[History of chloroform anesthesia]. / Die Geschichte der Chloroformnarkose.

The first narcosis with chloroform was performed by James Young Simpson on himself on November 4, 1847. The chemical substance had been first produced in 1831 almost simultaneously in the USA by Samuel Guthrie and in France by Eugène Soubeiran. Knowledge of the narcotic effect of chloroform spread rapidly, but very soon reports of sudden deaths mounted. The first fatality was a 15-year-old girl called Hannah Greener, who died on January 28, 1848. The opponents and supporters of chloroform were mainly at odds with the question of whether the complications were solely due to respiratory disturbance or whether chloroform had a specific effect on the heart. Between 1864 and 1910 numerous commissions in UK studied chloroform, but failed to come to any clear conclusions. It was only in 1911 that Levy proved in experiments with animals that chloroform can cause cardiac fibrillation. The reservations about chloroform could not halt its soaring popularity. Between about 1865 and 1920, chloroform was used in 80 to 95% of all narcoses performed in UK and German-speaking countries. In America, however, there was less enthusiasm for chloroform narcosis. In Germany the first comprehensive surveys of the fatality rate during anaesthesia were made by Gurlt between 1890 and 1897. In 1934, Killian gathered all the statistics compiled until then and found that the chances of suffering fatal complications under ether were between 1: 14,000 and 1: 28,000, whereas under chloroform the chances were between 1: 3,000 and 1: 6,000. The rise of gas anaesthesia using nitrous oxide, improved equipment for administering anaesthetics and the discovery of hexobarbital in 1932 led to the gradual decline of chloroform narcosis. In 1947, Ralph Waters attempted to reactivate chloroform, but failed. Possibly as a result of these efforts, however, chloroform played a role in American publications longer than elsewhere. The story of the clinical use of chloroform ended in 1976 with the second edition of V. J. Collins' textbook.

[Economic considerations in critically ill intensive care patients]. / Okonomische Erwägungen beim kritisch-kranken Intensivpatienten.

Since 1992 the data for all patients referred to our ICU have been entered on computer and analyzed for parameters relevant to therapeutic effectiveness on the one hand and cost-containment on the other. The analysis of data for 5424 patients concerning APACHE II-score, age, number of ICU days, time of mechanical ventilation and/or hemodialysis, cardio-respiratory complications and insufficiency, ICU discharge date and hospital discharge date demonstrates a profile or our intensive care services using all resources efficiently. The data revealed no ethically acceptable parameter or necessity to include economic considerations in medical decisions which had to be taken for individual patients and situations.

[Anesthesia technique for laser surgery in the region of the larynx]. / Narkosetechnik bei laserchirurgischen Eingriffen im Kehlkopfbereich.

Laser surgery can be performed using either endotracheal intubation, apnoea or jet ventilation. For operations performed under endotracheal intubation the same technical rules apply as for any other type of anaesthesia. To facilitate intubation a special laser tube is required. The Mallinckrodt Laser-Flex Tracheal Tube has the best physical qualities of all endotracheal catheters available commercially. Aspiration prophylaxis using ranitidin and metoclopramide is recommended for procedures under apnoea or using jet ventilation. For monitoring purposes during jet ventilation or procedures under apnoea, transcutaneous oximetry, ECG recording as well as non-invasive blood pressure measurements at short intervals is mandatory. In addition video monitoring is desirable to allow visual anaesthesiological surveillance of the larynx. The jet ventilator must meet established standards; the option must be available to survey inspiratory peak pressure and end-exspiratory pressure as well as the setting of appropriate alarm limits.

[Nifedipine versus nitroglycerin in aortocoronary bypass surgery. The effect on hemodynamics, kidney function and homologous blood requirement]. / Nifedipin versus Nitrat bei aorto-koronaren Bypassoperationen. Einfluss auf Hämodynamik, Nierenfunktion und Fremdblutbedarf.

