on the history of emergency medical services history of

JULY, 2001VOLUME 19, NUMBER 3A H A

Continued on Page 9

On The History of Emergency MedicalServicesby Peter J. Safar, M.D.University of Pittsburgh

[Selected Excerpts from Careers in Anesthesiology – An Auto-biographical Memoir, Volume V]

IntroductionThis article is in response to an invitation from Dr. Doris Cope, editor

of the Bulletin of Anesthesia History, to have parallel with Dr. Eugene Nagel’s fine article about the history of “emergency medicine,” sections from my autobiographical memoirs1 on my personal involvement in the history of “emergency medical services (EMS).” Placing these two articles side-by-side will illustrate how mobile intensive care units (ICU), ambulance services, and community-wide EMS systems were initiated or co-initiated by anesthesiologists after World War II, parallel with the development of ICUs in hospitals. These developments occurred almost simultaneously in the U.S.A. and abroad. In some other countries, anesthesiologists remained leaders in EMS and critical (intensive) care medicine (CCM), while in the U.S.A. our specialty lost this commitment and opportunity to serve beyond the operating room.

History written by participants is personal. That makes it more lively, but also inevitably biased. We all stand on the shoulders of those before us. What ultimately counts is that progress was made, not who gets the credit.

Concerning the article by my friend and former EMS co-activist, Eugene Nagel, I have three slight differences in emphases:

1) What sparked EMS? It was not the accidental rediscovery of ex-ternal cardiac massage, i.e., step C of cardiopulmonary resuscitation (CPR) basic life support.2 I believe that modern EMS would have come about without sternal compressions, namely through a coalescing of several new life-saving opportunities. They resulted in the public demanding EMS. It all began in the 1950s: Traumatologic resuscita-tion in World War II, pioneered by Anglo-American anesthesiologists and surgeons, was just waiting to be applied in the civilian sector. In 1956, anesthesiologist Elam3 sparked anesthesiologist Safar into researching resuscitation and first aid. This led to the documentation that backward tilt of the head plus direct mouth-to-mouth ventilation4 is physiologically superior to the then practiced back-pressure arm-lift methods of artificial ventilation. These steps A and B were combined with step C2 into CPR basic life support (BLS).5 Some anesthesiolo-gists6 and trauma surgeons7 found it challenging to apply the life-support measures for the reversal of asphyxia, shock and cardiac arrest learned in the operating room (OR), also outside the OR, and outside hospitals; this led to guidelines for community-wide EMS systems and EMS community councils, starting in Pittsburgh.1,6 EMS is only as effective

History of Emergency Medicine: A Memoirby Eugene Nagel, M.D.

�� A historian had written “…..For the pendant, dates are deities, worthy of worship, but for the true social historian, they are minutiae only, a shorthand, convenient reminders and no more. You do not ask a Titanic survivor, ‘Let me see now, just exactly when was that?’ You ask him this: ‘What was it like? How did you feel?’ And that is the job of the social historian: to make the past vibrant for the present; to emotionally involve those of us who were not there. And to make us understand.”

Marathon Man, William Goldman, 1974In the early 1960’s there occurred a revolution in how civil-

Continued on Page 4

I would like to dedicate this short paper to the memory of Dr. Jim Elam who was so instrumental in developing CPR and to Dr. Thomas Burnap who so enthusiastically joined in teaching this new discipline. I would also give thanks to my partner and cardiologist friend, Dr. Jim Hirschman without whose efforts none of this would have been possible. Finally to the City of Miami’s Finest, the fireman and their officers who were so loyal, so dedicated, and so principled that it was easy for me to follow their example.

ian emergency care went from simple first aid to sophisticated pre-hospital emergency medical care. Many who witnessed or participated in that event offered a variety of reasons: (a) military care developed during the Korean war including helicopter evacu-ation and “MASH” types of forward hospitals; (b) a “white” paper developed by the National Academy of Sciences/National Research Council1; (c) the development of a newer specialist of surgery called “trauma” surgeon; (d) the sudden decrease in funeral home emer-gency transport participation; (e) public outcry for an improved level of emergency pre-hospital care; (f) governmental programs which produced the impetus for improved pre-hospital care; and (g) medi-cal pioneers who saw the need and led the way for such development. As one who lived through this time period and participated in the development of the present day systems it is my view that none of the above played a highly significant or leadership role. Instead, it started with an accidental discovery of closed chest cardiac massage during experimentation on defibrillation techniques by an electrical engineer in the dog lab!

This eventually led to emergency medical service (EMS) as we know it today which is being chronicled by Dr. Safar in this issue. It is my contention that CPR came into public view in 1960-12-3 and the medical community and public saw that a simple procedure could provide enormous benefits if practiced widely both inside and outside the hospital. Thus, for the first time, the medical com-munity, rescue personnel, and general public saw that their efforts

2 BULLETIN OF ANESTHESIA HISTORY

BULLETIN OF ANESTHESIA HISTORY 3

Bulletin of Anesthesia History (ISSN 1522-8649) is published four times a year as a joint effort of the Anesthesia History As-sociation and the Wood-Library Museum of Anesthesiology. The Bulletin was published as Anesthesia History Association Newsletter through Vol. 13, No. 3, July 1995.

The Bulletin is now indexed in HISTLINE (history of medicine on-line), a database maintained by the U.S. National Library of Medicine at <http:igm.nlm.nih.gov>.

C.R. Stephen, MD, Senior EditorDoris K. Cope, MD, EditorDonald Caton, MD, Associate EditorA.J. Wright, MLS, Associate EditorFred Spielman, MD, Associate EditorDouglas Bacon, MD, Associate EditorPeter McDermott, MD, Book Review EditorDeborah Bloomberg, Editorial Staff

Editorial, Reprint, and Circulation matters should be addressed to:

EditorBulletin of Anesthesia History200 Medical Arts Building200 Delafield Avenue, Suite 2070Pittsburgh, PA 15215 U.S.A.Telephone (412) 784-5343Fax (412) 784-5350

Manuscripts may be submitted on disk using Word for Windows or other PC text program. Please save files in RICH TEXT FORMAT (.rtf) if possible and submit a hard copy printout in addition to the disk. All illustrations/photos MUST be submit-ted as original hard copy, not electronically. Photographs should be original glossy prints, NOT photocopies, laser prints or slides. Pho-tocopies of line drawings or other artwork are NOT acceptable for publication.

Corrections:

In the April 2001 issue of the Bul-letin, Dr. Maurice Albin’s name was incorrectly spelled as Aldin. The edito-rial staff apologizes for the oversight.

Please note that the correct dates for the combined meeting of the Anesthe-sia History Association and History of Anaesthesia Society are June 6-8, 2002. Please see the announcement on the preceeding page for more information on this meeting.

Wood Library-Museum of AnesthesiologyDuplicate Vintage Books for Sale

July 2001

Adriani J. The Chemistry of Anesthesia. Springfield: Charles C. Thomas; 1946. $10.00

Bendixen HH, Egbert LD, Hedley-Whyte J, et al. Respiratory Care. St. Louis: CV Mosby; 1965. $30.00

Bromage PR. Spinal Epidural Analgesia. Edinburgh: E&S Livingstone; 1954. $15.00

Burstein CL. Fundamental Considerations in Anesthesia. New York: Macmil-lan; 1952. $10.00

Grant JCB. An Atlas of Anatomy. Baltimore: Williams & Wilkins; 1951. $15.00

Lorhan PH. Anesthesia for the Aged. Springfield: Charles C. Thomas; 1971. $10.00

Lorhan PH. Geriatric Anesthesia. Springfield: Charles C. Thomas; 1955. $10.00

Lull CB, Hingson RA. Control of Pain in Childbirth. 3rd ed. Philadelphia: JB Lippincott; 1948. $30.00

McComish PB, Bodley PO. Anaesthesia for Neurological Surgery. London: Lloyd-Luke; 1971. $15.00

Ngai SH, Papper EM. Metabolic Effects of Anesthesia. Springfield: Charles C. Thomas; 1962. $15.00

Rollason WN. Electrocardiography for the Anaesthetist. Philadelphia: FA Davis; 1964. $10.00

Smith RM. Pediatric Anesthesia, in International Anesthesiology Clinics, Vol. 1, No. 1, 1962. $10.00

Stephen CR, Little, DM, Jr. Halothane. Baltimore: Williams & Wilkins. $10.00

Wylie WD, Churchill-Davidson HC. A Practice of Anaesthesia. 2nd ed. Chi-cago: Year Book Medical Publishers; 1966. $20.00

To order any of the above volumes, please contact:

Karen Bieterman, Assistant LibrarianWood Library-Museum of Anesthesiology

520 N. Northwest HighwayPark Ridge, IL 60068-2573e-mail: [email protected]

phone: (847) 825-5586 Ext. 58fax: (847) 825-1692


as the weakest step in the cardiopulmonary-cerebral resuscitation (CPCR) system8 (Fig. 1) applied in the weakest link of the EMS life support chain.6 Outcome results are still far below what they could be, because of the weakest first link, namely immediate life-supporting first aid (LSFA) skills applied by the lay public, not being available.9 This is in spite of training aids and systems for health professionals and lay persons.10

2) Who started mobile ICUs? Nagel and I have agreed since the 1960s that general mobile ICUs, for resuscitation from any cause of sudden coma or shock, will save more lives than mobile coronary care units (CCUs) for suspected myocardial infarction only. Lay persons cannot diagnose the cause of sudden coma. Physician-staffed general mobile ICUs were pioneered in Prague and Moscow (see later).

3) Paramedics vs physicians? In the U.S.A., training of paramedics exploded in the 1970s, mostly through efforts by anes-thesiologists in Miami and Pittsburgh and cardiologists in Seattle. In the U.S.A., the reluctance of physicians to resuscitate in the field (with the exception of Pittsburgh), has made it difficult to conduct objective outcome comparisons between the two systems. There are recent data suggesting outcome benefit from physicians on mobile ICUs compared to paramedics only. That impact may be greater for trauma than cardiac cases; and greater for rural than urban EMS systems. Beyond outcome benefit, however, there is a need for EMS physician leaders to go into the field, to acquire personal experiences in this difficult environment, to guide and teach non-physicians, and to conduct research.

Excerpts from American Society of An-esthesiologists (ASA) Memoirs, Volume V:1

The development of EMS we began in the late 1950s in Baltimore.11 The following were obvious to me then: 1. Because of the time constraints dictated by the vulnerabil-ity of the brain and heart, we should take to the scene, inside and outside hospitals, the resuscitation and life-support measures that we have learned as anesthesiologists. 2. EMS systems must be more than ambulances; they must include resuscitation and life support at the scene and during transport to (and in) the ED, OR, and ICU of the most appropriate hospital.6,12 These links of the EMS chain should be tied together by com-munication and education, and upgraded periodically, based on ongoing evaluation.

3. The EMS system is only as effective as its weakest link from scene via transport to hospital; and the weakest step of CPCR (fig. 1).8,13 4. EMS development should be multidisciplinary and adapted to the needs and potentials of each region.

There were no EMS systems in the 1950s. Most patients with acutely life-threatening conditions were picked up and rushed to the nearest hospital by police or firemen in sta-tion wagons or hearses, usually without an attendant at the patient’s side and without life support. Some “ambulance services” were staffed by firefighters or policemen who had received first-aid training, which at that time consisted of splinting, ban-daging, and giving back-pressure arm-lift artificial ventilation; this was difficult to do in the ambulance. Some ambulances were equipped with suck-and-blow pressure-cycled oxygen resuscitators or inhalators to be used via a face mask, which in our patient trials did not produce adequate ventilation. Paluel Flagg’s attempt in New York to take tracheal intubation to the streets was a laud-able, unique, and transient phenomenon. In New York and a few other cities where doc-tors rode in ambulances, they were interns without experience in life support.

In Europe, anesthesiologists developed and had been staffing general mobile ICUs since the early 1960s, starting in Magde-burg (by surgeon Werner Lembcke and anesthesiologist Wolfgang Röse), in Prague (by Bohumil Sefrna and anesthesiologists Hugo Keszler and Jiri Pokorny), in Moscow (by Negovsky’s associates) and in Mainz and Ulm (by anesthesiologists Rudolf Frey, Fritz Ahnefeld and Wolfgang Dick). They all implemented Pittsburgh’s guidelines6,12 before we could. Subsequently, in the mid-1960s, an impressive program by Pantridge in Belfast has been credited for the first physician-staffed mobile ICU to deliver advanced cardiac life support (ACLS); that was a mobile coronary care unit (CCU) – not a general mobile ICU — meant mostly for preventing cardiac arrest in patients with suspected myocardial infarction.

When I moved from Baltimore to Pitts-burgh in 1961, I had a plan for EMS already sketched out.12 Then, “ambulance services” in the city of Pittsburgh were provided by policemen with only limited first-aid train-ing, using station wagon-type vehicles. It took many years of frustrating efforts before EMS implementation was accomplished in the city of Pittsburgh.

