ANAESTHESIA SOClETY *- Dr T R Boulton Tie role of George Washington Crile in the developnent of anaesthesia 54 Dr A Csrreq?l et (31 The first 135 ather anaesthetics in Spin 59 Dr E T 'Int?7?'is Henrv Walter Featherstone; first President of the Association of Anaesthetists of Great Rcitain and Ireland 62 Prof H EbLlrer et 11 Cerebral anaemia for anaesthesia induction 66 Dr I: ileiss?r at a1 Martin rtirschner's spi~alz on? anaest%esi.a 68 Dr J J3erLj.n et 31 The history of hypnosis in anaesthesiolocg 71 Dr :*I Goeri? et 31. Th? contributions of L Rurc'khardt and H I(1nnnel1 to intravenous anaesthesia 76 &.?E H Ro5rer et aL Crimiial confe~sionsu nder the influence of anaest!~etica gents 82 Dr ?I Yus Cardiac resuscitation in Bland 84 Dr R Patterson European imprimatur of an American discovery Dr M Goerig et sl Georg Hirschel and Didrich Kule-ff: pioneers of local anaesthesia 92 win Dr L Vazrruez et .%l !The early u e o f chloroform in 94 ClhitUdry - Profsssor A Hunter An appreciation by Dr J M Horton Dr T B -ton (Oxford) George Washingtan Crile (Fig.l), the founder of the mrld renawntd Cleveland Clinic in Ohio, wss one of the great pioneers of modern surgery. The Mayo brothers and Harvey Cushinq were his contemooraries in the United States and, in some mys, he was more fmus and influential in his own corrntry than they were. Olildhcad and edmaticn Crile was the son of an industrious and successful fanner. He was k m near the smsll tawn of Chili in Ohio in 1864 and mrked his my t:~rough college and medical school by doubling as a school teacher. He ms awarded L9e MD degree by the Wmster Mdic31 SCao01 in Cleveland. Tnis mall insvtution ms later absorbed into the Western Reserve University. Crile's underqradu-ltn medical studios had consi.jt,& of an a~prenticeshinI ssting a year, followed by a tot21 of eight mnths of didactic instruction spread over two years. Yedical courses as short as this were not unusual in the (JSA in the 1383's. 'he Wooster School did rlot psssss a microscope and Crile had to assist in resurrecting cadavers for dissect ion fr an pi ipr graves. He seems to have been c e l l satisfied with the tuition he had received f rorn fledicated tutors 11m~ver. m l y mqical career Crile joined a surgical practica in Clevel3nd soon after q~alificationa t what he $ describes as the 'hqrse and \ /W .P! hignl era of surgery. ' Hospitals were smal-l and basic and many operations were carried out irl the ytients' beds or on the kitcnen tables in their am hhome. me surqery of tram fmin Fig.1 Gmrge Qile industrial accidents fc1nu?-1 a l?rqe prorxrtion of surgical practice at the time. Severe tra~mtic shock, far which treatment was very elementary, was cmnplace and often fatal. The nature of shock, the aetiology of which was not ~mderstmdw :l?n he q~slified,a nd its treatment became a life-long stlldy for Crsle. Clorton's s~mhald ermnstration of ether anaesthesia in 1846 had enabled surgeons to carry out 'xdy surface and orthopedic operations, which they had Wen undertaking without anaesthesia, with greater facility, but the dan~ero f sepsis prevented further surgical developat. TFle extension of the surrlfeon6s territory, particularly into the aMomen, had to wait the developent first of Lister's antiseptic technique in the 10601s, and later of aseptic smjery. Crile had the benefit of these discoveries then he started to practice in the 18RO's at a time when sirjery was rapidly developing: For example, Reginald Fitz had descri9 t3e surnicsl treatment of appendicitis the year before Crile qualified and he w,3s an early protagonist of the technique, despite his youth and the consh-ierable controversy surrounding the operation. Crile carried out tnany major procedures in the 901s, including early laryngectcmies and thyroi3ectomies but these operations required deep and greatly prolonged etherisation and also occasioned greater blood loss than had hen pr4eviously experienced; in the a'osence of intravenous fluid replacement, the danger of postoprative shoc!c in elective surgery was a constant :ntentF?