Richard von Foregger, Ph.D (1872-1960)

Chemist and Manufacturer of Anesthesia Equipment and His Contributions to the Development of Anesthesiology in the 20thCentury

Richard Foregger M.D. (a)

TABLE OF CONTENTS

INTRODUCTION

Richard von Foregger was born in Vienna, Austria June 27, 1872, the son of a socially prominent, Viennese family.(b) His father was a lawyer and a member of the Austrian Senate. His mother, Elizabeth von Etlinger, was born in Odessa, Russian Empire. From her he acquired a knowledge of the Russian language and was fluent in German, French and English. He studied at the University of Munich, where he joined one of the student corps. He participated in fencing in the corps and those who knew him will remember the large scar across the face and bridge of the nose, received in a dueling match from those student days. When he finished his studies at the University of Munich, he went to the University of Stuttgart and then to the University of Bern where, in 1896, he received the Doctor of Philosophy degree in chemistry. He came to America in 1898, and was employed by the General Electric Co. under the famous electrical engineer Karl Steinmetz and then by the Roessler and Hasslacher Chemical Co. of New York City from 1905 to 1914.(c) In 1914 he set up his own manufacturing firm. THE FOREGGER COMPANY

The Foregger Company specialized in the manufacture of equipment for the administration of anesthesia gases to human beings. The development of the company was his life work and he devoted his entire time and effort to it. The business of The Foregger Company, Inc. was built by virtue of his unceasing efforts to satisfy the needs of the medical profession for safe, reliable and efficient anesthesia equipment. Overlooking the New York Public Library and adjacent Bryant Park through the large picture window of his New York office for 44 years, he corresponded with manufacturers, surgeons, anesthesiologists, nurse anesthetists, hospital superintendents, government officials throughout the world, and in addition, with Foregger salesmen on the road, Foregger dealers and representatives, equipment suppliers and all the vendors necessary to keep a business thriving.

He worked personally with doctors, hospitals and institutions for the teaching of anesthesiology, devised and manufactured special equipment to meet the specialized requirements of particular doctors and institutions, and acquired patents on his developments. The business of The Foregger Company, Inc. was a highly personalized business revolving around his personality and personal ability for relying for its success upon the faith and confidence of the medical profession in him.

There was no commercial relationship between Foregger and anesthesiologists in the development of equipment. The anesthesiologists who came to him with their design requests did not ask for compensation. It was his position to make himself available at medical meetings for discussions, which he thoroughly enjoyed, as well as through correspondence. He would discuss new ideas or improvements in equipment at the Foregger display booth at medical conventions or in the evening at the hotel. He was very exacting and punctual, answering letters within a few days. His relationship with anesthesiologists interested in the design and improvement of equipment was the overriding essence of his life.

Fig.1) Richard von Foregger in his office across from Bryant Park and the New York Public Library 1942. Bryant Library, Roslyn NY

On Saturday mornings he would travel from our home in Roslyn, Long Island, to the factory located in nearby Roslyn Heights, where in a group meeting all the ideas gathered at medical meetings or accumulated during the week's correspondence were discussed at length by those responsible for equipment development.

He had a strict authoritarian personality with a determined drive to achieve each current project. Yet he could be warm and fun loving. Work consumed his life except for sports on weekends. He loved life intensely. When he attended a medical meeting, he usually arrived early to visit whatever historical sites there might be in that city, history and biography being of great interest to him.

IMPORTANCE OF EDUCATION

Dr. von Foregger placed great value on education and continually stressed its importance in all areas of life. Any books I needed were purchased and brought home within days. Any study course was paid for without question. Colleges and universities were directed to submit tuition and textbook bills directly to him. Each year at the University and during my internship and residency he took time from his busy schedule to visit.

In each of the catalogs of the Foregger Co. personally prepared by him every two years, he tried to impart useful and helpful information regarding anesthesia equipment along with detailed instructions. Articles describing apparatus in the anesthesia literature were cited and reprints distributed for anesthesiologists seeking further information. One prominent anesthesiologist wrote, "Your father's influence was the Foregger catalogue and many anesthesiologists took pride in seeing their ideas in the catalogue, named after them."

