[Beginning of continuous wound infusion with local anesthetics : With special emphasis on the contributions from Walter Capelle and Ewald Fulde]

Wound infusion with local anesthetics is a proven and safe analgesic procedure for modern perioperative patient care. Even the pioneers of local anesthesia practiced wound analgesia and emphasized the shortcomings of "single-shot" wound infusions. At the same time, they drew attention to the importance of long-lasting pain relief to prevent sequelae, especially after upper abdominal surgery with pneumonia, embolic events or postoperative ileus. In the early 1930s there were first sustained efforts to improve the efficiency and quality of pain therapy, especially after upper abdominal surgery by continuous wound infiltration with local anesthetics via intraoperatively introduced special cannulas. This measure was carried out to enable reduction in pain and allow early postoperative mobilization. The conceptual development of this pioneering analgesia method is closely connected with the names of the Berlin surgeons Walter Capelle and Ewald Fulde; however, their inaugurated and propagated therapy concept did not find the attention and dissemination that it deserved. This is a reason for us to remember their pioneering ideas on pain management in the context of current developments.

[History of anesthesia : "From narcosis to perioperative homeostasis"]

In the western World 16 October 1846 is often called "Ether Day", marking the beginning of anesthesia. Before that date, for physicians there was only a struggle against pain. In the following 170 years all fields of general anesthesia as well as regional and local anesthesia were continuously developed. Pharmacological developments and technical innovations made this evolution possible. The complexity of this field of medicine requires a specialist: the anesthesiologist, whose selection of the most suitable form of anesthesia for the patient makes the surgical intervention painless. In addition, the history of anesthesia was characterized by personalities who were responsible for the progress of this medical field. Anesthesia is one part of the discipline of anesthesiology, which also includes resuscitation, intensive care medicine, emergency medicine and pain therapy.

[Ernst von der Porten : looking for facts before and after forced emigration]

The Ernst von der Porten medal has been awarded for many years to exceptional personalities by the Alliance of German Anesthesiologists to honor the outstanding achievements of the physician Ernst von der Porten from Hamburg in the development of anesthesiology as an autonomous discipline Only recent access to hitherto inaccessible documents enabled the reconstruction of his final years. He was persecuted and excluded by the National Socialist (NS) regime due to his Jewish roots and finally forced to emigrate. Records revealed that even in the so-called safe exile, degrading treatment and humiliation continued for Ernst von der Porten and his family. He eventually evaded this situation by committing suicide.

[Co-editors and editors with Jewish origins of the first German journals for anaesthesia. Their fate under National Socialism and an attempt at a biographical appreciation]

The decision to publish the journals Der Schmerz and Narkose und Anaesthesie in 1928 was an important step towards the professionalization of anaesthesiology in Germany. The appearance of both journals, which for economic reasons merged into Schmerz - Narkose - Anaesthesie 1 year later, was initiated and vehemently supported by Jewish physicians. As editors and co-editors they were deeply involved with the editorial tasks of the journals for years from the early beginnings. When the National Socialistic Party took over the government in Germany many of the Jewish colleagues were forced to quit their editorial tasks, were eliminated and replaced by "Arians", they were persecuted and often arrested, forced to emigrate or decided to commit suicide due to inhumane personal circumstances. It is our intention to recall the biography and the terrible fate of the nearly unknown Jewish members of the editorial board of the first German anaesthesia journals. Moreover the biographic sketches promote a continuous discussion about the victims of an inhumane and barbarous ideology.

[Adam hammer (1818 - 1878) - remarks on a forgotten pioneer of ether anaesthesia in obstetrics]

Adam Hammer, born in 1818, and working as a doctor for the poor since 1847 in Mannheim, was the first person in the German speaking world to use ether for pain relief during labor on February 18th 1847. He took part in the abortive April 1848 Revolution in Mannheim - a pinnacle of German liberalism and later of political radicalism, which attented to abolish the Monarchy and introduce a democratic Republic. After the revolution was put down, Hammer emigrated to the United States and settled down in St. Louis, Missouri. Remaining politically active, he joined the Republican Party, founded in 1854 and served as a military surgeon in the Union Army during the American Civil War. Even before the war, he was engaged in efforts to improve the level of medical training in America and was involved with the foundation of High Schools which offered training courses along the lines of German universities. His ideas and innovations were not introduced immediately, but had a significant impact on medical training methology later on in the US. During a visit in Europe in 1876, he was the first to diagnose a coronary thombosis as the cause of a heart attack on a live patient. The diagnosis was later confirmed by post-morten autopsy on the patient. In 1877 he returned to Germany and died one year later. The biography of Adam Hammer mirrows that of many other German-Americans whose emigration proved to be a gain for America but a loss for Germany. This story was destinated to be repeated in terrible circumstances some decades later.

