The history of "modern" anesthesia technology - A critical reappraisal: Part I: Key criteria of "modern" anesthesia: Technology and professionalism definitions, backgrounds and a short introduction to a changing evidence-base.

This paper is the first in a series of publications. These investigate, whether important elements of the historiography of anesthesia require a critical reappraisal. A systematic, combined presentation, contextualization and assessment of recent European research is provided. This includes the author's own findings. These emanate from two extensive projects. They combine very recent findings with results of earlier research, conducted by the author and numerous collaborators over the last 18 years. The findings represent an ever increasing and ever more robust body of evidence. They add an important new element to our international historiography. As an introduction, several definitions will be given for criteria, which designate "modern" anesthesia and its technology. On one of these criteria, the history of professionalization and specialization, a short overview will be given. This will be followed by an overview of general contexts, key features and early achievements of anesthesia-related technology. All results will be compared with a currently dominating narrative: This alleges "dominance" of US-American and British pioneers and developments. Apparent biases and inconsistencies are identified. These suggest that our current, international historiography of anesthesia may require a critical reassessment. Three subsequent articles will focus on specific aspects of anesthesia technique and technology. Their results likewise suggest a history of internationalism and trans-disciplinary reciprocity, rather than of national dominances. Further investigations will aim to ascertain the nature and extent of potential interactions, which may nowadays be underrecognized.

The history of modern anesthesia technology - A critical reappraisal (Part II) An international comparison of contemporary devices and of nitrous-oxide-based anesthesia (c. 1900-1930s)- recognizing another changing evidence-base.

This paper is the continuation (Part 2) of an extensive, critical reappraisal of the international historiography on modern anesthesia and its technology. The first paper of this series provided general definitions, backgrounds and an update on recent research on one aspect of this topic: the history of professionalization / specialization (Part 1).1This paper goes on to provide a first, international comparison of entire anesthesia devices and on the history of nitrous-oxide-based anesthesia (c. 1900-1930s). Results: A comparative chronology of internationally recognized milestones of entire anesthesia machines does not suggest significant differences between the nations of continental Europe on one side, or the USA and Britain on the other. The international historiography on one of the key techniques for which these devices were designed (nitrous-oxide-based anesthesia), is likewise demonstrably biased. These findings are further evidence that a frequently held hypothesis, which suggests national dominances in these fields, is incorrect. Contributing factors and wider contexts of this phenomenon can be further confirmed: These are an under-recognition of non-Anglo-American (particularly continental-European) and of primarily surgical contributions; contemporary international conflicts and inter-professional demarcation disputes. In addition, it can be shown that these phenomena had already started around the same time (c. 1900s-1930s). There also is evidence to suggest that they were at times reciprocal and quite deliberate. The author illustrates and argues that the currently prevalent historiography on modern anesthesia requires a thorough reassessment. This should be based on a perspective of internationalism and transdisciplinary reciprocity and should recognize much broader historical contexts.

[100 years of Draeger Medical Technology (1902 - 2002) -- working for the applicability of oxygen]. / 100 Jahre Dräger-Medizintechnik (1902 - 2002) - oder: im Zentrum steht der Sauerstoff... Zur Bedeutung der Druckgastechnik für die Begründung der modernen Sauerstofftherapie und der Anästhesiologie.

This survey analyses the history of 100 years of Draeger Medical Technology. Between 1889 and 1902 a number of inventions on the field of pressure gas technology allowed to solve application problems, which until then proved major obstacles to the safe and efficient use of compressed gases such as oxygen, nitrous oxide or carbon dioxide for medical and industrial purposes. A special significance is to be awarded here to pressure reducing valves, but also reliable manometers, nozzles and valves for pressure tanks were not generally available until then. These were first successfully and on a really significant scale introduced into international medical and non-medical pressure-gas technology by Draeger Inc. (Luebeck/Germany), and proved particularly successful in anaesthesia and rescue-devices (e. g. in the "Roth-Draeger Anaesthesia Apparatus" (1902). Consequently, starting in 1902, Draeger Inc. increasingly put an emphasis on developing medical and rescue technology and -- by doing so -- gained an important influence on the history of the implementation of modern oxygen therapy and of inhalative anaesthesia. A survey of the historically most important Draeger-Developments is provided.

Mental competence and surrogate decision-making towards the end of life.

German legislation demands that decisions about the treatment of mentally incompetent patients require an 'informed consent'. If this was not given by the patient him-/herself before he/she became incompetent, it has to be sought by the physician from a guardian, who has to be formally legitimized before. Additionally this surrogate has to seek the permission of a Court of Guardianship (Vormundschaftsgericht), if he/she intends to consent to interventions, which pose significant risks to the health or the life of the person under his/her care. This includes 'end-of-life decisions'. Deviations from this procedure are only allowed in acute emergencies or cases of 'medical futility'. On the basis of epidemiological and demographical data it can be shown that the vast majority of surrogate decisions on incompetent patients in Germany is not covered by legally valid consent. Moreover, the data suggests that if consent were to be requested according to the legal regulations, both the legal and medical system could realistically never cope with the practical consequences of this. Additionally, empiric research has revealed serious deficits concerning medical 'end of life-decisions' and practical performance in palliative care. As a consequence a multidisciplinary discussion has developed in Germany about the reform of present legislation with respect to key-issues like the assessment of mental competence, the options for exercising patient self-determination via advance directives and durable powers of attorney, the improvement of palliative care facilities, the clarification of formal procedures for surrogate decision-making in health care and towards the end of life and the possibilities and their limitations of controlling these decision-making processes 'externally' (e.g., by Guardianship Courts or committees). The authors discuss those proposals, which clearly dominate the present debate: They all aim to comply with the scientific basis of German law, jurisdiction and the European traditions of philosophy of health care and bioethics.