DEVELOPMENT OF OXYGEN GENERATOR AND EARLY ANESTHETIC EQUIPMENT

In 1905, he became a member of the American Electrochemical Society, American Chemical Society, the Society of Chemical Industry and the New York Chemist's Club. His publications, 1905-1906, reveal his interest in the alkali metal and alkaline earth peroxides and superoxides that he soon came to employ for the generation of oxygen. (1-8)

The Niagara Falls Gazette, February 24, 1906 reports that:

"Some very interesting experiments have been conducted this week by Dr. R. von Foregger, of the Roessler and Hasslacher Chemical Company, and G. F. Brindley of the Niagara Electric Chemical Company at the laboratory of the latter company. The experiments were made with fused sodium peroxide that under the influence of moisture will give off oxygen and absorb carbon dioxide. In order to test the efficacy of this substance, Dr. Foregger this week got into an air-tight box three feet by six and remained there six hours. The supply of air was hardly enough for 20 minutes, at which time the man would have been dead or seriously injured had not the peroxide of sodium been present. As it was he sat there, was perfectly comfortable, and the air remained absolutely good for the six hours. At that time, it began to grow bad very rapidly. But only two pounds of the stuff was used. Had four pounds been put in the box the time would have been doubled. In generall the tests showed that the air remained constant, that is, the oxygen remained 20 per cent and the carbon dioxide stayed practically at zero. Dr. Foregger even felt better by his stay in the box. This new substance, as it has never been made on a commercial scale before, will, it is believed, enable submarine boats to stay under water a much longer time than they do at present."

In a paper read before the New York King's County Pharmaceutical Society March 13, 1906, he reports that he had constructed a small portable oxygen generator employing "Oxone", fused sodium peroxide. The apparatus was demonstrated making lighted cigars glow in the oxygen. (7,8) In 1906 at a meeting of the Electrochemical Society, he presented results of observations on a man in a sealed box with the oxygen generator for nearly six hours. He and coworker George Brindley calculated that 18 kg sodium peroxide would supply nine men in a submarine for 14 h. (9) The experiments were also presented at the Sixth International Congress of Applied Chemistry in Rome, Italy, April 27, 1906. (10) At the same meeting Dr. Herbert Philipp, in reporting on the uses of fused sodium peroxide said, " A very neat apparatus for the generation of oxygen gas from fused sodium peroxide has been invented by Dr. R. von Foregger." (11) The following year he was awarded a silver medal for an exhibit of the oxygen generator at the 1907 Jamestown Ter-Centennial Exposition. (12)

In 1907 Foregger first met the well known anesthetist James Tayloe Gwathmey. In his 1940 memorial to Gwathmey, he described how he and Gwathmey on more than one night at Madison Square Garden administered oxygen from the generator to relay teams of 10 mile runners as well as 6 day bicycle racers.(d) As a result of their relationship the oxygen generator was later modified to become an ether-oxygen outfit.(13) (e) In 1909,

Fig. 2) The oxygen generator, nine inches high and weighing less than three pounds, delivered fifteen gallons of oxygen with one full charge of oxone. A later model delivered 85 liters oxygen and was furnished with an ether attachment. Source: NY Med J 84:1007-1008, 1906

Foregger met Dr. William Anderson, a friend of Gwathmey and Director of Physical Education at Yale University. In a report on the oxygen generator which he had used for mountain climbing in Mexico, Anderson wrote, "Dr. R. von Foregger has invented a small oxygen generator. Foregger uses what he terms 'Oxone'.I carried the generator about my neck and breathed the gas almost constantly for three hours. It was like water to a thirsty man." (14)

In 1913 Foregger returned to the study of fused sodium peroxide for the purification of air, this time with Lt. (later Captain) Ernest W. Brown, MC, U.S. Navy. Ten respiratory apparatus were tested and experiments were carried out in a sealed room at Harvard University Medical School. Brown also made some tests on submerged E class boats, duration 17 hours. This work was of particular importance as it was the first detailed research on air purification for submarines in the U.S. Navy. (15)

In 1914 Foregger left Roessler and Hasslacher to set up a workshop in a barn at Roslyn, Long Island, NY, for the manufacture of the oxygen generator and anesthetic equipment with funds supplied by wife, Dorothy Ledwith. (f) The Foregger Company was incorporated on May 26, 1914. The Gwathmey apparatus was built there commencing in 1914 and for many years thereafter. This apparatus was constructed without reducing valves, but with control valves for oxygen and nitrous oxide. Each gas was led into a tube calibrated with a succession of openings, which allowed the gas to bubble separately through water into a glass mixing chamber so that the anesthetist could visually regulate the flow.