Even during adequate general anesthesia, hypertension is a common phenomenon in patients undergoing aortocoronary bypass grafting (CABG). In such cases application of vasodilators is recommended in order to decrease myocardial oxygen consumption. This study was performed to compare two commonly used substances, i.e., nitrates and nifedipine, with regard to their influence on hemodynamics, renal blood flow, kidney function, and the requirement for homologous blood transfusions. METHODS. Forty-four patients gave their informed consent to the study. They were randomly divided into 2 groups: group 1 received nitroglycerin (3.0 micrograms/kg.min), group 2 nifedipine (Adalat, 0.5 microgram/kg.min) in order to prevent hypertension in the phase before onset of cardiopulmonary bypass (CPB). Anesthesia was induced by etomidate and succinylcholine and maintained as a modified neuroleptanalgesia with fentanyl (up to 50 micrograms/kg), midazolam (0.3 mg/kg.h), and pancuronium (0.1 mg/kg). Systolic blood pressure was kept within the range of 120-160 mm Hg; in case of higher values boluses of either 0.25 mg nitroglycerin or 0.5 mg nifedipine were administered. Cardiac index, stroke volume index, rate-pressure product, intrapulmonary shunt, and pulmonary and total peripheral resistances were evaluated at five predefined points: (1) after induction of anesthesia; (2) before incision; (3) before cannulating the aorta; (4) after decannulating the aorta; and (5) at the end of operation. Creatinine and free-water clearances as well as sodium and potassium excretion were calculated for three phases of the operation: (A) induction of anesthesia--onset of CPB; (B) during CPB; and (C) end of CPB--end of operation. CPB was performed using a membrane oxygenator (Sorin 51) and a nonpulsatile blood flow of 2.5 1/min.m2, which was reduced during mild hypothermia of 30-32 degrees C to 1.7 l/min.m2. Mean arterial pressure in both groups was kept at approximately 70 mm Hg. In case of lower pressures norepinephrine (50-100 micrograms/bolus) was administered; higher pressures were treated as described above. Volume substitution was performed initially by 500 ml hydroxyethyl starch and continued, if necessary, by homologous blood or 5% human albumin in order to keep the hematocrit greater than 30 in the phases before and after CPB. RESULTS. Group 2 showed significantly higher values of cardiac index and stroke volume index at point 3 while the rate-pressure product was clearly lower, indicating better myocardial performance and lower oxygen consumption than in group 1. Creatinine and free-water clearances in all three phases did not differ. However, sodium excretion during CPB was significantly higher in the nifedipine group while potassium excretion showed no differences. The average requirement for blood and blood substitutes was lower in group 2, but the difference could not be confirmed statistically because of the large dispersion of values. Nevertheless, 4 patients in the nifedipine group but no patient in group 1 did not need homologous blood transfusion. CONCLUSION. In comparison to nitrates, nifedipine showed some advantages in the treatment of hypertension during CABG: (1) it provided better myocardial performance; (2) it had a more reliable but not too long-lasting effect on elevated total peripherial resistance, leading to better hemodynamic stability; and (3) by not affecting the capacitance vessels it may necessitate fewer homologous blood transfusions.

[Results of a questionnaire survey of the practice and organization of postoperative peridural analgesia at 461 anesthesia departments]. / Ergebnis einer Fragebogenerhebung zur Praxis und Organisation der postoperativen Periduralanalgesie an 461 Fachabteilungen für Anaesthesiologie.

