October 1999, Vol 17 - Anesthesia History Association

Transcription

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BULLETIN OF
ANESTHESIA }/ISTORY
AHA
VOLUME 17, NUMBER 4
OCTOBER, 1999
The Bristol Meeting:
Celebrating 200 Years of Nitrous Oxide
by Selma Harrison Calme� MD.
The British History of Anaesthesia So
ciety (HAS), the U . S .'s Anesthesia History
Associa tion (AHA) and the S o c ie ty of
Anaesthetists of the South Western Region
(SASWR) gathered in Bristol, England,
May 13-15, 1999, to mark the bicentennial
of Sir Humphrey Davy's researches into
nitrous oxide (NP). This research was car
ried out in Bristol at Thomas Beddoes'
Pneumatic Institute, so Bristol was the ap
propriate meeting site. Davy's discovery of
the pain-relieving properties of Np oc
curred April 17, 1799, so the meeting date
was also appropriate.
Bristol is an industrial city in southwest
England, along the River Avon. In the 18th
and 19th centuries, it was a prominent port
especially for the sugar and slave trades.
The meeting site was The Watershed Con
ference Centre, along Bristol's remaining
original quay. This area of Bristol had ex
tensive bomb damage during World War II
and was rebuilt in modern style. Walking
j ust a few blocks led to very historic areas,
incl uding parts of the original city wall. A
statue of Queen Victoria guarded the en
trance to the main hotel (the lovely Royal
Swallow Hotel), and the Bristol Cathedral,
whose foundations date to Roman times,
was the nearby background.
Twenty papers on the history of Np
were presented. Topics ranged from "Bed
does' Patrons" (Dr. E.T. Mathews, Birming
ham) to "Gardner Quincy Colton's 1848
Visit to Mobile, Alabama" (A.J. Wright,
Alabama) . There were some unusual pre
senters: three were English literature pro
fessors (two British, one from the U.S.) who
examined the relation of the Romantic po
ets to what was happening scientifically in
Bristol. Dr. George Bause, Honorary Cu
rator of the Wood Library-Museum and a
descendant of Humphrey Davy, announced
in his paper the discovery and acquisition
of the earliest known anesthesia machine.
Reception atAtwood Court with C atherine Ross (University ofTexas at TYler) and
the authOl; Selma Calmes.
This machine was designed by Amos M.
Long of Monroe, Michigan, who received
the patent in 1884. It was found in a Michi
gan hospital's storage area. The Humphrey
D a vy Lecture was given by D r. D avid
Wilkinson of St. Bartholomew's, London.
He studied Davy's scientific notebooks ex
tensively and came to the conclusion Davy
was a hasty, erratic researcher which may
explain why he did not go further in using
Np to treat pain. There were also displays
related to NP, which served as focal points
during tea breaks.
Tours of interesting sites nearby were
arranged. We saw the outside of the Pneu
matic Institute, now a private house. The
plaque marking the house as a historic site
is framed by a huge wisteria, in full bloom
when we visited. A special area of interest
was the back yard where Priestly would
rush to get fresh air whenever he got hy
poxic while breathing Np. The Pneumatic
Institute is in the Bristol suburb of Clifton,
an area of hot springs which had marly
medical "spas" in the 18th century. We also
went to B owood House, site of J oseph
Priestly's laboratory where both oxygen and
NP were actually discovered. This is a very
small room, which now serves as a library.
A display on the discovery of oxygen was
up, to mark the 225th anniversary of the
discovery of oxygen. Jenner's house was
nearby and we visited it, including the little
hut in the backyard where .he inoculated
his neighbors.
Con tin ued on Page 4
III'
BUllETIN OF ANESTHESIA HISTORY
Call for Abstracts: AHA 2000
Anesthesia History Association Annual Spring Meeting
March 29, 2000
Dolphin Hotel Wait Disney World
Orlando, Florida
The Anesthesia History Association invites the submission of abstracts for presentations at
its 8th annual spring meeting. This meeting will be held in conjunction with the 25th annual
meeting of the American Society ofRegional Anesthesia.
Presentations should be 20 minutes in length and relate in some way to the history of
anesthesia, pain management or critical care medicine. Abstracts should be no longer than
what can fit on one 8Y2" by 1 1" sheet of paper. If possible, abstracts should indicate the research
problem, sources and methodological approach used and may contain no more than 10 refer
ences.
Abstracts may be submitted by mail, fax or e-mail. Disk submission in Word-compatible
format is also permitted. All accepted abstracts will be distributed in some form to all meeting
registrants. Individuals who wish to organize a paper session around a theme should contact
us as soon as possible.
Abstracts must be submitted by December 1 5, 1 999, to: A.I. Wright, MLS; AHA Annual
Spring Meeting Organizing Committee; Department ofAnesthesiology Library; University of
Alabama at Birmingham; 619 19th Street South, JT965; Birmingham AL 35249-6810; (205)
934-4696 [voice]; (205) 975-5963 [fax] ,- <a.j [email protected]>
Further announcements will be made as details for the program develop.
"Inhaleing Gass [sic] which Stupefies the Senses"
An Experience from a Patient in 1847
byPatrick Sim) Librarian) WOod LibrrJ1y-Museum ofAnesthesiology
On January 27, 1 847, Boston resident M.E. Bassett wrote to his sisters in Scotland P.C.,
Massachusetts, describing among other things his personal experience of a dental operation
under the influence of a gas he had inhaled. The case of dental anesthesia described by Bassett,
a non-medical, non-dental contemporary of the Discovery, provides a patient's personal ac
count of the momentous introduction of painless surgery. It took place only 89 days after
Morton's public demonstration. In his letter to his sisters, he described in detail the effect on
him of the inhaled gas that "stupefies the senses" while undergoing dental surgery.
I have also been under the dentists hands-a fortnight since I went to have a tooth
filled. . . , in the process of preparing it, previous to filling he came directly upon the
nerve -. . . Something then must have done immediately. . . I suppose you have seen
accounts of people inhaleing gass [sic] , which stupefies the senses so much that surgical
operations have been performed without their knowledge. I was put to this test and
went through this process. My senses were not entirely suspended as I did not take
enough for that, only sufficient to make me insensible to this acute sensitiveness. You
remember it afterwards as a sort of dream half forgotten. In this state I had the nerve
destroyed, then I had to wait a week for it to heal previous to filling. . . There was a
constant sewing, fileing, scraping, digging, punching, grounding & poking [sic] all
through my brain. But since that time I have been very comfortable, much more so than
I have been for months . . . I feel as much relieved as the boy did after he had his
whipping . . . [sic]
-M.B. Bassett
January 27, 1 847
Stories of patients under anesthesia in the early days of the DiscovelY have been told, but
rarely told from the patient's personal perspective. Crawford Long solicited James Venable's
testimony to verify his claim. Venable went along, simply stating what happened between him
and his physician friend.l In most other instances in the early years of surgical anesthesia, the
famous patients are mostly historic figures known for their roles conveniently related to the
events involving them. Boston musician Eben Frost, stout and healthy, was Morton's patient
for painless dental extraction in September, 1 846. Like Venable, Frost testified for Morton on
Cantinued onPage 20
Wood Library-Museum of
Anesthesiology
Duplicate Vintage Books
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The Wood Library-Museum of anesthe
siology announces a duplicate Vintage
Book Sale. To order any of the following
volumes, please contact:
Karen Bieterman, Assistant Librarian
Wood Library-Museum of
Anesthesiology
520 N . Northwest Highway
Park Ridge, IL 60068-2573
phone (847) 825-55 86, Ext. 5 8
fax (847) 825-1 692
Adriani J. The ChemistlY and Physics of
Anesthesia. 2nd ed. Springfield: Charles C .
Thomas; 1 970. $1 5 .00
Adriani I. The Phalwacology ofAnesthetic
Drugs. 2nd ed. Springfield: Charles C. Tho
mas; 1 94 1 . $ 1 5 .00
Clement FW Nitrous Oxide-Oxygen An
esthesia. Philadelphia: Lea & Febinger;
1939. $30.00. Autographed copy.
Farr RE. Practical Local Anesthesia and
its Surgical Technic. Philadelphia: Lea &
Febinger; 1 9 2 3 . $40.00
Flagg PJ. The Art of Anaesthesia. Phila
delphia: J.B. Lippincott; 1939. $20.00
Gillespie NA. Endotracheal Anaesthesia.
2nd ed. Madison: University of Wisconsin
Press; 1950. $20.00
Greene NM. Physiology of Spinal Anes
thesia. Baltimore: Williams & Wilkins;
1 9 5 8 . $20.00
Hertzler AE. The Technic of Local Anes
thesia. 6th ed. St. Louis: C.Y Mosby; 1 937.
$30.00
Hewer CL. RecentAdvances inAnaesthe
sia and Analgesia. 4th ed. London: I. & A.
Churchill; 1 943. $1 0.00
Lundy JS. ClinicalAnesthesia:A Manual
of ClinicalAnesthesiolog), Philadelphia: WE.
Saunders; 1 942. $20.00
Smith RM Anesthesia for Infants and
Children. S t . Louis: C . Y Mosby; 1 9 5 9 .
$20.00
Waters RM © Madison: University of
Wisconsin Press; 1 9 5 1 . $20.00
Wylie WD, Churchill-Davidson HC. A
Practice of Anaesthesia. 2nd ed. London:
Lloyd-Luke; 1 966. $20.00
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4
Bristol.
. . Continuedfrom Page 1
The plaque commemorating the Pneumatic Institute)
sUlTOunded byblooming wisteria.
BowoodHouse) site ofJoseph Pn'estly 'slaboratOl),where both mygen and
�O were discovered.
Outside ofThomas
Beddoes'
Pneumatic
Institute) now a
private residence.
Collin Bause and George Bause in front of
the Pneumatic Institute. The Bauses are
descendants ofHumphrey Davy.
HAS President Dr. Jean M. Horton (Ox
ford) and AHA president Dr. Ted Smith
(Chicago) presided at the conference ban
quet, held in the stunning Great Hall of
the University of Bristol (which seats 1 000
for dinner). Its enormous pipe organ filled
the hall with glorious music as we entered
for a very grand dinner. Another evening
we enj oyed the displays of wine history in
the Harveys Wine Cellars and Museum,
previously a l3th century underground
hospital. Dinner on the S . S . Great Britain,
the first screw-propeller ship (now re
stored) was another social highlight. The
farewell reception at Atwood Court, Dr.
Peter Baskett's (immediate past-president
of the SASWR) home, gave us a picture of
English country life a s we prepared to
leave.
D r. Tony Bennett, recently retired from
Frenchay Hospital, Bristol, was the confer
ence organizer and did a truly superb j ob.
Everything was very well done. A special
j oy was Dr. Bennett's narrations on the bus
trips. He grew up in Bristol and made the
city's history very interesting. We can say
this meeting, the first joint meeting of the
societies, was a great success; congratula
tions to everyone involved. The HAS will
publish a small volume of the papers in the
future. (Note:The first edited drafts arrived
August 1 6, so production is on the way.)
TheJenner house
(left), nearBlistol,
and the hut in the
yard (light) where
Jenner vaccinated
his neighbors.
TedSmith
AHA
Pl'esldent, and
Catherine
Ross,
Universityof
Texas at 1jdel;
enjoya stJ'eet
scene in
Blistol
Reception at the conference banquet, with CathelineRoss, Sally Coniam
(Bath Spa University) and her husband, andJean Horton, pl'esident ofthe
Blitish HistolJ' ofAnaesthesia Society (left to dght).