Since 1957, I had been an invited member of Sam Seeley’s National Re-search Council (NRC)-National Academy of Sciences (NAS) ad hoc committees on artificial ventilation. Seeley was a former

distinguished military surgeon with great spirit. He became interested in EMS improvements because of “trauma as a neglected disease.”7 In the early 1960s, he invited me to co-initiate a new NRC-NAS committee to develop national guidelines for community-wide EMS. I was the first nonsurgeon on the committee. The majority were orthopedic surgeons focusing on frac-tures. Open-minded trauma surgeons on the committee included John Howard. I tried to represent resuscitation potentials not only of anesthesiology but also cardiology and other nonsurgical fields. CPR became the territory of cardiologists much later. Seeley asked me to chair the subcommittees on ambulances.14 My work with Seeley’s NRC committee in Washington enabled me to clarify at the national level the difference among mere first aiders, EMT-1 level BLS ambulance attendants, and EMT-2 level (paramedics) ALS ambulance attendants.

In 1964, I drafted for the Pittsburgh metropolitan area what apparently were the first guidelines for community-wide organi-zation of EMS. This I did with the blessing of the Allegheny County Medical Society and the Health and Welfare Association and Hospital Council of Western Pennsylvania. When I presented these guidelines in 1965 at a meeting of the International Association for Traffic Medicine in Stockholm,12 they were well received, and some Europeans im-plemented them right away. Authoritarian health ministries in “socialized countries” enabled implementation of such guidelines much faster than the democratic approach in the West would permit.

Between 1961 and 1966, I felt that efforts to improve EMS in Pittsburgh were hope-less without guidelines at the national level. Everybody with vested interests started to meddle. I wanted to publish our EMS guidelines with the blessing of American anesthesiologists, so that anesthesiology would get credit.6 Some academic leaders of anesthesiology preferred to seek recogni-tion by publishing laboratory findings; they hesitated to step into what they perceived as the territories of trauma surgeons and orthopedic surgeons. Some political leaders of anesthesiology seemed more interested in OR work, the source of personal income. Both gave me the impression that they were not interested in getting the specialty involved in the prehospital arena, as Euro-pean anesthesiologists had done following our urging. In Europe, EMS and CCM in-volvement brought much social recognition to anesthesiology.

In the U.S., John Bonica was an ex-ception. His attitude toward all of this was global, like mine. When he was ASA

History. . .Continued from Page 1


president in 1965, he agreed with me that the ASA needed a Committee on Acute Medicine, He asked me to chair it.6 I sought input from the committee members on my draft of community-wide EMS organization guidelines. After a long delay, ASA powers eventually agreed to have our EMS guide-lines published - in the name of the ASA Committee on Acute Medicine - in JAMA in 1968.6 These guidelines, accepted as a goal for Pittsburgh four years earlier, became the spark for national guidelines of the EMS Systems Act for the U.S. in the 1970s. We then also stressed and recommended “regional centralization of critical trauma care.” Twenty years later it is finally being promoted by the International Trauma Anesthesia and Critical Care Society (IT-ACCS). In the 1960s, my only outspoken supporter of EMS among anesthesiologists (besides Bonica) was Eugene Nagel, then in Miami. Nagel became a kindred spirit on EMS activism as a leader at the national level, and as my successor as chairman of the ASA Committee on Acute Medicine. Nagel pioneered the guidance of ambulance paramedics by physicians via radio. Later, Nagel and I helped Israel’s EMS through assisting Nancy Caroline.

Ambulance services are only one link of the EMS chain. I learned from non-physicians in Pittsburgh, as I did in Balti-more, where I had learned from ambulance leader Captain McMahon. In Pittsburgh, I sought out Mr. Richard Brose, a past ambulance leader with first-hand experi-ence, who was in charge of EMS programs at the Pennsylvania Department of Health in Harrisburg. He and I developed the first ambulance design modification plan for station wagons and hearses.15,16 In 1963, I discovered that Mr. Gerald Esposito was president of the Pennsylvania Ambulance Association. He was also in charge of an ambulance service in nearby Indiana, PA, which was more advanced. Esposito and I were mission oriented. We improved the ambulance design guidelines for ALS.17 The input from Brose and Esposito was valuable in drafting national guidelines for ambu-lance design and equipment and training of attendants at basic (EMT-1) and advanced (EMT-2, paramedic) levels. I drafted and pushed these guidelines through in the 1960s as chairman of the NAS-NRC EMS ambulance subcommittee of Seeley’s EMS committee.18,19

In Pittsburgh, I had strong support throughout from my anesthesiology resi-dent Don Benson and surgeons of town and gown, via the Allegheny County Medical Society. Hospital administrators opposed our recommendation for regionalized cen- Continued on next page

tralization of special critical care (which also means expensive care), particularly for severe trauma cases. Leaders of the vol-unteer fire department ambulance services of Western Pennsylvania, who controlled suburban ambulances, did not want to learn life-saving methods, nor did they like to lose to trained, salaried attendants their country club status in the communities. It took me quite a while to learn about the vested in-terests and politics of these organizations. Fighting EMS politics taught me to first try to charm them (cocktail party technique); then to bypass underlings and go to the top man (helicopter technique); and if this also failed, to threaten briefly and then move in with force (bulldozer technique).

Our and others’ efforts of the 1960s led to the EMS Systems Act of the federal gov-ernment, which began in the early 1970s. That act, however, influenced change only through grants, not through law. In Western Pennsylvania, Esposito and I decided to bring the vested-interest groups together for a democratic approach. In 1968, I asked county medical society president Fred Brady, a fine surgeon of Mercy Hospital, to meet with me in the plush basement res-taurant of the Pittsburgh Playhouse. There, under the influence of martinis, we plotted the nation’s first Community Council on EMS. In 1969, with the help of my associate Steve Galla and Veterans Administration Hospital (VAH) surgeon Francis Jackson, we created a “white paper” for EMS com-munity councils throughout Pennsylvania, sponsored by the state medical society. Ours was the first state to set up such councils state-wide.19 This move was made possible by the fact that an anesthesiologist, my old friend Leonard Bachman, was Secretary of Health of the Commonwealth of Pennsylva-nia from 1972 to 1979. He had run for U.S. Congress in 1964 but lost the election. He gave up his position as chief anesthesiolo-gist at Children’s Hospital of Philadelphia in 1972. I credit Bachman for his handling of the legionnaires disease outbreak in Philadelphia, for wise handling of federal EMS grants, and for having hired emergency physician Arnold Muller to run state EMS. Muller became Bachman’s successor with the next (Republican) administration.

David Lawrence, the former mayor of Pittsburgh and former governor of Penn-sylvania, was one of the finest leaders of the Democratic Party in the U.S. He was the pioneer who brought about collaboration be-tween the labor unions and local billionaires to achieve the first renaissance of Pittsburgh, one of America’s most industrialized cities. In October 1966, while in retirement, Law-rence suffered sudden cardiac death when

talking to a large audience in Pittsburgh. The police ambulance service was then still staffed with policemen untrained in life support. In our ED, modern CPR resulted in excellent return of his heartbeat. In spite of excellent life support in the ICU he remained unconscious. Family and physi-cians agreed to let nature take its course. This event drew attention to the need for an improved local ambulance service, and led to the Freedom House ambulance project, followed by the present EMS system, both among the catalysts for U.S.-wide EMS de-velopments. Our improvement efforts were slowed by Pittsburgh’s mayor in the early 1970s, who backed the police department’s jealous grip on “ambulance service.”

The Freedom House Enterprise (FHE) ambulance project of 1967-1975 was some-thing unique.20-24 In 1967, leaders of the predominantly African-American commu-nity near Presbyterian University Hospital (PUH) asked the hospital’s administrator, Edward Noroian, to advise them on the type of ambulance to buy to take sick citizens to PUH for checkups. Noroian referred them to me. Although I was not interested in elec-tive transport for nonemergent conditions, I saw an opportunity for Pittsburgh and beyond and offered them a deal: My depart-ment would help them (gratis) to get ambu-lances to transport critically ill or injured patients with life support, if they would let us train attendants as a pilot project. We would try to train “unemployable Blacks” as EMTs and paramedics.20,21 They would staff an experimental ambulance service to test the national ambulance design, equip-ment, and training guidelines we had just developed at the NRC committee.14 They agreed. The project eventually included 44 African-Americans who had been labeled “unemployable.” This program, started in 1967, occurred during times which included summer revolts in U.S. cities (outcries for civil rights, redistribution of wealth, and peace abroad), and the murders of Martin Luther King (in April 1986) and Robert Kennedy (in June 1968).

I delegated the medical direction of the FHE program to Benson and Esposito from 1967 to 1969 and to Nancy Caroline from 1973 to 1975. Benson, who in 1967 began work with the FHE during the third year of his anesthesiology/CCM training, received his stipend in part from a National Insti-tutes of Health (NIH) anesthesiology fel-lowship. After fulfilling his military duties, Benson returned to us in 1970 as assistant professor and continued working with am-bulances. Frustrated with the FHE program, he focused on the suburbs. There he became



the first to demonstrate that volunteer fire department ambulance attendants could be trained as ALS paramedics.

Nancy Caroline, educated at Harvard, had completed an internal medicine residency at Case Western Reserve Uni-versity Medical School in Cleveland. That included some anesthesiology experience under Gravenstein. In 1973 she began a CCM fellowship with us. Her takeover from Benson of the medical leadership of our FHE ambulance program upon my (she says irresistible) offer, led her into a new career pattern and helped establish modern ALS ambulance services first at Pitt22-24 and then in Israel. One reason for her great impact was the fact that she is a caring, dynamic, compassionate “super doctor,” a Renais-sance woman, and an eloquent writer. The FHE program gave Caroline the opportu-nity to demonstrate her exceptional skills in laying hands on victims in emergencies outside the hospital.24 I asked Caroline to write the national curriculum for training ambulance attendants, which the Depart-ment of Transportation had asked me to prepare. Little Brown published a slightly modified form of her document as a series of books that became the most widely read EMS and paramedics’ texts in the world during the first decades of the EMS move-ment.24 The royalties from her writings helped Caroline support her later missions. In 1976, Caroline decided to leave Pitt and become an Israeli citizen. For five years, she was the medical director of Magen David Adom, the organization responsible for ambulance services throughout Israel. She advanced that service from BLS to ALS capability. Nagel and I visited her programs in 1978. She saved lives in terrorist events. She spent the next five years in East Africa, where she applied EMS principles to overall health care, i.e., extending the physician’s impact through the hands of nonphysicians. She initiated medical and agricultural programs. Recently she returned to Israel, again changing her career; she became an innovator in palliative hospice care of terminally ill cancer patients and founded a hospice program in Galilee. It all ties to-gether, because principles learned in CCM are again applied, in this case to titrated terminal care.

Our FHE ambulance program had suf-fered from lack of finances throughout its existence, i.e., from 1967 to 1975. We had to meet the dovetailing needs of providing training and employment for the black community and providing a testing ground for our national standards of prehospital

EMS. Before I got into the act, the primary goal of a “Freedom House Enterprise” was to develop business ventures in the ghetto areas of Pittsburgh near PUH. The Falk Foundation, the Ford Foundation, and other local philanthropic groups, provided some financial support. My department provided EMT training and medical leadership. Ini-tially, I personally taught some of the student EMTs in ORs and ICUs. Besides funding, other problems included: 1. Reluctance of the city’s mayor to let FHE provide city-wide services; we were limited to the university district and other eastern sections of the city. 2. Suspected racial prejudices with white police officers eager to maintain control of ambulances city-wide. Our FHE ambulance program began in 1968 for African-Ameri-can trainees only, but integrated in reverse in the 1970s. 3. The previously noted vari-able, intermittent medical direction during 1969-1973 – in part my fault. 4. Differences between medical and FHE board priorities.

Nonetheless, the service continued to render care in the eastern half of Pitts-burgh and demonstrated the validity of the national guidelines for ambulance design and equipment and EMT training.14-21 By 1974-75, under Caroline, FHE reached my original goal for the program, namely ALS capability for paramedics (EMT 2). In April 1975, the city elected to implement its own mobile ICU services. The FHE service ceased to exist in October 1975, and most FHE employees were transferred to the city service. That was directed by Glenn Cannon, a FHE trainee, in the early 1970s. Cannon rose to safety director of Pittsburgh. Other FHE trainees also made unexpected careers. For example, Mitchell Brown, FHE paramedics’ instructor, rose to safety direc-tor of Cleveland and Ohio. The majority of the more than 40 trainees initially declared “unemployable,” rose in educational creden-tials, documented the national mobile ICU guidelines as practical, and found worth-while jobs. “The birth, crucifixion, death, and resurrection of FHE” is a complex story.23 The nationwide impact of the FHE program was commemorated in Pittsburgh’s History Museum in November 1997.

