Fifty years of anesthesia

FIFTY YEARS OF ANESTHESIA

JAMES T. GWATHMEY, M.D. Consulting Anesthetist, Metropolitan and New York Post-Graduate Hospitals

NEW YORK, NEW YORK

PERIOD OF DISCOVERY AND EMPIRICAL

USE

NESTHESIA was foreshadowed by A the discovery of ether, by an ItaIian, VaIerius Cordus, in 1540,

three centuries before its anesthetic properties were discovered. Oxygen and nitrous oxide were discovered by an English cIergy- man and scientist, Priestly, in 1774, over seventy years before their use in surgery. Von Liebig, in Germany, SamueI Gutherie, in America, and Souberan, in France, inde- pendentIy, discovered chIoroform in I 83 I, sixteen years before its use as an anesthetic.

Henry Hi11 Hickman, an English surgeon, in 1820 to 1828, made successful experiments upon Iower animals, rendering them insensibIe to pain, by the inhalation of nitrous oxide or carbon dioxide and the exclusion of air, and then proved insensibiI- ity to pain by performing various minor operations on these animals, but his work was treated with skepticism and scorn and he was not allowed to test his theories upon human beings.

The discovery of the anesthetic properties of ether and nitrous oxide was made by observations of a doctor (Long) and a dentist (WeIIs). They proved that ether and nitrous oxide when inhaIed to a point of intoxication, at “Ether FroIics” or “ChemicaI Lectures,” the human subjects were unaware of bruises or painfu1 spots received while in a semi-intoxicated stage.

Dr. Crawford W. Long, of Georgia, in 1842, was the first to use any drug (ether) in a surgical operation, to render the patient insensibIe to pain.*

* The words, unestbesiu and unesthetic, were then unknown. Oliver Wendell Holmes suggested the word (November 21, 1846).

Horace WeIIs, a dentist, in 1844, was the first to use nitrous oxide. His public demonstration was a failure, but he continued to use it in his private practice. W. T. G. Morton, aIso a dentist, was the first to demonstrate successfully in pubIic (Octo- ber 16, I 846) the anesthetic properties of ether (suggested by Jackson, a chemist).

Ether for surgery and nitrous oxide in dentistry were quite generaIIy used shortly after their discovery and introduction. J. Y. Simpson, a doctor of Edinburg, ScotIand, had used ether quite extensively in his obstetric practice, but the crude use of ether aIone with its disagreeable odor, nausea and vomiting was especiaIIy repug- nant to his patients. From WaIdie, a chemist, Simpson obtained chloroform, which he immediately tested upon himseIf and other doctors. He found it pleasanter to inhale and that it produced the same resuIts as ether. One year after Morton’s successfu1 demonstration of ether, Simpson commenced using it in his practice, in 1847, as did others. AI1 anesthetics at this time were used in an entireIy empirica manner, as nothing was known of the physiology or possibIe harmfu1 effects of the substances used.

Simpson was the pioneer and the first physician in history to give an anest.hetic for the reIief of pain in childbirth. Opposi- tion to this procedure was intense by physicians and cIergy as evidenced by the foIIowing incident:

Dr. Simpson was caIIed to Windsor Castle to deIiver Queen Victoria under the new anesthetic, On his Iecture room door, he posted a notice: “ Professor Simpson has gone to deliver the Queen.” Under this notice, some one, probably a student, wrote, “God save the Queen!” However, Her Majesty was so pIeased that she

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234 American JournaI of Surgery Gwathmey-Anesthesia

knighted the worthy doctor, thus bestow- ing upon him the highest honors of the British Government. Tradition and super- stition were superseded by the fact that in this notable instance anesthesia was safe in childbirth. In 1847, Flourens, in France, discovered the anesthetic properties of ethyl chIoride. Six years Iater, in 1853, AIexander Wood, in EngIand, invented the hypodermic needle, which made possible local, intravenous, regiona and spina anesthesia.

PERIOD OF SCIENTIFIC ADVANCEMENT

The fundamentaIs for the scientific advancement of a11 methods of anesthesia, as we know them today, were thus given to us to experiment with and deveIop in a scientific manner.

