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History of analgesia and regional anaesthesia through philately.

SUMMARY

Medical philately is the study of postage stamps commemorating events and pioneers in the field of medicine. In 1929, Dr Fielding H. Garrison, doyen of medical history, remarked that stamps were a great resource for the medical fraternity, something he hoped that physicians would soon recognise. His prediction has hardly come to fruition in the years since then, with medical philatelic articles rarely seen in the medical press.

The history of pain medicine is unique, diverse and extremely interesting, with many chemists, physicists, philosophers, contributing in their own way over centuries to pave the path to present day pain medicine.

Key Words: anaesthesia, analgesia, history, philately

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PAIN

Nature gives pain to life for its protection. Pain is the instinctive cry at the onset of injury and disease. Pain rings a sleepless alarm, warning all living creatures of danger. Pain saves the organism by informing it in time of disordered conditions. Pain is the cruel but life-saving guardian of protoplasm. The absence of pain in the early stages of cancer, for example, is one of the darkest tragedies of the human race.

From primitive times man has sought the separation of pain from the advancing knife. To the surgeon, pain was the barrier he was forced to penetrate before his terrible instrument became the healing knife. The pain of the patient often denied access to his body; the sick often preferred to die rather than submit to an operation.

The earliest references to pain relief come from the Indian Sanskrit epic, Ramayana, ascribed to the poet Valmiki, of the third century BC, which contains the injunction: "The wounded in battle should be quickly picked up, carried into a tent, the bleeding stayed, and upon the wounds should be dropped an anodyne oil with the juice of healing herbs". (Figures 1 and 2)

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HISTORY OF ANALGESIA

Avicenna's hypothesis of pain

Ibn Sina, known to the western world as Avicenna, was the dominant figure of the Arabian school of medicine. His Canon of Medicine codified all available medical knowledge: translated into Latin, it became the authoritative medical textbook of Europe for six centuries. In Islam it is still considered infallible. (Figures 3-6)

Avicenna enumerated the agents which alleviate pain: There are three groups of agents which alleviate pain: 1) those contrary to the cause of pain, which remove the pain, e.g. fennel; linseed made into a poultice and applied over the painful place; 2) those counteracting the acrimony of the humors, soothing, inducing sleep or dulling the sensitive faculties and lessening their activity, e.g. inebriants, milk, oil, sweet water; 3) those dulling the sensation in the painful parts, e.g. all narcotics and somniferous drugs.

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Avicenna also recommends opium, henbane and mandrake: "If it is desirable to get a person unconscious quickly, without his being harmed, add sweet-smelling moss or aloes-wood to the wine.

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If it is desirable to procure a deeply unconscious state so as to enable the pain to be borne, place darnel-water into the wine; or administer fumitory, opium, hyoscyamus (half dram dose of each); nutmeg, crude aloes-wood (4 grains of each). Add this to the wine, take as much as is necessary for the purpose. Or boil black hyoscyamus in water, with mandragora bark, until it becomes red, and then add this to the wine."

Avicenna discussed 15 types of pain: boring, compressing, corrosive, dull, fatigue, heavy, incisive, irritant, itching, pricking, relaxing, stabbing, tearing, tension and throbbing. His discourse on the relief of pain is subtle and if his remedies proved ineffective, the learned Avicenna tempered them with Avicenna philosophy.

In the vast brotherhood of pain, there is neither East nor West, both using opium, mandrake, hashish and henbane, which sought to bring to operated patients the balm of merciful sleep.

REGIONAL ANAESTHESIA AND ANALGESIA

Friedrich Wohler (July 31 1800 to September 23 1882) was a German chemist, best known for his synthesis of urea, but also the first to isolate several of the elements. Wohler is regarded as a pioneer in organic chemistry. Urea synthesis was integral for biochemistry because it showed that a compound known to be produced only by biological organisms could be produced in a laboratory, under controlled conditions, from inanimate matter. By showing that ammonium cyanate can become urea by an internal re-arrangement of its atoms, without gaining or losing in weight, Wohler furnished one of the first and best examples of isomerism. Wohler was also a co-discoverer of beryllium and silicon, aluminium, yttrium and titanium as well as the synthesis of calcium carbide. (Figure 7.)

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In 1858 Dr Scherzer, scientific officer on an Austro-Hungarian voyage, brought back to Europe sacks of coca leaves which were acquired by Friedrich Wohler. In Wohler's laboratory Albert Niemann in 1860 purified the alkaloid isolated from coca leaves, calling it cocaine. Though Wholer and Niemann noted the numbing effects of cocaine, this property was not explained until 24 years later.