Between 1961 and 1979, I was frustrat-ingly obsessed with the implementation gap in acute medicine (EMS and CCM). Inside and outside of hospitals, resuscitation po-tentials were not being applied. I therefore encouraged numerous colleagues to help advance EMS. We created an increasingly positive collaboration between town and gown. In the 1970s, our and others’ EMS community programs which had become increasingly frustrating, aroused national attention. National guidelines were based

on our guidelines.6,12,17 Development in Washington of the National EMS Systems Act was led by Chicago surgeon David Boyd. I could help a little bit in that legislative move because politicking by my former anesthesiology resident Sol Edelstein had resulted in President Ford inviting me to serve on the White House Interagency Advi-sory Committee on EMS in the early 1970s.

My attempts to establish university lead-ership of regional EMS were frustrated not only by the controversy between the mayor and the FHE ambulance service, but also by the lack of a University Health Center of Pittsburgh (UHCP) director of EDs; disin-terest in the prehospital arena among most UHCP anesthesiologists, surgeons, and in-ternists; and the need for a medicopolitically skillful person who could dedicate full time to EMS negotiations. Sol Edelstein made a partially successful attempt. After his anesthesiology residency with us, he joined our staff in 1975 to devote himself to EMS negotiations. He formed the Emergency Medicine Operations Center (EMOC), based at PUH. The EMOC provided full-time medical radio command of city ambu-lances via radio, optional radio guidance of other ambulances in Western Pennsylvania, consultation from CCM and other special-ties by radio and telephone (to influence regionalized centralization of special care), and help in EMS evaluations. This was to be done as an arm of the Western Pennsylvania EMS Community Council. This dream, based on our plans of 1964, was almost ac-complished by Edelstein in the early 1970s. He attracted some national EMS grants to our community. He subsequently became Medical EMS Director in Washington, DC; his service cared for President Reagan when he was shot.

My initial goal, still elusive in the U.S. but successful abroad, has been to have phy-sicians of multiple specialty backgrounds, with special interest and skills in life sup-port, jointly lead and cover the emergency and critical care medicine (ECCM) con-tinuum. That would include critical cases out-of-hospital, in the ED, and in the ICU. Multidisciplinary ECCM was defeated when the traditional base disciplines failed to cover community hospitals’ emergency departments and the new base specialty emergency medicine was initiated by some general practitioners to fill the gap. Since then, academicians in emergency medicine have taken on EMS leadership. Current politics preventing emergency medicine from obtaining additional CCM subspe-cialty certification is wrong.

In 1979, the EMOC became the Center for Emergency Medicine (CEM) of Western


Pennsylvania, led by emergency physicians Ronald Stewart and Paul Paris. Originally from Canada, Stewart was an emergency physician leader in Los Angeles in the late 1970s. Our then-new dean, Donald Leon (cardiologist) and I recruited Stewart as Car-oline’s successor. Stewart recruited Paris. They developed the pre-eminent emergency medicine residency program in the U.S. It became so attractive in part because Pitts-burgh was the only city in the U.S.A. where physicians go into the field together with paramedics — a tradition established in the 1960s and 1970s by Benson and Caroline. Stewart and Paris did it through initia-tion of an academic emergency medicine residency, which made resuscitating on the streets appealing. Other incentives for the emergency medicine specialty included high salaries, shift work (comfortable lifestyle), and “romantic” episodic work, avoiding the long-term care of critical cases.

When I decided in 1978 to switch full-time into basic research and turn the medico-political issues over to others, I made sure that the continued leadership of intrahospital ICU programs by Grenvik and of EMS programs by Stewart were secured.

All of these EMS developments locally were catalyzed also by efforts at the national and international levels. In the U.S., I was joined only by Eugene Nagel. Around 1970, he initiated in Miami the first medical control of fire department ambulance at-tendants in giving ALS by radio guidance from himself and standing orders. He and I also joined forces through the Emergency and Disaster Medicine Congresses with Rudolph Frey of Mainz, Germany and the second World Congress of Emergency and Disaster Medicine in Pittsburgh. Nagel later became chairman of Anesthesiology at Johns Hopkins. The only other American anesthesiologist who has remained active in EMS until now is Roger White of the Mayo Clinic.

Much credit for cardiac EMS should go to the cardiologists of Seattle, starting with Leonard Cobb. Based at Seattle’s King’s County Hospital, he not only initiated paramedic training in the 1970s, but also introduced CPR courses given by the am-bulance attendants, for as many laypersons as possible in Seattle. This made Seattle the first community with a relatively high proportion of CPR performed by bystanders in cases of out-of-hospital sudden cardiac death. A decade later, Mickey Eisenberg and his associate Richard Cummins expanded Cobb’s work, by what was probably the first epidemiologic community-wide study ap-proach to emergency cardiac care.

My concern for the potentially weak-

est link in the life-support chain, namely the bystander, first arose in Baltimore. Although we had documented the ability of untrained laypersons, from Boy Scout age up, to perform effective steps A-B on curarized human volunteers,4 we did not test the retention of their skills. In 1964, after my friend Lind in Norway had shown that steps A-B can be taught to laypersons, using Laerdal manikins, we conducted the first research of external CPR-ABC, i.e., the ability of laypersons to acquire these skills;25 we found self-training more effective than courses.9,26-29 We inspired similar studies in developing countries, by my friend John Lane of Brazil30,31 and others. They again confirmed the desirability of self-training by mass media.9 I believe that every fit hu-man being above a certain age (e.g., 10-12 years) should learn in school, continuously re-enforced by the media, the simple few steps of LSFA, including CPR steps A-B-C. Bandaging and splinting are unimportant. The LSFA concept was initiated in the 1960s jointly by Safar, Asmund Laerdal, and the Continued on Next Page

Figure 1. Heart-lung resuscitation. (Created by the author for the Pennsylvania Heart Association, 1961. From Safar with permission.

The A-B-C’s of Heart Lung Resuscitation, 1961. Renamed “Cardiopulmonary-Cerebral Resuscitation (CPCR)”

in 1970.

Laerdal Company’s Dahll, Eikeland, and Egeland.

ConclusionsLeadership in the delivery of modern

resuscitation and life support outside hos-pitals and in the ED could be improved by greater involvement of anesthesiologists. Anesthesiologists perform resuscitation at-tempts outside hospitals in about one half of EMS systems in central Europe and in almost all regions of Scandinavia. Most of these anesthesiologists work in the field with mobile ICU ambulance teams, and many are in charge of the EMS system. Many Eu-ropean anesthesiologists have led in EMS, not only in the past (e.g., Frey, Ahnefeld, Roese, Baskett, Lust, Delooz, Hugenard, Lund), but also at present (e.g., Dick, Sefrin, Lindner, Mullie, Baskett, Vaagenes, Gisvold, Edgren, Cerchiari, Ebmeyer). In the U.S., if the National Association of EMS Physicians (NAEMSP) and its parent organization, the American College of Emergency Physicians



(ACEP), prevent resuscitation-competent anesthesiologists and surgeons from per-forming EMS work (unless they complete an emergency medicine residency of three years), they also practice unwarranted terri-torialism. Every general anesthesia related components of EMS. This is a laudable trend, provided the ITACCS stands for multidisciplinary traumatology.

Concerning the future, we should ponder about lessons to be learned from the early32 and recent33 history of resuscitation. That teaches among other things that the public would be served better if some anesthesiolo-gists would rekindle their interest in EMS. Numerous health professionals are needed for effective EMS. They must acquire knowledge, skills, and judgement which in the future cannot be obtained primarily in clinical practice, but rather through an introduction with simulation and education research enhanced programs, which also have been initiated by some anesthesiolo-gists. Automatic external defibrillation and mild hypothermia will have to be included in first aid training. Therapeutic hypother-mia for cardiac arrest, stroke, brain trauma, spinal cord trauma, and other emergen-cies should be initiated out-of-hospital. For presently unresuscitable conditions, ultra-advanced life support, like open-chest CPR, emergency portable cardiopulmonary bypass, and, in the most distant future, perhaps suspended animation, will have to be initiated in the field by physicians. For cost-effectiveness, EMS for critically ill and injured patients must be included in “the basics” of national health care sys-tems, while ED cases should be cared for in 24-hour outpatient clinics. Ongoing resuscitation case registries should enable ongoing outcome evaluations with use of novel treatments. History has shown that EMS practiced with science, reason, and compassion can be a positive force in our striving to give more and more humans a chance to live full lives.

References1. Safar P: From Vienna to Pittsburgh for

anesthesiology and acute medicine. Careers in Anesthesiology. Autobiographical Memoirs, Volume V. American Society of Anesthesiologists, Wood Library-Museum, 2000.

2. Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed-chest cardiac massage. JAMA 173:1064-1067, 1960.

3. Safar P: Resuscitation Greats: James O. Elam, M.D., 1918 – 1995. Resuscitation, in press 2001.

4. Safar P: Ventilatory efficacy of mouth-to-mouth artificial respiration. Airway obstruction during manual and mouth-to-mouth artificial respiration. JAMA 167:335-341, 1958. [Reprinted in Anesthesiol-ogy 2001 as the first classic article of a new series.]

5. Safar P, Brown TC, Holtey WH, et al: Ventila-tion and circulation with closed chest cardiac mas-

sage in man. JAMA 176:574-576, 1961.6. American Society of Anesthesiologists, Com-

mittee on Acute Medicine (Safar P, Chairman): Community-wide emergency medical services. JAMA 204:595-602, 1968.

7. Seeley S: Accidental Death and Disability: The Neglected Disease of Modern Society. Committee on Trauma and Committee on Shock, Division of Medi-cal Sciences, 1966. National Academy of Sciences, National Research Council, 2101 Constitution Ave, Washington, DC, USA, 20418.

8. Safar P, Bircher NG: Cardiopulmonary-Cere-bral Resuscitation. An Introduction to Resuscitation Medicine. World Federation of Societies of Anaes-thesiologists. 3rd ed, 1988. A Laerdal, Stavanger; WB Saunders, London. (1st ed, 1968; 2nd ed, 1981). [Update expected in 2004, as Safar P: On Resuscita-tion Medicine in the 20th Century, Springer Verlag.]

9. Eisenburger P, Safar P: Life supporting first aid (LSFA) training of the public. Review and Rec-ommendations. Resuscitation 41:3-18, 1999.

10. Tjomsland N: From Stavanger with care. Laerdal’s first 50 years. Laerdal Medical, Aase Grafiske A/S, Stavanger, Norway. 1990.

11. Safar P, McMahon M: Resuscitation of the unconscious victim. A manual. Baltimore, MD, Fire Department, 1957; and Springfield, IL, Charles C. Thomas, 1959, 1961.

12. Safar P: Community-wide emergency care for acutely life threatening conditions. Proc. of 2nd Congress of International Association for Accident and Traffic Medicine, September 1966, Stockholm, Sweden (Skanetryck Publ., Malmo, Sweden).

13. Safar P: Community-wide cardiopulmonary resuscitation. J Iowa Med Soc, Nov:629-635, 1964.

14. National Academy of Sciences/National Research Council: (P. Safar task force chairman or member, under S. Seeley, Chairman of EMS Committee): a) CPR Conference proceedings, May 1966, publ. 1494, 1967. b) Medical requirements for ambulance design and equipment, 1968. c) Training of ambulance personnel … (EMT level I), USBHS publ. #1071-C4, 1970. d) Advanced training pro-gram … (EMT level II), 1970. e) Emergency medical systems …, 1973. f) Registration, certification and recertification of ambulance attendance. Proc. Airlie Conference on EMS, Warrenton, VA, May 1969, p. 78.

15. Safar P (ed): Respiratory Therapy, FA Davis Co., Philadelphia, 1965.

16. Safar P, Brose RA: Ambulance design and equipment for resuscitation. Arch Surg 90:343-348, 1965.

17. Safar P, Brose RA: Ambulance design and equipment for mobile intensive care. Arch Surg 102:163-171, 1971.

18. Safar P, Benson DM, Esposito G, Grenvik A, Sanos PA: Emergency and critical care medicine: Local implementation of national recommendations. In: Public Health Aspects of Critical Care Medicine and Anesthesiology. Vol. 10/3. FA Davis Co., Philadelphia, 1974, pp 65-126. Chapter 4.

19. Pennsylvania Medical Society, Commission on Emergency Medical Services: Emergency Medical and Health Services in Pennsylvania. Present Status, Recommendations for Improvement. Pennsylvania Medicine 74:43, 1971. [Commission members: Safar P, Esposito G, Galla SJ, Whitney R, Jackson F, et al.]

20. Safar P, Esposito G, Benson DM: Emergency medical technicians as allied health professionals. Anesth Analg 51:27-34, 1972.

21. Benson DM, Esposito G, Dorsch J, Whitney R, Safar P: Mobile intensive care by “unemployable” blacks trained as emergency medical technicians (EMTs) in 1967-69. J Trauma 12:408-421, 1972.

22. Caroline NL: Medical care in the streets. JAMA 237:43, 1977.

23. Caroline N: Emergency! Freedom House saved lives - yours and theirs, but now it is mostly shunted aside and forgotten. Pittsburgh Magazine, April 1977.