Selma Calmes alidA. Franco (fi'Om Santiago, Spain) enjoy
dinner at Hanrey's Wine Cellar andA1useum.
Joseph Priestly'slaboratOiY at Boxwood House, whel'e both oxygen and
N.zO wel'e discovel'ed
5
6
Anesthesia and the Soul
byJAntonio Aldrete, MD., MS.
ProkSSOlj Department ofAnesthesiology, UniversityofSouth FlOlida,'Presldent, Sunshine Medical Center, Destin, Flonda
and
A. f Wright,ML.S.
Librarian, Department ofAnesthesiolo!!Jj UniversityofAlabama, Birmingham, Alabama
Even before the first anesthesia was ad
ministered as we know it, men and women
have been intrigued about the soul as an
abstract concept, but they have concretely
been curious about communicating with
their inner being-their soul. Since anes
thesia is an altered stated of consciousness,
a number of investigators, psychics and
anesthetists have attempted to link these
two concepts in a variety of ways.
The concept of a soul or spirit animating
and perhaps transcending the body's physi
cal existence is an ancient and much-debated
point in the philosophies and religions ofboth
Eastern and Western cultures. 1 The preva
lence of this idea has even led to an attempt
in the early twentieth century to experimen
tally prove the soul's existence.2 The relation
ship between some anesthetic terms and the
soul or spirit or "breath" of life has been ex
plored by Gravenstein3 in a review of related
terminology, whether planned or incidental,
between the two topics. This concept might
be expanded to encompass the trans-anes
thetic experiences described by some pa
tients-the occurrence of dreams and hallu
cinations during anesthesia has been noted
from the early days of clinical anesthesia.4�6
Observations made on some of these cases
have resulted in various theories to explain
them, including: a) the personality of the
patient; b) preoperative anxiety and/or de
pression; c) certain anesthetic drugs, i.e. ,
ketamine, or d) adjuvants like scopolamine,
droperidol, etc. Alteration of consciousness
during the anesthetic state in itself may be
seert, from the physiological point of view, as
a reflection of the depressive effect of anes
thetic agents upon the reticular activating sys
tem; in other words, an interruption of one of
the brain's functions. However, some have ven
tured to say that the brain is only a tool of the
thought process, originating on the metaphysi
cal being governing both mind and body. 3 s,
Whether labeled soul, anima or spirit,
the concept, although vague, can hardly be
dismissed lightly. Evidence of the immor
tality of the soul is perhaps suggested in
descriptions by survivors of cardiac arrest
and/or cardiac surgery, who have observed
their bodies being resuscitated and felt no
p a i n or anxie ty. 7 S o m e s u rvivors of
near-death experiences have also described
seeing bright lights; people known to them,
both living and dead; and hearing a super
natural voice. 7�lo Autoscopy, the experience
of observing one's own body from outside
in, has been associated with numerous
other states, including ketamine and ni
trous oxide anesthesia;ll�13 depersonaliza
tion, or the syndrome of the doublel4,ls
which all of us are supposed to have; mys
tical experiences16 and psychotropic drug
useP Indeed, substantial esoteric literature
surrounds this phenomenon. IS
The image of a death-and-rebirth cycle
was vividly connected to the administra
tion of anesthesia by Irish playwright
Synge, who noted about his ether experi
ence, "The impression was very strong on
me that I had died the preceding day and
come to lif� again, and this impression has
never changed."19 This experience seems to
be c o m m o n a m o n g a n e s t h e ti z e d p a
tients.6 ,1l ,12 In addition, communications
through so-called "psychics," "mediums,"
or "channelers" have truly been revealing
about past events, previous lives, and the
habitation of one's soul in another body
centuries earlier.2o In his discussion on a
continuum of consciousness that includes
ecstatic, hyperaroused states and medita
tive, hypo aroused lethargy, Fischer has pro
posed that man is a dual system. The "Self"
operates "in the mental dimension of ex
alted states," and is "The Knower and Im
age Maker." The "I" functions "in the ob
j ective world" and is "The Known and
Imagined." Fischer further proposes that
''A discernible communication between the
'Self' and the 'I' is only possible during the
dreaming and hallucinatory states, whether
drug-induced or 'natural' ."21 Fischer's "car
tography of inner space" might be seen as
describing the soul and the personality, an
uneasy alliance made more apparent by
traumatic experiences such as cardiac ar
rest, by anesthetic-induced hallucinations,
transcendental experiences and the like.
Transcendental experiences, including
the feeling that one has encountered some
ultimate secret of the universe, have been
frequently described by patients under or
experimenters with anesthetic drugs; " . . .it
took days to shake off the feeling that I had
had a glimpse of another phase of exist-
ence," wrote Shoemaker22 after his ether an
esthetic. Talbot, using nitrous oxide on
himself, concurred; "I passed into the con
sciousness of having solved by experience
the riddle of the Universe . . . "23 Williams
J ames noted, concerning his own nitrous
oxide experiments, "Truth lies open to the
view in depth beneath depth of almost
blinding evidence. The mind sees all the
logical relations of being. . . "24 Perhaps the
greatest experimenter with nitrous oxide
and ether in this regard was Benjamin Paul
Blood,zs who spent 27 years in search of
what he called "the anaesthetic revelation."
"The lesson," he wrote, "is one of central
safety: The Kingdom is within."
Integration of the Real and
the Supernatural
Beyond the proposed theories of narco
sis and the apparent pharmacological
action(s) that anesthetic agents may have
upon the neuron's lypophyllic membrane,
the dreams, hallucinations, and even some
episodes of awareness during anesthesia
appear to be characteristic and individual
to each person. Preoperative anxiety main
tains physiological alertness as manifested
by tachycardia, tachypnea, diaphoresis,
pallor, etc. However, as anesthesia is in
duced, these physical signs subside, al
though the soul may, at least for some time,
remain awake. It is therefore not surpris
ing that awareness is more common under
light levels of anesthesia such as seen under
n e uroleptan algesia
and
high-dose
narcotic-oxygen anesthesia.26 Some patients
have described such experiences as "deep
fatigue," "absolute weakness," or a true dis
solution of their body, but more often than
not, they have heard sometimes derogatory
comments made by the anesthesia-surgical
teamP This disparity could be interpreted
as a dissociation between somatic function
and psychic function, with the latter still op
erative and in a position of observance or vigi
lance while the body is inert and defenseless,
at least for some time and to a degree. It ap
pears then that the sense of hearing acts as
the vigilant antenna or the observing peri
scope, therefore warning OR teams that they
should watch what they say seems warranted
indeed.26 ,2 7
This continuum of states associated with
anesthesia, from awareness through dreams
and hallucinations to mystical revelations,
may offer a means of psychological explora
tion as yet untapped in a methodical way. In
the late 1 940s, Henry Beecher made such an
observation: "With anesthetic agents, we
seem to have a tool for producing and hold
ing at will, and at little risk, different levels
of consciousness-a tool that promises to be
of great help in studies of mental phenom
ena. Thus anesthesia, in presenting a revers
ible depression, enables the study of the life
process itself." 28
The Relationship of
The dissociation of the body and soul
under circumstances of stress has been de
scribed and confirmed by J ung.32 Moreover,
Bastor-Ansart33 proposed an explanation
for the events occurring during the anes
thetic state as a somatic dream followed by
a psychic detachment. How that separation
takes place, where it takes place, or in
whom it is more likely to occur, can only
have speculative answers. However, this
exploration of the unknown can be a chal
lenge to anesthesiologists and psychia trists
alike. Perhaps when more is known, we will
better understand not only what we do to
the brain itself, but to the soul of our pa
tients as well.
Body and Soul
If the spirit truly remembers and the
soul is immortal in the metaphysical sense,
then the sta te of anesthesia may be defined
as an approximation toward the threshold
of the body's mortality. 29 Wyld noted in
1 895, "The startling and significant fact is
this: that while the body is as if dead un
der anaesthetics, the imagination becomes
active and at times exalted."30 But how far
anesthesia affects it, where the spirit goes,
and what the soul does during anesthesia,
no one really knows. There are some vague
manife stations as indicated by dreams,
hallucinations, awareness, and transcen
dental experiences as described to us by
some of our patients. If indeed conscious
ness is the most evident of all visible facts,
it may j ust visit our body, but unlike it, re
main existing for an indefinite period of
time. Although there have been allegations
that psychic powers have been lost after an
anesthetic, no obj ective to prove one or the
other has been provided, so communica
tion with the soul through medicines un
der anesthesia remains an unexplained
phenomenon. The fallacy or reality of
"truth serum" has been defined, since the
administration of intravenous sedation
with thiopental or propofol lowers the bar
riers of inhibition and one is able to obtain
some information otherwise withheld-but
is the soul talking?
Anesthesiologists deal with and thrive
on objective, quantitative measurements,
basing dosages on expected or observed
effects, tending to shy away from subjec
tive ideas, appearing skeptical about tran
scendental events, refuting everything that
is not seen, recorded, predicted or calcu
lated. However, as much of a science as it
is, anesthesia is also an art in which tech
nical skills and experience count. The fact
is that the short- and long-term affectation
of this altered state of consciousness upon
the emotive and intellectual functions of
the mind is barely known.31
References
1. Werblowsky RJZ. Soul. In Encyclopedia
Blitannica. Chicago: Britannica, 1970; pp. 924:
924-D.
2. MacDougall D. Hypothesis concerning soul
substance together with experimental evidence of
the existence of such substance. Am JlJed NS 1907;
2:240-3.
3. Gravenstein JS. A perspective on science:
The language and history of anesthesia. Ala J hIed
Sci 1984; 21:304-10.
4. Snow J. On the Inhalation of the VapourEther
in Surgical Operations. London: John Churchill,
1947, p. 11.
5. Stille M. Psychical effects of ether inhala
tion. AmJDent Sci 1855; 5:113-23.
6. Gibbons H. A personal experience of nitrous
oxide as an anaesthetic. Am J Dent Sci 1877;
11:69-74.
7. Moody R. Life afe
t rLife. New York: Bantam,
1976, pp. 36-93.
8. Blacher RS. Death, resurrection, and re
birth: Observations in cardiac surgery. Psychoanal
Q 1983; 52:56-72.
9. Negovsky VA. A neurophysiological analy
sis of "hallucinations" experienced by post
resuscitation patients. Resuscitation 1984; 11: 1-8.
10. Gabbard GO, Twenlow SW, Jones FC. Do
"near death experiences" occur only near death? J
NervMentDisl981; 169:374-377.
11. Collier BB. Ketamine and the conscious
mind. Anaesthesia 1982; 27:120-34.
12. Mittleman B. Psychoanalytic observations
on dreams and psychosomatic reactions in response
to hypnotics and anaesthetics. Psychoanal Q 1945;
14:498-5 10.
13. Atkinson RM , Green JD, Chenowith DE,
Atkinson JH. Subjective effects of nitrous oxide:
Cognitive, emotional, perceptual and transcenden
tal experiences.]PsychedelicDrugs 1979; 11:317-30.
14. Taylor FK. Depersonalization in the light
of Bretano's phenomenology. Br J jJJed Psychol
1982; 55:297-306.
15. Damas-Mora JMR, Jenner FA, Eacott SE.
On autoscopy 01' the phenomenon of the double:
case presentation and review of the literature. BrJ
MedPSycilO11980; 53:75-83.
16. Ludwig AM. Altered states of conscious
ness. Arch GenPsychiatry 1966; 15:225-34.
17. Fischer R. Cartography of inner space. In:
Siegel RK, West LJ, eds. Hallucinations, BehaviOlj
Eypedence and TheOl), New York: Wiley, 1975, p.
201.