The drop method of inhaIation anesthesia was universahy used. The patient was placed upon the operating table, and as the second or stage of excitement was reached, he was pinioned down by attendants, unti1 the third stage with reIaxation occurred. Then the attendants retired and the patient was prepared for operation. Upon return to bed after t,he operation, nausea and vomiting were usual and aIways serious in abdominal operations, and occa- sionahy were fataI. No other form of anesthesia was used at that time.

Dr. Thomas L. Bennett, of New York City, after studying in England ( r Sg5), and acquiring the method from Hewitt, of London, deveIoped an apparatus, and introduced the “gas-ether” sequence in America, in 1896 to 1897. Bennett was the first physician in America to devote himseIf excIusiveIy to anesthesia (1896 to 1932, thirty-six years), although it was custo- mary in England from aImost the first discovery of anesthetics.

The “gas-ether” method consisted of a very simpIe apparatus for getting the patient under nitrous oxide first, then switch- ing graduaIIy to ether and continuing the anesthetic with ether, thus eliminating attendants, the second stage and, to a great extent, nausea and vomiting. This method

was so obviousIy an improvement upon the “open” or drop method of giving ether that it was universalIy adopted.

A familiar saying of Bennett’s was that he had given “over thirty thousand (30,000) anesthesias without a death.” But not everyone who gave anesthetics had the naturaI and acquired ski11 of Bennett and surgeons began to experiment with other agents and methods. The foundation of local and spinal anesthesia was the discovery in 1858 of the alkaIoid of cocoa Ieaves, by AIbert Niemann. Scraff discovered the anaIgesic properties of cocain when pIaced on the tongue. Car1 KohIer (1884) demonstrated its anesthetic vaIue when placed in the eye. WilIiam Stewart HaIstead and James A. Corning gave cIinica1 demon- strations in 1885 of its value. “SpinaI anesthesia IargeIy replaced IocaI anesthesia for operations beIow the diaphragm.” (Hertzler, in “LocaI Anesthesia.“)

LocaI anesthesia rapidIy advanced with the introduction of novocain, which was discovered by Einhorn and was first cIinicaIIy tested by Braun in 1905. It is from seven to ten times Iess toxic than cocain, its solutions stand boiIing and keep without deteriorating for a Iong time. Its action is increased and prolonged by the addition of adrenaIin. Its derivitives are even Iess toxic and more suitable in every way than novocain.

A method of combining IocaI and inhalation anesthesia, was deveIoped by CriIe and Lower of CleveIand, in rgzo. The method is known as anociation, and when combined with preliminary medication, prevents fear, pain, shock and postoperative nervous manifestations. A minimum of each anesthetic is used, and the patient gets the benefit in increased safety and comfort.

INTRAVENOUS, SPINAL AND LOCAL ANESTHESIA

Research by Iaboratory workers has produced such definite resuIts for intravenous, spinal and local anesthesia that, together with the increased knowIedge and ski11 of the surgeons, reIief from pain is as safe and

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certain with these drugs, as with inhaIa- to promote the use of Iocal anesthesia. The tion anesthesia. “The dangers of spinal author has seen Dr. MitcheII do operations anesthesia Iie with the user more than in his offrce under IocaI agents that wouId

Nitrous oxide 93 per cent, oxygen 7 per cent. FIG. I. No preIiminary medication. Air spaces

f&d with edematous fluid; perivascular edema; congestion.

FIG. 2. PreliminaTy medication.:& spaces and bronchi clear; no p&vascular edema or congestion.

Ether vapor 34 per cent, oxygen 66 per cent. FIG. 3. No preliminary medication. Massive FIG. 4. Preliminary medication. Lung tissur rcla-

atelectasis and congestion; air spaces ob- tively normal. Iiterated.

The work of CharIes W. Hooper, assisted by the author. From Autochrome photomicrographs in Nelson’s LooseIeaf Surgery, Vol. I, page 514.

the drug.” (Babcock-Maxson, in “SpinaI usuaIIy be performed in a hospita1 under an Anesthesia.“) inhaIation anesthetic.

Dr. James F. Mitchell, a surgeon in Washington, D. C., by his writings and ski11 in the use of the needIe, has done much

Professor Gaston Labat, of New York University, was the outstanding teacher of regiona and spinal anesthesia, of his day.

Gwathmey-Anesthesia

Professor Babcock, of Temple University, prefers spinal anesthesia (using procain), Philadelphia, in his textbook on Surgery and uses it exclusively in obstetrics after (rg38), reported ten thousand (Io,oooj having tried all other relief methods.