[Early contributions for the development of nitrous oxide-oxygen anesthesia in central Europe]

The American dentist Horace Wells was the first to administer nitrous oxide for pain relief during painful tooth extractions. Since, however, an official demonstration of the pain-relieving properties of the gas at Massachusetts General Hospital in Boston ended in failure, use of the drug was abandoned. A few years later, Gardner Quincey Colton, a former coworker of Wells, took up Wells' idea to use nitrous oxide for pain relief and this was instrumental in its reintroduction into daily practice. Colton's publications on the advantageous use of nitrous oxide caused Stanislav Klikovitch from St. Petersburg, Russia, to administer the drug for pain relief during labour. In order to minimize the risk of asphyxia during the inhalation of the gas, he used an anaesthetic mixture consisting of 80% nitrous oxide and 20% oxygen. Moreover, it is to Klikovitch that we owe the first description of effective self-administration of nitrous oxide mixtures for pain relief. He recommended that inhalation should start 30-60 seconds before the expected pain and said between 2 and 6 inhalations would give the expected effect. Additionally, he suggested taking deep breaths and doing so at the beginning of subsequent pains. This is the first description of patient-controlled analgesia. Klikovitch reported his experiences with the new anaesthetic method in several German-language publications. Among those who were fascinated by his pain-relieving concept was Paul Zweifel from Leipzig, one of the leading obstetricians of his time in Germany. Together with numerous of his pupils, he popularized the method, using new apparatus for a safer kind of administration. Further technical developments in the early twenties, such as the introduction of the circle system or the clinical use of oxygen-monitoring devices, were additional milestones in nitrous oxide/oxygen anaesthesia.

The versatile August Bier (1861-1949), father of spinal anesthesia

"A professor is a gentleman with a different point of view." This characteristic and sarcastic statement was often recited by August Bier (1861-1949) and can also be aptly applied to him. As the father of spinal and intravenous regional neural blockade, Bier had a tremendous impact on surgery and anesthesia. It took him only two years to become a senior lecturer in surgery (so-called "Habilitation") under the guidance of Friedrich von Esmarch. In 1899, he was appointed chairman of the Department of Surgery at the University of Greifswald. From there, he moved to the University of Bonn in 1903 and then succeeded Ernst von Bergmann in Berlin in 1907. Bier's interest in the philosophical theories of Hippocrates and Heraclitus had a significant influence on his outlook on medical practice. His surgical colleagues disapproved of this and his interest in homeopathy. On the other hand, he earned much respect as the co-author of a surgical textbook, i.e., Chirurgische Operationslehre (Operative Surgery). He had a remarkable breadth of nonmedical interests, including philosophy and forestry, and the ideas he expressed are viable even today. His publications on philosophical subjects are as up to date as his concepts in forestry. In 1932, Bier finally decided to retire, although by then he was no longer operating. From that time on, he lived out his days at his estate in Sauen, and he died in 1949 at the age of 88. In this paper we describe some previously unknown aspects of Bier's work in both surgery and research; anesthesiologists and their patients are the beneficiaries of two other of his inventions, namely, spinal and IV local anesthesia. Unfortunately, it is not possible to acknowledge all the innovations of this ingenious surgeon, who truly deserved the description "A professor is a gentleman with a different point of view."

[The Eppendorf University Hospital, Hamburg--a cradle of German- speaking anesthesia?]

