.A. - MARCH 27-31.1992