Ethylene 94 per cent, oxygen 6 per cent. FIG. 5. No preIiminary medication. Extensive FIG. 6. Preliminary medication. Fairly normal

alveolar and perivascular edema; air spaces lung tissue. fiIIed with fluid.

Acetykne 94 per cent, oxygen 6 per cent. FIG. 7. No preIiminary medication. AIveolar FIG. 8. Preliminary medicalion. Normal lung

and perivascular edema. tissue.

spinal anesthesias without a death. Under George Pitkin, of New Jersey, has done as the guidance and supervision of John much as anyone else in cahing attention to Lundy, of the Mayo Clinic, the number of the value of spina anesthesia. operations under spina and regional anes- Methods of administering local, spinal thesia outnumber those under inhalation and regiona anesthesia are now taught in anesthesia. Dr. Cosgrove, of Jersey City, a11 medica colleges, but it wiI1 probabIy be

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another decade before they are universahy hundred and six (106) surgical operations used. “ SpinaI anesthesia was used once in under this gas, in ApriI 1923, at the rgq and more than 3,000 times in 1939.” Presbyterian HospitaI, in Chicago. It has a (Mayo Clinic.) wider margin of safety than nitrous oxide,

Carbon dioxide 70 per cent, oxygen 30 per cent. FIG. 9. No prehminary medication. Extensive FIG. 10. Preliminary medication. Relatively nor-

alveolar and perivascuIar edema; congestion. ma1 Iung tissue.

II er la a1 Dl

PropyIene 81 per cent, oxygen Ig per cent. FIG. II. No preliminary medication. Peri- FIG. 12. Preliminary medication. Normal lung

vascular edema, air spaces reIativeIy clear. tissue.

EthyIene (CzH4) was discovered by and more oxygen can be used with it to lgenhauss, in 1779. Its anesthetic prop- produce the same degree of surgical anes- ty was demonstrated on animals in the thesia than when nitrous oxide is used. It boratory by Luessem, in 1885. Luckhardt supphed a Iong felt need. EthyIene has Id Carter made experiments on its been used 58,690 times up to December 31. hvsiolonic oronerties. and renorted one IOTO. at the Mavo Clinic.

238 American Journal of Surgery Gwathmey-Anesthesia

The objections to it, are its odor and its expIosive nature. It shouId, therefore, be used with nitrous oxide. That is, the introduction shouId be with nitrous oxide and the maintenance with ethylene and oxygen. The terminal anesthetic shouId again be nitrous oxide and oxygen to ehminate whatever taste and odor may remain in the upper air passages of the patient.

Professor Chauncey D. Leake concludes his paper, “The Historicai DeveIopment of SurgicaI Anesthesia,” with this statement: “One of the most significant points empha- sized in recent works, is the importance of Oxygen in anesthetic conditions. An anesthetic agent is being sought, which is to be administered with so much Oxygen, that a11 deIeterious effects incident to Oxygen want, can be reduced to the minimum.”

It would seem that cyclopropane is the answer to Professor Leake’s wish. It was first prepared by August von Freund, in 1882, but no notice was taken of his discovery unti1 nearIy fifty years Iater (Ig2g), when Lucas and Henderson pubIished their Iaboratory experiments on animaIs. They found that anesthesia couId be maintained by using IO per cent to 12 per cent cycIo- propane, with 88 per cent to go per cent oxygen, with but IittIe change in bIood pressure, metaboIism or bIood sugar and with no damage to the Liver. There was a wide margin of safety between the surgica1 and the IethaI dose. Consciousness was regained in from one to three minutes. Respiration aIways faiIed before circuIa- tion, therefore, immediate measures shouId always be successful.

Four years after these experimenta find- ings, the first cIinica1 administration was given by Neff, Rovenstine and Waters (1930), of the University of Wisconsin. Under the direction of RaIph W. Waters, professor of anesthesia at the University of Wisconsin, the technic was successfuhy developed, and in 1937, they reported over two thousand (2,000) administrations. The indications and contraindications for cycIo- propane are practicaIIy the same as for

nitrous oxide or ethyIene. On account of its expense, Waters evoIved the carbon dioxide absorption technic. This consists of passing the respirations through a mixture of caIcium and sodium hydrate, so that the carbon dioxide is absorbed, and the respirations are kept within physioIogic Iimits. In this way, a minimum amount of cycIopro- pane is used.