18. Twemlow SW, Gabbard Go, Jones FC. The
out-of-body experience: A phenomeno-Iogical ty
pology based on questionnaire responses. Am J
PsychiatIyl982; 139:450-55.
19. Synge JM. Under ether. Personal experi
ences during an operation. Interstate jJJed J 1916;
23:45-9.
7
20. McLaine S. Out on a Limb. New York: Ban
tam, 1983; pp. 105-59.
21. Fischer R. Cartography of inner spacer. In:
Siegel RK, West JL, eds. Hallucinations, BehaviOlj
Eypen'ence and Theor)( New York: Wiley, 1975, pp.
197-239.
22. Shoemaker
GE. Recollections after
ether-inhalation-psychical and physiological.
Therapeutic Gazette, 3rd Serio 1886; 2:521-26.
23. Talbot F. Psychic disturbances in nitrous
oxide analgesia. BrDentJl915; 36:668-670.
24. James W. On some Hegalisms. In: The lJ7ill
to Believe and OtherEssays inPopularPhilosophy,
New York: Dover, 1956, p. 294.
25. Smith PB. Chemical Glimpses of Paradise.
Springfield, Illinois: T homas, 1972, p. 20.
26. Guerra F. Awareness during anesthesia. In
Guerra F, Aldrete JA, eds. Emotional Reactions to
SurgeIy and Anesthesia. New York: Grune & Stratton,
1980, p. 1-8.
27. Aldrete JA, Wright AJ: Is the patient asleep?
Int Surg 1987; 72:58-61.
28. Beecher HK. Anesthesia's second power:
Probing the mind. Science 1947; 105:164-166.
29. Krutch J\V, hIoreLives than One. New York:
Williams and Sloane, 1962, p. 329-357.
30. Wyld G. On certain psychological phenom
ena accompanying the administration of
anaesthetics. Lancetl895; 1:776.
31. Wright AJ, Aldrete JA. Patient memories
of anesthesia; An historical perspective. jViI d East
J Anestl987; 9:233-259.
32. Jung CG. JlJemoIies,Dreams and Reflections.
New York: Vintage, 1912, pp. 72-123.
33. Bastos-Ansart M. La actividad onirica du
rante el sueiio anestesico. irIedicina Clinica 1964;
2:512-514.
Bulletin of Anesthesia HistOlY(IS SN 1522-864 9)
is published four times a year as a joint effort
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BulletInwas published asAnesthesia HistoryAs
sociation Newsletterthrough Vol. 13, No. 3, July
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tained by the U.S. National Library of Medi
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C.R. Stephen, MD, SeniorEditor
Doris K. Cope, MD, Editol'
Donald Caton, MD,AssociateEditor
A.I. Wright, MLS, AssociateEditor
Fred Spielman, MD,AssociateEditor
Douglas Bacon, MD,AssociateEditor
Peter McDermott, MD, BookReviewEditor
Debra Lipscomb,Editon'al Staff
Editorial, Reprint, and Circulation matters
should be addressed to the Editor, UPMC
Shadyside, Multidisciplinary Pain Program,
5230 Centre Ave., 1 South, Pittsburgh, PA
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gram. Please save files in RICH TEXT FOR
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...
8
Dr. Cyril Courville: The Anesthetist's Pathologist
by Gerald L. Zeitlin) MD.) FR. CA. )
Newton) Massachusetts
Cyril Courville was born in Traverse
City, Michigan, in 1900 and he died in
Southern C alifornia in 1968 . (Figure 1)
Grand Traverse County was first settled
by Protestant missionaries in 1839. Under
a treaty with the local Chippewa Indians
imposed by the Government, white settlers
were allowed to dispossess them and ac
quire their lands. Courville's father was a
carpenter who had to travel widely to find
work. His mother made him a suit that he
wore for all fou r years of medical school.
He spent his summers selling books in or
der to pay tuition charges.
One of his associates later said this
about him: "Dr. Courville was reared in
that part of mid-America where idealism,
genuineness of character and persistent
industry were the ingredients of success in
any field. Perhaps it was his religious up
bringing by his mother." Another colleague
wrote: "His colleagues have said that they
have never known him to waste as much as
5 minutes-yet his neighbours tell that the
children had known him as good friend . . .
who has had time for their friendship."
His talent for teaching became appar
ent while he was a medical student at Loma
Linda University. The pages of his student
notes, based upon lectures and wide read
ing, were neatly penned, logical and copi
ously illustrated with his own drawings.
Many of his fellow students were thankful
for a look at his notes and appreciated his
voluntary coaching sessions. When he
qualified, he received the highest score that
year from the National Board of Medical
Examiners. In 1927, he spent a year with
D r. Harvey C u shing at the Peter Bent
B righam Hospital in B o s ton. His rise
through the academic ranks was rapid and
he was appointed Professor of Neuropa
thology at Loma Linda University Medi
cal S chool in 1933, at the age of 33.
Among his many interests, the most
prominent was forensic pathology. His most
conspicuous moment in the public eye oc
curred when he was a consultant in the in
vestigation of a fatal ring injury suffered by a
professional boxer, Davey Moore, in 1963.
Courville described the death blow accurately,
based solely on his pathological findings. No
one present at the ringside recalled such a
blow, but the motion pictures ofthe fight re
vealed precisely the mechanism ofinjury that
Courville had described.
Figure 2 illustrates an example of the
breadth of his interests. Dr. Courville be-
�Jh:()n �
......"1-...,; .
in. V.
19()(}·I96X
Figure 1.
came fascinated in military helmets used
in older times to protect soldiers from blows
to the head. The photo comes from an ar
ticle he wrote on this subject.
In order to demonstrate the importance
of C o u rville's work, some information
about the use of hypoxic methods of anes
thesia during the first three decades of this
century will be reviewed.
In December, 1920, E. !. McKesson (Fig
ure 3) of Toledo, Ohio, published an article
titled "Gas-Oxygen Anesthesia in Relation
to M a j or D ental S urgery." He starts by
quoting Henderson's 1908 contention that
a low blood CO 2 tension caused surgical
shock. He then reached the unproven con
clusion that rebreathing, by causing a high
C O 2 tension, was desirable. But by 1920 he
went one step further, proposing two con
cepts new to the practice of anesthesia.
First, he used extremely low percentages
of oxygen as a test of a sick patient's abil
ity to undergo surgery. He slowly titrated
increasing oxygen concentrations until the
patient stopped showing signs of hypoxic
distress. To prove the validity of this idea,
9
said, ''All you need is gas and she has it."
The first patient was a beefy giant with a
set of rotting stumps. I thought, "No Pen
tothal, no halothane and no succinylcho
line." As though she were reading my
thoughts, the dentist said, "All you need is
gas. " And she meant it. With 10% oxygen
in the nitrous oxide, the p atient smiled
pleasantly instead of his scowling at me.
She said, "Turn the oxygen off, you fooL" I
refused. She asked me to leave immediately,
which I did. My chief and I never discussed
the matter, but he never asked me to go
again.
Recently Dr. Al Betcher wrote, "I was
interested in hypoxia because I was in
volved in giving anesthesia to patients in a
postgraduate course in D entistry at my
hospital in the mid-thirties. Back in the
18 80s dentists would not allow the use of
oxygen with nitrous oxide. My group felt
the same way. They claimed they needed
the cyanosis to know when they could pro
ceed with their dentistry. As an anesthesi
ologist, I thought of cyanosis differently. I
had read Courville's book on cerebral an
oxia following anesthesia."
Where does Cyril Courville fit into all
this? How did he become interested in an
esthesia and its complications? One had
assumed it was an offshoot of his fascina
tion with forensic pathology. But it was
more specific than that. In one of the brief
biographies stored in the Loma Linda
Medical S chool Archive, one reads,
FiguJ'e 2.
he described a patient with severe heart dis
ease on whom he used this technique. With
out recognizing the significance of the ob
servation, he remarks: "the patient took 30
minutes to regain consciousness instead of
the usual 30 seconds."
Later in the same paper, McKesson de
scribes "primary saturation." He gave 100%
nitrous oxide until there was twitching of
an eyebrow, an arm or a leg, at which point
he introduced 5% oxygen. He comments,
"they (the dentists) knew these convulsive
movements were not excitement but were
due to the temporary lack of oxygen, like
those of a chicken with its head cut off."
This, he says, was only useful for ultra brief
surgery. For longer cases, he described "sec
ondary saturation." He stated that nitro
gen entering the blood from body stores
diluted the nitrous oxide and that it must
be restarted at 100% concentration until a
fixed dilated pupil was obtained, accom
panied by rigid muscles and cyanosis. Then
one or two breaths of either pure or 50%
oxygen were administered, which was again
reduced to 5 or 10% oxygen. For several
years, he resorted to secondary saturation
in obstreperous patients. He concludes,
"the true signs of (depth) of anesthesia are
muscular phenomena."
This paper influenced the practice of a
whole generation of anesthetists. But in
1922, Dr. Arthur Guedel called a halt. He
strongly advocated a slow induction (at
least 10 minutes) using a minimum of l O%
oxygen at all times and morphine premedi
cation to increase the effectiveness of the
nitrous oxide. But again it seems that little
changed, because in 1945 , B arach and
Rovenstine (Reference 2, Figure 4) felt
obliged to write: "Nitrous oxide, suppos
edly the safest of all anesthetic agents, has
become one of the most, if not THE most,
dangerous today." They added that the
chief problem was its lack of potency.
Yet this "schJ'ecJdichkdt'1ingered on. In
1962, the author was a resident at the
Whittington Hospital in North London.
My chief asked me to substitute for him at
a nearby dentist's office one evening. He
Dr. Courville is the first to recognize
an element of serendipity. While he
was a resident in charge of neuropa
thology at the Los Angeles County
Hospital, his attention was called to
a series of totally unsuccessful ad
ministrations of Nitrous Oxide. In
vestigation of these cases required
the exploration of many pathways
gross inadequacies in the calibration
of anesthesia machines, contamina
tion of nitrous oxide with nitrogen,
and the possibility that brain dam
age was due to embolic phenomena.
But at the suggestion of one of his
internist colleagues, Courville finally
pinned down the common denomi
nator-hypoxia. And with this he
embarked on a long series of studies
in which he correlated the micro
scopic findings with the clinical
course of patients unfortunate to die
as a result of the use of hypoxic an
esthesia.
In 1936 he published his first paper on
the issue. Figure 4 summarizes all the paCon tin ued on NextPage
,.....
10
Courville.
. .
ContinuediIomPage9
pers he wrote on the subject. The papers
published in the anesthesia literature are
emphasized in heavy type. In the first pa
per, he described the case of a 27-year-old
woman who, in 1924, suffered an anoxemic
episode under nitrous oxide followed by
coma and convulsions. She was blind for
three months and dysphasic for six. She had
remained unconscious and seized for sev
eral days after the operation. Later that
same year, C ourville published a ISO-page
article in the j ournal Medicine, describing
13 similar cases. This was later published
as a book which described the complete
clinico-pathological scenarios for each.
This was a unique approach; until that
time any unexpected operative death was
analyzed in a coroner's court, but the evi
dence was based on opinion and not on
pathology. In this way he must slowly but
surely have influenced anesthetists. For
example, in 1945 Barach and Rovenstine
said, "Never use less than 20% oxygen."
In 1954, Courville was invited to give a
lecture on hypoxia at the I.A.R.S. meeting.
In 1953, Dr. Roland Whitacre wrote to Dr.
Morris Nicholson as follows, "Dear Nick:
I t h i nk you should write to D o c t o r
Courville asking h i m t o attend our (the
I.A.R.S .) meeting in Los Angeles and in
form him that the B oard of Trustees has
unanimously voted to present him with a
scroll." The author recently wrote to Drs.