24. Caroline NL: Emergency Care in the Streets. Boston, Little Brown, 1979, 1983, 1987.

25. Winchell SW, Safar P: Teaching and testing

lay and paramedical personnel in cardiopulmonary resuscitation. Anesth Analg 45:441-449, 1966.

26. Berkebile P, Benson D, Ersoz C, Safar P: Pub-lic Education in Heart-Lung Resuscitation. Evalua-tion of three self-training methods in teenagers. (a) Crit Care Med 1:115-116, 1973. (b) Proc National Conf on CPR 1973, Dallas, Amer Heart Assoc, 1975.

27. Safar P, Berkebile P, Scott MA, Esposito G, Medsger A, Ricci E, Malloy C: Education research on life-supporting first aid (LSFA) and CPR self-train-ing systems (STS). Crit Care Med 9:403-404, 1981.

28. Bircher N, Safar P: Self-training systems I: Life-supporting first aid (LSFA) and infant CPR (ICPR) in school children. Crit Care Med 11:251, 1983 (abstract).

29. Braslow A, Brennan RT, Newman MM, Bircher NG, Batcheller AM, Kaye W: CPR training without an instructor: development and evaluation of a video self-instructional system for effective performance of cardiopulmonary resuscitation. Resuscitation 34:207-220, 1997.

30. Lane JC: Cardiopulmonary resuscitation training in developing regions (1981). Prehospital Disaster Med 1/Suppl I:88-89, 1985.

31. Capone P, Lane JC, Kerr CS, Safar P: Life supporting first aid (LSFA) teaching to Brazilians by television spots. Resuscitation 47:259-265, 2000.

32. Safar P: History of cardiopulmonary re-suscitation. Anesthesia History Association Newsletter 12:(1/2)10-21, 1994.

33. Safar P: On the history of modern resuscita-tion. Crit Care Med 24/S:S3-11, 1996.

Continued on page 11


EMS. . . Continued from Page 1

in the field could reverse apparent death in the field. Simple first aid now had a power-ful adjunct that required a massive teaching effort and the American Heart Association took upon itself the initial efforts in this program.

However, pre-hospital medical care required that a physician and British war hero of WWII demonstrate that emergency cardiac care could reverse apparently fatal acute cardiac events in the field. Dr. Frank Pantridge was the originator of pre-hospital emergency cardiac care and the designer of the mobile coronary care unit (MCCU)4. Cardiologists in the US quickly followed his example and started their own versions of the MCCU in Seattle (Dr. Len Cobb), New York City (Dr. William Grace*), Los Angeles (Dr. Michael Criley), Columbus, Ohio (Dr. James Warren*), and Charlottesville, VA (Dr. Richard Cramp-ton).

In this same period, I was working with the City of Miami Fire Rescue and thought that a disease specific system (cardiac) which demanded a doctor’s physical pres-ence in the field was not feasible for the entire country. I envisioned an intensive care system rather than just cardiac care and a vehicle and specially trained crew which did not demand a physician’s physical presence. In other words a mobile intensive care unit (MICU), connected to the doctor by radio (telemetry and voice), and staffed by specially trained fire rescue person-

nel whom we decided to call paramedics. The development of the telemetry systems (voice and electrocardiogram) permitted the remote doctor to give medical commands to the paramedic in the field.5-6 Standing orders and advanced protocols were to come

Figure 1.

Figure 2.

*Deceased.

several years later. At this time there were no training aids, instructional manuals, sup-porting legislation, or special malpractice protections for the fledging paramedic sys-tems. These pioneering systems in the cities previously mentioned and in Miami, at-tracted enormous national media attention and caught the public’s eye so that medical and governmental bodies saw that it was necessary to support and try to lead further development lest they be left behind. The National Highway and Safety Administra-tion was organized in 1966 and this agency furnished some of the initial impetus on the part of the government and offered support under Standard 11 (Emergency Care) and funded research in Miami and later support to the University of Pittsburgh for the first

definitive curriculum to teach paramedics.**

The training of the para-medics in Miami was done in the classroom and in the dog lab, usually at night (fig. 1). After intensive training in CPR including reading of the electrocardiogram, and defi-brillation techniques, we went to the City of Miami fire chief to ask his permission to begin to treat patients in the field. We had been monitoring, com-municating with the doctors in the hospital, and telemetering (fig. 2) since 1967. Our first successful defibrillation and discharge from the hospital

was in June, 1969.7 Emboldened by this success we succeeded in gaining permis-sion for intravenous therapy and drugs

**US Dept. of Transportation Curriculum for Paramedics. Dr. Nancy Caroline did this milestone work while in Dr. Safar’s Dept. of Anesthesiology, Pittsburgh, PA. Continued on Next Page

by demonstrations in front of the City of Miami Commission and Mayor. Finally, we taught intubation and the final exam was the successful intubation of myself and an anesthesia resident (HH) by the six Miami paramedic officers. This convinced our fire chief to allow those so trained to intubate in the field. In effect we now had what was later called “advanced cardiac life support” in the field administered by paramedics and remotely monitored by doctors in the hospital8 (fig. 3).

By the early 1970’s the further develop-ment of emergency medical systems (EMS) was given enormous impetus by a private philanthropy and television programming. The Robert Wood Johnson Foundation gave fifteen million dollars to 44 sites in the US specifically targeted to develop EMS com-munications systems including 9-1-1.

In President Nixon’s State of the Union address in 1973, he cited the more than 115,000 lost lives in accidents each year. However, the same President threatened to veto the EMS act of 1973 and a consortium of physicians traveled to Washington and lobbied with their respective congressmen to overturn the promised veto. A compromise was eventually reached and the Act passed the following year providing nearly $125 million in financial aid for EMS throughout the country. EMS was now established as a necessary service just as is the provision of fire and police protection.

Today, EMS is provided by four main agencies: fire departments, private ambu-lance services, volunteer organizations, and public safety EMS systems (so called third service). The services these agencies provide often include both rotary and fixed wing aircraft. In many areas of the country the off-duty paramedics are also utilized as hos-pital employees, mainly in the emergency departments and intensive care units. The


EMS. . . Continued from Page 9

medical supervision of these EMS systems is usually by members of the newer specialty of medicine called Emergency Physicians.9 There is an organization of such physicians who direct EMS systems nationwide.10 The number of paramedics and EMT’s trained and active in the US is estimated at 815,000 working in some 17,000 ambulance services and there are few areas in the US that are without EMS services.11

The anesthesiologists in the early devel-opment of EMS came from the University of Miami and University of Pittsburgh. Drs. Safar and Nagel were chairmen of the ASA Acute Medicine Committee and members of the AMA’s Commission of Emergency Medical Services. Anesthesiology (ASA) was one of the very first medical specialties to support the development of Emergency Medicine as a medical specialty, first with conjoint boards and later with its own ac-crediting board. In Europe and other parts of the world anesthesiology has a strong role to play both in emergency and intensive care. In the US despite its early contribu-tion to emergency care it has generally left the leadership role to the newer specialty of emergency medicine. This is a natural outcome of the events which made the emer-gency physician the leader in the emergency care departments of the hospital. I would be remiss not to mention Drs. Don Benson and Paul Mesnick, both of whom served as EMS directors during their anesthesia careers. I’m sure that there are more of whom I am not aware.

The future of emergency medicine and EMS remains to be written. In some countries the practice of having physicians aboard the rescue vehicles remains. Mean-while, paramedics are being considered for advance practice in areas such as wilderness medicine and remote areas, off-shore oil rigs,

and some parts of the military. Paramedics have also been dually trained to accompany

SWAT teams which means that they have received both para-medic and police training. In densely populated urban areas EMS systems emphasize rapid response striving for a 4-6 min-ute response from time of call to arrival on the scene. In the suburban and the more rural or remote areas, the response times are necessarily longer and are usually 8-12 minutes or longer. There is little question that modern EMS systems offer the victim a maximal chance for recovery and diminished morbidity. Meanwhile, the

hospital emergency departments regularly receive information from the paramedics on the scene and can prepare for the arrival of the victim properly. Triage begins before the arrival of the patient, as a consequence. Urban EMS providers commonly downplay the role of early treatment in the field where response times are low (usually 4-6 minutes) and where hospital emergency departments are relatively close by. Rural EMS providers take the opposite view because of longer response times and much longer transport times to the more widely dispersed hospi-tals. Since most of the clinical research is done by urban medical centers the EMS literature is slanted toward the urban EMS model. The usual patient groups requiring advanced definitive critical care include: cardiac, stroke, trauma, burns, spinal cord injury, poisoning, high risk infants and mothers, and behavioral emergencies.

Summarizing the history of EMS, it be-gan with the development of resuscitation which Dr. Safar outlines in this issue of the Bulletin. Defibrillation experimentation led, unexpectedly, to discovery of closed chest cardiac massage and CPR. Inten-sive care techniques were exported to the streets in Belfast, Ireland and eventually to the streets in the US. The development of paramedics and the mobile intensive care ambulance was aided by widespread media attention and, eventually, a popular television series, Emergency. The spread of EMS systems in the US and world-wide has forced local and national governmental bod-ies to consider this service as necessary for the public good as fire and police services. The clinical research necessary to prove the ultimate value of the service, scientifically, remains to be carried out. The funding by state and federal grants and subsidies ini-tially (1966-1980) is presently dwarfed by the ongoing support at the city and county

level, country wide. Nearly all major cities have EMS as a part of fire services. Smaller cities and the rural-suburban areas are served by a mix of private ambulance, local government EMS as a third service, and volunteer services. In the author’s mind, the igniting spark that fueled this development was CPR.

References and Notes1. Accidental Death and Disability. Washington,

D.C., National Academy of Sciences, National Re-search Council, 1966.

2. Kouwenhoven, WB, Jude, JR, and Knicker-bocker, GG. Closed-Chest Cardiac Massage. JAMA, 123:1064, 1960.

3. Jude, JR., Kouwenhoven, WB, and Knicker-bocker, GB. Cardiac Arrest: Report of Application of External Cardiac Massage on 118 Patients. JAMA, 178:1063, 1961.

4. Pantridge, JF, Geddes, JS. A Mobile Intensive-Care Unit in the Management of Myocardial Infarc-tion. Lancet, ii (1967): 271-3.

5. Nagel, EL, Hirschman, JC, et al. Telemetery of Physiologic Data: An Aid to Fire-Rescue Personnel in a Metropolitan Area. Southern Med J, 61:598-602, 1968.

6. Nagel, EL, Hirschman, JC, et al. Telemetry-Medical Command in Coronary and other Mobile Emergency Care Systems. JAMA, 214:332-338, 1970.

7. Captain Manuel Padron, City of Miami Fire Rescue administered the first successful difibrilla-tion in the field by a remotely supervised physician.

8. Liberthson, RR, Nagel, EL, et al. Pathophysi-ologic Observations in Pre-Hospital Ventricular Fi-brillation in Sudden Cardiac Death. Circulation, 49:790-798, 1974.

9. American College of Emergency Physicians. 1125 Executive Circle, Irving, Texas, 75038-2522.

10. National Association of EMS Physicians. P.O. Box 15945-281, Lenaxa, Kansas, 66285-5945.

11. American College of Emergency Physicians 1998 “National EMS Week Fact Sheet”.

Figure 3.


MedNuggetsby Fred J. Spielman, M.D.Department of Anesthesiology, University of North Carolina

Thank God, in the 1860’s we had one great boon- Anesthesia! My elders have described to me the horrible ordeal an operation was for patient, surgeons, and witnesses before 1846. The screams and struggles of the patient were heartrending.

—W.W. KeenBoston Medical and Surgical Journal,

187:592, 1922

We are just not getting our story over to the patient and to the public. Let’s make anesthesiology a part of the practice of medicine--not limit it to the operating or delivery room.

—H. Boyd StewartAnesthesiology, 10:223, 1949

For myself, I am repaid for the anxi-ety and often wretchedness which I have experienced since I first discovered and introduced the anesthetic qualities of ether, by the consciousness that I have thus been the instrument of averting pain from thousands and thousands of maimed and lacerated heroes, who have calmly rested in a state of anesthesia while undergoing surgical operations, which otherwise have given them intense torture.

—William T.G. MortonMay, 1864 (Civil War memoir)

The necessity of enlarging the field of regional and local anesthesia cannot be emphasized too much. To my mind it should take the place of general anesthesia wherever this is feasible and I know I do not stand alone in this demand.

—Willy MeyerAmerican Journal of Surgery, 1:63, 1926

While surgeons know that a competent anaesthetist is one of the important factors in the operating-room for his own comfort, as well as that of his patient, there is no class of work that has so little encourage-ment, and few are willing to follow this line of work long enough to become familiar with the first requirements of a good an-aesthetizer.

—Alice MagrawSurgery, Obstetrics and Gynecology,

3:795, 1906

The only completely safe procedure for the control of pain during labor is psycho-therapy or hypnosis; there is some danger

associated with the use of any drug, even in small doses.