"The time will come when German medicine, too, will have to concern itself with the issue of a professional narcotiseur. Until then it will be our duty to keep the interest in narcosis, which has increased satisfactorily in the past years, alive." With this statement the editors of the journal "Der Schmerz" substantiated the publication og a German-speaking anestesiological journal in 1928. Ernst von der Porten, a professional anesthesist working in Hamburg was the chief initiator for the appearance of the new journal. Possible he was incited by his former teacher, the Eppendorf surgeon Paul Sudeck, to delve deeper into our special field. Very early Sudeck himself began to concern himself with anesthesiological questions and he found an ardent supporter of the idea of specialisation in anesthesiology (quite unheard of in Germany at that time) in Helmut Schmidt, a staff member. Schmidt habilitated on an anesthesiological theme and that again was reason enough for the editors to write an editorial about. Schmidt who one of the chief organizers of the "90. Tagung Deutscher Naturforscher und Arzte" in the late summer of 1928 was hindered by the surgeons on founding the Deutsche Narkosege-sellschaft (German Narcosis Society) with colleagues. After World War II German surgeons rethought their position, mainly influenced by Anglo-American narcosis specialists. After the foundation of the Deutsche Gesellschaft für Anaesthesiein the year 1953, the first professorate for the special field of anesthesiology was given to Karl Horatz--one of the founding members--10 years later. Not surprisingly the professorate was instituted at the university hospital in Eppendorf which could be called the cradle of German-speaking anesthesia. The following concerns itself with some of the impulses that were given by the "Neues Allgemeines Krankenhaus Eppendorf" and became important stepping stones in our special field through the decades.

[Aloys Martin and the Society of German Physicians in Paris]

The news about the discovery of the anaesthetic properties of ether swept rapidly from America to Europe. The first informations concerning this topic reached England in late fall of 1846 and after that came to France and especially Paris. The German physician Aloys Martin from Munich who was living in Paris at that time was largely responsible for conveying the news about these new findings in medical science to the German-speaking nations. Controversial discussions concerning the anaesthetic properties of ether developed among the members of various scientific circles right after the news from America had reached the city--and many members of the "Verein Deutscher Aerzte in Paris" (Association of German Physicians in Paris) took part in them, Martin then was one of the club's most active members and repeatedly reported on the new method as a correspondent for the widely read "Augsburger Allgemeine Zeitung": Documents discovered recently at the archives of the "Leopoldinisch-Carolinischen Akademie" of Halle provide an interesting insight into this association, whose members tried to find out more about the anaesthetic properties and side effects of ether carrying out a series of well appreciated self-experiments in the spring of 1847. The following text reports on the history of the "Verein Deutscher Aerzte in Paris" which has largely fallen into oblivion and emphasizes the importance of Aloys Martin whose name is strongly attached to the spread of the use of ether throughout the German-speaking countries.

[Helmut Weese--an attempt at an appreciation of his importance for German-language anesthesia]

In addition to the two surgeons Hans Killian and Helmut Schmidt the pharmacologist Hellmut Weese was elected honorary member of the German Association of Anaesthesiology at the organisation's founding congress in 1953. Especially the younger colleagues are quite unfamiliar with his name, although a "Hellmut Weese commemorative" lecture is annually held at our national association's gathering. While it is widely known that his name is intimately connected with the introduction of evipan anaesthesia during the early thirties, only few people know about his extensive research on the therapy of shock that lead to the development of the plasma-expanding substance "Periston"". Moreover, his pharmacological investigations on sympathomimetic amines and long-term studies on cardiac glycosides which he published in a well recognised monograph in 1936 have fallen into oblivion. Since he had not collaborated with Nazi regime he was able to start teaching at the University of Cologne again in the fall of 1945. One year later he became head of the Department of Pharmacology at the Medical Academy of Düsseldorf. There he started--together with colleagues of similar ideas and opinions--holding lectures on clinical anaesthesia at the beginning of the winter term 1948/49. People who attended his lectures later claimed that these were the "best lesson ever". At the same time the call for specialists for anaesthesiology that was commonly heard in Anglo-American countries could not be ignored in Germany any longer. Weese, who was already an honorary member of the International Anesthesia Research Society at the Association's congress in New York in 1938, realised the lack of trained physicians. Thus he fought enthusiastically for the idea of producing specialists and as a member of a committee for questions concerning anaesthesia played in important part in founding the "Deutsche Arbeitsgemeinschaft für Anästhesiologie". He lived to see the association's name being changed to "Deutsche Gesellschaft für Anaesthesiologie" in 1953 but died before the textbook of anaesthesia (Die Narkose) he had written together with Hans Killian was published in 1954. The following text reports on Weese's medical career and on some of his most important contributions to the knowledge of anaesthesia.