~lh azard which frequently resulted in a fatal outcame. Crile's interest in the prohlem was stimulated further and he began an- l research in primitive surroundings. l George Crile was an officer in the Reserve, and he was therefore called upn to serve in the Spanish-American war of 1898, when Cuba was liberated frm w i s h control and Puerto Rico was ceded to the United States. The standard of :IS Army hygiene was low and many soldiers died of yellow fever and dysentery. Crile greatly reduced the rate of infection in the rmits which were his immediate responsibility by insisting on elementary preventative measures. l CMparatively few soldiers were wounded in the fighting, but Crile mentions one case of ruptured spleen in a troopr who was kicked by a horse. The only resuscitative fluid available was saline administered subcutaneously. Crile re~rtedth at the patient survived the operation, 'but tells us laconically that what he described as the 'inevitable change1 occurred some hours after the operation, and the patient died.' The kinetic theory of shock and anoci-association Crile returned to civilian practice and %came an Associate Professor at the bkeside Hospj~iin 1901 and developed what he called the kinetic theory of shxk. He b c m c onvinced that shock was the result of exha~~stioonf the brain as a result of bombardment with nociceptive stimuli origimting both from the tramtic wound or the operation site and as the result of fear. He thereEore advocated very gentle surgery in conjlmction xith simple local infiltration with procaine to block off the impdses coming from the part on which he was operating, and he combined this with generql anaesthesia with n i t r o ~ox ide to elimimt? the nociceptive effect of fear. He called this technique moci-association. The prxedure in - aWcminal cases was layer by layer infiltration skin, s1'9f2ne0us fat, rnilscle, peritoneum, and the mzsentery of the t3rgt orgms. Patients operatd on under anoci-association recovered more rapidly and had less ~stoprativesh ock than those h o had had surgery under deep ether. The latter did W-11 enough during the opration under the symp~thetico~tiscti mulus of etherisation ht, in the a5sence of fluid replacenent, became shocked in thr? long recovery p2rid before autonomic control of Cqe perip~eralv ascular system ;.ms restsred; in contrast, tine ptients who had had their suirqery under anoci-association recovered their vascular tone mfiidly and camparatively quickly compensated for their hypovolaemia. Crile did not see it this w3y, however; he believed that nitrous oxide had a protective effect on the brain, whereas ether did not. He was rather unfair in contrasting 'nitro~lso xide1 and 'ether', as he often did in his papers; in fact, the nitrous oxide was often e riched with a little e,ther, especially for the closure of the a ~ r n n . ~ ~ ~ What Crile had act~mllyd one was to prcduce a form of what is now called '%lanced anaesthesia'. If anoci-association is considered in relation to Gray's now familiar triad of an< 3thesi.a (unconsciousness, reflex suppression and muscular relsxation) it can be seen that, in Cri.le9s anoci-association technique, reflex su.npression and relaxation are largely taken care of by local anaesthesia, enabling ~mmnsciousnesst o be maintained by very light anaesthesia. John Lucky of the myo Clinic actually originated the term 'tnlanced anaesthesia' in 1936 but his technique of 'a moderate amount of preliminary hypnotic, a morlerate amount of local anaesthetic, a derate amount of nitrow oxide or ethylene and a sufficient anount of ether to obtain the desired result1 apparently owas much to Crilels ideas;=of course, if you ask the present day examiqation candidate 'what is meant by balanced anaesthesia ?', you \rill be referrad to tne nitro:ls oxide, relay, oxygen, muacle . technique, which Gr2y originally called 'selective anaesthesia Crile and his assxiates undertook extensive animal work using trawtised dogs. They came to tile conclusion that they could demonstrate actual histoloqical changes in the brains of t e a imls which they believed to have been caused by nociceptive stinulil 3 0 1 Bit, as rmon pointed out in thc 19201s, the hyperchrornatic and chrmlytic changes which they observed were identical with t%ose of extreme cellular hypxia due to c.?' oillary stasis which is the primary lesion in shoc!c, whatever the callse Qile's use of blood transfusion Crile w3s one of the earlier users of b l d transfusion in the &ern era of surgery; hogever, he regdrded it as an adjunct to the treatment of tra~mtic and pstop?rative shock rather than a first-line tqerapeutic method. He also tried blood transfusion as a pssible treatment for a nwkr of other conditions, including thyrotoxicosis, tukercmlosis in cattle, the treatment of sarcm an with justification, in tbe treatment of carhn nmoxide poisoning. 