The Gwathmey apparatus undoubtedly influenced the design of the British made Boyle apparatus, as Boyle himself stated. (16) Various authorities in equipment design concur. (17-19)

Fig. 3) Gwathmey appartus. This was the standard hospital unit for nitrous oxide, oxygen and ether with 2 sight feed tubes. Source: Foregger Co. Catalog 1926

Professor Dennis Jackson (1878-1980) reported that at the Detroit AMA Convention in June, 1916, he was assigned an exhibit space not far from where Foregger was exhibiting the Oxygen Generator. Jackson called it the "oxydonor" and described it as "looking like a rather tall nickel-plated, old fashioned coffee pot" containing sodium peroxide which generated pure oxygen when water was added. Jackson said, "This was a splendid idea but it shows the status of oxygen supplies and anesthesia in 1916." Foregger, he says, was also much impressed with Jackson's anesthesia apparatus which was equipped with a device for absorbing carbon dioxide. (g) (20)

ACTIVE YEARS IN THE DEVELOPMENT OF ANESTHETIC APPARATUS

In 1923, Dr. Ralph Waters (1883-1979) then in private practice at Sioux City, Iowa, introduced the closed system of carbon dioxide absorption into clinical practice.(h) (21) He gave the design of the to- and-fro filter to Foregger with a request to construct the device, which was at first employed with the Gwathmey apparatus. However, the closed absorption system required an oxygen delivery of very fine adjustment for which there had to be an improvement in the rather coarse sight feed method of measurement. Also, in 1923 the introduction of ethylene as an anesthetic agent led to the need for more accurate methods of delivery. In order to improve on the sight feed flowmeter, Foregger, in 1924, designed and developed a flowmeter based on the principle of depression of a column of water.In his paper describing the method, delivered at the 6th Annual Congress of Anesthetists, 1927, he was frank to say that there was nothing new in this principle but that its practical application for anesthetic gases and the form in which it was done was novel.(i) (22) Flowmeters were developed at this period of time for oxygen, nitrous oxide, carbon dioxide, acetylene, propylene and helium. Professors Yandell Henderson and Howard Haggard of Yale University, Laboratory of Applied Physiology with whom Foregger had a working relationship, recalibrated and tested the first flowmeters.

Strange as it may seem to the current generation of anesthesiologists, the metric system of measurement was not widely used in medicine or in engineering at that period of time. The traditional apothecary or troy system was used for weight and gallons per minute for gases. Von Foregger, however, was a vigorous proponent of the metric system. He carried out a continuing educational effort through correspondence, the biennial catalog of the Company and advertisements. His work to apply the metric system of measurement for use on anesthetic apparatus was a genuine pioneering effort and may have been his major achievement. (j)

HOW FOREGGER CAME TO MAKE THE CIRCLE ABSORBER

Fig.4) Early circle respiration carbon dioxide Absorber. Foregger Co. Catalog 1929.

In early 1927 he designed and constructed a carbon dioxide absorber with unidirectional valves to be used in a closed respiratory circuit on an anesthetic apparatus, for which he was later granted a U.S. patent. (23-25) Fig.4.

When Helmut Schmidt (1895-1979) and Hans Killian (1892-1982) came to American in 1928 they visited Foregger at the exhibit hall of the 7th Annual Congress of Anesthetists in Minneapolis, June 11-15th and at his New York office on their way back to Germany. In reporting on the visit, Killian wrote, "

We asked Foregger why in America only the to-and-fro breathing system is used with carbon dioxide absorbers but not the circle breathing system. For a long time in Germany our rescue apparatus and anesthesia machines have been constructed with the circle device. Foregger understood and he soon proceeded with construction of a circle breathing system with very sensitive flutter valves to direct the gas stream and introduced the system in America. Today one finds the closed circle system featured on all modern American anesthesia machines. (26)

During 1926 Waters had been pressing Foregger to construct a "closed circuit filtration device". At an anesthesia society meeting in Montreal in October 1926, Foregger had taken occasion to carefully study for the second time, several metabolism apparatus on exhibit with flutter valves. On January 31, 1927, Waters wrote again stating, "I shall be very glad when you are able to do something with the closed circuit filtration device." On March 15th Waters wrote, "If you should place the filter on the apparatus, it should be made considerably larger in order to avoid refills." He was also concerned about the length of tubing and the chance for leaks. On April 18, 1927, Foregger wrote to Waters that the new closed circle device was practically ready and on April 27th the device was sent to Waters who had insisted on testing it before it was exhibited at the Washington meeting of the Congress of Anesthetists, May 16-19, 1927. As the device was modified, each model was tested and further suggestions made by Waters, now at the University of Wisconsin, Madison. Subsequently during 1927-1928 the device was sent to Dr John Lundy at Mayo Clinic, to Brian Sword, New Haven CT, to Thomas Collier of Atlanta GA, to Richard W. Jones, Wausau WI and others. With each distribution Waters was notified. The foregoing condensed paraphrased correspondence indicates that R.M.Waters exerted a prominent role in inducing Foregger to construct a circle absorber in the 1926/1927 period and actively participated in its further design and development.(k)

