The Flying Death and Other Adventures in Anesthesia

It is amazing to think that curare, a poison sometimes known as “The Flying Death” and used on the tips of darts and arrows by indigenous people of South America, could prove to be an important stepping stone in the path to modern anesthesia. But then again, curare is not a simple poison, but actually a powerful muscle relaxant; after injection, an animal that has been shot with a curare-tipped dart can actually be kept alive through artificial respiration. More importantly to the native tribes—as they would not have needed to resuscitate their dinners—curare brings about paralysis and asphyxiation when injected (either by dart, arrow, or needle), but is not poisonous if ingested.

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A native tribesman demonstrating his prowess with a blowgun typically used with curare darts. Clip taken from Richard Gill’s film “White Water and Black Magic”.

Curare was first brought to the United States by Richard Gill, an American living in Ecuador, in 1938. Gill had become interested in the medicinal uses of curare after falling off his horse and developing neurological symptoms including spasticity. After being told about curare by his neurologist, Gill sought out and befriended a tribe who used the arrow poison. The indigenous people then showed him how to procure and use it, and Gill eventually returned to the US with approximately 25 pounds of curare paste.

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Richard Gill sitting with a native tribesman while watching another tribesman cook down curare. Clip also taken from “White Water and Black Magic”.

Medical experiments with curare began as early as the 19th century, but its use in anesthesia didn’t start until the mid-20th century, after Gill had introduced it in the US. One of its first uses was to prevent bone fractures brought about by spasms during electro-convulsive therapy. Since it is such a powerful muscle relaxant, curare proved helpful for tracheal intubation, and in keeping the patients’ muscles relaxed during operative procedures. It also lessened the need for the use of deep general anesthesia during highly invasive operations, like abdominal or thoracic surgeries.

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1943 cartoon by Clark Haas depicting Richard Gill visiting native peoples to obtain more curare. Arthur Guedel collection, MSS 2016-03.

Despite its usefulness in relaxing patients, curare has no analgesic (painkilling) or anesthetic qualities. This was proven in the 1940s, after curare was given to some infants and children as the sole anesthetic agent during operative procedures. The patients who were old enough to communicate complained that they had felt everything during the surgery but were unable to move or cry out about the excruciating pain they were feeling. Upon hear this, anesthesiologist Dr. Scott Smith volunteered to take the drug in order to test whether curare did have any pain-relieving qualities. He became paralyzed but reported that the reduction of painful sensations was not impacted. Like the young patients before him, Smith had felt everything, but had not been able to move to stop it.

Who was Dr.Arthur Guedel?

This is a guest post by Dr. Selma Calmes

Arthur Guedel, MD (1883-1956), was an early anesthesiologist who made many important contributions to the development of anesthesiology.  His papers are now available at UCSF Archives & Special Collections.  Who was Dr. Guedel and why is he important?

Guedel’s early life was difficult.  He was born in Cambridge City, Indiana, and had to leave school at age 13 to help support his family.  A work accident led to the loss of the first three fingers of his right hand—and he was right-handed.  Guedel dreamed of practicing medicine even though he had no high school diploma and no financial resources.  American medical schools had few admission requirements then, and his family physician helped him get into the University of Indiana Medical School.  He graduated in 1908.
Guedel administered his first anesthetics while an intern at Indianapolis City Hospital.  This was a common duty for interns of the time because there were then few physicians interested in anesthesia.  Guedel started a general practice in Indianapolis in 1909 and earned additional income by giving anesthesia in hospitals and dental offices.  He was an exceptional observer, analyzing carefully what might be going on with his anesthetized patients and thinking of possible solutions to the problems.

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First version of Guedel’s signs of anesthesia

One example of his contributions is his work on the signs of anesthesia.  The various devices that tell us how an anesthetized patients are doing today, such as EKGs, blood pressure devices and pulse oximeters, weren’t available when Guedel began to do anesthesia.   Four stages of anesthesia were accepted:
Stage I: Induction, the start of administration until loss of consciousness
Stage II: Struggling, breath-holding, delirium, from loss of consciousness to onset of surgical anesthesia
Stage III: Surgical anesthesia, characterized by deep, regular, automatic breathing
Stage IV: Bulbar paralysis, irregular breathing, pupils no longer respond to light

Guedel’s contributions were to expand these observations and to look for other physical signs.  He better defined Stage III, the level at which surgery could be done, by further dividing it into four planes and by adding eye signs. This improved patient safety by making clear when the patient was too “deep” and might possibly die from overdose of anesthesia.

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Dr. Arthur Guedel during World War I

The setting for these developments was Guedel’s service with the US Army in WW I in France.  The Army had no anesthesiologists when the US entered the war, and casualties were overwhelming.  After working 72 hours straight along with three other physicians and one dentist, and needing to run as many as 40 operating room tables at a time, Guedel decided additional staff had to be trained.  He developed a school that taught physicians, nurses and orderlies to give anesthesia.  But, how could he help his trainees do safe anesthesia once they left the school?  He prepared a little chart of his version of the signs and stages of ether anesthesia, the most common agent in use at the time and one with a wide margin of safety.  This chart was a visual version of the concepts he had been developing before his Army service.  Armed with their charts, the trainees went out to nearby hospitals to work on their own.  Guedel acquired a motorcycle so he could make weekly rounds of the six hospitals for which he was responsible.  He would roar from hospital to hospital through the deep mud that characterized WW I battlefields, checking on his trainees.  He was known as “the motorcycle anesthetist” of WW I.
After his return to the US in 1919, he presented his chart at meetings.  In 1920, he wrote an article on his signs for the first anesthesia journal. Additional articles appeared in 1935 and 1936 and also in Guedel’s notable book, Inhalation Anesthesia: A Fundamental Guide, published in 1937.

