A History of Anaesthesiology – Flash 11

A History of Anaesthesiology – Flash 11

  • Issue 62

George Litarczek

The beginning of the use of general anaesthesia can be easily identified to 16 October 1846. Pin pointing the first time local and regional anaesthesia was used is far trickier. Instinctive reactions to pain and injury lead animals and human beings to apply natural anaesthesia: animals will lick a wound thus producing hyperstimulation to close the medular gate and cleansing it; humans might suck on a cut or rub it producing a liminal pain sensation which lessens the pain. Hypothermia has long been applied as pain relief. Baron Larrey, Surgeon-in-Chief of the Napoleonic armies performed amputations on frozen limbs without anaesthesia during the Russian Campaign.

Primitive civilisations applied herbal mulches with analgesic and antiseptic effects to wounds. They also compressed nerve trunks or arteries to induce hypoxia followed by anaesthesia of the subjacent region. Coca leaves were used for maximum analgesic effect.

Karl Koller, the Austrian ophthalmologist and colleague of Sigmund Freud, demonstrated the tissue numbing properties of cocaine. Medical breakthrough was made in 1884 when he performed local anaesthesia during eye surgery by diffusing cocaine through the conjunctive mucosa.

Cocaine was first extracted by Goedeck in 1855 and first purified by Vassili von Anrep in 1879. The development of the hypodermic syringe and hollow needle was an important prerequisite for local anaesthesia by injection. French physician Dominique Anel is usually credited with the invention of the syringe in the 17th century.

In 1853, Charles Pravaz and developed a medical hypodermic syringe with a needle fine enough to pierce the skin. Around the same time Alexander Wood devised a subcutaneous injection method and Daniel Ferguson developed a syringe practically made of glass. This important change permitted visual monitoring of injections. The next big step was made by William Halsted and his team in 1855 who made extensive trials on themselves by infiltrating cocaine solutions along peripheral nerve trunks performing what is now called trunk anaesthesia. The first spinal channel puncture was performed by James Corning (1885) in the US, first on dogs and then moving to healthy humans, injecting cocaine into the para-vertebral and in fact the epidural space. He did not describe the flow of spinal fluid or the slow onset of analgesia.

The lumbar puncture was introduced by Heinrich Quincke in 1891. In 1898, August Bier performed the first operation under spinal subarachnoid anesthesia on patients and himself. The same technique was carried out by Théodore Tuffier in France just months later and by Constantin Severanu in Romania in 1899. At the beginning of the 20th century, the reknown Romanian surgeon, Thomas Ionesco developed local spinal anaesthesia by introducing the new anaethestic stovaine in thyroid surgery.

Infiltration anesthesia was introduced by Carl Schleich in 1892 by using low concentrations of cocaine. The first low toxicity local anaesthetic procaine (Novocain) was synthesized in 1904 by Emil Fischer. This breakthrough was an important step in a wider use of loco-regional anaesthesia in continental Europe. Spinal anaesthesia was frequently used by French army surgeons during WWI. In Eastern Europe and particular in Romania spinal anaesthesia was widely used for abdominal, gynecological, urological and orthopedic surgery. Gertie Marx (1900) and Walter Stoeckel (1909) used spinal anaesthesia with cocaine to alleviate pain during labour. In 1909, Stoeckel pioneered caudal anaesthesia.

When I began working in surgery in the late 1940s, spinal anaesthesia reigned in all operating theatres. The method had been refined by using new anaesthetic solutions: tetracaine (pontocaine) (1928) and nupercaine (1925) (percaine cincocaine, dibucaine, first amide compound),which had a higher toxicity but a longer lasting effect, up to 3 hours when used for spinal anaesthesia. Trials to correct hypotension were made by introducing caffeine with the anaesthetic solution or by administering ephedrine in the dorsal muscles at the end of the spinal injection. In 1929, the Romanian surgeon Nicolae Hortolomei perfected abdominal analgesia with infiltration of the vagus and splanchnic nerves during or at the end of laparotomy. Spinal anaesthesia continued progressing with the use of slim (22-28g) short beveled spinal needles through an introducing guiding leader, pushed down the yellow ligament thus replacing the barbotage technique (pumping spinal fluid after injection of anaesthetic).

The concept of continuous spinal anaesthesia was first described by the British surgeon Dean in 1907 who left the spinal needle in the subarachnoid space during an operation. In 1940, Lemmon continued this technique using a flexible silver needle to overcome the problem of needle trauma and breakage. Eugen Aburel (1934), again from Romania, performed re-injection of anaesthetic by the anterior abdominal route by puncturing, under laparotomy, an inter-vertebral disc in the upper lumbar region and advancing into the spinal channel and in 1938 introduced an uretheral catheter into the epidural space. Later Manahan (1940) introduced the catheter by the caudal route. In 1944, Edward Tuohy brought significant change by replacing the sharp ended needle with the development of the curved bevel Tuohy needle and the use of a specially tailored mattress to accommodate the needle’s hub and the syringe connecting tube which was, at the time, made of rubber. Hustead, Weiss and Crawford brought further enhancements were made to this needle.

Of the anesthetics available at the time, Procaine was the least toxic but had low penetration power, others had serious side effects due to their central nervous system toxicity. The great breakthrough came with the discovery of lidocaine by the Swedish chemist Nils Löfgren in 1946. Typically Lidocaine has rapid onset, good pentration and about one hour’s duration.

Ten years later 2 new amides entered the daily practice, mepivacaine and bupivacaine, the later dominating the operating room until the appearance of ropivacaine at the late 1990s. Both drugs had a duration of around 3 hours. In the meantime a lot of other esters were produced, among them prilocaine, a very short acting substance, to be used by continuous infusion and with a rapid plasma hydrolysis and no toxicity.

An interesting technical tip was the introduction of hypo- and hyperbaric anaesthetic solutions, to be directed in the spinal channel by special positioning of the patient. In 1927, George Pitkin introduced hyperbaric solutions with spinocaine, a mixture of procaine, starch, alcohol and strychnine. Later Baker introduced a mixture of stovaine and 5% dextrose. B. Quarella (1929) introduced the hypobaric pontocaine and nupercaine solutions. These solutions permitted a certain guidance of the anaesthetic from the level of injection in higher segments producing thoracic anaesthesia, or lower regions producing saddle block or unilateral spinal anaesthesia, limited to a single leg.