CHAPTER

1

The History of Anesthesia

Although most human civilizations evolved some method for diminishing patient discomfort, anesthesia, in its modern and effective meaning, is a comparatively recent discovery with traceable origins dating back 160 years. (An epitaph on a monument to William T. G. Morton, one of the founders of anesthesia, reads: “Before whom in all time Surgery was Agony.”) (Jacob AK, Kopp SL, Bacon DR, Smith HM. The history of anesthesia. In: Barash PG, Cullen BF, Stoelting RK, Cahalan MK, Ortega R, Stock MC, eds. Clinical Anesthesia. Philadelphia: Lippincott Williams & Wilkins; 2013: 1–27.)

I. ANESTHESIA BEFORE ETHER. In addition to limitations in technical knowledge, cultural attitudes toward pain are often cited as reasons humans endured centuries of surgery without effective anesthesia.

A. Early Analgesics and Soporifics (Table 1-1)

B. Almost Discovery: Clarke, Long, and Wells

1. In January 1842, William E. Clarke, a medical student, may have given the first ether anesthetic in Rochester, NY, for a dental extraction.

2. Crawford Williamson Long administered ether for surgical anesthesia to James M. Venable on March 30, 1842, in Jefferson, GA, for the removal of a tumor on his neck. Long did not report his success until 1849 when ether anesthesia was already well known.

3. Horace Wells observed the “analgesic effects” of nitrous oxide when he attended a lecture exhibition by an itinerant “scientist,” Gardner Quincy Colton. A few weeks later, in January 1845, Wells attempted a public demonstration in Boston at the Harvard Medical School, but the experience was judged a failure.

C. Public Demonstration of Ether Anesthesia. William Thomas Morton Green was responsible for the first successful public demonstration of ether anesthesia. This demonstration, which took place in the Bullfinch Amphitheater of the Massachusetts General Hospital on October 16, 1846, is memorialized by the surgeon’s statement to his audience at the end of the procedure: “Gentlemen, this is no humbug.”

D. Chloroform and Obstetrics

1. James Young Simpson, a successful obstetrician of Edinburgh, Scotland, was among the first to use ether for the pain relief in obstetrics. He became dissatisfied with ether and encouraged the use of chloroform.

2. Queen Victoria’s endorsement of obstetric anesthesia resulted in acceptance of the use of anesthesia in labor.

3. John Snow took an interest in anesthetic practice soon after the news of ether anesthesia reached England in December 1846. Snow developed a mask that closely resembles a modern facemask and introduced a chloroform inhaler.

II. ANESTHESIA PRINCIPLES, EQUIPMENT, AND STANDARDS

A. Control of the Airway

1. Definitive control of the airway, a skill anesthesiologists now consider paramount, developed only after many harrowing and apneic episodes spurred the development of safer airway management techniques.

2. Joseph Clover, an Englishman, was the first person to recommend the now universal practice of thrusting the patient’s jaw forward to overcome obstruction of the upper airway by the tongue.

B. Tracheal Intubation

1. The development of techniques and instruments for intubation ranks among the major advances in the history of anesthesiology.

2. An American surgeon, Joseph O’Dwyer, designed a series of metal laryngeal tubes, which he inserted blindly between the vocal cords of children having diphtheritic crises.

3. In 1895 in Berlin, Alfred Kirstein devised the first direct-vision laryngoscope.

4. Before the introduction of muscle relaxants in the 1940s, intubation of the trachea could be challenging. This challenge was made somewhat easier, however, with the advent of laryngoscope blades specifically designed to increase visualization of the vocal cords.

5. In 1926, Arthur Guedel began a series of experiments that led to the introduction of the cuffed tube.

6. In 1953, single-lumen tubes were supplanted by double-lumen endobronchial tubes.

C. Advanced Airway Devices. Conventional laryngoscopes proved inadequate for patients with difficult airways. Dr. A. I. J. “Archie” Brain first recognized the principle of the laryngeal mask airway in 1981.

D. Early Anesthesia Delivery Systems. John Snow created ether inhalers, and Joseph Clover was the first to administer chloroform in known concentrations through the “Clover bag.” Critical to increasing patient safety was the development of a machine capable of delivering calibrated amounts of gas and volatile anesthetics (also carbon dioxide absorption, vaporizers, and ventilators).

E. Two American surgeons, George W. Crile and Harvey Cushing, advocated systemic blood pressure monitoring during anesthesia. In 1902, Cushing applied the Riva Rocci cuff for blood pressure measurements to be recorded on an anesthesia record.

1. The widespread use of electrocardiography, pulse oximetry, blood gas analysis, capnography, and neuromuscular blockade monitoring have reduced patient morbidity and mortality and revolutionized anesthesia practice.

2. Breath-to-breath continuous monitoring and waveform display of carbon dioxide (infrared absorption) concentrations in the respired gases confirms endotracheal intubation (rules out accidental esophageal intubation).

F. Safety Standards. The introduction of safety features was coordinated by the American National Standards Institute Committee Z79, which was sponsored from 1956 until 1983 by the American Society of Anesthesiologists. Since 1983, representatives from industry, government, and health care professions have met as the Committee Z79 of the American Society for Testing and Materials. This organization establishes voluntary goals that may become accepted national standards for the safety of anesthesia equipment.

III. THE HISTORY OF ANESTHETIC AGENTS AND ADJUVANTS

A. Inhaled Anesthetics. Fluorinated hydrocarbons revolutionized inhalation anesthesia (halothane in 1956, methoxyflurane in 1960, enflurane and isoflurane in the 1970s, desflurane in 1992, and sevoflurane in 1994).

B. Intravenous Anesthetics. Thiopental was first administered to a patient at the University of Wisconsin in March 1934 followed by ketamine (1960s), etomidate, and most recently propofol.