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Dr. Guedel (under the operating room table) and his anesthesia machine in the Zakheim mural. Chauncey Leake is standing above him

In 1929, Dr. Guedel moved from Indianapolis to Los Angeles.  He continued his careful observations and worked to solve important problems.  He collaborated with others, most importantly Dr. Ralph Waters of Madison-Wisconsin (considered the father of academic anesthesiology) and pharmacologist Dr. Chauncey Leake, then UCSF’s chairman of pharmacology.  Guedel would travel from Los Angeles to San Francisco for various research projects at UCSF. He even appears in the Bernard Zakheim murals at UCSF!   The papers now available in the UCSF Archives document many other contributions made by this important anesthesiologist.

Selma Harrison Calmes, MD is a retired anesthesiologist interested in history. A 1965 graduate of Baylor College of Medicine, she trained in anesthesiology at the University of Pennsylvania. She came to UCLA in 1976 as their first pediatric anesthesiologist. In 1988, she became chair of anesthesiology at Olive View-UCLA Medical Center. She retired from clinical work in 2007 and now is the Anesthesiology Consultant to the Los Angeles County Coroner.
In 1980, she took a National Endowment for the Humanities Summer Fellowship in Medical History at the University of Cincinnati under noted medical historian Dr. Sol Benison. She writes on various aspects of anesthesia history, especially in California, and on the many women who were early leaders in anesthesiology, especially Dr. Virginia Apgar. She co-founded the Anesthesia History Association with Dr. Rod Calverley in 1982 and served as the first editor of their publication, now the Journal of Anesthesia History. She is on the Board of Trustees of the American Society of Anesthesiologists’ Wood Library-Museum and is president of the Guedel Memorial Anesthesia Center Board of Trustees. She appeared in the National Library of Medicine’s 2003-2005 exhibit on women in medicine, “Changing the Face of Medicine” and is listed in their biographic dictionary.

Arthur E. Guedel Anesthesia Collection transferred to UCSF archives

The UCSF archives would like to announce the acquisition of the Arthur E. Guedel Anesthesia Collection. The agreement to transfer these unique materials of high research value that will complement existing archival holding was signed by the Arthur E. Guedel Memorial Anesthesia Center Board of Trustees and the UCSF Library last March. This extensive collection contains more than 40 linear feet of personal papers, rare books on the history and development of anesthesia, journals and artifacts, including anesthesia equipment and unique collection of artifacts from Richard Gill’s journey into Ecuador to collect curare, as well as audio-visual materials.

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Drs. Merlin Larson and Selma Calmes signing the agreement to transfer the Arthur E. Guedel Anesthesia Collection to the UCSF Archives & Special Collections, March 2015

The Arthur E. Guedel Memorial Anesthesia Center was founded in 1963 by a small group of anesthesiologists who were interested in preserving the history of their specialty. The center is dedicated to the memory of Dr. Arthur E. Guedel, a pioneer of modern anesthesiology on the West Coast. For many years it was housed in the Health Sciences Library at California Pacific Medical Center and we are grateful to our colleagues there, in particular Anne Shew, director of the Health Sciences Library for an outstanding stewardship of these materials. The personal papers have detailed finding aids and after they are moved to the UCSF library later this summer, they will be made accessible to the visitors in the archives reading room. The reminder of the collection will be transferred to archives after removing duplicate material within a year. The Guedel collection materials will be incorporated into UCSF library catalog and archival collections finding aids describing the contents of personal papers will be added to the Online Archive of California. At the conclusion of the transfer, a Guedel collection digital portal describing history and materials in the collection will be built by the archives and linked to the UCSF Department of Anesthesia website.
Dr. Selma Calmes, retired Clinical Professor of Anesthesiology at UCLA and president of the Guedel Board of Trustees, noted in her 2004 article that Dr. Chauncey Leake, Professor of Pharmacology at UCSF was a person with strong ties to anesthesia and was instrumental in naming and organizing the center: “He suggested dedicating it to the memory of the only pioneer of modern anesthesia on the West Coast, Dr. Arthur Guedel of Los Angeles. Leake had been good friends with Guedel, who often visited UCSF to do research.” (1) The UCSF archives is the home of the Leake papers (as well as collection of rare books on anesthesia) and the addition of the Guedel collection will reunite these resources. It includes the papers and correspondence of several pioneers in the field on anesthesia, in particular, Richard C. Gill, Drs. Ralph Waters, Abram Elting Bennett, William Neff, and Arthur E. Guedel.

We would like to express our gratitude to the Guedel Board and in particular Drs. John Severinghaus, Merlin Larson, and Selma Calmes. Tomorrow we will be publishing a guest post written by Dr. Calmes and in the next year are planning to share updates about the transfer of the collection to UCSF, as well as showcase its treasures.
1.    Calmes, Selma. “The History of the Arthur E. Guedel Memorial Anesthesia Center.” California Society of Anesthesiologists Bulletin. 2004 July-September; 53 (3): 71-72.