—L.E. ArnoldTexas State Journal of Medicine, 37:211,

1941

To make all patients fit one type or agent of anesthesia is as stupid as making the pa-tient fit an operation instead of adapting the procedure to the individual patient.

—Allen O. WhippleSurgery, 25:172, 1949

The patient is taking a greater risk in the hands of the poorly trained and inexpe-rienced anesthetist than he is at the hand of the amateur surgeon.

—Frances E. HainesAnesthesia and Analgesia, 6:25, 1927

Comparatively few members of the medi-cal or legal profession sufficiently realize that women, during the induction period of narcosis, are subject to hallucinatory and delusional sensations, identical with the eroticism and orgasm associated with the sexual act.

—F. Hoeffer McMechanAnnals of Surgery, 58:956, 1913

The skill and experience of the anesthe-tist will determine his choice of anesthetic agent and technic. It is safer for him to adopt the method with which he is most skillful rather than to attempt to follow the rule of someone else.

—Ralph M. Waters, M.D.American Journal of Surgery, 39:470,

1938

It has not been possible to find in the literature any subjective account of the effect of intramuscular suxamethonium and intubation in the conscious patient. Therefore, it was felt that the experiences of a trained medical observer under the influ-ence of intramuscular suxamethonium, but unanaesthetised, would be of value and one of us acted as a subject of the experiment to be described.

—J. T. DavidsonAnaesthesia, 16:227, 1961

Unless the indications for a spinal an-aesthetic are very definite don’t use it in fat, flabby, or dehydrated patients.

—E. Hill FalknerBritish Journal of Anaesthesia, 15:142,

1937-8

The present-day utilization of new anesthetic agents, modern gas machines, improved technics and certain combinations of agents has given general anesthesia a flexibility and safety indicative of important progress in recent years.

—Leo P. ZentgrafNew England Journal of Medicine,

22:437, 1943

Anesthesiologists are, in the main, a group of young physicians. It is their re-sponsibility to acquaint themselves with the trends in the economic aspects of medicine and to participate actively and positively in the formulation of a suitable plan for the provision of self-supporting medical service to the low income group.

—EditorialAnesthesiology, 5:193, 1944

Anesthesia greatly needs investigators capable of working in the basic sciences. As long as anesthesia leads a parasitic exis-tence, scientifically speaking, depending as it does almost wholly on scientists in other fields for fundamental developments, it can hardly have much stature among other and stronger medical disciplines.

—Henry K. BeecherJournal of the American Medical Associa-

tion, 172:449, 1960



Lewis H. Wright Memorial Lecture:Dale C. Smith, Ph.D., to Discuss “Anaesthetists: Arguments, Attainments, and Authority, 1870-1920” by Kathryn E. McGoldrick, M.D.Chair, Lewis H. Wright Memorial Lecture CommitteeTrustee, Wood Library-Museum of Anesthesiology

The Lewis H. Wright Memorial Lecture, sponsored annually by the Wood Library-Museum of Anesthesiology, honors its namesake, an indefatigable pioneer in American anesthesiology who was devoted to enhancing the stature of anesthesiology as a clinical science and medical specialty. A dynamic innovator, Dr. Wright was a founding member of the Board of Trustees of the Wood Library-Museum and, in later years, served as its President-Emeritus. He was also a founder of the World Federation of Societies of Anaesthesiol-ogists in 1955, working in close collaboration with Harold Griffith, M.D.

This year’s distinguished Wright Me-morial Lecturer is Dale C. Smith, Ph.D., Professor and Chairman of the Depart-ment of Medical History at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. His lecture, titled “Anaesthetists: Arguments, Attainments, and Authority, 1870-1920,” will be delivered at the ASA Annual Meeting on Tuesday, Oc-tober 16, 2001, at 1:00 p.m. in New Orleans. Dr. Smith will describe the emergence of a protospecialty of anesthesiology and discuss why its acceptance remained a minority opinion during the early years of the twen-tieth century.

Born in Orlando, Florida in 1951, Dr. Smith has an impressive academic back-ground, having received his B.A. degree from Duke University and his Ph.D. in History of Medicine from the University of Minnesota. Dr. Smith has written exten-sively and has delivered numerous lectures nationally and internationally. Among the many eponymous lectures to Dr. Smith’s credit was the Annual Samuel Clark Har-vey Memorial Lecture held in 1991 at Yale University School of Medicine where he spoke about “Curing with Cold Steel: The Emergence of Surgery as a Therapeutic Op-tion 1880-1930.” Other presentations reflec-tive of his eclectic historical interests have explored medicine’s place in the university, the Flexner report and its consequences, a historical perspective on surgical training and certification in the United States, the impact of the Civil War on orthopedic sur-gery, the influence of malaria on military

WLM Board of Trustees Meeting, 10/14/2000, San Francisco, CA.From Left: seated, Drs. Elliott V. Miller, T. B. Boulton (2000 Laureate), Donald Caton, Kathryn E. McGoldrick, Nicholas M. Greene, Doris K. Cope; 2nd Row, Drs. Adolph H. Giesecke, Susan A. Vassallo, William D. Hammonds, Mary Ellen Warner, Leroy D. Vandam, John W. Pender, Patrick Sim (Librarian), Selma H. Calmes; 3rd Row, Drs. Alan D. Sessler, George S. Bause, Jonathan C. Berman, Douglas R. Bacon, and Charles C. Tandy.

operations and medical history, the role of women in American medicine, the influence of anesthesia on the development of modern surgery, and an historical perspective on medical malpractice litigation in America.

Anyone who has had the good fortune of hearing Dale Smith speak knows that he possesses a savant’s reverence for accuracy, provenance, and context. Yet, his erudition sparkles with a vibrant wit and an unwilling-ness to be held hostage by the tyranny of convention. An insightful, engaging, and provocative speaker, Dr. Smith is fascinated by the romance and humor of history. None-theless, he is a consummate realist with no tendency to hide the less savory moments of our past nor to give a glossy make-over to historical figures. His lectures provide a palimpsest of historical references, suggest-ing by turns the cultural values as well as the political, economic, geographic, and social

factors that have shaped medicine. Adapt at exposing myths and misconceptions, Dr. Smith is not one to package a tidy set of simplistic historical images suggesting that medical history is a neat continuum moving toward perfectly realized objectives. Rather, he reflects an abiding appreciation of the concept that the “real” picture is vastly more intriguing than the retouched and sanitized version.

The Wood Library-Museum of Anes-thesiology is honored to have the eminent medical historian Dale Smith as the 2001 Lewis H. Wright Memorial Lecturer. And we thank him for his unique gift of infusing life and relevancy into our medical heritage, rather than merely preserving it like an insect in amber.


Forum on the Writing of the History ofAnesthesiologySponsored by the Wood Library-Museum of Anesthesiology

1. Getting Started: What is a good proj-ect to undertake?Douglas R. Bacon, M.D., M.A.Associate Professor, Mayo Clinic Rochester, Minnesota

2. Funding Resources: How can I get money to research history?Dale C. Smith, Ph.D.Professor and ChairDepartment of Medical HistoryUniformed University of the Health SciencesBestheda, Maryland

3. Historical Resources Available at the Wood Library-Museum of Anes-thesiologyDoris K. Cope, M.D.Professor, Anesthesiology and Critical Care MedicineClinical Director, UPMC Pain MedicineUniversity of PittsburghPittsburgh, Pennsylvania

4. Out of Print, Out of Date: How can I find this Resource?Patrick Sim, MLSLibrarianWood Library-Mueseum of AnesthesiologyPark Ridge, Illinois

5. What’s in Cyberspace: Finding the History of Anesthesia on the WebAJ Wright, MLSLibrarianDepartment of AnesthesiologyUniversity of Alabama at Birmingham 6. Learning from “Professional Histo-rians”: Writing history the “right” waySelma Calmes, M.D.Professor and ChairDepartment of AnesthesiologyOlive View-UCLA Medical CenterSylmar, Calfornia

7. Publishing the Results of Your EffortsDonald Caton, M.D.Professor of Anesthesiology and ObstetricsUniversity of FloridaGainsville, Florida

8. Discussion

ASA History Panel:Colorful Figures and Moments of Conflict in the History of Anesthesiology

Objectives: After attending this panel, participants will have a greater understanding of several of the major controversies in the history of anesthesiology. The participant will learn to appreciate the historical background to important events that impacted on the develop-ment of the specialty of anesthesiology. This information will be helpful in understanding how certain relationships developed in anesthesiology and will influence the development of anesthesiology in the future.

Moderators: Douglas R. Bacon, M.D., M.A.Associate Professor of AnesthesiologyMayo ClinicRochester, Minnesota

Maurice Albin, M.D., M.Sc.Professor of Anesthesiology and NeurosurgeryUniversity of Texas at San AntonioSan Antonio, Texas

Patenting Letheon: The Morton-Jackson Gambit Ines H. Berger, M.D. Assistant Professor Mayo Clinic Rochester, Minnesota

James Young Simpson and Obstetrical Anesthesia: Science vs. God? Donald Caton, M.D. Professor of Anesthesiology and Obstetrics University of Florida Gainsville, Florida

The Brain Under Pressure—Harvey Cushing’s Triad:Where are the References?

Maurice Albin, M.D., M.Sc.

Francis Hoeffer McMechan and the International College of Anesthetists: Whatever Happened?

Robert P. Sands, Jr., M.D. Assistant Professor of Clinical Anesthesia SUNY at Buffalo Buffalo, New York The Quest for Credentials: The American Board of Anesthesiologists, the American As-

sociation of Nurse Anesthetists and a Very Curious Passing Moment Douglas R. Bacon, M.D., M.A.

If the A-Bomb Strikes: What Anesthetic Should We Stockpile? David B. Waisel, M.D. Instructor of Anesthesiology Boston Children’s Hospital, Harvard University Boston, MA


The Book Cornerby Peter McDermott, M.D.

Careers in Anesthesiology: Two Posthumous MemoirsM. T. Jenkins, M.D., A Biography by Adolph H. Giesecke, M.D.

Francis F. Foldes, M.D., An Autobiography with Contributions by Ephraim S. Siker, M.D.

Edited by B. Raymond Fink and Kathryn E. McGoldrickWood Library-Museum 2000 ESBN 1-889595-03-9

historians. There is enormous potential for the biographer to exercise a kind of abuse of power. Biographers (or biografiends as James Joyce called them) are burdened with known and unknown biases: they have a sort of “cafeteria privilege.” They decide what facts and events to incorporate into their work and those must necessarily be but a small part of the available whole, and they may not even constitute a representative sampling. As a genre biography is a hybrid at best and a mongrel at worst. For those who approach it from the realm of literature, it is an art. For historians it is supposed to represent an attempt to contextualize a life and its significance by a sustained act of attention.

It is truly said that the biographer has added a new terror to death. “You can die, but you can’t hide.” The greatest fear is perhaps contained in the following state-ment of peculiar encouragement: “Anyone can do biography who puts half a mind to it. Indeed, half a mind is usually all the subject gets, since biography, as a well known retire-ment pastime, is frequently a matter of the half-dead chasing the dead.”

These two memoirs, the first a biogra-phy and the second an autobiography with comments, are about anesthesiologists written by anesthesiologists. The first one,

Giesecke’s homage to “Pepper” Jenkins, is a well-written tribute by a disciple to one of the truly great men in our specialty. “ Buddy” Giesecke (for everyone in Texas has a nickname) follows a narrative chro-nology of a remarkable founder of modern anesthesiology. It is astonishing that in one too brief lifetime so great a transforma-tion in a medical specialty could occur. Of course it didn’t happen by itself. Men and women like Pepper had the genius and the skill to recognize possibilities and to effect changes. Pepper was a gifted clinician and an educator, a passionate representative of his specialty, and one of the kindest, warmest people I’ve ever met. All this and more shows through in Giesecke’s detailed and lively hagio-graphical story of one of the giants who redefined anesthesiology according to its potential as the scientific discipline it has since become. This is what we historians call a “good read.”

No less fascinating is the life of Francis Foldes. He was born in the Jewish quarter of Budapest in 1910 and didn’t emigrate to the United States until 1941. It is almost impos-sible to describe the significance of this time period, this geographical location, and the terrors and uncertainty of life as a Hungar-ian Jew. Most of what I had known about Foldes was related to his research work

specifically on muscle relaxants. His vivid retelling of his childhood and youth and the intercontinental career that followed his escape from Europe are poignant and inspiring. Courage, tenacity, and good for-tune were the bedrock upon which he built a life as a scientist, scholar, and educator.

In his own words:All my life, awake and in my

dreams, I have been haunted by the tormenting question: why was I spared from the horrors of the Ho-locaust when three beloved brothers and the majority of my classmates in the graduating class of the Jewish Gymnasium in Budapest perished without a trace, in their prime of life. To preserve my sanity, I had to believe I survived to be able to help others, just as I have been helped, through the grace of providence and by many people . . . There is a great movie struggling to get

out of this biography. But until it is made, you should not miss the book.