In June 1928 at the Minneapolis meeting of the Congress of Anesthetists, Foregger presented a paper in which he described the closed circle absorber under development in several different designs and acknowledged that DraegerWerk, Lubeck, with their long experience in building self contained oxygen breathing apparatus for mine rescue work, had preceded him with their circle absorber system for anesthesia. (27) A closed circle absorber system for anesthesia had become a standard feature on the Gauss-Wieland apparatus, Models #3 and #4, for acetylene anesthesia built by DraegerWerk in 1924 for which Bernard Draeger had been granted a German patent in 1927. (28) In the aforementioned paper (27), presented in June 1928, at the Minneapolis meeting of the Congress of Anesthetists, Foregger still considered the method to be in its early experimental stage but by the time of the Congress in October 1929, Dr. Brian Sword was able to report on the use of the closed circle carbon dioxide absorption apparatus in about 1200 cases. (29)

Helmut Schmidt who accompanied Killian on the trip to America and attended the Congress of Anesthetists meeting at Minneapolis in June 1928, reported that,

"As a forthcoming method, gas anesthesia with to-and-fro or circle breathing and CO2 filtration were exhibited. A neat little inexpensive apparatus for nitrous oxide with circle breathing similar to the Draeger portable apparatus was shown." (30)

When Schmidt returned to Germany, he brought one of these Guedel- Foregger Midgets with him. (l)

The development of the closed system of carbon dioxide absorption required a close working relationship between Waters and Foregger which lasted for many years. The advent of cyclopropane required continued and more exacting flowmeter precision. Other devices were improved, including the change from the base and upright stand models to the present day combined anesthesia table and apparatus in 1931.

Fig.5) Metric Gas Machine, Texas Model Foregger Co. Catalog 1938

Foregger also manufactured and distributed an anatomically improved oropharyngeal airway made of metal which had been designed by Waters. The original Guedel-Waters inflatable cuffs for endotracheal tubes were also marketed by the Foregger Company. (31)

OTHER WORKING RELATIONSHIPS

During the 1940's Foregger worked with Dr. John Adriani (1907-1988) to improve the design of carbon dioxide absorbers. Dr. Arthur Guedel (1883-1956) of Santa Barbara, CA, working with cadavers, designed and constructed a series of different size oropharyngeal airways made of rubber, later of plastic, intended for use in the smallest infants to the largest adults.(32) Previous to this airways had been cast of metal and some had been anatomically incorrect. Foregger manufactured and marketed these non-traumatic airways for many years. Prof. Emery A. Rovenstine (1895-1960) at New York University-Bellevue Medical Center, was a frequent visitor to the New York office of the Foregger Company for exchange of information on new designs and development. Rovenstine devised an endotracheal tube set-up, angular slip-joint connectors and forceps which were

Fig. 6) Foregger Folding Laryngoscopes Advertisement, Anesthesiology 1941

produced by Foregger. Likewise Dr. Vincent Collins, then at St. Vincent's Hospital, NY, often visited, sometimes with his resident students. Collins says, "The company was ready to make and supply new instruments and anesthesia accessories, and the tooling skill of the company has been appreciated by inventive anesthesiologists for many years." (24)

Foregger was very much involved in the design and development of laryngoscopes, working with Guedel,(m) Waters, Prof. Robert Macintosh of the Nuffield Department of Anesthetics, Oxford University, England, (1897-1989), (33,34) Dr. Robert A. Miller (1906-1976) of San Antonio, TX,(35) and many others. All together the 1959 catalog shows some 20 different shaped laryngoscope blades, in several sizes.

The development of the Macintosh laryngoscope blade was completed while the son Richard Foregger was on a one year assignment from the U.S. Army at Oxford University during World War II and Macintosh gave him the blade to insure that it was sent to America safely.

Others with whom Foregger worked to design and improve anesthetic equipment included Dr. Wesley Bourne (1886-1965) and Dr. Harold Griffith (1896-1985) for both of whom he developed the Montreal Model gas machine. Dr. Paluel Flagg, (1886-1970) lived and practiced in the New York City area and von Foregger produced more than 15 devices for anesthesia and resuscitation designed by Flagg.

Besides anesthetic gas machines, carbon dioxide absorbers, equipment for oxygen therapy and resuscitation, Foregger manufactured an entire series of accessories; pharyngeal airways in various sizes, endotracheal tubes, forceps, connectors, adapters, slip joints, pediatric non-rebreathing valves and laryngoscope blades in several sizes and in numerous varieties. The 1959 catalog, published before his death in 1960, consists of 167 pages, each page containing illustrations and descriptions of several devices.