It is the most inffammabIe and explosive of a11 gases used in anesthesia. In spite of its many advantages and its carefu1 in- troductions, deaths have occurred, prin- cipaIIy from expIosions, and, therefore, has been definitely excluded from some hospitals. Its very great advantage over other agents is that it gives a reIaxation equal to that of spina anesthesia. In order to do this, however, many anesthetists produce anoxia and then carry on respiration by pressure on the gas bag, thus producing artihcia1 respiration. Other anesthetists cIaim that this is unnecessary. It would seem from confficting reports, that cycIo- propane is stiI1 on the waiting Iists.

CycIopropane has ushered in the golden era for the manufacturers of anesthetic apparatus. The Iatest gas machines have attachments for nitrous oxide, ethylene, cycIopropane, heIium, carbon dioxide, ether and oxygen, so that the seIection may be made as indicated by the patient’s condition.

Vinethene: (vinyl ether, divinyI oxide) has a formula of:

Per Cent Pure divinyl ether. . 96.49 Absolute alcohol.. . . 3.5 Nonvolatile oxidation inhibitor. 0, o I

Vinyl ether was first suggested by Leake (Leake and Chen); it was synthesized by Major and Ruigh, and its pharmacology was studied by Leake and Gelfan and associates.

Vinethene is a cIear, coIorIess liquid with a boiIing point ten to thirteen points beIow the boibng point of ether. Its action is quicker and recovery is more rapid than with ether. It was deveIoped as an anesthetic, at the University of Pennsylvania,

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by I. S. Ravdin, professor of surgery, and his associates, and has been used over five thousand times in that institution. It is now employed for painfuI dressings and for operations of less than one bow, in obstetrics and dentistry, and especially for chiIdren.

Liver damage to one patient, in an operation Iasting over two hours, caused the use of vinethene to be discontinued except for short operations; it is now used with oxygen which decreases the possibility of Ever damage. The ratio of the anesthetic dose of vinethene to the lethal dose, is I to 2.4;

with ethy1 ether it is I to 1.5. For short operations, vinethene is safer than ethy1 chloride; it is accompanied by less nausea and vomiting and is not as toxic to the liver as chloroform.

It is used routinely at the University of Pennsylvania, for short operations, such as, opening abscesses, inserting drainage tubes and appIying painfuI dressings. It should be seen in use, by those who wish to employ it, under Professor Ravdin’s direction.

COLONIC ANESTHESIA

This method was first mentioned nearIy one hundred years ago, in 1847, by Pirigoff. His method was first to introduce liquid ether, and next he devised a method of vaporizing the ether by means of heat, and thus administer the drug. He reported eighty-one (81) cases, with two deaths, but the method fell into disuse. Cunningham, of Boston, in 1905, added to the technic by employing air to carry ether vapor into the intestine, a more sensible, safer, and satisfactory plan.

In 1910, Sutton published the resuIts of a series of one hundred and forty cases at the RooseveIt HospitaI, by using an apparatus consisting of three parts: (I) The generator in which the mixture of oxygen and ether was made, (2) an afferent tube system which carried this product into the intestine, and (3) an efferent for exhausting the contents of the bowel.

This method was successful, but the apparatus was so comphcated that its use

was never attempted by others. The record of cases of Cunningham and Sutton were prominent factors in the deveIopment of oil-ether coIonic anesthesia.

OIL-ETHER COLONIC ANESTHESIA

In 1913, at the seventeenth InternationaI MedicaI Congress in London, the author read a paper on oil-ether colonic anesthesia. The experimental work on animaIs was compIeted just previous to this date.

George Barkley WaIIace, professor of pharmacology of the University and BeI- Ievue MedicaI ColIege, conducted experi- mentaI laboratory work on animaIs. He found that the heart rate, respiration and bIood pressure were evenly maintained in a dog under o&ether recta1 anesthesia, an experiment repeated many times with the same result.

The late CharIes Baskervihe, professor of chemistry, of the CoIIege of the City of New York, made laboratory experiments to determine: (I) A comparison of the rate of evaporation of ether from different mixtures of ether and the same oiI, and, (2)

a comparison of the rate of evaporation of ether from the same per cent mixtures of different oils.