“... Physicians must have art in their system to practice

good medicine, and practically allphysicians could paint if they

were stimulated to do so.It is really lifesaving for

a physicianto create some form of art

as a hobby, and for the physicianwho is retired

such an acquired hobbybecomes a paramount importancefor his well-being and happiness.”

Sir William Osler

“... Los médicos deben tener arteen su sistema para prácticar buena

medicina,y prácticamente todos los médicos

podrían pintarsi fueran estimulados a hacerlo.

Es realmente una medida de salvar suvida

para el médico crear alguna forma de artecomo entretenimiento, y para el médico

que está retiradoese entretenimiento adquirido es de

principal importanciapara su bienestar y felicidad.”

Sir William Osler

Biography has fallen out of style among

Spanish translation by Miguel Colón-Morales, M.D.


From the Literatureby A.J. Wright, M.L.S.Department of Anesthesiology Library, University of Alabama at Birmingham

Note: In general, I have not examined articles that do not include a notation for the number of references, illustrations, etc. I do examine most books and book chapters. Books can be listed in this column more than once as new reviews appear. Older articles are included as I work through a large backlog of materials. Some listings are not directly related to anesthesia, pain or critical care but concern individuals important in the history of the specialty [i.e., Harvey Cushing]. Non-English articles are so indicated. Columns for the past several years are available in the “Anesthesia History Files” at http://www.anes.uab.edu/aneshist/aneshist.htm as “Recent Articles on Anesthesia History.”

Books [I would like to thank Dr. Joseph Rupreht of

Rotterdam for alerting me to the items by Jukic and Pokorny below. I urge readers to send me any citations, especially those not in English, that I may otherwise miss!—A.J. Wright [email protected]]

Booth M. Opium: A History. New York: St. Martin’s Griffin, 1999. 381pp. [Rev. Young JH. Bull Hist Med 75:158-159, 2001]

Elkins J. Pictures of the Body: Pain and Metamorphosis. Stanford: Stanford University Press, 1999. 347pp. [Rev. Gilman SL. Bull Hist Med 75:185-186, 2001]

Fenster JM. Ether Day: The Strange Tale of America’s Greatest Medical Discovery and the Haunted Men Who Made It. San Francisco: HarperCollins, 2001. 256pp.

Gootenberg P, ed. Cocaine: Global Histories. London: Routledge, 1999. 213pp. [Rev. Young JH. Bull Hist Med 75:158-159, 2001]

Jay M. Emperors of Dreams: Drugs in the Nineteenth Century. Sawtry: Dedalus, 2000. 277pp. [includes nitrous oxide, opium, ether, cocaine]

Jukic M. Anaesthesiology in Croatia (From Ivo Bettini until now, year 1998). Zagreb: Medi-cinska Naklada, 1999. 272pp. Illus. [Croatian]

Pokorny J, Bohus O, et al, eds. Anaesthesiol-ogy and Resuscitation in the Czech and Slovak Republic: On the Way to Specialty Independence. Prazska Vydavatelska Spolecnost, 1996. 184pp. Illus. [Czech]

Schulte am Esch J, Goerig M, eds. Proceedings of the Fourth International Symposium on the History of Anaesthesia. Lubeck: Verlag Drager Druck, 1999. 878pp. [Rev. Smith TC. Anesth Analg 92:1078, 2001]

Spillane JF. Cocaine: From Medical Marvel to Modern Menace in the United States, 1884-1920. Baltimore: Johns Hopkins University Press, 2000. 214pp. [Rev. Courtwright DT. J Hist circle. 19th Century Music 21(2):223-243, 1997.

Gagnon RE, Macnab AJ, Blackstock D. An inventory of Canadian anesthesiology: human Continued on Next Page

Med Allied Sci 56:89-90, 2001; Young JH. Bull Hist Med 75:158-159, 2001]

Articles and Book Chapters Altzinger G, Reckel P. History of aspirin in

the Grand Duchy of Luxembourg. Bull Soc Sci Med Grand Duche Luxemb 1:55-73, 2000. [French]

Bacon DR. The Wood Library-Museum of Anesthesiology: WLM dedicates curator’s room in John Lundy’s honor. ASA Newsletter 65(4):23, 2001. 2 illus.

Bacon DR, Albin M, Pender JW. Anesthesiol-ogy’s greatest generation? Anesthesiology 94:725-726, 2001. 1 illus., 2 refs. [Editorial]

Ball C, Westhorpe R. The history of intrave-nous anaesthesia: the barbiturates, part 1. Anaesth Intens Care 29:97, 2001. Illus., 6 refs. [Cover note]

Batt RE, Bacon DR. Clarence J. Durshordwe, the International Anesthesia Research Society, and the World Federation of Societies of Anes-thesiologists: the last true disciple of Francis Hoeffer McMechan. Anesth Analg 92:1349-1354, 2001. 5 portraits, 11 refs.

Bergfeld D, Hanke CW. Historical back-ground. In: Hanke CW, Sommer B, Sattler G, eds. Tumescent Local Anesthesia. New York: Springer, 2001, pp. 5-8. 20 refs.

Bhatt AD. Aspirin: aspiring for a century (1899 to 1999) and the willow bark is still batting! J Assoc Physicians India 46:374-376, 1998.

Bush GH. Gordon Jackson Rees FRCA FRCP FRCPCH, pioneer of paediatric anaesthesia. An-aesthesia 56:370-371, 2001. 1 portrait. [Obituary]

Bush GH. Gordon Jackson Rees FRCA FRCP FRCPCH, pioneer of paediatric anaesthesia. European Academy of Anaesthesiology Newsletter no. 14: 14, May 2001. 1 portrait.

Bynum WF. Ether at University College Hospital 1846. In: Kaufman L, Ginsburg R, eds. Anaethesia Review 13: 1-4, 1997. 1 illus., 11 refs.

Carli F. Dr. John W. Sandison 1927-2000. Can J Anesth 48:316-317, 2001 [obituary].

Cheng TO. Who discovered circulation of blood? Ann Intern Med 134: 1008-1009, 2001. 5 refs.

Cooper SM, Dawber RPR. The history of cryosurgery. J Roy Soc Med 94:196-201, 2001. 2 illus., 44 refs.

Cortiula M. Collecting blood for battle: the wartime origins of the transfusion service in New South Wales. J Roy Aust Hist Soc 85(2):105-119, 1999.

Cousin M-T. L’apport des scientifiques fran-cais a l’anesthesiologie: les curares et la jonction neuromusculaire. Hist Sci Med 34(3):219-230, 2000 [French].

Feurzeig L. Heroines in perversity: Marie Schmith, animal magnetism, and the Schubert.

research from 1995 through 1999. Can J Anesth 48:452-458, 2001. 10 tables, 7 refs.

Giesecke AH. John F. Kennedy and M.T. “Pep-per” Jenkins: a moment in Dallas that lasted 29 years. Am J Anesthesiol 28: 102-104, 2001. 3 illus., 5 refs. [Rep. Bull Anesth History 18(3):1,4-5, 2000]

Goldman ND. Nasal airway devices from ancient history to the present. Facial Plast Surg Clin N Amer 7:379-390, 1999. 16 illus., 39 refs.

Goldman R, Blickstein I. Dr. Virginia Ap-gar—1909-1974. Harefuah 140: 177-178, 2001. [Hebrew]

Guivarc’h M. Antoine-Joseph Jobert de Lam-balle 1799-1867 ou l’Essor de la chirurgie mod-erne. Hist Sci Med 34(3):253-270, 2000. [French]

Harris NA, Hunziker-Dean J. Florence Hen-derson: the art of open-drop ether. Nurs Hist Rev 9:159-184, 2001. 4 illus., 68 notes.

Hawgood BJ. Silas Weir Mitchell (829-1914): toxicologist, neurologist and novelist. J Med Biog 8:63-70, 2000. 2 illus., 57 refs.

Hessel EA II. History of cardiac surgery and anesthesia. In: Estafanous FG, Barash PG, Reves JG, et al. Cardiac Anesthesia: Principles and Clinical Practice. 2nd ed. Philadelphia: Lip-pincott Williams and Wilkins, 2001, pp. 3-35. 1 illus., 7 tables, 303 refs.

Howat DDC. Sir Frederic William Hewitt MVO MD. J Med Biog 8:123, 2000. [correction to author’s article on Hewitt in J Med Biog 7:63-68, 1999]

Keynes M. The aching head and increasing blindness of Queen Mary I. J Med Biog 8:102-109, 2000. 4 illus., 59 refs.

Lawin P, Opderbecke HW, Schuster HP. History of the development of intensive care in Germany—contemporary reflections. 12. The development of intravenous infusion techniques from personal experience. Anaesthesist 48:919-923, 1999. [German]

Lehmann DF, Roberts G, Moellentin D. The search for a nonaddicting opioid. Pharos 64(1):24-27, 2001. 3 illus., 22 refs.

Leveau P. L’anesthesie et les techniques de reanimation des noyes. Hist Sci Med 34(3):249-252. [French]

Lopez-de la Pena XA. First anesthesia with ether in Aguascatientes, Mexico. Gac Med Mex 137:85-86, 2001. 10 refs. [Spanish]

Lundy JS. From this point in time: some memories of my part in the history of anesthesia. AANA J 65:323-328, 1997. 2 illus., 1 ref. [Rep. AANA J 34:95-102, 1966]

MacDougall S, Blair J. L’anesthesie survint rapidement; l’anesthesiste suivit plus lentement: histoire de la dissemination de la decouverte de l’anesthesie dans le Royaume Uni et les Etats Unis d’Amerique. Hist Sci Med 34(3):213-217, 2000. [French]

Maurizio B. L’analgesia generale in travaglio di parto: da James Young Simpson (1847) ai giorni nostri. Lanternino 23(3):12-17, 2000. [Italian]


Peter Mark Roget and the Bristol Ni-troux Oxide Experiments, 1799-1800*by A.J. Wright, M.L.S.Department of Anesthesiology Library, University of Alabama at Birmingham

Nitrous oxide is an anesthetic gas also widely known as “laughing gas.” Humans first inhaled nitrous oxide more than 200 years ago, and its anesthetic properties were first explored in the 1840s. Used in dental and short surgical procedures, nitrous oxide remains one of the most frequently-used anestheltic gases in the world. The gas is also a component of youth “rave” or dance culture in the United States and Great Britain, and appeared regularly among the legion of fans who followed the Grateful Dead musical group from city to city.1-2 Rec-reational use of the gas has been reported at Philadelphia Eagles football games, and its abuse sometimes results in death due to oxygen deprivation.3-5 Famous recreational or self-medication users of nitrous oxide have included William James, Timothy Leary and Hunter S. Thompson.6-8

The first person to isolate nitrous oxide was Joseph Priestley. The British Unitarian minister, prolific author and scientist had begun experiments on “airs” or gases in 1770. In the summer of 1773 Priestley be-came librarian and intellectual companion to William Petty, Earl of Shelburne. This position gave Priestley even more time and resources for his chemistry work with such gases as oxygen, carbon dioxide, nitrogen dioxide and nitrous oxide. Between 1774 and 1786 Priestley published six volumes of a work entitled Experiments and Obser-vations on Different Kinds of Air, which included material on nitrous oxide.

Priestley envisioned future medical uses for these “factitious airs,” as he called the gases. “I cannot help flattering myself,” he wrote, “that, in time, very great medicinal use will be made of the application of these different kinds of air to the animal system. Let ingenious physicians attend to this subject, and endeavor to lay hold of the new handle which is now presented them…”9

By the late 1790s a number of physi-cians had begun experiments with some of the gases.10 One of the most energetic of these investigators was Thomas Beddoes. After undergraduate work at Oxford, Bed-does studied medicine for three years in

*Some of this material was presented at the annual meeting of the Southeastern American Society of Eighteenth Century Studies, Huntsville, Alabama, March, 2001.

Edinburgh, at that time one of Europe’s greatest centers of medical education. His instructors there included chemist Joseph Black, who had discovered carbon dioxide. After receiving his medical degree, Beddoes embarked on the standard continental tour of newly-minted physicians. His trip in-cluded France, where he met Lavoisier. By 1788 Beddoes had returned to Oxford as a reader in chemistry. Some accounts contend he became the most popular lecturer there since the thirteenth century.