The liquid anesthetic vaporizer invented by Dr. Lucien Morris in 1952, then at the University of Wisconsin, and manufactured by the Foregger Company as the Copper Kettle, was one of the last major appliances which von Foregger assisted in developing. (36)

FINAL YEARS

In the summer of 1940 Dr. Clayton Wangeman (1909-1975) resident anesthesiologist at the University of Wisconsin and Major in the US Army Medical Corps Reserve, reported to the Department of Anesthesiology that while on recent 2nd U.S. Army maneuvers, a Foregger Military Model anesthetic apparatus that he had been using had tipped over and could not be used owing to the resulting malfunction of the water flowmeter. The report was also sent up through Army channels with a copy to Foregger.

Largely as a result of this report, Foregger sold very few machines to the U. S. Armed Forces. Suggestions to change to a dry flowmeter were resisted by him. In England the rotameter had been in use since 1937. In Germany it had been used in 1910, and again in 1923 when DraegerWerk had employed the rotameter in the Gauss-Wieland acetylene apparatus. (n)

Following the Wangeman report, through correspondence to Foregger and in a paper at the 1941 annual session of the American Medical Association, Waters suggested that the rotameter should be studied. (37) U.S. Army anesthesiologists working in British hospitals during 1942-1944 while waiting for the invasion of the Continent had gained experience with the device and were aware of its advantages. In 1946 a further recommendation was made in the U.S. anesthetic literature to change to the rotameter.(38) There was continued resistance by Foregger for several more years. In response to demands by an increasing number of anesthesiologists, in 1950, 10 years after Wangeman had made his report, the rotameter was placed on the American market; by 1958 it had almost replaced the obsolete water flowmeter.

Fig.7) Rotameter Anesthesiology 7:549-57, 1946

Dr. James Elam had established an anesthesia research center devoted to equipment design and testing at Roswell Park Memorial Institute, Buffalo. Elam and Dr. Elwyn Brown, chemical engineer and anesthesiologist, were the designers and proponents of the large capacity canisters for carbon dioxide absorption. (o) In his published studies Brown found that all the canisters made by Foregger were inadequate in size.(39) Several other manufacturers had already increased canister capacity and efficiency based on features of design proposed by Elam. (40) In the 1950s following success with the innovation of the large canister, Elam was anxious to develop a mechanical ventilator to be combined with an anesthetic machine but when he approached Foregger the suggestion was rebuffed.

The delay in the manufacture of the rotameter, delay in marketing a large capacity carbon dioxide absorber, and failure to develop a respirator cost Foregger and the Company the loss of competitive leadership.

TRAGIC ENDING

The last fourteen years of his life were surrounded by turmoil of his own making, not being able to deal with and control his private life. This interfered with his business life and no doubt had a devastating effect on him. (p) In addition his physical condition began to deteriorate. In 1948 he was laid up at Doctor's Hospital NYC for seven weeks with a painful infected ulcer of the leg which required paravertebral sympathetic nerve blocks administered Dr.Vincent Collins. Subsequently he developed cardiac failure for which he was treated at the same hospital..

His son Richard Foregger was notified in 1958 by several attending physicians, including a board certified psychiatrist, of his father's deteriorating mental condition. There was a diagnosis of paranoid psychosis. A visit and examination confirmed the foregoing. His son reported the condition to his father's long time attorneys, and commenced a competency hearing which was bitterly contested by von Foregger's third wife in a widely publicized trial reported in the Long Island newspapers. A jury of 12 declared von Foregger incompetent. (q) A very capable Long Island attorney was appointed by the Court to supervise the management of the Company.

Von Foregger died at the age of 87 on January 18, 1960.

The Company was subsequently acquired by several other firms, but the loss of the founder's knowledge, along with experienced and valued employees, had destroyed institutional memory. A committee of the United States Congress presided over by the then Congressman Albert Gore, (now U.S. Vice President) carried out an investigation and held a hearing following a number of patient deaths due to faulty and obsolete equipment designs, and on the conduct of the Foregger Company in connection with those deaths. (r) Following the investigation and hearing the Foregger Co. was liquidated. As a consequence, according to the Hearing Report, there were no longer any major American owned firms in the business of manufacturing anesthesia machines, the remaining firms being foreign owned.(s)

APPENDIX I: LIST OF MAJOR ADVANCES BROUGHT TO MARKET BY FOREGGER COMPANY

1. Oxone Generator and Autogenor: Two portable devices employing sodium peroxide to generate oxygen. 1906 and 1908. These devices were manufactured by Roessler and Hasslacher Chemical Co. from 1906-1914 and for many years by the Foregger Co. after 1914. The patents were held by Foregger.