Morris N i cholson, Al B e tc her, Leslie
Rendell-Baker and the I.A.R.S., asking if
they knew anything of the whereabouts of
the scroll. They all replied most courte
ously, but it seems it is lost forever. If found,
it might be a significant addition to the
Wood Library-Museum.
In 1959, the j ournal Anesthesia andAn
algesia praised Courville in a two-page ar
ticle under the heading, "We Salute." A
brief quotation makes the point, "Every
person who deserves the honor of being a
specialist in anesthesia is influenced by
Courville's studies. These transformed hy
poxia from an accepted anesthetic tech
nique to its role as the chief menace in an
e s t h e s i a . Ye t s t r a ngely enough D r.
Courville is not an anesthetist nor a physi
ologist nor a biochemist."
What manner of man was Dr. Courville?
I believe the answer lies in the preface
to an article he wrote in 1941:
In the dim and distant back
ground of anesthesia still lurk the
dark spectres of disaster. These un
welcome guests at every operation
not infrequently claimed the sleep
ing victim. Elbowed further and fur-
ther from the operating table by each
new advance in knowledge . . . these
haunts of anesthesia are now com
pelled to stand at a considerable dis
tance-so often as to be forgotten.
But still, too often, the long arms of
one of these phantoms reaches out
to strike. As the physiology of nar
cosis becomes better understood, it
is not surprising to learn that the
most ruthless of these spectres is
found to be named 'Asphyxia'.
References
l. McKesson EI. Gas-oxygen anesthesia in re
lation to major dental surgery. CU11'ent Research in
Anesthesia and Anaigesia 1920; 8:1-5.
2. Barach AL, Rovenstine EA. The hazard of
anoxia during nitrous oxide anesthesia. Anesthesi
oiogyl945; 6(5):449-46l.
The author wants to thank Mr. Patrick Sim of
the Wood Library-Museum and Mrs. Marilyn
Chase of the Lorna Linda Medical School Archive
for considerable assistance.
Figure 3. El McKesson.
Figure 4.
The CourvilIe Bibliography:
Papers referring to the Pathology of Anesthesia
Lenticular Syndrome Following Nitrous Oxide Narcosis. Bull Los Angeles Neurol
Soc 1936; 1:30-32.
Asphyxia As a Consequence of Nitrous Anesthesia. Medicine 1936; 15: 129-145 .
Mental Disturbances following Nitrous Oxide Anesthesia. Anesthesiology 1940;
1:261-273.
Ether Anesthesia and Cerebral Anoxia; A Study of the Causative Factors in
the Serious Anesthetic and Post-Anesthetic Complications. Anesthesiology 1941;
2:44-58.
The Problem of Serious Complications of Anesthesia. Anesthesiology 1941;
2:686-687.
Effects of Anesthetic Agents on the Tissues of the Central Nervous System.
Trans Anesthesiology Soc 1953; 8-14.
Case Studies in Cerebral Anoxia; Ill . Structural Changes in the Brain after Car
diac Standstill during Spinal Anesthesia . Bull Los Angeles Neurol Soc 1954; 19:142150.
Narcosis and the Fetal Brain. Bull Los Angeles Neurol Soc 1955; 20:97-111.
Untoward Effects o f Spinal Anesthesia o n the Spinal Cord and its Investments.
Curr Res Anesth Analg 1955; 34:313-333.
Asphyxia following Nitrous Oxide Anesthesia. Surv Anesthesiology 1958; 2:660704.
General Anesthesia and the Vulnerable Brain. J Michigan State Med Soc 1960;
5 9: 1 057 - 106 1.
Residual Changes in the Brain Incident to Anoxia under General Anesthesia:
Report of a Case with a Period of Six Years. Current Research Anes Analg 1960;
39:361-368.
The Development of the Concept of HypoxialAnoxia. Canad Anaesth Soc J
1960; 363-373.
BULlETIN OF ANESTHESIA HISTORY
II
The Race between
Education and Catastrophe
byFredJ Spielman) MD.
Prokssor ofAnesthesiology
University ofNorth Carolina) Chapel Hill
In The Outline ofHistory; H.G. Wells
wrote, "Human history becomes more and
more a race between education and catas
trophe." He might well have been writing
about anesthesiology and its inexorable
j ourney toward education and specializa
tion.
For more than 50 years after the intro
duction of ether, chloroform, and nitrous
oxide in the mid-nineteenth century, the
anesthetist was commonly an office assis
tant, nurse, or orderly. In the United King
dom, a surgeon often sought the assistance
of a butler to give a "whiff of anesthetic,"
believing that this "menial" j ob required
minimal knowledge and skill. The deliv
ery of anesthesia was deemed a task that
could be performed without a cerebral or
intellectual basis, without knowledge of
respiratory or circulatory physiology or
pharmacology. The systematic teaching of
anesthesiology by way of lectures or dem
onstrations did not exis t . John Snow
(18 13-185 8), a general practitioner who was
b e s t known for a n e s th etizing Queen
Victoria with chloroform, strongly dis
agreed with the notion that a person with
out appropriate education should provide
anesthesia. He wrote, "No person ought to
administer chloroform without first mak
ing its action a subject of special attention."
John Snow, like many others who followed,
was not trained; those early anesthetists
learned, they had a passion for education,
and they taught others what they knew.
At the end of the nineteenth century, the
practice of anesthesia in England became
more complex. The body of knowledge, new
innovations, and increases in the number
of practitioners required a focus on educa
tion. In 1 8 93, the London S oc iety o f
Anaesthetists w a s established with a man
date to advance education and training. A
vocal critic of the status quo was D r.
Frederic Hewitt, born in London in 1 8 57,
and educated at Cambridge. In 1901, he
was appointed physician to King Edward
VII. He was a prolific inventor of anesthetic
equipment, and wrote the bookAnaesthetics
and Theil' A dministration in 1 893. He
strongly preached that there must be ad
vancement of available anesthetics, and im
provement in the knowledge of anesthesia
providers. In 1 896, he wrote, "The ques-
tion may well be asked why do not deaths
from anaesthetics show signs of diminu
tion? The reply is that the administration
is often placed in the hands of compara
tively unskilled men. The first step should
be an educational one."
In 1912, two decades after the inaugu
ral meeting of the London S ociety of
Anaesthetists, the first meeting of anesthe
siologists on a national scale in the United
States occurred in conj unction with the
gathering of the American Medical Asso
ciation. A decade later, CUlTent Researches
in Anesthesia andAnalgesia became the first
published journal devoted to anesthesiol
ogy (in 1 9 5 7 , the name of the j ournal
changed to Anesthesia andAnalgesia). In the
late 1920s, the Anesthesia Travel Club was
organized for the purpose of exchanging
information and ideas about anesthesia.
Although the initial membership was only
15, it included American and Canadian
anesthesiologists who became great lead
ers of the twentieth century: Ralph Waters,
John L u ndy, Arthur G u e d e l , Emory
Rovenstine, and Paul Wood.
In the 1930s, the increasing reach and
breadth of surgical operations (e.g., cardiac
and thoracic surgery) and the introduction
of new anesthetic drugs and techniques
(e.g., cyclopropane and intubation) made
it clear that anesthesiology was to become
an area of medicine requiring the dedica
tion of a specialist, and necessitating resi
dency training and qualifying examina
tions. Nevertheless, few medical complexes
paid much attention to anesthesiology.
Nurse anesthetists and a few physicians
were the only instructors of medical stu
dents and surgical interns in the practice
of administering anesthesia.
Ralph Waters is credited with establish
ing the first resident training program in
anesthesiology. In 1927, Waters became the
director of anesthesiology at the new Hos
pital of the State ofWisconsin at Madison,
which opened in 1924. In 1933, he was ap
pointed professor of anesthesia. Waters was
one of the first champions of a prolonged
and organized educational process for the
learning of anesthesiology. Writing in the
Journal oftheAmerican Medical Association
in 1946, he stated, "The public as a whole
is not receiving the best services tha t anes-
thesiology is capable of supplying. Proper
education of undergraduate and graduate
students in our medical schools and hospi
tals is one method of improvement." In
1938, Virginia Apgar was appointed Direc
tor of the Division of Anesthesiology at
Columbia-Presbyterian Medical Center.
She organized an undergraduate training
program for medical students comprised of
didactic teaching and operating room ex
perience. In the first year of the program,
approximately 300 anesthetics were admin
istered by members of the senior class.
In 1936, Arthur Guedel authored Inha
lation Anesthesia, the first comprehensive
and clinically useful textbook. By 1937, 10
anesthesiology residency programs existed
in the United States. The duration of train
ing was one year or less, with the excep
tion of Bellevue (New York) and Wiscon
sin, which offered two and three years of
training, respectively. The first examina
tion of the American Board of Anesthesi
ology (ABA) took place in October, 1938,
two years after the commencement of a
similar test in England. In 1955, the ABA
organized the residency review committee
(RRC) . Development of the ABA RRC had
a strong impact on the continued improve
men t of residency training programs, even
though the ABA was one of the last exist
ing boards to form such a committee.
The expansion of residency training
programs in anesthesiology mandated con
siderable contemplation of the goals of
medical education. In 1966, Medical Edu
cation andAnesthesiawas published, edited
by Joseph M. W hite, M . D . The editor
stressed that to accomplish the goal of edu
cation, one must abide by a well-established
philosophy. He stated, "It is axiomatic that
education and medical care are inextrica
bly interdependent." Although Dr. White's
tenets of education were written almost 40
years ago, they remain valid and wise. He
stated that the residency must be designed
to develop a physician who is adept tech
nically, and who has an interest and knowl
edge in surgical anesthesia as well as in as
sociated fields such a s pulmonary medi
cine. The "complete" anesthetist is not ex
pected to restrict his or her functions to the
operating and recovery rooms. Teaching
Continued on Page 13
...
12
The Book Corner
byPeterMcDelmott; MD.
The Consonan t with our viewofthe universe ofanesthesiologists as an expanding one, we offeranother bookreviewwhich visits the early years ofthe
"scientificrevolution. " Some recentscholarshave gone so f8r as to deny that a "revolution" tookplace at all Nudging theparadigmatic Copernican
shift back to the fourteen th cen turyand the specula tive m usings ofJohn BUlidan andNicole Oresme, the concept-thepossibility-of the earth in
motion was openly discussedand didn'tresultin heresy trials and ceremonialimmolations.
The bookreviewed beIowis a fine study ofthe waysin which A listotle andEuclid confivnted (metaphorically) thenewmath andmathematics ofthe
seventeenth centUlY
Warning: the comm unityofscholars workingin thehistOIY ofscience don't talklike we do. They seem to undeJ'Stand one anotheI; but thereis cognitive
dissonance ahead
Discipline and Experience:
The Mathematical Way in the Scientific Revolution
Peter Dear (Chicago: University of Chicago Press, 1995)
Well, the " revolution" is back and the
cast of players has been considerably aug
mented-a squadron of Jesuits, an obscure
French mathematician, an Italian "demon
strative regressor"-and hovering over this
consideration of "socially embedded genres
of argument" and the "inferential moves . . .
taken for granted or contested within par
ticular knowl-edge-producing communi
ties" are Aristotle on one end and Steven
S h a p i n on the o ther. Using a sort of
Rosencrantz a n d Guildersternian ap
proach-a supporting cast brought front
stage-Dear reconstructs the ways in which
universal truth-claims were produced and
received. A field reversal in natural philoso
phy was first required: Aristotle's empha
sis on causation was replaced by combin
ing the mathematical sciences-which were
not dependent upon process and teleology
as were Aristotle's-with Zabarella's reso
lution of Aristotle's two forms of demon
strative induction. His use of regressus
theory turned attention from an emphasis
on causes to an emphasis upon effects as
the point of departure in natural philoso
phy. This mixed mathematics resided
somewhere between metaphysics and natu
ral science. Dear's contention in establish
ing this rather recondite point is that the
community of knowledge producers were
p r e p a r e d to a c c e p t a n d understand
Newton's fusion of mathematics and phys
ics as a scientific experience within their
disciplinary boundaries. Practices and tra
ditions of experiment and reporting were
becoming authoritative additions to the
requirements of Aristotelian intellectual
methodologies.