The oiIs used were vegetabIe, animaI and mineral. He demonstrated that regardless of the per cent mixture, the rate of evaporation remained constant. This would seem to indicate that oiI-ether, administered coIonicaIly, is a safe procedure, giving an absoIuteIy even plane of anesthesia.

In the laboratories of the Department of HeaIth of New York City, experiments were conducted under supervision of the Director of the Bureau, William H. Park, on the bacteriacida1 action of oil-ether mixture against the Bacillus cob. These tests showed that the mixture kiIled prac- tically a11 B. coli in from five to fifteen minutes after exposure.

All of this work was completed in I 9 I 2 to 1913. Thus it wiII be seen that this method of anesthesia was most thoroughIy tested before being tried upon human beings.


ClinicaI resuIts were as satisfactory as the Iaboratory experiments. Reviewing thousands of cases with this method, we find that p&e, respiration and bIood pressure remain more nearIy norma with this method than with inhalation, spina1, re- giona1 or IocaI anesthesia. The amount for the average aduIt, weighing about one hundred and fifty pounds, (ether, 5 ounces, oi1, 245 ounces) Iasts two and one haIf to three hours. If the operation lasts Ionger, onIy small supplements are indicated, as the resuIt is more anaIgesic than anesthetic. Trained nurses administer the o&ether. It is onIy necessary for the anesthetist to note and rectify the condition of the patient before removal from bed, i.e., twenty minutes before operation.

LATHESIA

RecentIy, F. E. Guntrip, of Santa CIara, CaIifornia, has invented a rubber mixture that mixes readiIy with ether, and reduces both the amount to be given and the expense of administration. These reasons make it superior to the oiI-ether. Five ounces of ether in lathe.&, is onIy five ounces, instead of the oiI-ether seven and one haIf to eight ounces. It acts, clinicaIIy in every way as the oiI-ether mixture and shouId popuIarize both the surgical and obstetrica procedures.

OBSTETRICAL ANALGESIA

An offshoot of oiI-ether coIonic anesthesia is the method developed for the reIief of pain in obstetrics. The idea1 sought was the relief of pain, with consciousness but IittIe, if at a11 impaired, so that fuII cooperation is obtained at a11 times. The method was deveIoped at the Lying-in HospitaI of New York City, in 1923, exactIy ten years after its successfu1 deveI- opment for surgical purposes. The method was developed under the direct supervision of Asa B. Davis, Chief, and his staff.

At that time, (1923) between three hundred and four hundred confinements occurred each month, in this hospita1. Seven years later, in 1930, twenty thousand

(20,000) cases were reported with the above method, from the Lying-in HospitaI and other hospitaIs, with no increase in morbidity or mortaIity.

In the same year, ( rgso), modifications and improvements of the above method, were made by C. 0. McCormick, of Indian- apoIis. His method was intended for the genera1 practitioner as we11 as for the expert. The cooperation of the patient is enhsted, and the pain is the criterion as to when to give medication, instead of dilita- tion of the cervix and the usua1 multipIe examinations. He invented a specia1 apparatus for giving the oil-ether, by which the instiIIation is completed in thirty or forty seconds, instead of ten to fifteen minutes, the time necessary with the earIier catheter or funne1 method. The retention is higher, better and more comfortabIe. Over one hundred thousand cases (IOO,OOO) of oiI-ether obstetrical anesthesia, with and without McCormick modifications, have been reported in the United States without danger to mother or chiId. The method is now used routinely at the Indiana Uni- versity SchooI of Medicine, aIso at the Temple HospitaI in PhiIadeIphia and in many other hospitaIs. In his new book, Arnold states : “The unprejudiced testing and weighing of drugs and methods, so far deveIoped, Iead us to the concIusion that, a11 things considered, the Modified Gwathmey Course comes nearest to meeting a11 demands, under the widest range of circumstances, and therefore, that is what we shaI1 continue to preach and practice unti1 convinced that there is something better.”