2. Gwathmey Apparatus: 1914-- Patent held by Foregger.

3. Construction of portable Seattle model anesthetic apparatus for nitrous oxide, ethylene, carbon dioxide and oxygen, and an ether bottle, at the request of Dr. John Lundy. 1923-

4. Waters to-and-fro carbon dioxide absorber 1923--

5. The Metric Gas Machine 1923-- with flowmeters for nitrous oxide, oxygen, carbon dioxide, ethylene, propylene, individually calibrated with metric scale; later available for helium, cyclopropane. Patent held by Foregger

6. Circle breathing system with carbon dioxide absorber 1927/28-- Patent held by Foregger.

7. Waters-Wisconsin metal pharyngeal airway, 1931/33--

8. Guedel rubber/plastic pharyngeal airway 1933-- NOTE; Foregger Co. had made pharyngeal airways since 1916, notably the Lombard and the Miller modification, Connell, Poe, Buettner, Flagg, Branower.

9. Midget gas machine, Guedel 1928---

10. Guedel, Flagg, Anesthetist's Laryngoscopes 1935-- Manufactured by Welch-Allyn, marketed by Foregger

11. Magill and other endotracheal tubes began to appear in the catalog at this time along with laryngoscopes, 1935-

12. Table model gas machines 1931--

13. Foregger laryngoscope patent, assigned to Welch-Allyn, 1941--

14. Foregger starts to manufacture laryngoscopes, 1941-- Patent for folding detachable blade held by Foregger.

15. Foregger starts manufacture of Macintosh laryngoscope followed by about 16 other models, 1943-- Total 20 models. U.S. patent for Macintosh laryngoscope held by Macintosh.

16. Manufacture and sale of complete apparatus models, C02absorbers, accessories, endotracheal equipment, oxygen and resuscitation equipment, increased extensively during and following World War II.

17. Rotameter 1950--

18. Copper Kettle Vaporizer 1952-- Patent held by L. Morris.

19. Enlarged capacity carbon dioxide absorber, 1959---

Source:List of Exhibitors,Technical Exposition, JAMA, 1916-1960; Foregger Co. catalogs.

ENDNOTES

a) The son Richard Foregger was never employed by or affiliated with the Foregger Company. There are three other biographies: Haid B: Der Anaesthesist 1960;9(5):188. National Cyclopaedia of American Biography Vol.48:1965 p.406. Anesthesiology 1996; 84(1): 190-200.

b) For details of the family history, von Foregger zum Greiffenthurn, see, Wiener Genealogisches Taschenbuch 7:42-44, 1935/1936; and J. Siebmacher, Wappenbuch, Vol. 4, Section 8, p. 149 and plate 14, 1879.

c) In 1900 General Electric sent him to Paris to attend the International Universal Exposition. After the Exposition closed he remained in Berlin where he married for the first time. He and Elza von Foregger visited the U.S. in 1901/1902 and again in April 1904. Elza, age 20, returned to Berlin where the marriage was dissolved.

d) For remarks on the use of oxygen for Marathon runners see. R V Foregger: Is Oxygen a drug? Sci Am 1912 July; 107(1): 7.

e)For an informative account of the history of the Gwathmey apparatus see, D K Cope,: James Tayloe Gwathmey: Seeds of a developing specialty. Anesth Analg 1993; 76: 642-647; D K Cope: The international medical congress of 1913, World War I and the transatlantic triangle. History of anesthesia,3rd International Symposium. Park Ridge IL, Wood-Library Museum of Anesthesiology, 1992.

f) Dorothy Ledwith Foregger (1891-1981) was educated at the Academy of the Sacred Heart, New York City, and married von Foregger in 1911. They were divorced in 1927.

g) Jackson's work in the development of apparatus for carbon dioxide absorption during anesthesia is reviewed by John Stetson in, Dennis Emerson Jackson (1878-1980), pp 564-571, and by Leslie Rendell-Baker, Development and function of anaesthesia breathing systems, pp 301-319, History of Anaesthesia. edited by Atkinson RS, Boulton TB. Park Ridge NJ, Parthenon Publishing Group, 1987. The 1916 meeting of the AMA, held at Detroit, MI, was the first time the Foregger Co. is listed as an exhibitor.

h) Waters was aware of the researches of Brindley and Foregger on the use of sodium peroxide for purification of the atmosphere of submarines when he became interested in carbon dioxide absorption during anesthesia. (Noel Gillespie: Ralph Milton Waters: A Brief Biography. Br J Anaesth 1949; 21:197-214)

i) Also see Richard Foregger, U.S. Patent 1,778,716, October 21, 1930, with specifications showing flowmeters with metric scale.

