A History of Anaesthesiology – Flash 11B

A History of Anaesthesiology – Flash 11B

  • Issue 63

George Litarczek

From the Chief Editor.

We publish in this issue Flash 11B, actually the 12th chapter of the history of anaesthesia, conceived by Prof. George Litarczek, the founding father of modern Romanian Anaesthesiology.

Recently Prof. Litarczek celebrated his 90th birthday.

The ESA Newsletter Editorial staff would like to congratulate him on this occasion and wish him and his family good health, a good mood, and a continuation of his intellectual achievements.

Epidural lumbar anaesthesia was introduced clinically by Fidel Pages (1921) who named it ‘metameric anaesthesia’. It followed the epidural technique performed by the sacral (caudal) route, as proposed by Cathelin (1901) and later performed by Dania (1913), Stoeckel (1909), and even in a continuous technique by means of an uretheral catheter by Bourgois. But it was Mario Dogliotti in Turin who made the technique popular by proposing a very easy method to locate the epidural space, the so-called loss of resistance method. Later, methods like the use of a water or aneroid manometer, the hanging drop, the McIntosh distended balloon, and the ‘gaseous mandarin’ were proposed and widely used. Continuous techniques started with Aburel’s first introduction of a catheter into the epidural space, but became popular only after the introduction of Touhy’s needle and plastic catheters. This innovation permitted a prolonged duration of anaesthesia, actually quite indefinitely, and constituted, along with continuous spinal technique, the basis for high duration analgesia by injecting opioids instead of local anaesthetics (Wang 1970). It also was the basis for the combined technique of epidural analgesia and general anaesthesia, thus obtaining a reduced stress reaction to surgery and pain.

Local infiltration anaesthesia, introduced by Schleich in 1892 with cocaine in low concentration, was extensively used only after the introduction of procaine in 1904. It was usually given in a concentration of 1%. Wishniewski in Russia (1906?) proposed an even lower concentration, of 0.25%, by increasing the quantity of injected fluid and performing a hydraulic dissection of the tissues, a method that was also favourable to the patient as a volume replacement in a period in which i.v. fluid administration did not exist, even as a concept. Then the mixed procaine and nupercaine solutions in low concentration were used (Hortolomei 1945?). This combination offered the advantage of a quick start and a long duration of action.

The introduction of the new local anaesthetics, the amides, like lidocaine had a clear advantage since these drugs produced almost no allergic reactions.

Plexal anaesthesia was used for first time as a technique of brachial plexus anaesthesia by Kuhlenkampf in 1904 by using the subclavian route. Since then at least nine other methods to reach the fibrous pouch enveloping the plexus were proposed and clinically used, among them the axillary and interscalenic route have gained more popularity.

Historically, trunk anaesthesia was actually the first type of local anaesthesia introduced by Halsted after Koller used the cocaine direct contact anaesthesia. It is still used mostly in anaesthesia for segments of extremities, mainly the upper ones.

Another technique is that of anaesthesia for individual fingers and for fist articulation, in which the 3 main trunks, radial, ulnar, and median nerves, are intercepted at the base of the fist. For the lower extremity the method mostly used is the 3-in-1 femoral nerve block, along with infiltration of the sciatic and external tibial nerve plus infiltration of the finger bases for small interventions.

Intravenous local anaesthesia was introduced in 1905 by Bier. Soon it became popular; since it needs no location of nervous trunks, it assures a bloodless surgical field and can be used for short surgical procedures on extremities. The use of an Esmarch band limits the time of the intervention, but the two bands technique could solve this impediment.

At the beginning all techniques were performed by locating nerve trunks or anatomical points in the spinal channel, which demanded a good knowledge of the anatomy of the region and a certain manual skill. But two new methods improved the placement of the needle or, later on, the catheter. The first was electrical stimulation, using the insulated needle by Pearson in 1955 and the first electrical stimulator by Greenwall and Denson in 1962. This method dramatically increased the precision of location of the needle’s tip, especially for trunk and plexal anaesthesia. Second came the ultrasound location of nerves and needle guiding. The use of the method was regulated by the Nice Guidelines (2002). As per today, it is more and more used for its efficiency and since the price of the equipment has decreased drastically.

The ultrasound guidance of the needle for loco-regional anaesthesia could be considered as the first visual method of placement of the anaesthetic.

I would like now to briefly mention the progress achieved by the introduction of plastic vascular catheters. It was mentioned in a paper from the Mayo Clinic in 1950, written by Massa and collaborators. Since then a great variety of catheters for very different uses have been produced covering every need in loco-regional anaesthesia. The introduction of catheters for continuous analgesia, especially in the postoperative period, represented a real revolution, offering the patient comfort and significantly reducing the magnitude of the surgical stress.

In conclusion, we must mention the fact that today loco-regional anaesthesia techniques play an important role in many fields of modern surgery, alone or in combination with sedation or superficial general anaesthesia. It is performed today in every single operating room, it is appreciated by the surgeons, it reduces the need for general anaesthesia, and offers the patient a smooth postoperative course.