At the annua1 meeting of the American MedicaI Association, in 1939, W. C. C. CoIe read a paper in which he states that a comparison of the weights of one thousand babies, showed that the Ioss of weight in the new born, was not physiologic as uni- versalIy beIieved. The weight of the babies, whose mothers had received ether, was better than the weight of the babies of the untreated patients. This would seem to make it imperative for the obstetrician to

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use ether for reheving pain in chiIdbirth. C. A. Smith, of Boston, in a paper on the “ Effect of Obstetric Anesthesia on Oxygen- ation of Maternal and Fetal BIood, with Particular Reference to Cyclopropane,” states that, “Judged by biochemica1 data, CycIopropane as an obstetrica anesthetic, appears to be, perhaps, Iess safe for the infant than the clinical appearance of the mother would indicate.” Also: “ In generaI, Ether anesthesia definitely increased the Oxygen capacity of maternal blood, and under this anesthesia, feta1 Oxygenation appeared to be satisfactory.” From a11 sources, then, it wouId seem that ether and oiI per rectum, and ether and oxygen by in- haIation, are ideal anesthetics in chiIdbirth.

The endotrachea1, endobronchial and nasotracheal anesthesia, and the more genera1 use of the ordinary air-way tubes, have unquestionabIy made a11 forms of anesthesia safer.

PRELIMINARY MEDICATION

The data now given have been pubhshed in NeIson’s Loose Leaf Surgery. Observa- tions upon the value of preliminary medication in preventing morbidity and mortality, are not as generahy known as they shouId be. It is our firm behef that a11 patients shouId be put to sIeep and awakened in their own beds in a state of analgesia. Our reasons for this are based, as are a11 advanced surgica1 methods, upon laboratory research.

The second stage of anesthesia, com- monIy known as the stage of excitement, raises the bIood pressure from IO to 40 mm. systohc, ordinariIy and occasionally up to 80 to 90 mm. just prior to administration of the anesthetic. This is true, even when patients are given the ordinary hypodermic of morphine ( 34 to $4 gr.), which proves that this so-caIled prebminary does not compIeteIy remove psychic imp&es. Pneu- monia and other postoperative troubIes, ordinariIy attributed to ether, are due to the patient’s not having received proper preliminary medication.

AImost forty years after the discovery of

ether, Alexander Crombie, of the CaIcutta Medical CoIIege, applied Claude Bernard’s idea of pre-anesthetic medication of morphine, and thus in a great measure, abohshed the disagreeable features of ether administration. As stated above, experience has proved that this medication is not satisfactory now.

LABORATORY EXPERIMENTS WITH

PRELIMINARY MEDICATION

It has been proved experimentally, by Professor George Barclay WaIIace, of the PharmacoIogicaI Department of the New York University and BeIIevue Hospital MedicaI CoIIege, that when ether is administered intravenously, without prehminary medication, nearly twice as much anesthetic is required to produce anesthesia, as when preliminary medication is used. Again, without prehminary medication, a very small amount of ether produces respiratory paralysis, whereas, with preliminary medication, two and a half times the amount of ether is required to produce the same result. This proves that a laboratory animaI is much safer with preliminary medication than without. The above experiment was verified severa years later with ether, propyIene, acetylene, ethyIene and nitrous oxide administered by inhalation.

This research was under the supervision of the Iate Charles W. Hooper, assisted by the writer. It represents a year’s work in which approximateIy five hundred (500) animaIs were empIoyed to determine the value of prehminary medication, in inhalation anesthesia. HaIf of the animaIs were used as controIs and the other half were given preliminary medication; a11 of them were placed in the same gas chamber. The animaIs without the prehminary medication had a stage of excitement, jumped around and struggled against the anesthetic. The animals with preIiminary medication never moved, but sank quickIy and quietIy under the anesthetic and lived twice as long as the controls in the same gas chamber. Necropsy reveaIed that their Iungs were reIativeIy normal. The Iungs of


the animaIs that had not received pre- Iiminary medication, on gross examination, showed distention, edema and congestion. Microscopic Iesions were perivascmar edema, diffused petechiae and alveoIar spaces IiIIed with Auid. The bronchi con- tained edematous ffuid. Other organs appeared normal

Surgeons and anesthetists in various parts of the country empIoy different methods and drugs for putting patients fast asIeep in their own beds. It is aImost the universal custom of those giving cycIo- propane to use avertin with amylene hydrate per rectum for this purpose. When the anesthesia is properly timed they aIso awaken in bed. Others using ethylene or ether with oxygen have used evipal rectally, but in the last few years have used pento- tha1 sodium (sodium ethyl barbiturate) with anhydrous sodium carbonate as a buffer given rectalIy as the basa1 anesthetic. The patient goes to sIeep in three to fifteen minutes, never knows when he is taken to the operating room or when the mask is appIied to the face, and usually awakens in his own bed. These methods foIIow and are in conformity with the Iabor- atory experiments of WalIace and Hooper. The use of oxygen throughout a11 operations and immediateIy afterwards is rapidly increasing with a11 methods of analgesia and anesthesia.