Now for the middle of the book. Dear
sees Christopher Clavius as the prime
mover in bringing mathematics into the
university curriculum in the late 16th cen
tury and a group ofJesuit mathematicians
(B l a n c a nu s ,
S em p i l i u s ,
S ch e i n e r,
Aguilonius, household names) as very sig-
nificant in raising mathematical disciplines
in the a c a demic community, deriving
norms and constructing experiences into
properly accredited knowledge. These cre
ators of new math never let go of Aristotle's
Posterior Analytics, but they reformulated
the criteria by which experience-based dis
coveries of an empirical nature could be
articulated, authorized, and authenticated.
Alli tera tively, that is.
Arriaga, Riccioli and C abeo took on
some of the claims and explanations of
Galileo regarding falling bodies and the
value of repeated experiments, multiple
eye-witnesses, measurements, and repeat
ability in establishing a "quality of exper
tise." Scientific experience was placed in a
temporal (historical) context in a attempt
to compare and contrast the past and the
present-an attempt to control innovation
in the knowledge continuum.
Phenomena and observances were made
distinct by members of an informal com
munity of truth seekers who needed to
agree upon a vocabulary and the place of
mathematics in the description of experi
ences. " Galileo," Dear observes, "was not
merely making new claims about the world,
he was creating, by means of the technical
wherewithal, the very observational com
munity he needed to validate those claims."
There is a lot in this book: marvelous
equivocations ("It must be stressed that [for
the time being] the purpose of this consid
eration is only to set up an analogy to the
situations hitherto discussed; it is not to
suggest that religious practices structured,
conditioned, or reflected those found in the
making of new knowledge. Such might still
be the case, of course."); wonderful obscu
rities ("The numbers given are not evidence
for a general claim; they are simply illus
trations of it."); occasional inscrutable pro
fundities ("The science develops from its
roots; they do not grow with it."); and ex
a m p l e s of p e p p e ry, turgid p o s t-
structuralisms ("Those groups . . . pros
ecuted the literary endeavors . . . " which I
think means "wrote").
But quibbles aside, and linguistic pecu
liarities aside, and disorganization aside,
this is a pretty good book. It deals with
Descartes, Hume and Pascal; the Boylean
"detour" away from true experimentalism;
the art/nature/metaphor; the event, the
narrator and the truth paradigm; the sci
entific culture of the so-called "revolution."
Dear doesn't tie all this up into a coherent
whole and that's too bad and probably in
evitable. But there are valuable nuggets of
research into the sub-culture of t h a t
never-never land o f papists who were actu
ally scientists and continental types, and
some velY useful insights and illuminations
of the scientific intellectual terrain of this
very important century.
The following book reviewis replin ted here
with the kindpelwission ofthe author and of
the New England Journal ofMedicine, in
which it first appeared (NEJM340(22): 1777,
June 3, 1999. CopYligh t @ 1999 A1assach u
settsMedical Society. Allrights resenTed)
Black Lung: Anatomy of a
Public Health Disaster
Alan Derickson
(237 pp., illustrated. Ithaca, NY, Cornell
University Press, 1 9 9 8 . $ 2 2 . 9 5 . I S B N
0-8 0 14-3 1 86-7
Reviewed by GregoryR. fragnel; MD.
Nationallnstitute forOccupational
Safetyand Health) Morgan town) WV
In the classic story that exemplifies the
public health approach to disease preven
tion, John Snow removed the handle of the
Broad Street pump in London to halt a
cholera epidemic. Snow knew neither the
agent of the disease nor its mechanism, but
he acted after making reasoned conclusions
drawn from systematic observations of the
distribution of the disease. In his carefully
researched and exhaustively referenced
book, Black L ung: Anatomy of a Public
Health Disastelj historian Alan Derickson
asks why the "pump handle" was not re
moved-why dust was not controlled
when so much was known for so long about
the harmful effects of excessive dust expo
sure among coal miners.
Black L ung is a cautionary tale, warn
ing of the consequences of allowing eco
nomic and political considerations to con
trol public health decisions. Engaging,
well-organized, and fast-paced, the book
guides the reader through a century of
change in the mining, scientific, and
regulatory communities.
Beginning in the mid-19th century, first
in the United Kingdom and then in the
United States, lung diseases, commonly
c a l l e d "min e r ' s a s thma" or " m i n e r ' s
consumption" and medically labeled "an
thracosis," were observed in coal miners.
Sick miners had progressive dyspnea, chest
discomfort, and cough, sometimes dramati
cally accompanied by the expectoration of
copious quantities of black, inky sputum.
Medical textbooks, including Osler's clas
sic Principles and Practice ofA;fedicine(New
York: D . Appleton), first published in 1892,
described a lung disease observed in min
ers and caused by exposure to dust.
But early in the 20th century, according
to Derickson, conventional scientific wis
dom seemed to have undergone a critical
transformation. The observation in the
United Kingdom that rates of tuberculosis
were lower among miners than among la
borers in urban areas led to the assertion
in the United S tates that inhalation of
coal-mine dust had a beneficial effect and
that dust-induced pulmonalY fibrosis hard
ened the lungs against infection. Derick
son argues that as concern about the dev
astating effects of silica dust became wide
spread, a " reductionist" approach equated
all dust-related hazards with silica, thereby
deflecting attention from the independent
risk posed by coal-mine dust. From this
arose the belief tha t in the absence of silica,
coal-mine dust is benign-discoloring the
lungs but not causing impairment.
The belief that exposure to coal-mine
dust had only benign effects could have
been challenged by scientific inquiry. In
fact, Derickson cites reports produced for
the U . S . Department of Labor and the re
sults of field investigations conducted by
the U . S . Public Health Service indicating
that miners had high death rates; dimin
ished longevity and reduced pulmonary
function as compared with other manual
laborers; and a high rate of absence from
work due to lung conditions. These reports,
however, were not widely distributed, be
cause access to workplaces was granted to
government agencies in return for agree
ments to restrict communication of the re
sults of investigations. For this reason, sci
entific evidence of the hazards of coal-dust
exposure did not prompt requirements for
improved ventilation or other preventive
actions. Derickson also explores how ef
forts to minimize compensation to miners
with lung disease may have affected the
willingness of official bodies to recognize
the connection between work and disease.
Unfortunately, Derickson fails to de
scribe accurately the current concept of
diversity in the lung diseases of coal min
ers. Exposure to coal-mine dust causes not
only coal workers' pneumoconiosis but also
chronic bronchitis and emphysema and,
depending on the quartz content of the in
haled dust, silicosis. A clearer presentation
of this complex of diseases would have pro
vided readers with context for understand
ing the evolution of the varied beliefs and
approaches to lung diseases among coal
miners.
Compensating for this weakness is an
important strength of the book: D erickson's
description of the social and economic con
sequences of 1ung disease in the coal fields.
Young boys began work as slate pickers,
cleaning and sorting coal for entry-level
wages in densely dusty environments. As
the children grew older and stronger, they
moved progressively up the job and pay
ladders, helping to transport, load, and ul
timately mine coal. When inj ury or disease
incapacitated miners, these men, having no
social safety net and minimal employment
alternatives, climbed back down the job
ladder, sometimes ending their careers in
the breakers, cleaning coal as they did in
their youth, still for entry-level wages, only
this time in failing health.
The ultimate lesson of Derickson's book
is one worth heeding: to prevent public
health disasters, prudent action may be
necessary, even in the face of scientific un
certainty.
13
Catastrophe. . .
Contin uedfi'Ofll Page 11
should not be channeled to provide answers
to questions on ABA examinations. Resi
dents should find time to conduct "special
projects" and to read. Teaching should
avoid the "spoon-feeding" of information.
In 1971, anaesthetist C.F. Scurr wrote, in
the Annals ofthe Royal College ofSurgeons of
England, "The aim of training is not only
to produce an expert anaesthetic specialist
but an educated man who will be able to
cope in due course with presently unfore
seen innovations, and who will therefore
keep up continuing study throughout his
professional life. "
Anesthesiologists have always felt that
it is their duty and privilege to teach other
healthcare providers. Students vary greatly
in their learning styles and areas of inter
est, and in their access to educational ma
terials. However, formal lectures and dis
cussions, in addition to informal transmis
sion of oral history, have been the most sig
nificant methods of teaching anesthesiol
ogy. Lecturers who show humor, enthusi
asm, and speaking ability satisfy their stu
dents more and stimulate higher scores on
tests.
Over 50 years ago, Dr. Ralph Waters pro
nounced his view on the importance of
medical education. "We must disabuse our
selves of a generally held belief that the im
portance of anesthesiology lies in the
'choice of agents' or in the particular 'tech
nic' employed. All drugs and the methods
by which they are administered are subject
to abuse. Through fundamental knowledge
and diagnostic skill the abuses are avoided
or neutralized." The wisdom of Dr. Waters
remains paramount.
Suggested Reading
Waters RM. Anesthesiology in the hos
pital and in the medical school. JAMA
1946; 130:909-912.
White JM. Medical Educa tion andAnes
thesia. F.A. Davis Company, Philadelphia,
1 966.
Scurr CF. Evolution and revolution in
anaesthesia training. Ann Roy ColI Surg
Eng1 l 971; 48:274-292.
Henderson RS . Continuing education
committee of anaesthetists of New Zealand
(CECANZ)-The first five years. Anaesth
Intens Care 1992; 20:211-214.
Willenkin RL. Lectures in anesthesia
training. Anesth Analg I992; 74: 1 -2 .
'"
14
BULLETIN O F ANESTHESIA HISTORY
From the Literature
byA.j lr1ight, AiL.S.
Department ofAnesthesiologyLibrar;; UniversityofAlabama at Bliwingham
Books
Bergman NA. The GenesisofSurgicalAnes
thesia. Park Ridge, Illinois: Wood Library
Museum of Anesthesiology, 1 998 [rev. Bacon
DR, BullHistMed73:319-320, 1999; Pernick
MS, NEjJl1 341 :458-459, 1 999]
Caton D. Whata BlessingShe Had Chloro
f01m: The Medical and SocialResponse to the
Pain ofChlldbirth fivm 1800 to thePresent New
Haven, Connecticut: Yale University Press,
1 999 . [rev. Bibel BM, LibJ'EllYJouma11 5 May
1 999, p 1 1 7]
FairmanJ, Lynaugh JE. Ciitical CareNurs
ing: A History. Philadelphia: University of
Pennsylvania Press, 1 998 [rev. Romaine
Davis A. Bull HistMed73:350-3 5 1 , 1 999]
Morris DB. Illness and Culture in the
Postmodem Age. Berkeley: University of Cali
fornia Press, 1 998 [rev. Rothstein WG,]AMA
281 :2050, 1999; includes material on chronic
pain]
Spillane JF. Cocaine: From MedicalMar
veltoil1odernil1enacein the UnitedStates; l8841920. Baltimore: Johns Hopkins University
Press, December 1 999
Starr D. Blood' An Epic Histoq ofMedi
cine and Commerce. New York: Knopf, 1998
[rev. Rosen FS, Nature 398:303-304, 1 999;
Pierce EH Jr., JAMA 282:797-798, 1 999]
Articles and Book Chapters
Adams AK. From faculty to royal college:
the golden j ubilee of the Faculty of
Anaesthetists of the Royal College of Sur
geons ofEngland. Ann R Coll SurgEng 80(6,
supp1) :273-275, November 1 998 [5 illus.]