j) It was not until 1947 that the U.S. Pharmacopoeia, in its 13th Revision, discontinued the apothecaries' and avoirdupois systems in favor of the metric system. It did not go unnoticed by Foregger. It was not until 1973 that the JAMA and the AMA specialty journals began to publish weights and measures solely in the metric.

k) Waters-Foregger correspondence: Jan. 27, 1927, Jan 31, 1927, Mar 8, 1927, Mar. 15, 1927, Apr. 18, 1927, Apr. 20, 1927, Apr. 25, 1927, May 2, 1927, Aug 10, 1927, Sept. 15, 1927, Sept.19, 1927; Jan. 26, 1928, Mar. 12, 1928, Mar. 15, 1928, Oct.25, 1928, Feb. 19, 1929, Mar. 6, 1929, Apr. 30, 1929, May 16, 1929, Nov. 1, 1929. (University of Wisconsin Archives Division, General Files, Medical School, Anesthesiology, R.M.Waters Correspondence 1928-1950, Series 12/4/3, Box 7.)

l) Waters-Foregger correspondence, July 9, 1928. (University of Wisconsin Archives Division, General Files, Medical School, Anesthesiology R.M. Waters Correspondence 1928-1950, Series 12/4/3, Box 7.)

m) The Guedel Blade Laryngoscope was the standard issued to the U.S. Armed Forces Medical Corps during the Second World War. The large orders received for their Military Endotracheal Set kept the Foregger Company factory employed at full capacity during the war years. U.S. Patent number 2,289,226 for the Guedel laryngoscope was issued to Richard von Foregger on July 7, 1942. The U.S. Patent for the Macintosh laryngoscope was held by R.R. Macintosh of Oxford and assigned to the Foregger Co. Macintosh refused any remuneration for the patent.

n) For a detailed history of the rotameter in anesthesia see, H.Kronschwitz: 50 Jahr Rotameter für Narkoseapparate. Der Anaesthesist 1961;10: 97-99, with correspondence by R.R. Macintosh 1961;10: 213, and H. Kronschwitz 1961;10: 214. E.A. Pask in Modified Flowmeters for Anaesthetic Gases. Lancet 1940; 2: 680- 681, summarizes the disadvantages of wet flowmeters.

O) For review of the work of Elam and Brown see, James E. Peppriell, Douglas R. Bacon et al, The Development of Academic Anesthesiology at the Roswell Park Memorial Institute: James O. Elam and Elwyn S. Brown. Anesth Analg 1991; 72:538-545

p)In 1946, von Foregger married his housekeeper, Mrs. Lillie Mae Holt (1900-1990), his third marriage.

q)Supreme Court, Nassau County, Mineola, NY, Matter of the appointment of a Committee for Richard von Foregger (Incomp). Index No 3861/59, entered April 16, 1959, trial held Sept. 10-23, 1959. Complete newspaper reports of the trial are on file at Wood Library-Museum of Anesthesiology, Park Ridge IL.

r)Anesthesia Machine Failures: Hearing before the Subcommittee on Oversight and Investigations of the Committee on Energy and Commerce, House of Representatives, 98th Congress, 2nd session, September 26, 1984, Serial No. 98-188, Washington DC GPO, 1985, pp. 263.

s) For an historical account of the Foregger Co. See, Death of a Company, Milwaukee, Harmar Press, 1997 by Richard Foregger.

REFERENCES

1.von Foregger R: A legitimate food preservative: active oxygen. Am Inventor 1905 Jan; 13(1):6-7

2. von Foregger R: Bacteriocidal activity of calcium peroxide and of hydrogen peroxide. Am Drug and Pharm Rec 1905 May 22; 46: 289

3. Foregger Rv: Water purification. Boston Med Surg J 1905 Feb; 152 (6): 177

4. von Foregger R: Oxygen toilet preparations. Am Drug Pharm Rec 1906 Feb 12; 48: 61-62

5.von Foregger R: New pharmaceutical sources of oxygen. Am Drug Pharm Rec 1906 Mar 26; 48: 155-157. Abstracted in Merck's Report 1906 May; 15(5): 132-134

6. von Foregger R, Philipp H: Earth alkali and allied peroxides: properties and applications. J Soc Chem Ind 1906 April; 25(7): 298- 302

7. von Foregger R: Utilization of active oxygen electrically and chemically produced. Tran Am Electrochem Soc 1905 Sept; 8:141- 60

8. [Foregger Rv:] New oxygen generator. New York Med J 1906 Nov; 48: 1007-1008

9. Brindley G, Foregger Rv: Report on experiments with fused sodium peroxide on the regeneration of air for submarines. Tran Am Electrochem Soc 1906; 9: 291-304

10. Brindley GF, Foregger Rv: Report on experiments with fused sodium peroxide for the regeneration of air in submarine boats. Atti d VI Congr Int Chim Appl 1907; I: 737-47

11. Philipp H: Fused sodium peroxide. Atti d VI Congr Int Chim 1907; I: 734-37

12. Foregger Rv: Process and machine for regeneration of air. Exhibit and silver medal award.Charles Russell Kiehy, Official Blue Book of the Jamestown Ter-Centennial Exposition 1907. Norfolk, 1909, pp.806 with index. See p. 497.