Yet Beddoes, like Priestley, could not refrain from supporting political radical-ism. He was an early supporter of both the French and American revolutions. One of his recent biographers declares, “In the 1790s, Beddoes was a fiery radical. I do not believe his radicalism ever diminished. His expectations of rapid and imminent political improvement did not, however, last beyond about 1795.”11 During the years at Oxford Beddoes also developed interests in education, public health and the potential medical applications of gas inhalation. English balloonist James Sadler designed equipment for Beddoes’ chemistry classes and breathing apparatus to be used in the doctor’s clinical work. Beddoes sought a treatment for tuberculosis and other respira-tory ailments that were increasing as Britain rapidly industrialized. Beddoes also devel-oped relationships with physician Erasmus Darwin and industrialist and chemist James Keir, who were members of the loosely-organized Lunar Society, which has been described as “an eighteenth-century tech-nological research organization.”12 Through Keir and Darwin, Beddoes met other mem-bers of the group who would become impor-tant supporters of his gas research. These men included Richard Lovell Edgeworth, Josiah Wedgewood and James Watt and his partner Matthew Boulton. In 1793 Beddoes published Letter to Dr. Darwin, one of the first of his many accounts of “a new mode of treating pulmonary consumption.”13

By the early 1790s Beddoes political radicalism made him a notorious figure in Oxford. He was condemned to Parliament by locals for “sowing sedition” via his broad-sides and public speeches. By April 1793 Beddoes had departed Oxford “marked as a revolutionary.”14 The doctor settled in Clif-ton, near the Bristol seaport in southwestern England and also close to the Hotwells, a

hot springs resort that attracted the wealthy sick from all over Britain. Beddoes was introduced into Bristol society by Richard Lovell Edgeworth, a wealthy Irishman and Lunar Society member who brought his consumptive son Lovell to the hot springs. In April, 1794, Beddoes married Anna, one of Edgeworth’s daughters.

For the next several years, in the midst of a busy clinical practice and revolutionary journalism with Samuel Taylor Coleridge who resided in Bristol at this time, Bed-does began to raise money for his visionary Pneumatic Medical Institute. He expected the Institute to include three primary activi-ties: research, teaching and clinical care. These three elements are today the pillars of academic medical centers all over the world, yet this combination was essentially unknown in the late eighteenth century. By 1798 Beddoes was ready to begin and purchased two houses on Dowry Square in Clifton for his Institute.

In the preceding years Beddoes and James Watt had formed a working rela-tionship in the search for medical care for consumptives. Watt’s daughter Jessie had died of the disease.15 The firm of Boulton and Watt designed and distributed breath-ing apparatus as specified by Beddoes, and Watt and the doctor published a three-volume work describing the clinical efforts of Beddoes and other physicians in England and the apparatus their patients were us-ing to breath gasses—primarily oxygen. Lunar Society members who contributed financially to Beddoes’ project included Watt, Darwin, Edgeworth, Boulton, Keir and Josiah Wedgewood. The sons of several of these men would also participate in the nitrous oxide trials in Dowry Square.

Beddoes wanted to hire a research director for his Institute and on the recom-mendation of his good friend Davies Giddy [later Gilbert], he hired a young man from Penzance named Humphry Davy. In early October, 1798, Davy arrived in Bristol. The two houses in Dowry Square had been altered to make room for a lecture room, space for outpatient care and a few beds for inpatients, and the laboratory where Davy began research on the gases using Watt’s equipment and other equipment designed by William Clayfield. By March, 1799, Davy had begun trials of human inhalation of nitrous oxide. Between that time and the


Continued on Page 18

end of the trials in May or June of 1800, more than 40 healthy individuals had tried the gas from a breathing bag at least once; more than 80 outpatients had been seen by early April 1799.16 One of the individuals at the Institute who began by assisting Davy in the laboratory and who also participated in the nitrous oxide experiments was Peter Mark Roget.

Roget was born in Broad Street in Soho on January 18, 1779.17 He was the son of John Roget, a Swiss minister who had come to England to take charge of a French con-gregation in London. Soon he moved to a chapel in Soho and married Catherine, the daughter of Sir Samuel Romilly, a politician and reformer who was a member of that con-gregation. The elder Roget returned to Swit-zerland soon after Peter was born. He appar-ently suffered from tuberculosis and sought a better climate. However, John Roget died in 1783, and Peter and his mother came back to England to live with a Mr. Chauvet, who operated a small school in Kensington. As a student there, Peter showed an early skill at mathematics, and when he was fourteen his mother moved with him and younger sister Nanette to Edinburgh and enrolled him in the university. Two years later he entered the medical school and on June 25, 1798, at the age of nineteen, received his medical degree. His thesis, entitled De Chemicae Afiinitatis Legibus, explored the laws of chemical affinity.

After graduation Roget began a period of travel that would take him to Bristol, London and Geneva over the next six years. After sightseeing trips around the English Lake district, Roget visited Erasmus Darwin at Derby, James Keir near Birmingham and arrived at Beddoes’ Pneumatic Institution in the late summer of 1798. About a year later he left Bristol, traveled some with his mother, and arrived in London in the fall of 1800. In that city he spent over a month in the household of Jeremy Bentham, with whom he had already corresponded in some detail about the nitrous oxide experi-ments. Their discussions included Roget’s ideas about London’s sewage and work on Bentham’s Frigidarium project, a sort of commercial icehouse. Roget took further medical studies under Dr. Robert Willan at the Public Dispensary and St. George’s Hospital, and attended lectures by such prominent figures as Matthew Baillie, Wil-liam C. Cruickshank, William Heberden and James Wilson.

By June 1801 Roget had begun another period of travel. First he visited James Watt in Birmingham, then spent Christmas Day with James Keir at Hill Top near that city. Over the following several days he toured

several of the great factories in the area. After visits with family connections in Man-chester and Liverpool, Roget settled into a job as tutor to the two young sons of John Philips, who owned the largest cotton-mill in Manchester. Roget and the boys sailed for the European continent in February, 1802.

Over the next 20 months Roget’s group traveled to Geneva, then located in France; Switzerland, and such German cities as Stuttgart, Frankfurt and Berlin. His adult companion was Lovell Edgeworth, the half-brother of author Maria Edgeworth. Roget and his charges returned to Manchester in December, 1803, and Roget then became physician to that city’s infirmary. This post, a prestigious one for a 25-year old physician, led to Roget’s involvement in the beginnings of medical education in Manchester. Roget and several other physicians began a series of medical lectures in rooms provided by the Manchester Literary and Philosophi-cal Society. Roget’s first series of eighteen lectures began on January 29, 1806, and covered chemistry, anatomy, and physiology. In 1805 Roget had begun a classified catalog of words that would serve as the blueprint for his great thesaurus almost 50 years later. Yet Roget eventually became disillusioned with his situation in Manchester and in late October 1808 resigned his appointments in the city and returned to London.

Roget’s uncle Samuel Romilly bought him a house at 39 Bernard Square in Janu-ary 1809, and that remained his home for 40 years. Having given up the frequent travel and changes of employment, Roget began a spectacular chain of achievements and hon-ors. In March 1809 he received his license from the Royal College of Physicians and later became a member of the equally pres-tigious Royal Institution where he lectured alongside such distinguished company as his old acquaintance Humphry Davy. He also lectured at the Russell Institute near his home. Along with a friend from medi-cal school and Physician to Guy’s Hospital, Alexander Marcet, Roget worked tirelessly to promote the Medical and Chirurgical Society, which had formed in 1805 as the second medical society in England.

Samuel Romilly and several other bene-factors supported the Northern Dispensary, which Roget founded and served without pay for 18 years. In 1820 Roget received an appointment as physician to the Span-ish embassy. Three years later he was also appointed physician to a major prison, the Millbank penitentiary. In 1824 he became Secretary of the Royal Society, and in 1831 was elected a fellow of the Royal College of Physicians. In November, 1824, at the age of 45 Roget married Mary Taylor Hobson,

the daughter of a wealthy Liverpool busi-nessman. Mary and Peter had two children, John and Kate, before Mary died of cancer at 38 in April, 1833. Roget never remarried.

By the time he retired in 1840, Roget had published more than 90 papers on medical and other topics in publications ranging from the Royal Society’s Philosophical Transactions to the Encyclopedia Britan-nica. Roget’s Bridgewater treatise, Animal and Vegetable Physiology of 1834 was a ma-jor influence on Tennyson’s great poem In Memoriam.18 His most famous paper is per-haps “Explanation of an Optical Deception in the Appearance of the Spokes of a Wheel” published in the Philosophical Transactions in 1825. In this piece Roget described an illusion of the movement he had noticed while observing a carriage wheel through a window with Venetian blinds. This paper is widely cited as the first description of the physiological phenomenon that makes the illusion of motion pictures possible. Among other accomplishments Roget also designed a slide rule and a portable chess set.

After his retirement, Roget began work in earnest on the project for which he is so well-known today. The first edition of his thesaurus appeared in January, 1852, in an edition of 1000 copies costing 14 shillings each. Roget received 12 free copies and half the profits. By the time Roget died in Sep-tember, 1869, at the age of 90, twenty-eight more editions of the work had appeared. A fitting tribute to Roget’s thesaurus appears several times in James M. Barrie’s classic Peter Pan, most importantly as Captain Hook’s one redeeming quality: “The man is not wholly evil—he has a Thesaurus in his cabin.”

Roget’s participation in the Bristol nitrous oxide experiments can be character-ized as a minor episode in a long life filled with many other accomplishments. In retrospect, those experiments fill a similar role in the careers of other individuals who participated. Poets Samuel Taylor Coleridge and Robert Southey had lived in Bristol since the early 1790s; Beddoes had worked with Coleridge on the latter’s short-lived democratic newspaper The Watchman. Poets Anna Letietia Barbauld and George Burnett also participated, as did Barbauld’s husband, the Rev. Rochemont Barbauld. Southey friends Grosvenor Bedford and John Rickman were there. Rickman created the first national census in Great Britain in 1801 and served for almost forty years as Secretary to the Speaker of the House of Commons. Such famous sons as Joseph Priestley, Jr., James Watt, Jr., Lovell Edge-worth, and Tom and Josiah Wedgewood, Jr.,


Roget. . . Continued from Page 17

joined the research effort at the Pneumatic Institution. Novelist Maria Edgeworth and poet and publisher Joseph Cottle were among those who observed the activities at Dowry Square but did not inhale the gas themselves.

Today we might characterize these events as the youthful indiscretions of participants in one of the earliest experiments with a consciousness-expanding drug.19 In Decem-ber 1799 Beddoes published a pamphlet of almost 50 pages, which is the first extensive account of the nitrous oxide research.20 Re-actions of some participants to inhalation of the gas are included. In the summer of the following year Humphry Davy published a massive account of the laboratory, animal and human experiments on nitrous oxide over a period of about a year. About 80 of the 580 pages of this book contain descriptions by many participants of the effects they felt after breathing the gas.

Davy himself noted that under the influence of nitrous oxide he “…existed in a world of newly connected and newly modified ideas. I theorized; I imagined that I made discoveries….I have often felt very great pleasure when breathing it alone, in darkness and silence, occupied only by ideal existence.” James W. Tobin, brother of play-wright John Tobin, felt that “My senses were more alive to every surrounding impression; I threw myself into several theatrical at-titudes and traversed the laboratory with a quick step; my mind was elevated to a most sublime height.” Coleridge described his reaction on one occasion as “…of more un-mingled pleasure than I had ever before ex-perienced.”21 Robert Southey also writes his brother Thomas in July 1799 and declared, “Oh, Tom! Such a gas has Davy discovered, the gaseous oxyde! O,Tom! I have had some; it made me laugh and tingle in every toe and fingertip. Davy has actually invented a new pleasure, for which language has no name!…I am sure the air in heaven must be this wonder-working gas of delight!”22

Roget’s reaction is more restrained, although his biographer claims “the ex-perience shook him to his boots.”23 Roget declared that “I cannot remember that I experienced the least pleasure from any of these sensations.” Yet he did observe that “…I seemed to lose the sense of my own weight, and imagined I was sinking into the ground…My ideas succeeded one another with extreme rapidity, thoughts rushed like a torrent through my mind, as if their velocity had been suddenly acceler-ated by the bursting of a barrier which had before retained them in their natural and

equable course.” Roget also declared that “My whole frame felt as if violently agitated: I thought I panted violently: my heart seemed to palpitate, and every artery to throb with violence.”24 These physiological reactions, similar to those reported by other participants, would no doubt frighten many individuals who felt them.

In late summer 1799 Roget and his mother took a short vacation during which he became sick. Catherine expressed her concern about her son’s experiences in Bristol to her father Sir Samuel Romilly. His response outlines some of their worries, which apparently included Beddoes’ politi-cal radicalism. Romilly expresses his sorrow “that P is out of spirits about it, though I am not very much surprised.”25

Despite the presence of numerous patients at the Pneumatic Institution and the spectacular behavioral effects being reported about nitrous oxide inhalation, the activities on Dowry Square were becoming rather notorious. An observer of the experi-ments, Joseph Cottle, declared that “The Pneumatic Institution, at this time, from the laughable and diversified effects produced by this new gas on different individuals, quite exorcised philosophical gravity, and converted the laboratory into the region of hilarity and relaxation.”26 Two savage, satiric poems that attacked the nitrous oxide experiments appeared in 1800 just after the research had ended.27 “The Pneumatic Rev-ellers: An Ecologue” appeared anonymously in the Anti-Jacobin Review and Magazine. This piece has been identified as the work of Richard Polwhele, a Cornish clergyman and poet remembered today for his antifeminist poem The Unsex’d Females. “The Pneu-matic Revellers” associates the gas breath-ers with such supporters of democratic revolution as William Godwin and Erasmus Darwin, and mentions five participants by name: Thomas Beddoes, Anna Barbauld and her husband Rochemont, Robert Southey and poet George Dyer. Polwhele includes extensive fictitious quotes from these indi-viduals praising the effects of gas inhalation. The poem has Anna Barbauld declare that breathing nitrous oxide is “Sweeter than the breath of fame.”