1n':4~9 In orcler to aapreciate Crile's use of blood transfusion, it is important to realise that ,alrqough Landqteiner reprted the existence of blood groups in 1101, it was not until the work of Jansky in Bohemia (now prt of ech~slovakia)~a' nd of Moss at Jobs Hopkins Hospital, Fmltimre.8 working indemndently alrost a decade later, that cross- mtching k.zame a practical propsition, and not until ustin reported 14! t!le use of citrate that anticoagulation was practicable. Crile's earlier transfusions were made before cross matching or anticoagulation Iiere available. lie ernployed the direct donor to patient method, usually connecting donor radial or ulnar artery to the patient's hasilic vein. He was not the first to use this technique but the . technical pro'hlem had always been clotting in the connecting cannula mile overcame the difficulty by designing a very short cannula; by cuffing tile vessels, allowed direct intima to intima continuity. If consider,lt,ion is confined to AB0 group compatibility, the chances of a cornatible transf!lsion are abut 60% in a European ppllation. Crile naturally had complications but the mortality frm incanpatibility was - I:RIC~loI ger than might have keen expected presumably because of the relstively simll amounts of blood transfused before the transfusion was disconti:lu~id. T'le quantity of blood transfused was variable: some pf Crile's transfusions resulted in serious exsanguination of the donor ! Later, when the anticoagulant properties of citrate had become known, a combined jlass container and cant-lula r a used. Positive pressure was applied with a Aiq~inson's syringe;lr' great care must have been necessary to avoid air ehlism ! Modern drip chamber intravenous infilsions e r e not introduced until 1935 wh n Marriott and Kekwick pblished their classic mpsr in the 'Lancet'. 12 clrile in the Great war Crile intrduced bth his anoci-association technique and blood transfusion Wen i.le served with an American civilian team in France fran 1914 to 1315 soon after the start of the Great rmr, lcut it tms not irntil he returned as an lkmy surgeon when the United States came into the war in 1717, that ile succeeded in establishing its use in American and British military hospitals. l George Washington Crile (1864-1943) ran'cs amongst the very greatest surgeons. he had a p asant personality and was not afraid to acknwledge his mistakes? The list of his achievenents as a surqeon is lengthy, ht he also certainly deserves an honoured place in tie histsry of anaesthesia. Crile G.M. George Crile. An a~ttobioqraphye dited with sideliqhts by Grace Crile. Philadelphia: Lippincott, 1947. Fitz RH. Perforat* inflmtion of the vermiform appendix. American Journal of Medical Sciences 1886; 92: 321-346. Crile GW,Lower WE. Surgical Shock and the Shockless Operation through Anoci-Association. Pniladelphia: Saunrlers 1914. Crile GW, Lower WE. Sugical Shoclc and the Shockless Operation thmugh Anoci-Association. 2nd.Mn. Philadelphia: Saunders 1320 Gray T. Disintegration of the nervous system. Clover Lecture. Annals of Royal College of Surgeons of EngLand lc154;402-419. bmdy JS. Balanced Anesthesia. Minnesota Medicine 1926;9:399-405 Gray E. A reassessment of the signs of anaesthesia. me Irish Journal of Mica1 Science 1960; 419: 499-508. Cannon WB. !Traumatic Shock. New York: Appleton,1923: 115-120. Crile GW. Haemrrhage and Transfusion. An exprkntal, and Clinical Research. New York: Appleton, 1909. landsteiner K. Ueber agglutinationserscheinungem nomlen mensh lichen Blutes. Wiener kliniscbe \iochenschrift 1901; 14:1132-1140 Jansky J. Etude Hernatolcgiques, dans les mal3des mentales. Sbornik Klinicky Praze 1907; 8: 85-139. Wss \a.S tudies on isoagglutinins and isohemlysins. Bulletin of the Johns Hopkins Hospital 1991; 21: 63-70. Hustin A. Note sur une nowelle rnethode de transfusion. Bul1.Soc. male de la Science de Medicine de Elruxelles 1914;72:104-11. Marriot HL Keckwick A. ContL?uous drip blood tranfusions with case records of very large transfusions. Lmcet; i: 977-991. Anonynous. In menvsriam George Washinton Crile 1564-1943. British Jourml of Surgery 1942-1943; 30: 353-354. Drs A Carregal, S Boveda, M Cid, A Rmco (Santiago de CXmpstela) A search of t!