Aldrete JA. Valentino D.E. Mazzia (19221 999) . Anesthesiology News 25(6):6, 8, June
1 999 [obituary]
Ball C, Westhorpe R. The water depres
sion flowmeter. Anaesth Intens Care27(3):237,
June 1 999 [cover note]
Ball C, Westhorpe R. Maximillian Neu
and the first anaesthetic rotameter. Anaesth
Intens Care 27(4) :333, August 1 999 [cover
note] [1 illus., 6 refs.]
Benad G, Rose W The histOlY of the de
velopment of intensive care medicine in Ger
many. Contemporary reflections. 4. Struc
tural development of operative intensive care
medicine in the former German Democratic
Republic. Anaesthesist 48(4):25 1 -262, April
1 999 [35 refs., German]
Bernstein AM, Koo HP, Bloom DA. Be
yond the Trendelenburg position: Friedrich
Trendelenburg's life and surgical contribu
tions. SUlgely126(1):78-82, July 1 999 [3 illus.
including portrait, 14 refs.]
Caton D. The history of obstetric anes
thesia. In: Chestnut DH, ed., ObstetricAnes
thesia. 2nd ed. St. Louis: Mosby, 1 999, pp 31 3 [9 illus., 52 refs.]
Daves P. Crawford W Long, M.D. JMed
Assoc Ga 88(2):34-35, April 1 999 [portrait, 4
refs.]
Engel BT. An historical and critical review
of the articles on blood pressure published
in Psychosomaticil1edicinebetween 1939 and
1 997. Psychosom Med60:682-696, 1998 [208
refs., 1 illus., 2 tables, append.]
Feeley TW Emery A. Rovenstine Memo
rial Lecture: Carl C. Hug, Jr., M.D ., will
present "Patientvalues, Hippocrates, Science
and Technology." ASA Newsletter 63(7):7,9,
July 1 999
Feeley TW, ed. Back in time: selected ar
ticles from 1 962 to 1970. IntemationalAnes
thesiology Clinics; 36(4), Winter 1 998. [rev.
Spence AA, BrJAnaesth 82:957, 1 999]
Feeley TW, ed. A History of critical care
and hyperbaric oxygen therapy as docu
mentedin theInternationalAnesthesiologyClin
ics. Int Anesthesio1 CliI1 37(1):1-1 74, Winter
1 999 [rev. Norman J, BrJAnaesth 8 3 (2):366367, August 1 999]
Franco A, Cortes J, Aneiros F, Naveira A,
Rabanal S, Alvarez I. Obstetric anesthesia/
analgesia in Spain. Study notes on its histori
cal evolution during the 1 st half of this cen
tury. RevEspAnestesio1Reanim46(1):19-36,
January 1 999 [Spanish]
Galve BJ, Gotzens VJ. Spinal anesthesia
and ana tomical knowledge. RevEspAnestesiol
Reanim 46(3):97-98, March 1 999 [editorial;
Spanish]
Gatt S . George Madgwick Davidson.
Anaesth Intens Care2 7 (3) : 3 1 2-3 l 3, June 1999
[obituary; portrait]
Historical abstract: The Hyderabad Chlo
roform C ommission. Paediatr Anaesth
9(4) :365-366, 1 999
Holzman RS. The legacy of Atropos, the
fate who cut the thread oflife. Anesthesiology
89:241 -249, 1 999 [63 refs., 4 illus.] [covers
anticholinergic agents as anodynes in the
ancient world] [see Lai DC and Takrouri
MSM letters cited below] [Holzman re
sponds: Anesthesiology90(6):l795-1796, June
1 999]
James FAJL. The bicentenary of the Royal
Institution of Great Britain. Chemical Heri
tage 1 7 (2):45, Summer 1 999 [illus.: Gillray's
caricature of H. Davy's nitrous oxide dem
onstration]
Jay V. On a historical note: Dr. Virginia
Apgar. I 2 (3): 292-294, 1 999
Kopp VI. HeillY Knowles Beecher and the
development of informed consent in anesthe
sia research.Anesthesiology90 :1756-1765, 1999
[23 refs., 1 table] [see editorial by Truog RD
et a/. cited below]
Lai DC. More on the legacy of Atropos,
with special reference to Datura stramonium.
Anesthesiology90 (6): 1794-1795, June 1 999 [22
refs.] [see Holzman RS, cited above] [letter]
Lawin P, Opderbecke HW History of the
development ofintensive care medicine. Con
temporary considerations-part 3: structural
development of internal intensive care medi
cine. Anaesthesist48 (2):97-107, February 1 999
[German]
Lemburg P. History of the development
of intensive care medicine. Contemporary
considerations-part 5. Structural develop
ment of pediatric intensive care medicine.
Anaesthesist48(5):325-336, May 1 999 [Ger
man]
Mackey DC. The history of spinal drug
delivery: the evolution of lumbar puncture
and spinal narcosis. In: Yaksh TL, ed. Spinal
Drug Delivery New York: Elsevier, 1 999, pp
1 -41 [32 illus., numerous references]
May C, Doyle H, Chew-Graham C. Medi
cal knowledge and the intractable patient: the
case of chronic low back pain. Soc Sci il1ed
48(4):523-534, February 1 999
McGoldrick KE. Lewis H. Wright Memo
rial Lecture: Sherwin B. Nuland, M.D., re
cipient of the National Book Award, to
present "Surgery as It Was on that Day in
1 846: Before and After." A SA Newsletter
63(7):8-9, July 1999
McNally RJ. EMDR and mesmerism: a
comparative historical analysis. J Anxiety
Disord 1 3(1-2):225-236, January-April 1 999
[numerous references; EMDR is "eye move
ment desensitization and reprocessing"]
Menendez Jv, Burns T, Bacon DR. Lin
coln Fleetwood Sie: regional anesthesia's for
gotten man? RegAnesth Pain Med24(4):364368, 1 999 [2 illus., 25 refs.]
Morris LE. Earliest encounters with a
friendly stranger, and the current resurgence
of interest [in xenon] . Appl Cardiopu1mon
Pathophysio17 (3): 149-1 5 1, 1998 [editorial; 1 3
refs.]
Nelson CW Dr. John S. Lundy and the
75th anniversary of anesthesiology at Mayo.
jl1ayo Clin Proc74(7):650, July 1999
Owens WD. Harry H. Bird, M.D., receives
1 998 Distinguished Service Award. A SA
15
The Impact of Linus Pauling on
Modern Medicine and Society
byBenjamin Barankin) B.A.
kledical Student; Universityof�f7esteJ'11Ontario) London) OntaJio) Canada
This article is reprinted with pelwission !i'om the Annals ofthe Royal College ofPhysicians and Surgeons ofCanada) 32(4): 232-234; June) 1999.
Abstract
Linus Pauling (1901- 1 994) is one of the
most distinguished scientists of modern
times. During a career spanning over 60 years,
he was awarded two unshared Nobel Prizes
(chemistry, 1 954; peace, 1962). He published
more than 600 scientific articles and books.
This article reviews the literature pertain
ing to Pauling's discoveries and their impact
on science, medicine, and society. He was the
first to describe the alpha-helix structure of
protein molecules. The lineage of the
double-helix model for deoxyribonucleic acid
(DNA) can be traced back to his concept of
complementarity and the alpha helix. Pauling
also rela ted the mechanism of sickle-cell ane
mia to a genetic defect in hemoglobin syn
thesis, and thus defined the first molecular
disease. Furthermore, Pauling espoused the
virtues ofvitamin C, which brought him both
fame and criticism.
During the Second World War, Pauling
was involved in over 1 8 military projects for
which he received the Presidential Medal for
outstanding contribution to the war effort.
Later, he made many speeches for world peace,
for prohibition of nuclear warfare and nuclear
weapons, and for a nuclear test ban treaty.
This review is a tribute to a humanitarian
and scientist who performed groundbreaking
chemistry research, struggled against disease,
and crusaded for world peace.
Linus Pauling is the only person to have
won two unshared Nobel Prizes. Although he
won his Nobel Prizes in chemistry and peace,
much of his work also had an impact on medi
cine. During a career spanning over 60 years,
he published more than 600 scientific articles
and books in fields ranging from theoretical
physics to medicine. Pauling contributed to
the foundation of modern chemistry through
his pioneering work on chemical bonds and
molecular structure . His concept o f
complementarity, which helped Watson and
Crick elucidate the structure of deoxyribo
nucleic acid ( DNA), and his description of
the alpha-helix structure of protein molecules
have been monumental contributions to sci
ence. Our understanding of hemoglobin
chemistry, sickle-cell anemia, and molecular
diseases has its roots in Pauling's work. He
also invested time and energy into working
for world peace. While colleagues carried on
their work in the sciences, Pauling put enor
mous effort into peace rallies, speeches, and
campaigns to educate the world on nuclear
weapons and their consequences. Unfortu
nately, many of his contributions have been
overshadowed by his ardent promotion of
vitamin C. Although we are learning to ap
preciate the benefits of vitamin C, a tarnished
image of Pauling arose in the scientific com
munity as a result of this work. The idea that
supplemental vitamins can help prevent
health problems and the multi-billion dollar
industry that surrounds this stem directly
from Pauling's vitamin C crusade.
Pauling was born in Portland, Oregon, in
1 90 1 . His intellectual abilities were nurtured
by his father until he died suddenly when
Linus was nine years old. Science became
Pauling's refuge from the emotional chaos
that surrounded his childhood. While his
mother wanted him to get a job to support
the family, he worked instead at menial jobs
to pay for a college education. In 1 9 1 7, he
entered Oregon Agricultural College (now
Oregon State University) where he studied,
and was soon teaching, chemistry. He went
on to graduate studies at ,the California In
stitute of Technology where he stayed until
he resigned in 1964. In 1 994, he died of can
cer at his ranch in California.1•2
Pauling's scientific achievements began
with a landmark paper in 1 928 in which he
formulated a set of five rules to simplify the
task of elucidating crystal structures. In 1931,
he published a paper titled "The Nature of
the Chemical Bond." Using the principles of ,
quantum mechanics, Pauling formulated six
rules for the electron-pair bond. This led to
his work on resonance in molecular structures
such as benzene.3
Pauling's earlier work focused on molecu
lar structure and the nature of the chemical
bond. By the mid-1 930s, he began to probe
the applicability of his work to molecules of
biological importance. His work with R.B.
Covey during the 1 940s on X-ray diffraction
of amino acids and small peptides led to the
description of the alpha-helix structure of
protein molecules. His theoretical papers in
1940 did not successfully explain antibody
formation, but they embodied the crucial
concept of molecular complementarity. The
lineage of the double-helix model for DNA
can be traced back to Pauling's concept of
complementarity and the alpha-helix.3 In the
late 1940s, he studied sickle-cell anemia with
Itano, Singer, and Wells; through this work was
born the modern concept of molecular disease.
Pauling also made use of hemoglobin structure
in his important studies with Zuckerkandl on
the process of molecular evolution.