[The centennial of oxygen-therapy (1902 - 2002) -- reassessing its history. Part II: The contributions of the "Roth-Draeger anaesthesia apparatus" (1902) and other inventions of 100 years of Draeger-Medical-Technology (1902-2002) to the history of truly "therapeutic" application of oxygen]. / 100 Jahre Sauerstofftherapie (1902 - 2002) -- Eine medizinhistorische Neubewertung -- Teil II: Die Bedeutung des Roth-Dräger-Narkoseapparates (1902) und weiterer Entwicklungen aus 100 Jahren Dräger-Medizin- und Anästhesietechnik für die Etablierung der Sauerstoffanwendung im therapeutischen Methodenspektrum.

This is the second part of a survey which analyses the history of inhalative oxygen therapy and its interactions with the history of anaesthesiology. Specific emphasis is put here on illustrating inventions of modern pressure gas technology such as pressure reducing valves. These enabled Draeger Inc. to be the first firm to develop and trade on a large scale technically convincing products allowing a rational, therapeutic application of oxygen. Especially Draeger anaesthesia apparatus (e. g. the "Roth-Draeger Anaesthesia Apparatus") and respiratory protective devices, which were available from 1902, proved also internationally successful from the very beginning. In the international historiography on inhalative oxygen therapy, however, these contributions have to our knowledge so far never been systematically considered. Consequently, J. S. Haldane (1860 - 1936) is regarded there to have "founded" of modern oxygen therapy in 1917. Critically reviewing this earlier research, we propose a historical reassessment, concluding that the year 1902 was the historically decisive "turning point" towards the development of modern oxygen therapy.

[The centennial of oxygen-therapy (1902 - 2002)--reassessing its history. Part I: "The long way of oxygen"--from its discovery to its implementation as a rational therapy in anaesthesia and emergency-medicine]. / 100 Jahre Sauerstofftherapie (1902 - 2002) - Eine medizinhistorische Neubewertung - Teil I: Der lange Weg von der Entdeckung des Sauerstoffs bis zu seinem Durchbruch bei der therapeutischen Anwendung in der Anästhesiologie und Rettungsmedizin.

This historical survey in two parts analyses the history of inhalative oxygen therapy and its interactions with the history of anaesthesiology. For this purpose, we will start with illustrating "the long way of oxygen" from its first isolation by Carl Wilhelm Scheele (1772) and Joseph Priestley (1774) to its breakthrough for therapeutic application in the 20th century. We will show that the two main factors delaying the successful implementation of a truly rational oxygen therapy were of technical nature: The complicated and costly production of the gas and insufficient means to apply it continuously and with reliable and sufficient dosages to the patients. Both problems could not be satisfactorily solved until 1902. From this year on, however, the "Linde Process" allowed cheap mass-production of oxygen. Simultaneously, various inventions of modern pressure gas technology allowed to solve the application problems. Here, a special significance is to be awarded to pressure reducing valves. These were first introduced into medical technology by Draeger Inc. (Lübeck/Germany) on a significant scale, proving particularly successful in anaesthesia and rescue-devices (e. g. in the "Roth-Draeger Anaesthesia Apparatus" [1902]). Critically discussing earlier research on the history of oxygen therapy, we therefore propose a historical reassessment, accepting the year 1902 as the internationally decisive "turning point" towards the development of modern oxygen therapy.

[Proxy decision in health questions and advance designations by patients. A practice-oriented review of the legal and ethical problems in treating the incompetent patient]. / Stellvertreterentscheidungen in Gesundheitsfragen und Vorausverfügungen von Patienten. Eine praxisorientierte Ubersicht zu rechtlichen und ethischen Problemen bei der Behandlung nicht einwilligungsfähiger Personen.

Except in emergencies, the medical treatment of incompetent patients also has to be based upon an informed consent between the physician and a legitimate legal representative (durable power of attorney). Consequently, the German 'Betreuungsrecht' advices persons to designate in advance such a proxy or surrogate. However, an additional court-decision is demanded, if a medical measure poses significant risks for the future health or the life of the incompetent patient. On the base of the available epidemiologic data we illustrate that neither our medical nor our legal system could realistically cope with the practical consequences of this legislation: The vast majority of our present decisions in such cases is not covered by a legally valid informed consent, which implies possible forensic consequences. This article provides relevant clinical and legal advice on how to protect the legitimate interests of all concerned within the present framework, which should urgently be revised.

John Gregory (1724-1773) and his lectures on the duties and qualifications of a physician establishing modern medical ethics on the base of the moral philosophy and the theory of science of the empiric British Enlightenment.

In 1769/70 the Scottish physician and philosopher John Gregory (1724-1773) published Lectures On the Duties and Qualifications of a Physician. Gregory developed a truely ethical - in the sense of (moral) philosophically based - system of conduct in a physician. His concept of practising and teaching ethics in medicine and science is established on a very broad footing: combining Bacon's (1561-1626) general philosophy of nature and science with both, the general, likewise empirically based moral philosophy of his personal friend David Hume (1711-1776), and with the principles upheld by the so-called Common-Sense Philosophy. His Lectures had - particularly via the famous Code of Medical Ethics of Thomas Percival (1740-1804) - a decisive influence on our contemporary concepts of ethics in medicine and science. John Gregory is, without doubt, one of the most important and certainly the most comprehensive among the founders of what is known today as modern Bioethics.