~ed aily scientific press of Barcelona and mdrid for the year 1847 throws light on the introduction of sulphuric ether in Spain and the chronology of the first surgical operations performed with this anaesthetic. Perusal of the Madrid press for 1947 shows that, contrary to some recent as~ertionsl-~th e first surrjical, operation carried out in Spain under sulphuric et'7er was performed on January 13th of that year by Fmfessor Ar-~umoq-Obregan in the Surgical Clinic of the Faculty of Medicine in Madrid, a d consisted of lancing and draining a neck abscess. Eie:is of tie discovery of this anaesthetic arrived in Spain by several route?. Te,, accordiig to the 'Gac,?ta Medica'of Madrid of February 10 1847, orlglnatd from Dr Forbes, editor of the 'British & Foreign hledical Review', who wrote from London to one Senor Barron in Madrid who,in turn, cmlnicnted the news to Professor Arqumsa. As well as the above operation, ?W.pmsa carricd out at least two others in January, with resillts that were not entirely satisfactory. Tie first pblic announr:ement in Spain of the discovery of ether anaes hesia was made by the Madrid newspaper 'La Opiniont on January 14, 1847.' in an itsm on Liston's first enpriments. This was followed on January 24 by a mre extensive article in the same newspaper describing the oprations c;lrrietl out in London in December 1M6 and at the beginni-ng of January 1 ~ 4 7 .T~he oprations prformerl by Professor Arcpmsa tiere mentioned by the scie tific press of Madrid, spcificall 3 'Anales de Cimgia' of January '42 and 'bF acultad' of January 28 (altllough ~itiioutq iving dates), and were imnediately c ~ # t e don by the Madrid dailios 'El Poyxilar' on Friday January 29 and 'El Imprcial ' on Saturday January 30. L2eanruhile neds of the discovery was also sent £ran Boston to Oliver Machechan, a highly respected .lmerican dentist in practice According to the Ma1drh'd4 d ailies 'El Tiemp', January 28 O@inion1, January and 'El Espectadort, January performed a nmhr of dental operations under ether, starting on January 20; wz h ve recently reported this finding in a Spanish scientific .4 mgazine The news of ether also entered Spain via Barcelona, possibly via the English weekly 'T?le Illustrated London News ' , the JarIuary 9,1847 which mentioned many of the first trials carried out in Ehgland. appears to have been these reprts that prompted Castells, Mendoza and otl~err nernkers of the Faculty of Medicine in Barcelona to perform expriments on dogs, the results of which they presented to the Real Academia de Medicine y Cirugia de Barcelona on February 1, 1047. Later, on F&Lu~I1~6 , Professor Mendoza made the first clinical application of ether in %rcelona during a leg amputation; this operation was described in the Darcelona medical j o w l 'El Wleqrafo Medico' February 1847 issl~e'' and extensively comnented on in the Barcelona daily 'El \$, Fhnento8, February and 18,18~19 and in the Madrid dpf;fts 'El mplarl, February 23 and 'El Heraldo', Fetn-uary 24 and 25. me use of ether anaesthesia spread so rapidly through Spin that by the end of Etarch 1847 it had been employed by the great majority of Sp3nish surgeons. !The best documented series conprises 56 operations carried out in various cities on patients who were mostly aged under 40 years, the oldest being 64. Most of t!e operations performed constituted major surgery at that time, including a number of mastectomies and several amptations of l*; tooth axtracticms and a few self experiments also figure on the list. By contrast, we have been able to unearth very little infomtion about a group of 79 operations carried out in Madrid and Santiago de Cc~npostela. In Septar 1047, the Real kademia de Medicine de Madrid awarded Dr Basilio San-Martin a prize for a pper on ether in which he described 53 cases of ether anaesthesia, 16 of them experiments he carrisd out on himself while, in Santiago de Ccsnpostela, Professor Gonzalez Olivaries mentioned on several occasions his dissatisfaction with the results obtained in 26 operations with ether anaesthesia that he performed in 1847. In their first tri3ls of ether anaesthesia, Spanish surgeons addnistered it either with apparatu? desir~nedb y themselves, or using devices that had become popular in other Wopean countries, such as those developed by Luer and Charriere (with or without modifications by the users). The ad hoc apparatuses designed by Mendoza and Arqnmsa were described in detail in the literature, but without illustrations. In conclusion, the date of Argwmsals first operation with ether anaesthesia in Wrid, January 13 1R47, makes *in the fourth country to have employed this anaesthetic, the first three having keen United States, United Kingdan and France. We now know about many of the first Spanish trials thanks partly to the surgeons who reprted their findings in scientific publications, and partly due to the great interest aroused by the subject of anaesthesia mng the general pblic, which was echoed in the daily press of the time.