Pauling's largest contribution to medicine
was probably his work on molecular interac
tions and diseases. He studied the nature of
molecular interactions in greater depth than
anyone previously had.4 His book The Nature
ofthe Chemical Bonddisplays Pauling's ap
proach to structural chemistry. In describing
his methods, Pauling gave direction to the
then young Watson and Crick in their quest
for the structure of DNA.4
After a dinner where physicians com
plained about their frustrations in dealing
with sickle-cell patients, Pauling began ex
perimentation with Itano and Singer from
1945 to 1 948 on this "molecular disease."
Pauling orchestrated the research, which led
to the publica tion of "Sickle-Cell Anemia, a
Molecular Disease," a paper showing that a
change in the electrical charge of a molecule
meant the difference between a healthy per
son and one with a deadly disease.s During
their research, Pauling and Itano also devel
oped a rapid diagnostic test for sickle-cell
disease. People had theorized about the mo
lecular basis of disease before, but no one had
ever shown it in the way that Pauling's group
did.
By pinpointing the source of a disease in
the alteration of a specific molecule and link
ing it to genetics, Pauling's group created a
landmark in both medicine and molecular
biology.s It turned the interest of a genera
tion of physician-researchers toward disease
at the molecular level; it substantiated his
idea that medical research needed to be
grounded in the methods of modem chemis
try; it opened up new vistas in the study of
inherited medical disorders; and it resulted
in years of productive research into abnor
mal hemoglobins.s
By the late 1 960s, Pauling was moving into
his next research arena: human nutrition in
general, and vitamin C in particulal� Pauling
believed that "having the right molecules in
the right amounts in the right place in the
Can tin ued on NextPage
-
16
BUllETIN OF ANESTHESIA HISTORY
Pauling. .
.
Continuedfrom Page 15
human body at the right time is a necessaty
condition for good health."! From 1970 until
his death, Pauling preached the gospel of vi
tamin C. His enthusiasm came not only from
reports that he read but also from his direct
experience of its benefits. Pauling wrote jiJ'
tamin C and the Common Cold, which became
a surprise bestseller; it was simple and read
able, and it dealt with an annoying but com
mon problem. As a result, he was in demand
for speaking engagements and interviews,
and vitamin C supplies were running out in
drugstores. He quickly became vitamin C's
champion worldwide with book translations into
eight languages. His zealous support for vita
min C made many colleagues and physicians
believe that he was becoming senile.! Pauling
was interested in continuing his orthomolecu
lar research, but Stanford University was un
willing to give up more laboratory space. As a
result, Pauling and a few colleagues created what
became the Linus Pauling Institute of Science
and Medicine. Pauling is probably better re
membered by the public for his vitamin C cru
sade than for anything else.!
C ameron and Pauling's 1979 book Can
cerand Vitamin Cshowed ascorbic acid's use
fulness in cancer therapy. Pauling stated that
"in the not too distant future, supplemental
ascorbate will have an established place in
all cancer treatment regimes."3 According to
the National Cancer Institute of Canada,
"There is epidemiological evidence that
populations who consume diets high in vita
min C have a lowered risk for some cancers"
and "The strongest epidemiological finding
has been the association between high intakes
of foods rich in vitamin C and a reduced risk
of stomach cancer."6 While this institute does
not officially recommend vitamin C for can
cer therapy, it recognizes that there is an as
sociation. These comments should give some
credence to Pauling's beliefs. Research trials
underway by the National Institutes of Health
and other medical bodies using randomized
controlled trials should help determine a con
sensus regarding vitamin C for cancer adjunct
therapy or prevention. It was Pauling who
first gave popular notice about the use of vi
tamins for disease prevention or treatment.
Thus, while many health practitioners and
the public are discovering the benefits of vi
tamin E for heart disease, the attention given
to this matter can be traced back to Pauling's
efforts in questioning the medical establish
ment. Vitamin C's usefulness will probably
be debated for years to come. Perhaps in the
end, Pauling will get his j ust recognition.
Pauling's scientific abilities were put to
good use during the Second World War. He
invented the Pauling oxygen analyzer to
monitor oxygen levels inside submarines, and
an improved stabilizer for rocket powders. He
also co-developed an armor-piercing shell.!
For these and other contributions to the war
effort, Pauling received the Presidential
Medal for Merit. Pauling was asked by J.
Robert Oppenheimer to help with the race
against the Germans to build a fission bomb.
He declined, not because he thought it wa�
wrong to work on developing nuclear weap
ons, but because he had other jobs to do.
While Pauling did not directly help develop
"weapons of mass destruction" like Einstein,
they both eventually spoke for peace. For
someone who gave so much to both the sci
entific and military fields, later accusations
ofbeing "un-American" by Senator McCarthy
in the 1 950s were hurtful and unjustified.
Later, while sailing to Europe, Pauling
made a pledge on a piece of cardboard: "I
swear that I will make some mention ofworld
peace in evety speech I make."3 From 1 945
to 1 957, Pauling made many speeches for
world peace, for prohibition of nuclear war
fare and nuclear weapons, and for a nuclear
test ban treaty; he also spoke at peace rallies
all over the U.S.3 He was a founding member
of the Emergency Committee ofAtomic Sci
entists, which included Einstein as a mem
ber. Pauling presented a written appeal to the
United Nations with the signatures of thou
sands of scientists and 40 Nobel laureates
urging a stop to the spread of nuclear weap
ons.3 For his contributions, Pauling was
awarded the Nobel Peace Prize in 1 962.
The key to Pauling's success was his un
fettered curiosity and skepticism. He showed
this when he was asked to give a speech upon
receiving his first Nobel Prize. He told the
youthful masses, "when an old and distin
guished person speaks to you, listen to him
carefully and with respect-but do not be
lieve him. Never put your trust in anything
but your own intellect. Your elder, no matter
whether he has gray hair or has lost his hair,
no matter whether he is a Nobel Laureate,
may be wrong. . . So you must always be skep
tical-always think for yourself:"! Pauling
remained brilliant, undisciplined, and re
bellious to the end.
Few people have had such a profound
effect in so many fields as did Pauling. Even
though his contributions are often forgot
ten in the classroom and by the media,
Pauling was a world-renowned scientist
whose research and peace efforts have had
a major impact on the way we understand
nuclear warfare, chemistry, vitamins, and
molecular diseases.
Acknowledgments
The author thanks Dr. Paul Potter and Kimberly
Liu for reviewing the manuscript.
References
1. Hager T Force of Nature: the Life ofLinus
Pauling. New York Simon & Schuster, 1995.
2. Bernstein J.A TheOlyforEvelything. New York:
Copernicus, 1996.
3. Goertzel T, Goertzel B. UnusPauling: a Life in
Science andPolitics. New York: BasicBooks, 1995.
4. Marinacci B. LinusPauling in His Own lfiJids.
New York: Simon & Schuster, 1995.
5. Serafini A. LinusPauling: a Man and His Sci
ence. New York: Paragon, 1989.
6. Canadian Breast Cancer Research Initiative.
Vitamin A, C, and E supplements: an information
package. Toronto: CBCRI, 1996.
Literature.
. . Continued
Newsletter63 (8): 19, August 1999 [portrait]
Podoll K, Robinson D. Lewis Carroll's
migraine experiences. Lancet353: 1 366, April
1 7, 1999 [5 refs, 1 illus.]
Poll JS. The story of the gauge. Anaesthe
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Poppers PJ. Anesthesiology: past, present
and future. A personal perspective. NYSSA
Sphere5 1 (2) :58-68, April-June 1999 [portrait
of author]
Rose W Forty years of anesthesiology in
German. Anaesthesiol Reanim 24(1): 1 9-26,
1999 [German]
Rutkow 1M. Crawford Williamson Long.
Arch SUlg1 34(5):578, May 1999 [Illus.: 1 940
U.S. postage stamp]
Rutkow 1M. Anesthesia during the Civil
War. Arch SUlg 134(6):680, June 1 999 [illus.:
"rare extant example of bottled chloroform"]
Schmidt PJ. 50 classic illustrations of the
beginnings ofbloodletting and transfusion. Ther
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Spence AA, Smith G. Postoperative analge
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17
Yellow Fever and the Panama Canal
The following article is being repl1n tedfrom a journal calledOld News, which ispublished mne times a year by the Susquehanna TIm es and
A1agaZlne, Inc. , at 400 Stackstown Road, Malietta, PA 17547-9300. We are Indebted to Old News, and to the EditorRick Bromery for their
pelwission tOI'epl1nt thispaperin theBulletin.
The role ofDJ: Callos Rnla); a Cuban physician who was educa teda tJefferson Medical School, isperhaps somewha t underplayed by the text, but
there is no doubting the efforts ofDI: Gorgas, which reallyresultedin the Panama Canal being built.
Yellow Fever Hits Panama Canal Zone
by PatJicia Lynn Knee
William C. Gorgas studied medicine at
Bellevue Hospital Medical College in New
York City during the late 1 870s. According
to his classmates, Gorgas was a devout Chris
tian, a bad speller, and the most likable man
in his class. Mustachioed and handsome,
William was modest, charming, and ex
tremely serious about his work.
Gorgas received his medical degree in
1 879. He then joined the United States Army
as a surgeon.
Dr. Gorgas' first encounter with yellow
fever came in 1 882 when he was 28 years old.
He was stationed at Fort Brown, Texas, on
the Rio Grande River, when an epidemic of
yellow fever struck the fort and the nearby
town of Brownsville. Dr. Gorgas was appalled
by the suffering and death that the infection
caused.
Yellow fever, an epidemic disease of the
tropics, sometimes invaded the United States
during hot summers. The cause of the dis
ease was thought to be filth-rotting carcasses
of animals, rubbish, human and animal
waste. Foul odors and night winds, called
"yellow fever winds," were suspect. But the
greatest source of contamination was thought
to come from the yellow fever victim, his
clothing, his bedding, and his dead body.
Burials of victims of the disease were careful
and swift.
When Dr. Gorgas first reported to work
at the fort's fever ward, one of his patients
was his commanding officer's sister-in-law,
Marie Doughty. She had contracted yellow
fevel; and was not expected to live. Her grave
had already been dug.
His commander de
spairingly asked Dr.
Gorga s to c a re for
Marie to the end, and
to arrange for her fu
neral.
Gorgas agreed and
nursed the dying
young woman. While
attending to her, he
contracted the disease
himself.
The symptoms of
yellow fever are com
mon to all victims.
During the first stage
of infection, vomiting,
fever and headache oc
cur. The second stage
includes massive hem
orrhaging from the
mucous membranes.
Degeneration of the
liver follows, causing
jaundice or a yellowing
of the skin-thus the
term yellow fever.
Death usually occurs
between the fourth and
eighth days of the in
fection.
W'brkel:s' from Caribbean nations anive in Panama to build the canal.
1l7illiam C. Gorgas
Victims who manage to survive, however,
become immune to yellow fever for life .
Remarkably, both Dr. Gorgas and Marie
Doughty recovered from yellow fever. They
fell in love, and they were married on Sep
tember I S, 1885.
Thirteen years later, in 1 898, yellow fever
attacked United States troops occupying
Cuba during and after the Spanish-American
War. Dr. Gorgas was 44 years old and held
the rank of major in the United States Army.
Immune to yellow fever, he was posted to
Havana, Cuba, as chief sanitary officer.
Havana was a dirty, crowded city. Dr.
Gorgas subscribed to the common belief that
yellow fever was caused by filth, and that the
best way to eradicate the disease was to elimi
nate the filth. As chief sanitary officer, he
initiated a clean-up project of massive pro
portions, but his efforts failed to slow the
spread of yellow fever.
In Havana, Dr. Gorgas met a Cuban phy
sician, Dr. Carlos Finlay, who suggested that
yellow fever might be spread by mosquitoes.