Sigmund Freud (May 6 1856 to September 23 1939) was an Austrian neurologist and the co-founder of the psychoanalytic school of psychology. Freud is best known for his theories of the unconscious mind, especially involving the mechanism of repression; his redefinition of sexual desire as mobile and directed towards a wide variety of objects; and his therapeutic technique, especially his understanding of transference in the therapeutic relationship and the presumed value of dreams as sources of insight into unconscious desires. He is commonly referred to as "the father of psychoanalysis", with his work being extremely influential in the popular imagination, popularising such notions as the unconscious, defence mechanisms, Freudian slips and dream symbolism, while also making a long-lasting impact on fields as diverse as literature, film, Marxist and feminist theories, literary criticism, philosophy and psychology. (Figure 8.)

[FIGURE 8 OMITTED]

In 1884 when Freud was a junior doctor in the neurology department of the Vienna General Hospital, he noted that cocaine overcame depression while incidentally rendering mucous membranes insensitive. He invited his friend Carl Koller, then house surgeon in ophthalmology, to participate in experiments on the drug. While Freud was away (visiting his fiancee), Koller established that cocaine worked extremely well as a local analgesic--first on animals, then on himself and finally on a patient, on whom he performed a cataract operation. Four days later on September 15, 1884, he had a short report on the discovery read at a meeting in Heidelberg of ophthalmologists.

William Stewart Halsted (September 23 1852 to September 7 1922) is known as the father of American Surgery and accredited with starting the first formal surgical residency in the United States. He is one of the first proponents of haemostasis and investigators of wound healing. Halsted pioneered the modern surgical fundamental principles of absolute control of bleeding, accurate anatomical dissection, complete sterility, exact approximation of tissue in wound closures without excessive tightness and gentle handling of tissues. The first radical mastectomy for breast cancer was performed by Halsted. Other achievements include advances in thyroid, biliary tree, hernia, intestinal and arterial aneurysm surgeries. Halsted in 1884 originated "nerve block" when he performed the first mandibular nerve block, following which he pioneered brachial plexus block. He is perhaps best remembered as the man who introduced the use of rubber gloves in surgery (1890).

[FIGURE 9 OMITTED]

Richard Martin Willstater (August 13 1872 to August 3 1942) was a German chemist whose study of the structure of chlorophyll and other plant pigments won him the 1915 Nobel Prize for chemistry. He invented paper chromatography independently of Mikhail Tsvet.

Willstatter obtained his doctorate from the University of Munich (1894) for work on the structure of cocaine. This led to the commercial production of local anaesthetics. In 1905 he was given a professorship at the University of Zurich and began work on chlorophyll. He elucidated its structure, showing that the blood pigment haem bears a structural resemblance to the porphyrin compound found in chlorophyll. When his work was interrupted by the war, at the behest of Fritz Haber he turned his attention to developing a gasmask.

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Hans Karl August Simon von Euler-Chelpin (February 15 1873 to November 6 1964) was a Swedish (German born) biochemist. With Arthur Harden he won a Nobel Prize in chemistry in 1929 for their investigations on the fermentation of sugar and fermentative enzymes.

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He was professor of general and organic chemistry at Stockholm University from 1906 to 1941 and director of its Institute for organic-chemical research from 1938 to 1948. The development of the local anaesthetic drug lignocaine began in 1932 in Stockholm when Professor Hans von Euler-Chelpin isolated the alkaloid gramine from a mutant of barley. In 1935, while trying to determine the structure of gramine, von Euler-Chelpin together with Holger Erdtman synthesised isogramine. Erdtman tasted the isogramine finding that it numbed his tongue. He grasped the significance but isogramine proved too irritant for clinical use. Consequently Erdtman and Nils Lofgren began searching for a more suitable derivative. After a lapse in the project, Lofgren synthesised lignocaine in 1943. This was found to have more penetrative power and less toxicity than all previous local anaesthetics. It remains the most versatile local anaesthetic drug in clinical practice.

In 1988 trials began on a new local anaesthetic, ropivacaine, its development based on the science of stereochemistry. It was crystallised in 1874 at J. H. van't Hoff's suggestion of the tetrahedral arrangement of the carbon atoms. For this work van't Hoff was awarded the inaugural Nobel Prize for Chemistry (1901). Ropivacaine has been prepared as a single optical isomer (enantiomer).