A second poem, The Sceptic, also ap-peared anonymously in 1800. Again, the Dowry Square activities were associated with political and scientific revolution. Franz Mesmer and Antoine Lavoisier are at-tacked by name. Beddoes’ group are labeled “Quacks-Pneumatic” and “bladder conjur-ers” little better than pimps, because “if certain innuendo’s have foundation” female patients have become pregnant. Historian of British chemistry Golinski has noted

that despite “Beddoes enlightened aspira-tions, the experiences of the Bristol group appeared to many as the shared delusions of an isolated religious sect.”28 No wonder Roget left the city disillusioned.

Roget’s grandfather Samuel Romilly had met with Jeremy Bentham in London about this time, and Bentham declared, “that he had a project respecting Peter.”29 In response to a letter from Bentham, Roget replied in January, 1800, and satisfied Ben-tham’s curiosity by describing the nitrous oxide experiments at Bristol in detail. Ro-get outlined how best to manufacture and handle the gas, and also wrote about his animal experiments. Roget soon appeared in London and spent several months in the Bentham household.

Roget’s final documented connection with the gas experiments appeared in 1824 in a supplement to the Encyclopedia Bri-tannica. Roget wrote several biographical sketches for this volume, including one of Thomas Beddoes. This lengthy profile explores the doctor’s impressive list of achievements as well as his failures. Roget notes about the hopes for the nitrous oxide experiments that “These, like the other splendid visions, in which his ardent imagi-nation was but too prone to indulge, have never been realized; and have even created, by their signal failure, an unfortunate preju-dice against future attempts to improve the art of medicine by novel methods of treat-ment founded on chemical or philosophical principles.”30

“Unfortunate prejudice” is an incredible understatement. Near the very end of his long work on the nitrous oxide experiments, Davy wrote, “As nitrous oxide in its exten-sive operation appears capable of destroy-ing physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.” 31 Here, in the summer of 1800, is a description of surgical anesthesia. Unfor-tunately, neither Davy nor Beddoes were seeking a method of surgical pain relief, and given the notoriety of the gas experiments in Bristol, no one else would purse the idea successfully until the 1840s.

Although he lived more than two decades past the discovery of surgical anesthesia, Roget strangely left no record of his reaction to that momentous medical achievement. In his 1799 pamphlet on the nitrous oxide research, Beddoes observed, “It could not therefore escape me that this pursuit might, in its own nature, be highly rational, and yet that those who first engaged in it, might never strike into the right path. It was plain that we might even prepare a happier era for mankind, and yet earn from the mass of our


contemporaries nothing better than the title enthusiasts.”32 Eight years later, not long before his death, Beddoes wrote in a letter to James Watt, “So, on we go, deciphering the world.” 33 Despite the shambles in which the nitrous oxide experiments ended, Ro-get—like so many of the participants—left Bristol and spent the rest of their lives, in their own ways, “deciphering the world.”

References1. Cummings S. Spin doctors: James for a sleep-

less generation. LA Weekly 22 May 1992.2. Maron C. A short time to be there: the last five

shows of the Grateful Deadhttp://b.rox.com/atop/cmdead.html.3. Russell D. Buzzed fans no laughing matter.

Philadelphia Daily News 10 October 2000.4. Dale M. Philadelphia clamps down on nitrous

oxide use at Vet. Boston Globe 3 December 2000.5. Valdez A. Nitrous oxide draws more young

users. Philadelphia Inquirer 1 January 2001. See also Wen P. Nitrous oxide use for kicks seen rising. Boston Globe 2 September 1999 and DiMaio VJM, Garriott JC. Four deaths resulting from abuse of nitrous oxide. J Forensic Sci 23:169-172, 1978.

6. James W. On some Hegelisms. In: The Will to Believe and Other Essays in Popular Philosophy. New York: Dover, 1956, pp 294-295. See also Ty-moczko D. The nitrous oxide philosopher. Atlantic Monthly 277(5):93-101, May 1996

7. Leary T. Design for Dying. San Francisco: Harper Edge, 1997, pp 103,105,132,225.

8. Thompson HS. Fear and Loathing in Las Vegas: A Savage Journey to the Heart of the American Dream. New York: Popular Library, 1977.

9. Priestley J. Experiments and Observations on Different Kinds of Air. 6 Vols. London: J. Johnson, 1774-1786, 1:228.

10. Wright AJ. Joseph Priestley’s “factitious airs” and medical practice before 1800. Balli Anesth Dist 18(4): 1,4-6, October 2000.

11. Porter R. Reforming the patient in the age of reform: Thomas Beddoes and medical practice. In: French R, Wear A, eds. British Medicine in an Age of Reform. London: Routledge, 1991 p. 41. See also Porter R. Doctor of Society: Thomas Beddoes and the Sick Trade in Enlightenment England. New York: Routledge, 1991.

12. Schofield RE. The industrial orientation of science in the Lunar Society of Birmingham. Isis 48:408-415, 1957.

13. Beddoes T. A Letter to Dr. Darwin, on a New Method of Treating Pulmonary Consumption…Bristol: Bulgin and Rosser, 1793.

14. Stansfield DA, Thomas Beddoes, M.D., 1760-1808. Dordrecht: D. Reidel, 1984, pp 78-79.

15. Cartwright FF. The association of Thomas Beddoes, M.D. with James Watt, F.R.S. Notes Records Royal Soc London 222:131-143, 1967.

16. Wright AJ. Humphry Davy’s small circle of Bristol friends. Mid East J Anesth 13(3): 233-278, 1993. Rep. Bulletin Anesth History 15(2): 22-24, April 1997; 15(3): 16-20, July 1997; 15 (4): 16-21, October, 1997.

17. The following outline of Roget’s life is taken from Emblen DL. Peter Mark Roget: The Word and the Man. New York: Crowell, 1970.

18. Gliserman S. Early Victorian science writers and Tennyson’s “In Memoriam”: a study in cultural exchange. Victorian Studies 18(3):277-308, 1975.

19. Hoover SR. Coleridge, Humphry Davy, and some early experiences with a consciousness-altering drug. Bull Res Humanit 81:9-27, 1978.

20. Beddoes T. Notice of Some Observations Made at the Medical Pneumatic Institution. Bristol: Longman and Rees, pp 4-5, 1799.

21. Davy H. Researches, Chemical and Philo-sophical: Chiefly Concerning Nitrous Oxide, on Dephlogisticated Nitrous Air, and its Respiration.

London: J. Johnson, 1800, pp 488, 491, 501, 518.22. Southey CC, ed. Life and Correspondence

of Robert Southey. New York: Harper, 1851, p 113.23. Emblen DL. Peter Mark Roget: The Word and

the Man. New York: Crowell, 1970, p 42.24. Roget PM. V. Letter from Dr. Roget. In: Davy

H. Researches, Chemical and Philosophical: Chiefly Concerning Nitrous Oxide, on Dephlogisticated Nitrous Air, and its Respiration. London: J. Johnson, 1800, pp 509-512.

25. Emblen DL. Peter Mark Roget: The Word and the Man. New York: Crowell, 1970, pp 44-45.

26. Cottle J. Reminiscences of Samuel Taylor Coleridge and Robert Southey. New York: Wiley and Putnam, 1847, p 243.

27. Wright AJ. “I fill three quarters of immen-sity!” Satires of early nitrous oxide research. Bulletin Anesth Hist 14 (1): 15-18, Jan 1996.

28. Golinski J. Science as Public Culture: Chem-istry and Enlightenment in Britain, 1760-1820. Cam-bridge: Cambridge University Press, p 170.

29. Emblen DL. Peter Mark Roget: The Word and the Man. New York: Crowell, 1970, p 45.

30. Roget PM. Beddoes T. Supplement to the fourth, fifth, and sixth editions of the Encyclopedia Britannica. Edinburgh. 2:206-210, 1824.

31. Davy H. Researches, Chemical and Philo-sophical: Chiefly Concerning Nitrous Oxide, on Dephlogisticated Nitrous Air, and its Respiration. London: J. Johnson, 1800, p 556.

32. Beddoes T. Notice of Some Observations made at the Medical Pneumcbia Institution. Bristol: Long-man and Rees, 1799, pp 4-5.

33. Thomas Beddoes to James Watt, 20 June 1807.

EXCITINGOPPORTUNITY!

THE WLMFELLOWSHIP

The WLM Fellowship will provide recipients with fi nancial support for one to three weeks of scholarly historical research at the Wood Library-Museum.

The Board of Trustees of theWood Library-Museum invites ap-plications from anesthesiologists, residents in anesthesiology, physi-cians in other disciplines, historians and other individuals with a devel-oped interest in library and museum research in anesthesiology.

For further information, contact:Librarian, Wood Library-Museum of Anesthesiology, or call(847) 825-5586. Visit our Website at <www.ASAhq.org/wlm/fel-lowship.html>.

Complete proposals must be re-ceived before January 31, 2002, for consideration.

The Wood Library-Museum serves the membership of ASA and the anes-thesiology community.

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Bulletin of Anesthesia HistoryDoris K. Cope, M.D., Editor200 Medical Arts Building200 Delafield Avenue, Suite 2070Pittsburgh, PA 15215

McIntyre N. Medical statues: Claude Bernard (1813-1878). J Med Biog 9:15, 2001. 1 illus. [Ber-nard’s statue in Paris]

Minagar A, Lowis GW. Dr. Heinrich Irenaeus Quincke (1842-1922): clinical neurologist of Kiel. J Med Biog 9:12-15, 2001. 1 portrait, 15 refs.

Pinkerton PH. Canada’s transfusion medicine pioneer: Lawrence Bruce Robertson. Transfusion 41:283-286, 2001. 1 illus., 41 refs.

Rehfeld JF, Viby-Mogensen J. Poul Bjorndahl Astrup 14 August 1915-30 November 2000. Euro-pean Academy of Anaesthesiology Newsletter no. 14: 6, May 2001. 1 portrait. [Obituary]

Rosenberg H, Axelrod JK. Two surgeons who popularized spinal anesthesia. Reg Anesth Pain Med 26: 278-282, 2001. 3 illus., 21 refs. [George Pitkin and Wayne Babcock]

Rosenstock C, Moller J, Hauberg A. Com-plaints related to respiratory events in anaesthesia and intensive care medicine from 1994 to 1998 in Denmark. Acta Anaesthesiol Scand 45: 53-58, 2001. 1 illus., 1 table, 13 refs.

Rupreht J. Relevant key-points from the histo-ry of anaesthesia at the eve of the third millenium. Minerva Anesthesiol 66: 849-852, 2000. 14 refs.

Scherpereel P. Professor Pascal Adnet. Euro-pean Academy of Anaesthesiology Newseletter no. 14: 8, May 2001. 1 portrait. [Obituary]

Sieberth HG. History of the development of intensive care medicine. Part 13: historical over-view of the treatment of acute kidney failure in Germany. Anaesthesist 49:58-64, 2000. [German]

Snow SJ. John Snow MD (1813-1858). Part I: a Yorkshire childhood and family llife. J Med Biog 8:27-31, 2000. 3 illus., 1 table, 20 refs.

Snow SJ. John Snow MD (1813-1858). Part II: Becoming a doctor—his medical training and early years of practice. J Med Biog 8:71-77, 2000. 2 illus., 45 refs.

Staggers N, Thompson CB, Snyder-Halpern R. History and trends in clinical information systems in the United States. J Nurs Scholarsh 33:75-81, 2001. table, extensive references.

Szulc R. Professor Witold Jurczyk MD PhD on his 70th birthday: an appreciation. Eur J An-aesthesiol 18:192-193, 2001.

Tierris C. Dr. Steven Couremenos, FRCA.

European Academy of Anaesthesiology Newseletter no. 14: 10, May 2001. 1 portrait. [Obituary; among other contributions Dr. Couremenos founded the Greek Society of Anaesthesiology in 1956]

Toman C. Canadian nursing and blood trans-fusion, 1942-1990. Nurs Hist Rev 9:51-78, 2001.

Unzueta Merino MC, Hervas Puyal C, Villar Landeira J. Robert R. Macintosh and Spain: a fruitful relationship. Rev Esp Anestesiol Reanim 48:21-28, 2001. 1 illus., 51 refs. [Spanish]

Waisel DB. The role of World War II and the European theater of operations in the develop-ment of anesthesiology as a physician specialty in the USA. Anesthesiology 94:907-914, 2001. 7 illus., 69 refs.

Zimmer M. Role du dentiste Christopher Starr Brewster et de certains medecins d’origine americaine dans les debuts de l’anesthesie. Hist Sci Med 34(3):231-248, 2000. [French]

From the Literature. . .Continued from Page 15

on the history of emergency medical services history of

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