ANAESTHESIA SOClETY

51 Pages·2008·5.97 MB·English

ANAESTHESIA SOClETY
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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
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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
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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.