Monocytic-endothelial cell interaction: regulation of prostanoid synthesis in human coculture

Coculture of a monocytic cell line (HL-60) and iliacal endothelial cells as an in vitro model of vascular inflammation was investigated for cooperative regulatory mechanisms of prostanoid synthesis under conditions of selective prestimulation. In coculture of endothelial cells and 12-O-tetradecanoylphorbol 13-acetate (TPA)-prestimulated monocytic HL-60 cells the capacity of prostanoid synthesis from arachidonic acid was strongly increased compared with monocultures. Concomitant with up-regulation of specific adhesion molecules, cyclooxygenase (COX) 2 mRNA was induced in endothelial cells in coculture independent of cell contact. HL-60 cells exhibited no alterations in mRNA expression of cyclooxygenases or thromboxane synthase. Coculture of TPA-prestimulated endothelial cells with unstimulated HL-60 cells led to a selectively increased capacity of thromboxane production. Under this condition HL-60 cells up-regulated COX1 and COX2 mRNA, whereas endothelial mRNA levels did not change. Our data demonstrate that the increase in prostanoid synthesis in coculture essentially depends on rapid induction of COX2 mRNA within 2 h.

[Helmut Schmidt--a protagonist of modern anesthesia in Germany]

Helmut Schmidt, an assistant of the reputed surgeon Paul Sudeck, who headed the Surgical Department of the University in Hamburg at that time, habilitated in 1928. The title of his monograph was "Merits of nitrous oxide anaesthesia--a comparative study seeking reintroduction and increase of the use of nitrous oxide in Germany". With this paper, Schmidt qualified himself as the first lecturer for anaesthesiology in Germany. He had been eager since the mid-twenties on establishing our special medical discipline separate from surgery. Schmidt's merits also include introducing students and doctors to the practice of anaesthesiology, teaching both a practical approach towards anaesthesia at the operating room, and theory during lectures on general surgery. This method was absolutely new at that time. Due to the resistance by conservative surgeons, he failed to establish a "German Society of Anaesthesia" during the 90th meeting of the "German Society of Natural Scientists and Physicians" held in Hamburg in 1928. In fact, this was accomplished only as late as 1953. The following text recalls a number of contributions to anaesthesiology made by the honorary member of the "German Society for Anaesthesiology" Helmut Schmidt, who was born a hundred years ago and whose name and merits have fallen into oblivion during the past decades.

[Interaction of frequency-adaptive pacemakers and anesthetic management. Discussion of current literature and two case reports]

We describe unexpected episodes of paced tachycardia in two patients with rate-responsive pacemakers during anaesthesia. Five months after a heart transplant and implantation of a pacemaker a 43-year-old patient suffered cardiac tamponade as a result of chronic pericarditis. The second case involved embolic occlusion of the femoral artery in a 33-year-old female patient previously operated on for tricuspid valve replacement and implantation of a pacemaker. In both cases induction of anaesthesia was performed with fentanyl, etomidate and vecuronium. Following intubation and mechanical ventilation, the heart rates (HR) of the two patients increased to 140 and 130 min-1 respectively. This was interpreted as a sign of inadequate anaesthesia, and therefore additional doses of fentanyl and etomidate were given, with no effect on the tachycardia. After exclusion of other possible reasons for this complication such as hypokalaemia, hypercapnia, hypoxaemia or allergic reactions, unexpected functioning of the rate-responsive pacemakers due to thoracic impedance changes was assumed. Minute ventilation was reduced, lowering paced HR in 3-5 min.

CONCLUSIONS

These case reports suggest that anaesthetic management affects the action of rate-responsive pacemakers, causing haemodynamic complications, and inadequate interventions by the anaesthesiologist. Thus, it is necessary for anaesthesiologists to make a preoperative evaluation of the underlying medical disease and the type of pacemaker in order to adjust anaesthetic management accordingly and to understand the haemodynamic responses that may occur during the perioperative period. Preoperative programming to exclude the rate-responsive function is advised.