13. Foregger R: Gwathmey. Anesthesiology 1940; 5: 296-299

14. Anderson WG: Use of oxygen in mountain climbing. Am Phys Educ Rev 1909; 14: 277-287

15. Foregger R Jr: Use of alkali metal and alkaline earth peroxides and superoxides for control of atmospheres in closed spaces; annotated bibliography. Toxicol Environ Chem 1996; 53: 255-263.

16. Boyle HEG: Recent developments in gas and local anaesthesia. St. Bart's Hosp J 1919 Nov; 28: 22-23

17. Thompson PW, Wilkinson DJ: Development of anaesthetic machines. Br J Anaesth 1985; 57: 640-648

18. Rendell-Baker L: Development and function of anaesthesia breathing machines in, The History of Anaesthesia. Edited by Atkinson RS, Boulton TB. Park Ridge NJ, Parthenon Publishing Group, 1987, pp. 301-319. See p. 305.

19. Atkinson RS, RushmanGB, Lee JA: Synopsis of Anaesthesia . 10thed. Bristol, England. Wright, 1987. See pages 145 and 18.

20. Jackson DE: Anesthesia equipment from 1914 to 1954 and experiments leading to its development. Anesthesiology 1955; 16: 953-969

21. Waters RM: Clinical scope and utility of carbon dioxide filtration in inhalation anesthesia. Curr Res Anesth Analg 1924; 3: 20-22.

22. Foregger Rv: Percentages and true flow of gasses for gas oxygen anesthesia. Curr Res Anesth Analg 1927; 6: 225-234.

23. National Cyclopaedia of American Biography. 1965; 48: 406, "Richard von Foregger."

24. Collins V: Principles of Anesthesiology. 2nd Edition. New York, Lea & Febiger, 1976, p. 15.

25. Betcher AM: Anesthesiology in New York. N Y State J Med 1976; 76: 1165-70.

26. Killian H: Das Abenteuer der Narkose: Erfahrungen und Erlebnisse aus 40 Jahren Narkoseforschung. Tubingen, Grabert, 1966, p. 71.

27. Foregger R: Position of the breathing bag. Curr Res Anesth and Analg 1929; 8: 34-39.

28. Foregger R II: Kreisatmer und CO2- Absorption: Eine Frage der Priorität. Der Anaesthesis 1995; 44: 917-918.

29. Sword BC: The closed-circle method of administration of gas anesthesia. Curr Res Anesth Analg 1930; 9: 198-202.

30. Schmidt H: Die Gasnarkose vom Standpunkt des Amerikanischen Narkosespezialisten. Narkose Anaesth 1928; 1: 530-540.

31. Guedel AE, Waters RM: A New Intratracheal Catheter. Curr Res Anesth Analg 1928; 7: 238-239.

32. Guedel AE: A nontraumatic pharyngeal airway. JAMA 1933; 100: 1862.

33. Macintosh RR: A new laryngoscope. Lancet 1943; 1: 205.

34. Jephcott A: The Macintosh laryngoscope. Anaesthesia 1984; 39: 474-479.

35. Miller RA: The development of the laryngoscope. Der Anaesthesist 1972; 21: 145-147.

36. Morris LE: A new vaporizer for liquid anesthetic agents. Anesthesiology 1952; 13: 587-593.

37. Waters RM: Chemical absorption of carbon dioxide from anesthetic atmospheres. Anesthesiology 1943; 4: 596-607.

38. Foregger R II: Rotameter in anesthesia. Anesthesiology 1946; 7: 549-557.

39. Brown ES: Voids, pores and total air space of carbon dioxide absorbents. Anesthesiology 1958; 19: 1-6.

40. Elam JO: The design of circle absorbers. Anesthesiology 1958; 19: 99-100. NOTE: There are 2 other papers written by Richard von Foregger which are not included in the above references: 1.) Demonstration der Kjeldsen Lampe zur Lichtbehandlung nach Finsen. New Yorker Medizinische Monatschrift 15: 33-41, 1903. A talk and demomstration presented at the Deutsche Medicinische Gesellschaft, New York City, Monday June 2, 1902. 2. Resuscitation Apparutus. Science 99: 470-471, June 9, 1944. This is evidently his last published paper.


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