PRESENT PROFESSIONAL STATUS OF

ANESTHETISTS

The greatest advance in anesthesia is the changed attitude of the medical profession as a whoIe toward anesthesia and anesthetists. It is a far cry from the misery and menta1 suffering of the pioneers and dis- coverers of anesthesia to the statement of August 31, 1940, in the JournaI of the American MedicaI Association giving com- pIete recognition to the American Board of AnesthesioIogy, an affiliate of the American Board of Surgery, thus pIacing those quaIi- fied anesthetists upon the same professiona status as other members of the profession. This board charges a fee of seventy-five

doIIars for an examination, which if passed, gives the anesthetist a standing in the medical profession, fuIly equal to that of other members of the profession.

The change has been very gradual, as with other specialties in medicine. ProbabIy no one deserves greater credit than the Iate F. H. McMechan, editor and secretary genera1 of the pubIication devoted to anesthesia, especially in America, and covering anesthetics in a11 parts of the worId. AI1 of us wiI1 agree with Howard W. Haggard when he states that “For this progress, we owe a great debt to one of the bravest men I have ever met, Dr. F. H. McMechan.” Fortunately, for the cause of anesthesia, we have unusuahy competent men to fiI1 his pIace: the editor of AnesthesioIogy, PauI M. Wood, and CharIes J. WeIIs, secretary of the Associated Anesthetists of the United States and Canada.

The 1936 Year Book of the American CoIIege of Surgeons, states: “The science of anesthesia is rapidIy deveIoping. New types of anesthesia, new methods of administration, and compIicated apparatus demand serious medica thought. It is unfortunate that a Iarge number of hospitals fail to recognize the necessity and vaIue of a we11 organized department of anesthesia. This presupposes competent medica supervision, preferabIy a medical anesthetist. . . . Such a requirement does not precIude the use of the nurse anesthetist, who is properIy trained and quaIi- fied to give anesthesia. It is unfair to expect the nurse to be responsible for the service, but rather, she shouId work under proper medica supervision. As the administration of anesthesia is generally conceded to be the practice of medicine, and in as much as it involves risk to human life, it is only reasonabIe to expect medica supervision. This cannot be done properIy by the surgeon, for he is frequently not especially trained in this work, nor should he have to carry the responsibiIity, when under the strain of operating.”

So great has been the advance in discovery and administration that within the

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last few years professors of anesthesia have been appointed in medica coheges, and skilled physicians are devoting their time exclusively to research in anesthesia in certain medica centers.

At the University of Wisconsin, in Madi- son, RaIph W. Waters has been appointed professor of anesthesia, with a staff for research and anesthetic work. E. A. Roven- stine, professor of anesthesia in New York University CoIIege of Medicine, has the same standing as other professors in the University. John Lundy, of the Mayo Clinic, Rochester, Minnesota, has long been an outstanding figure in anesthesia. He now has a staff and is devoting himseIf especiahy to regiona and spina anesthesia. Other coIIeges and universities are rapidIy fahing in line.

Yandell Henderson, professor of physiology, at YaIe University, first caIIed attention to the value of carbon dioxide, in 1906. He has also pointed out the mistake of assuming that nitrous oxide is the safest of a11 anesthetics, whereas, it has a very nar- row margin of safety, and compIete anesthesia can hardIy be acquired without anoxemia. In many other ways, he has promoted the science of anesthesia.

The next great advancement in the sup- pression of pain, wiII be the discovery of

some substance, taken as a pi11 or as a hypodermic, that wiI1 produce general anaI- gesia and thus entirely eliminate a11 present forms of anesthesia, as it wiI1 be much safer, easier and pIeasanter both to give and to take.

REFERENCES

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1924. GWATHMEY, .I. T. Recta1 administration of evipal

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Fifty years of anesthesia