[Priority conflict concerning the discovery of lumbar anesthesia between August Bier and August Hildebrandt]

The history of anaesthesiology like that of other medical branches has not been free of quarrels concerning priority. International disputes between the surgeon August Bier from Kiel and his former colleague August Hildebrandt concerning the question of who was the actual inventor of spinal anesthesia have almost fallen into oblivion. While Hildebrandt and numerous other colleagues frequently stated that the New York neurologist James Leonhardt Corning was the inventor of spinal anesthesia, Bier insisted on having described and developed this method first and without any knowledge of Corning's experiments. Corning's use of the term "spinal anesthesia" in his publications probably caused the error that he was the first to describe and apply this new widespread technique. Only recently, American scientists emphasized the fact that this is not true. There will, unfortunately, not be an answer to the Question why Hildebrandt started this quarrel about priority. His reason might have been hurt feelings as he had not been mentioned as co-author in Bier's epoch-making survey.

Peripheral natural killer cell activity and intraperitoneal soluble p55 tumor necrosis factor receptor in patients with malignant ascites: two possible indicators for response to intraperitoneal combined tumor necrosis factor alpha and interferon gamma treatment

Tumor necrosis factor alpha (TNFalpha) and interferon gamma (IFNgamma) are important immunomodulators. They are capable of acting in a synergistic manner on tumor cells in vitro and in vivo. In a clinical phase I study 13 patients with malignant ascites due to abdominal spread of different primary tumors received intraperitoneally (i.p.) TNFalpha and IFNgamma once weekly over 3-8 weeks in order to evaluate the effect of locoregionally administered TNFalpha/IFNgamma on ascites formation. Therefore some peripheral and local immunological functional parameters of peripheral blood and malignant ascites were investigated. Mononuclear lymphocytes and natural killer (NK) cell activity of peripheral blood and ascites, TNF-inhibitory activity, soluble p55 and p75 TNF receptors, and prostaglandin E2 values in ascites were measured immediately before and 24 h after each TNFalpha/IFNgamma infusion. Peripheral mononuclear lymphocytes and NK activity decreased significantly 24 h after i.p. TNFalpha/IFNgamma application. However, over the entire treatment schedule, peripheral NK activity in all responders showed a continuous increase, when compared to pre TNFalpha/IFNgamma treatment levels. In contrast, NK activity in non-responders constantly decreased. In contrast to non-responders, TNF-inhibitory activity and soluble p55 TNF receptor levels, determined in ascites, decreased in responders. Taken together, our findings suggest, that successful locoregional i.p. TNFalpha/IFNgamma therapy induces systemic immunological reactions possibly after saturation of soluble p55 TNF receptors in ascites, which leads to an increase of peripheral NK activity.

Early proponents of cardiac massage

Open-chest cardiac massage in humans to treat chloroform syncope was first performed by Niehans in Berne and Langenbuch in Berlin in the late 1880s. Closed-chest cardiac massage in humans was advocated by Koenig and Maass in Göttingen in the last two decades of the 19th century. The closed technique was used in Central Europe for several decades to treat chloroform syncope.

[Otto Kappeler--a pioneer in anesthesia in German-speaking regions]

The publication of textbooks on anaesthesiology reflects the enormous progress made over the last decades. This new branch of medicine was first completely described in Germany by Otto Kappeler from Switzerland, who was asked to do so by his famous colleague Theodor Billroth from Vienna. Starting with remarks concerning the history of anaesthesiology, he described on more than 220 pages everything that was known about the anaesthetics used at that time. Additionally, he outlined the prospects of the then also brand new methods of local anaesthesia. Undoubtedly it was of Kappeler's special concern to avoid the risk of iatrogenic complications while the patient was under any anaesthetic. This can easily be proved by the fact that he put special emphasis on precautions concerning life-threatening situations and their therapy. To avoid the dangers of an acute airway obstruction by the patient's tongue, he modified the so-called "Esmarch-Heidberg" manoeuvre, which later on became known as the "Kappeler" flick. For the first time ever, Kappeler managed to describe sphygmographically the circulatory effects of narcotics in an anaesthesia-related textbook. Basically, he could not find any differences between them, since " ... all higher dosages of anaesthetics used during operations caused ... a strong widening of the blood vessels ... by paralysing the vasoconstrictors". He believed it would be possible to exclude the dangers of overdosing drugs by introducing devices to perform anaesthesia. In using his self-designed device, which was a modification of the device used at that time, invented by Junker, he was able to come closer to the goal of "in somno securitas" he so vehemently fought for. This confidence he derived from the fact that he was already a strong believer in the advantage of the "self-conducted chloroformation or anaesthesia".