Dr. Gorgas was at first skeptical of the idea
that mosquitoes could transmit human dis
eases, but he changed his mind when a Brit
ish physician, Sir Ronald Ross, demonstrated
Con tin ued on NextPage
"'""
I8
Yellow Fever.
. .
Continuedfiom Rlge 17
that mosquitoes were responsible for spread
ing malaria in India.
In 1900 a research team, headed by Dr.
Walter Reed of the United States Army, dis
covered that mosquitoes were responsible for
spreading yellow fever in Cuba. Reed dem
onstrated that the tiny insects could become
infected with the disease when they bit hu
man victims ofyellow fever. The mosquitoes
then transmitted the disease by biting other
people.
Many physicians continued to insist that
yellow fever was spread by filth, but Dr.
Gorgas was persuaded by Reed's scientific
evidence that mosquitoes were the actual
culprits. To combat yellow fever in Cuba, Dr.
Gorgas decided that he must destroy the of
fending insects.
He ordered screens to cover infected pa
tients. He ordered the liberal use of insecti
cide around Havana. Because mosquitoes lay
their eggs in pools of standing watel� he sent
teams of soldiers throughout the city to drain
ponds, cover cisterns, seal water j ars, clear
gutters, and eliminate every possible breed
ing ground for the mosquitoes that cause yel
low fever.
In October, 1900, there were 1,400 known
cases of yellow fever in Havana. In 1901, there
were 37. By the end of the next year, there
were none. For the first time in 150 years,
Havana was free of yellow fever.
In 1904, Dr. Gorgas was reassigned to
Panama, a county menaced by both yellow
fever and malaria. The United States govern
ment was planning to build a canal across
Panama to link the Atlantic and Pacific
oceans. Dr. Gorgas's mission was to combat
the tropical diseases which had helped to
defeat a French attempt to build a canal in
Eycavating the Panama Canal in 1909.
Panama in 1 880. The French had sent 86,800
laborers to work in Panama. Of these, 22,000
men had died from disease before the French
abandoned their canal project in 1 888.
When William Gorgas arrived at the
Panama Canal Zone in 1 904, he found that
there was no public water supply system in
the country. Fresh water from the frequent
rainfalls was collected and stored for daily
use in huge stone jars near each house. These
j ars made ideal breeding pools for the spe
cies of mosquitoes that carry yellow fever.
Other species of mosquitoes, which carry
malaria, bred among the swamps and rain
forests through which the canal was to be
built.
Dr. Gorgas saw the potential for dev
astating epidemics of yellow fever and ma
laria. He had no doubt that he could rid the
Canal Zone of dangerous mosquitoes, but it
would cost the United States government a
large sum of money.
Despite Gorgas' prior success in Havana,
the military officials and members of the
Canal Commission rejected the idea of
mosquito-borne disease. Admiral J,G. Walker
of the Canal Commission said, "I am not go
ing to spend good American dollars on a
group of insane enthusiasts who spend their
time chasing mosquitoes. Chasing mos
quitoes through the Panama j ungle seems to
me the very height of folly. Even the French
in their wildest moments never did anything
as bad as that. As everyone knows, what
causes yellow fever is not mosquitoes, but filth
and dirt."
Admiral Walker suggested that Dr. Gorgas
and his team of seven men and one nurse get
rid of the dead cats and garbage in the streets,
then whitewash the houses and pave the
streets of Panama City.
Dr. Gorgas also encountered opposition
from
Colonel
George Goethals,
the engineer in
charge of the con
struction of the ca
nal. When Gorgas
approached
Goethals with his
proposal to elimi
nate the mosqui
toes, Goethals re
sponded, "Do you
know, Gorgas, that
every mosquito you
kill costs the U.S.
government ten
Undollars?"
D r.
daunted,
Gorgas replied,
"But j us t think,
John F Stevens
Colonel, one of those ten-dollar mosquitoes
might bite you, and what a loss that would
be to the country!"
The officials would not relent, but Dr.
Gorgas stood by the mosquito theory. He
hounded the federal government, repeatedly
cabling his requests for assistance to Wash
ington. He was told that sending telegrams
was a costly business, and that he should use
the regular mail instead. He then traveled to
Washington to personally press his case with
the government, but he could not get fund
ing for his mosquito-control program. The
construction of the canal was of top impor
tance, he was told, not "chasing mosquitoes."
When the American canal-building
project began in 1904, there was no outbreak
of yellow fever in Panama. But Dr. Gorgas
expected that, with the great influx of
non-immune workers pouring daily into the
Canal Zone, the disease would reappear soon.
Yellow fever hit the Canal Zone in January,
1 905, when there were 19 cases with eight
deaths. In April, nine cases occurred with two
deaths. May saw 33 cases, with eight dead. In
June, there were 62 cases, and 1 9 dead. In
July, there was panic.
Terrified, many Americans demanded to
go home. Admiral Walker, Gorgas' most ar
dent opponent, lost his architect, his auditOl�
and his executive secretary to yellow fever.
In nvo weeks, over 200 people resigned. One
worker, after reaching New York, said, "A
white man's a fool to go down there, and a
bigger fool to stay."
A feeling of impending doom settled on
the remaining workers. Dr. Gorgas later re
called, "the men began to believe that they
were doomed just as had been the French
before them." In all, three-quarters of the
Americans working on the Isthmus went
home. Finally, even Commissioner Walker
fled, insisting that he had to return to the
United States President
Theodore Rooseveltplays with
the controls ofa 95-ton steam
shovelin Panama) dUling the
construction ofthe canal.
States to "confer" with Secretary ofWar Wil
liam Taft, and that he was not motivated by
fear of the epidemic.
Walker was removed from his position and
was replaced by Commissioner John Stevens.
While meeting with his new staff, Commis
sioner Stevens turned to Dr. Gorgas and said,
"Sit; we are not here to demonstrate any theo
ries in medicine . . . you have four months to
rid Panama of yellow fever."
S uddenly Dr. Gorgas found himselflead
ing the most expensive health campaign the
world had ever seen. Stevens gave the doctor
all the manpower that he required, which at
one point totaled 4,000 men. Dr. Gorgas'
working budget was so greatly increased that
now it included $90,000 j ust for screening
material. The doctor obtained all the supplies
that he needed, including 1 20 tons of pyre
thrum powdet; 300 tons of sulfU1; 50,000 gal
lons of kerosene oil, 3,000 garbage cans, 5,000
pounds of soap, lanterns, lawn mowers, and
1,200 fumigation pots.
Gorgas and his clean-up crews went
through every house in Panama City and
Colon. Fumigation brigades searched each
dwelling for traces of mosquito breeding ar
eas. All standing water was removed. Any
one not cooperating was fined five dollars.
Cisterns and cesspools were covered with oil.
The cities of Panama were furnished with
plumbing and running wa ter for the first time,
thereby eliminating the need for water stor
age. The vegetation of the surrounding jungle
was cut down and scorched with flame
throwers. Vermin were destroyed and rubbish
was burned. New buildings were elevated
19
above ground level, with screened doors, win
dows and porches. Hospital beds were pro
tected by portable enclosures of mosquito
netting. Ships coming from disease-ridden
areas were placed under quarantine. Large
pans of fresh water were placed in numerous
locations to entice breeding mosquitoes. Af
ter the mosquitoes laid their eggs, the water
was poured down disinfected drains.
In Havana, it had taken about eight
months to rid the city of yellow fever. In
Panama, it took a year and a half. With Dr.
Gorgas' measures in place, the epidemic was
almost over by September, 1 906. By Decem
ber, there was not one case of yellow fever
reported on the Isthmus.
Dr. Gorgas was also successful in his cam
paign against the mosquitoes that carry ma
laria. By eliminating both yellow fever and
malaria in the Canal Zone, he made it pos
sible for the Panama Canal to be successfully
completed in 19 14.
Promoted to the rank of major general,
Dr. William Gorgas became surgeon general
of the United States Army in 1914. He re
signed from the army at the conclusion of the
First World War. Dr. Gorgas suffered a stroke
while visiting London in 1 920. King George
VI visited him at the hospital and knighted
him for his "great work for humanity." Dr.
Gorgas died soon afterward.
Sources
GJ'eat jlledicaJ DisasteJ's. by Richard Gordon.
Dorset Press, 1983.
11ledicine's GJ'eatjoumej( edited by N. Richardson.
Universal Press, 1990.
ThePath Between the Seas. by DavidMcCullough.
Simon & Schustel; 1 977.
The!irstmel'Chantshippasses through the caal on August l� 1914.
....-
20
"Gass".
'
.
. . Canlmued fium .RJge 2
the occurrence of the painless tooth extrac
tion. No personal experience of the case was
described.2 Twenty-year-old printer Edward
Gilbert Abbott was the famous patient whom
Morton anesthetized, and lC. Warren oper
ated on, at the October 1 6, 1 846, demonstra
tion at MGH. By nature a rather reticent
young man, Abbott was originally scheduled
for operation to remove a tumor below his
j aw. Dr. Warren remembered his appoint
ment with Dr. Morton for the demonstration,
and obtained Abbott's acquiescence to post
pone the operation until the 1 6th. The his
toric event impacted the practice of medicine
in the next century and half. Here again, no
personal account on the anesthetic experience
e m a n a ted from p a tient Abbott whom
Vandam considers an enigmatic figure.3-4
To appreciate the new found blessing of
painless surgery, Bassett's description was in
stark contrast to the graphic recounting of
the excruciating experience of surgery with-
Bulletin of Anesthesia History
Doris K. Cope, M . D . , Editor
UPMC Shadyside
5230 Centre Avenue, 1 South
Pittsburgh, PA 15232 U . S .A.
out anesthesia by Fanny Burney 3 5 earlier in
1 8 1 z.s A cursory investigation on patient M.B.
Bassett has not turned out any information
about his life. This makes Bassett's surgical
experience under inhaled anesthetic even
more remarkable and important for histori
cal study. Family papers, especially letters of
this nature, hardly survive the passage of
time. Harvard and Columbia historian Simon
Scharma used archives and records of ordi
nary people contemporary to the French
Revolution to write the history of the tumul
tuous era, and titled it Citizens. Similarly, the
Bassett letter presents another area of anes
thesia historiography for researchers to in
terpret the story of anesthesia.
The Wood Library-Museum is very proud
to acquire this unique holographic letter
which measures 20" x 25", folded once to cre
ate four pages for the text. Perhaps consis
tent with the mailing tradition of the time,
the letter was folded the second and third
time with two folded ends meeting mid-way
on page 1 . The folding process in Step 2 re-
peats to create a mailing space for address
and the postmark. In addition to the anes
thetic message, Bassett's letter addressed
other subjects, both social and domestic, in
cluding the performance of the 48-member
"Viennese Children Dance," and the univer
sal concern of a younger member of the fam
ily experiencing growing pain.
References
1. Long CWo An account of the first use of
Sulphuric Ether by Inhalation as an Anaesthetic in
Surgical Operations. Southern jil1edical and Surgical
Jaurnal 5(l2):5-14, 1849.
2. Hodges RM. A NalTative afEvents Connected
with the Introduction of Sulphun'cEther inta Surgical
Use. Boston Little, Brown, 1891. pp 24-26.
3. Ibid, pp 29-30.
4. Vandam LD, Abbott JA. Edward Gilbert
Abbott: Enigmatic figure ofthe ether demonstration.
NEJM 311:991-994, 1984.
5. Tandy CT. ''A terror that surpasses descrip
tion," Anesthesia History Exhibit Catalog, 1 969.

October 1999, Vol 17 - Anesthesia History Association

Transcription

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