In 1988, questionnaires were sent to 1225 departments of anesthesiology to evaluate the practice of postoperative epidural analgesia (EA) in the Federal Republic of Germany. The following problems were investigated. To what extent are anesthesiologists concerned with postoperative pain therapy? Does EA play a major role in this, in particular outside the intensive care setting? Who is allowed to administer epidural injections: anesthesiologists, other physicians or nurses? What kind of monitoring is used? What agents are used for epidural injections and what problems and complications have arisen? In all, 461 (38%) evaluable forms were returned. Most anesthesiologists said they were responsible for postoperative pain control. In 75.3% of the responding departments EA was used as a method of postoperative pain therapy, while in 24.7% the catheter was removed immediately after the operation, in most cases for fear of complications resulting from insufficient monitoring. In clinical practice, however, EA was the only major alternative to routine intermittent injections of opioids as needed. Some departments reported that they restricted postoperative EA to patients in the intensive care unit or in the recovery room because adequate monitoring was not feasible on the ordinary wards. EA was administered in 62.4% on ordinary wards. But in only 25.7% were trained nurses allowed to give epidural injections. Most responding departments (77%) preferred epidural use of opioids during intensive care, in most cases morphine or buprenorphine in combination with low-dose local anesthetics, and 66.7% also favored epidural opioids on ordinary wards.

History of anesthesia in Germany.

The first ether anesthetic was administered in Germany by J.F. Heyfelder (1798-1869) at the Erlangen University Hospital on January 24, 1847. Thereafter, famous discoveries occurred in the field of pharmacology. Albert Niemann isolated cocaine from the coca shrub in 1860; Emil Fischer synthesized the first barbiturate, Veronal, in 1902; and Helmut Weese promoted the first ultra-short-acting barbiturate, hexobarbital (Evipan), in 1932. The local anesthetic effect of cocaine was reported by Koller at the Congress of the German Society for Ophthalmology on September 15, 1884, in Heidelberg. Many new techniques were tried first in German hospitals. Friedrich Trendelenburg carried out, by tracheotomy, the first operation with endotracheal intubation in 1869, and Franz Kuhn promoted and clinically practiced endotracheal intubation in Heidelberg beginning in 1900. August Bier performed the first operation under spinal anesthesia at the Kiel University Hospital on August 16, 1898. Carl Ludwig Schleich (1859-1922) standardized the methods of infiltration anesthesia by using a cocaine solution in sufficient dilution. The development of anesthesia machines was greatly influenced by Heinrich Dräger (1847-1917) and his son Bernhard Dräger (1870-1928). The Dräger Company in Lübeck built the first anesthesia machine with a carbon dioxide (CO2) absorber and circle system in 1925. Paul Sudeck and Helmut Schmidt worked with this system at the Hamburg University Hospital and reported their results in 1926. The first Dräger anesthesia machine was produced in 1902 and introduced into clinical use by Otto Roth (1863-1944) in Lübeck. Before the Second World War, three universities in Germany carried out research in the field of anesthesia: the University of Freiburg with H. Killian, the University of Hamburg with P. Sudeck and H. Schmidt, and the University of Würzburg with C.G. Gauss. Killian and Gauss established the first journals, Der Schmerz and Narkose und Anaesthesie, in 1928. After the Second World War, the field of anesthesia in Germany rapidly regained international standards. The journal Der Anaesthesist was founded in 1952, and the German Society for Anesthesiology and Intensive Medicine was established in 1953.

[Postoperative treatment of phantom pain and causalgias with calcitonin]. / Postoperative Behandlung von Phantomschmerzen und Kausalgien mit Calcitonin.

Results of IV calcitonin treatment in patients suffering from postoperative phantom limb pain (n = 12) or causalgia following peripheral nerve lesions (n = 4) are reported. All patients were complained of severe pain after a traumatic event or amputation, with disturbed sleep in many cases. After only 1-2 infusions 10 patients with phantom limb pain (83%) were discharged from hospital pain-free. Pain was effectively reduced by up to 5 infusions in 2 patients (17%). A follow-up for maximally 24 months showed a recurrence of pain in only 4 patients with obvious stump problems or reamputations. Three patients with causalgia also profited from a remarkable but transitory pain reduction; in 1 patient therapy was ineffective. Recurrent pain due to causalgia could not be improved by repeated calcitonin infusion, although this was effective for phantom limb pain. The administration of calcitonin IV can be recommended as a valuable treatment for phantom limb pain and causalgias in the early postoperative period. Therapy was effective with negligible side-effects, and long-term follow-up revealed a long-lasting effect.