[Cerebral monitoring with trancranial doppler-sonography and cerebrovenous oximetry during resuscitation]

This case report describes cerebral monitoring of intracranial haemodynamics using transcranial Doppler sonography (TCD) and jugular bulb oxygen saturation (SjO2) by fiberoptic jugular bulb oximetry during cardiac arrest following cardiac surgery involving cardiopulmonary bypass (CPB). CPB for aortic valve replacement and coronary artery bypass grafting was performed in a 63-year-old patient previously operated upon for heart disease. Mean blood flow velocity was measured in the middle cerebral artery using a bidirectional 2 MHz TCD system. SjO2 was measured using a fiberoptic thermodilution catheter placed in the right jugular bulb via the right internal jugular vein under radiographic control. At the end of the operation, low cardiac output syndrome and cardiac arrest occurred, which required reopening of the thorax and cardiopulmonary resuscitation (CPR) until CPB could be resumed. Following extrathoracic cardiac resuscitation, systolic "spikes", loss of the diastolic flow profile, and no increase in SjO2 were recorded by the monitors, indicating cerebral circulatory arrest. However, a normal flow profile with increasing diastolic portions and an increase in SjO2 to 52% were seen following optimisation of the open thorax cardiac resuscitation. This monitoring may be able to give information to optimise therapy during CPR to avoid ischaemic cerebral injury.

[Martin Kirschner: anesthesiologist--intensive care physician--pain therapist]

The development of numerous modern anaesthetic technics and methods in the mid of the twenties and thirties, which had become a main topic of scientific interest in the German-speaking countries, is connected with the name of the surgeon Martin Kirschner. Reputed as an outstanding surgeon at home and abroad, he realised the need of modern anesthetic technics and monitor systems for the further progress in all areas of operative medicine. His research enhanced our knowledge of the mode of action of various anaesthetic procedures and the prevention of iatrogenic complications became a central part of his interest. His concept to use a physician-aided rapid transportation system, so that the emergency physician comes to the patients and not vice versa, has become an integral part of emergency medical system nowadays. Not surprisingly, he asked for a physician-controlled transportation of such "high-risk-patients" with the aid of aeroplanes. Furthermore, he demanded continuous control of vital parameters of such severely injured persons, best realized in an intensive-care unit. Comparably modern were his concepts concerning the perioperative sedation of patients, operated under any kind of local anaesthesia. Recommending advantageous drugs to do so, he suggested the possibility of using a wireless or television set, a technique absolutely new at that time, within the operation theatre. Reviewing Kirschner's contributions to pain alleviation procedures, we can consider him to be a passionate surgeon, but also a surgeon with the deliberations and actions of an anaesthesiologist: "Divinum est, sedare dolorem."

[Arthur Läwen--a pioneer of modern anesthetic techniques]

The development of modern local anaesthetic techniques is connected with the name of Arthur Läwen. At the turn of this century, he started his surgical training with Heinrich Braun, who had performed a lot of research with various local anaesthetic methods and who was renowned world-wide as an authority for his contributions. It is not surprising that a main topic of Läwen's research was the development of new local anaesthetic regimes. In close collaboration with the Institute of Pharmacology at the University of Leipzig, he examined new available local anaesthetic drugs and their practicability for daily use. Due to an own, new pharmacological preparation of a bicarbonated novocaine solution, paravertebral, sacral and epidural conduction blocks became a reality in clinical practice. Thus several, still valid methods in the treatment of acute or chronic pain became manageable. The further development of new techniques for the differential diagnosis of various illnesses must also be mentioned. A remarkable step towards a modern anaesthesia concept was the administration of curare for muscle relaxation in operative surgery. Another evidence of his foresight are his contributions in the development of an electrically driven apparatus to overcome respiratory failure "Läwen was in many ways a man before his time:" This appraisal by a surgeon colleague is true even today for several of his anaesthesia-related contributions, which are still part of the armamentarium of modern anaesthetic methods.