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Alexander Vasilievich Vishnevsky (August 27 1874 in Dagestan to November 13 1948 in Moscow) a Russian surgeon who pioneered transverse injection anaesthesia--"the squirt-and-cut-technique", which was widely used during World War II. His research on Novocaine block and oil-balsam bandages greatly contributed to the development of therapy. In 1937, A. V. Vishnevsky for the first time in the world performed the removal of lung under local anaesthesia.

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Lorenz Bohler (January 15 1885 to January 20 1973) was an Austrian physician and famous surgeon. He was born in Wolfurt, Austria. Bohler is most notable as the creator of modern trauma surgery. He was the head of the AUVA-Hospital, that was later named after him, in Vienna, Brigittenau. The hospital was an international model during his time as the leading surgeon there.

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He was fascinated by medicine early on, when as an 11-year-old boy, he saw the X-ray of Wilhelm Rontgen's wife's hand. He started studies in medicine in 1904, then after graduating, worked as a physician on a ship. During World War I he was leading surgeon in a military hospital, expanding it to a special station for bone fractures. On his initiative the AUVA-Hospital opened in 1925, where he later published his book on bone fractures and modern techniques in that field in 1928. In 1929 Lorenz Bohler developed haematoma injection of local anaesthetic for reduction of certain fractures, e.g. Colle's fracture. In radiology, the measurement of 'Bohler's angle' on a foot X-ray can help detect fractures of the calcaneum.

Rene Leriche (1870 to 1955) was a famous French surgeon, who gave his name to two syndromes:

* Leriche's syndrome--impotence and buttock claudication and absent pulses in the groin and legs due to saddle embolus or atherosclerosis at the aortic bifurcation.

* Sudek-Leriche syndrome--aseptic necrosis of bone following injury--Sudek atrophy.

Born in Roanne, the son of a lawyer, Leriche began his career in Lyon. In 1924 he was appointed Professor of Surgery in Strassburg. In 1927 he was made a honorary Fellow of the Royal College of Surgeons of England. He was the first surgeon to be appointed Professor au College de France. He was a technically gifted surgeon with a flair for teaching. This attracted students to him, many of whom became renowned in their own right. He emphasised the importance of regarding the patient as a whole--the holistic approach. He devised a surgical procedure, sympathectomy, to increase blood flow within arteries.

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In 1934 he introduced a form of sympathetic nerve block (stellate ganglion block). He was very interested in pain relief, in 1937 extending infiltration of local anaesthetic to intra-articular injection.

Leriche was a flamboyant character who enjoyed French cuisine and fine wine. He had a fine collection of art (one of his patients was Matisse). He was also an excellent public speaker who never needed notes.

Nikolay Ivanovich Pirogov (November 13 1810 to November 23 1881). was a prominent Russian scientist, doctor, pedagogue, public figure and corresponding member of the Russian Academy of Sciences (1847). He is considered to be the founder of field surgery and was one of the first surgeons in Europe to use ether as an anaesthetic. Administration of an anaesthetic by rectal route was introduced by Pirogov. He was the first surgeon to use anaesthesia in a field operation in 1847, invented various kinds of surgical operations and developed his own technique of using plaster casts to treat fractured bones. As his name is one of the most widely recognised in Russian medical history, he is considered a Russian national hero.

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Accepted for publication on February 9, 2008.

BIBLIOGRAPHY

(1.) Robinson V. Victory over Pain: A History of Anesthesia. 1946; p. 24-25.

(2.) Diz JC, Franco A, Bacon DR, Rupreht J, Alvarez J. The History of Anesthesia, International Congress Series. 2002; p. 163-167.

(3.) Keys TE. The History of Surgical Anaesthesia. New York, Schuman, 1945; p.41.

(4.) Wildsmith JAW, Strichartz GR. Local anaesthetic drugs--an historical perspective. Br J Anaesth 1984; 56:937-939.

(5.) Keys TE. Dr August Karl Gustav Bier 1861-1949. Anesth Analg Curr Res 1975; 54:322.

(6.) McKenzie A. A History of Anaesthesia through postage stamps. Maclean Dubois, Edinburgh. 2000; p.16-18.

(7.) From www.wikipedia.com

(8.) From www.whonamedit.com

(9.) Gibbons S. Simplified Catalogue, Stamps of the world. 2004.

P. RANGAPPA *

Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia

* M.B., B.S., D.N.B. (Int. Medicine), F.J.F.I.C.M., E.D.I.C., P.G.Dip. E.C.H.O., Senior Fellow.

Address for reprints: Dr P. Rangappa, Unit 5/10, The Grove, Woodville, SA 5011.
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Author:Rangappa, P.
Publication:Anaesthesia and Intensive Care
Geographic Code:8AUST
Date:Jul 1, 2008
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