C. Local Anesthetics. Amino esters (procaine in 1905, tetracaine) were commonly used for local infiltration and spinal anesthesia despite their low potency and high likelihood to cause allergic reactions. Lidocaine, an amino amide local anesthetic, was developed in 1944 and gained immediate popularity because of its potency, rapid onset, decreased incidence of allergic reactions, and overall effectiveness for all types of regional anesthetic blocks. Since the introduction of lidocaine, all local anesthetics developed and marketed (mepivacaine, bupivacaine, ropivacaine, levobupivacaine) have been of the amino amide variety.

D. Opioids are used routinely in the perioperative period, in the management of acute pain, and in a variety of terminal and chronic pain states. Meperidine, the first synthetic opioid, was developed in 1939 followed by fentanyl in 1960 and sufentanil, alfentanil, and remifentanil. Ketorolac, a nonsteroidal antiinflammatory drug (NSAID) approved for use in 1990, was the first parenteral NSAID indicated for postoperative pain.

E. Muscle relaxants entered anesthesia practice nearly a century after inhalational anesthetics. Curare, the first known neuromuscular blocking agent, was originally used in hunting and tribal warfare by native peoples of South America. Clinical application had to await the introduction of tracheal intubation and controlled ventilation of the lungs. On January 23, 1942, Griffith and his resident, Enid Johnson, anesthetized and intubated the trachea of a young man before injecting curare early in the course of an appendectomy. Satisfactory abdominal relaxation was obtained, and the surgery proceeded without incident. Griffith and Johnson’s report of the successful use of curare in a series consisting of 25 patients launched a revolution in anesthetic care. Succinylcholine was prepared by the Nobel laureate Daniel Bovet in 1949 and was in wide international use before historians noted that the drug had been synthesized and tested in the early 1900s. Recognition that atracurium and cis-atracurium undergo spontaneous degradation by Hoffmann elimination has defined a role for these muscle relaxants in patients with liver and renal insufficiency.

F. Antiemetics. Effective treatment of patients with postoperative nausea and vomiting (PONV) evolved relatively recently and has been driven by incentives to limit hospitalization expenses and improve patient satisfaction. The antiemetic effects of corticosteroids were first recognized by oncologists treating patients with intracranial edema from tumors. Recognition of the role of the serotonin 5-HT₃ pathway in PONV has led to a unique class of drugs (including ondansetron in 1991) devoted only to addressing this particular problem.

IV. ANESTHESIA SUBSPECIALTIES

A. Regional Anesthesia. The term “spinal anesthesia” was coined in 1885 by a neurologist, Leonard Corning, although it is likely that he actually performed an epidural injection. In 1944, Edward Tuohy of the Mayo Clinic introduced the Tuohy needle to facilitate the use of continuous spinal techniques. In 1949, Martinez Curbelo of Havana, Cuba, used Tuohy’s needle and a ureteral catheter to perform the first continuous epidural anesthetic. John J. Bonica’s many contributions to anesthesiology during his periods of military, civilian, and academic service at the University of Washington included development of a multidisciplinary pain clinic and publication of the text The Management of Pain.

B. Cardiovascular Anesthesia. Many believe that the successful ligation of a 7-year-old girl’s patent ductus arteriosus by Robert Gross in 1938 served as the landmark case for modern cardiac surgery. The first successful use of Gibbon’s cardiopulmonary bypass machine in humans in May 1953 was a monumental advance in the surgical treatment of complex cardiac pathology. In 1967, J. Earl Waynards published one of the first articles on anesthetic management of patients undergoing surgery for coronary artery disease. Postoperative mechanical ventilation and surgical intensive care units appeared by the late 1960s. Transesophageal echocardiography helped to further define the subspecialty of cardiac anesthesia.

C. Neuroanesthesia. Although the introduction of agents such as thiopental, curare, and halothane advanced the practice of anesthesiology in general, the development of methods to measure brain electrical activity, cerebral blood flow, and metabolic rate put neuroanesthesia practice on a scientific foundation.

D. Obstetric Anesthesia. Social attitudes about pain associated with childbirth began to change in the 1860s, and women started demanding anesthesia for childbirth. Virginia Apgar’s system for evaluating newborns, developed in 1953, demonstrated that there was a difference in the neonates of mothers who had been anesthetized. In the past decade, anesthesia-related deaths during cesarean sections under general anesthesia have become more likely than neuraxial anesthesia-related deaths, making regional anesthesia the method of choice. With the availability of safe and effective options for pain relief during labor and delivery, today’s focus is improving the quality of the birth experience for expectant parents.

V. PROFESSIONALISM AND ANESTHESIA PRACTICE

A. Organized Anesthesiology. The first American medical anesthesia organization, the Long Island Society of Anesthetists, was founded by nine physicians on October 6, 1905. Members had annual dues of $1.00. One of the most noteworthy figures in the struggle to professionalize anesthesiology was Francis Hoffer McMechan. He became the editor of the first journal devoted to anesthesia, Current Researches in Anesthesia and Analgesia, the precursor of Anesthesia and Analgesia, the oldest journal of the specialty. Ralph Waters and John Lundy, among others, participated in evolving organized anesthesia.

B. Academic Anesthesia. In 1927, Erwin Schmidt, a professor of surgery at the University of Wisconsin’s medical school, encouraged Dean Charles Bardeen to recruit Dr. Ralph Waters for the first American academic position in anesthesia.

C. Establishing a Society. The New York Society of Anesthetists changed its name to the American Society of Anesthetists in 1936. Combined with the American Society of Regional Anesthesia, the American Board of Anesthesiology was organized as a subordinate board to the American Board of Surgery in 1938, and independence was granted in 1940. Ralph Waters was declared the first president of the newly named American Society of Anesthesiologists in 1945.