[Risks in postoperative pain therapy using a peridural catheter in a normal general ward]. / Das Risiko einer postoperativen Schmerztherapie mittels Periduralkatheter unter den organisatorischen Bedingungen normaler Krankenpflegestationen.

In general surgical wards postoperative epidural analgesia was performed in 286 patients consecutively. Epidural catheters were kept in place 8.3 days in the average with a minimum of 24 h and a maximum of 45 d. Bupivacain was applied as a 0.25% solution with an average daily dose of 75-250 mg and single doses of 12.5-50.0 mg. An uncomplicated course was noticed in 250 cases, 19 cases showed haemodynamic, 7 cases neurologic and 10 cases technical complications. Severe decrease of systolic blood pressure more than 30% of the control value was due to postoperative haemorrhage, to anaemia with Hgb-concentration lower than 11 g/dl or to untreated chronical hypertension. On the basis of these observations a list of conditions has been drawn up which should be adhered to when epidural catheters are used for postoperative pain relief in normal wards.

[The history of anesthesia apparatus: basic principles]. / Die Geschichte des Narkoseapparates in Grundzügen.

The beginnings of modern anesthetic equipment date back to Morton's inhalation flagon in 1846. The numerous devices developed and introduced subsequently can be divided into four groups: 1. Simple ether and chloroform masks for open inhalation anesthesia, from Simpson (1847) to Brown (1928). 2. Vapour inhalators according to the "draw over" principle of Snow (1847) up to the Oxford vaporizer (1941). 3. Closed or half-closed inhalation equipment for ether or chloroform with to and fro breathing, from Clover (1877) to Ombredanne (1908). 4. Equipment for anaesthesia with nitrous oxide. From 1868 onwards this led to the incorporation of gas bottles in anaesthetic equipment and between 1885 and 1890 to the construction of mixing-valves for nitrous oxide and oxygen. In addition, reducing valves, flow meters and vaporizers were developed. The first anaesthetic apparatus with circle system and CO2-absorber was constructed in 1925 by the Dräger factory in Lübeck. Sudeck and Schmidt introduced this technique of anaesthesia in the university hospital of Hamburg-Eppendorf between 1920 and 1925.

[Statistical calculation from pH-values (author's transl)]. / Die Berechnung statistischer Masszahlen aus pH-Werten.

In all cases, statistical parameters of a H+-activities ought to be evaluated from data of pH values. Owing to the fact that the lower range of variability of the concentratons of H-ions is limited by zero, the values ought to be transformed into a logarithmic scale. In order to facilitate comprehension, the handling of transformations for the statistical evaluation of random samples is first explained by the example of the tidal volume of newborns and infants. In the second part of the paper, statistical parameters of several significant random samples of pH data are computed from various transformation systems and are contrasted in order to allow comparisons. Thus it becomes apparent that, under certain circumstances, the method of computing mean and standard deviations from a H+-activities may result in a characterization of random samples that are implausible.

[The removal of anaesthetic vapours using t-piece circuits in paediatric anaesthesia (author's transl)]. / Die Abteilung von Narkosegasen aus einem halboffenen Narkosesystem

In order to remove exhaled vapours from T-piece circuits, a rebreathing bag with an additional outlet (double ended bag) may be used. The narrow end of the bag is connected to a circle closed circuit with a filter incorporated in the expiratory side. So T-piece technique remains convenient. A small increase of expiratory resistance of about 1.5-2.5 ml H2O does not change spontaneous ventilation, compared with commonly used semi-closed breathing circuits in pediatric anaesthesia. Assisted or controlled ventilation may be performed, adjusting the expiratory valve at the circle closed system.