8 - 8-04 History of Anesthesiology

The History of Anesthesiology
An Overview
Copyright 2003 American Society of Anesthesiologists. All rights reserved.
Before From the Letters of Frannie Burney, early 19th century literary figure: When the dreadful steel was plunged into the breast cutting through veins-arteries-flesh-nerves I needed no injunction not to restrain my cries. I began a scream that lasted unintermittently during the whole time of the incision, and I almost marvel that it rings not in my ears still! So excruciating was the agony. Oh, Heaven! I then felt the knife racking against the breast bone, scraping it! This performed while I yet remained in utterly speechless torture.
Surgery Before and After Anesthesia
After Oblivious, painless surgery (i.e., total joint protocol)

Image courtesy of Wood-Library Museum, Park Ridge, Illinois
History I
Unlike many other medical specialties, anesthesiology is young. Effective surgical anesthesia has only been available for slightly more than 150 years. The greatest advances in anesthesia have been made since 1950.
Prehistory
Surgery has been practiced for thousands of years. Ancient Americans trephined the skull. Cocaine may well have been used as a topical anesthetic.
Prehistory
Many herbs have been used to create anesthesia. Among them: hellebore, dittany, mulberry, hops and lettuce!
Mandrake
Heavily used during the Middle Ages. Thought to have a soul. Harvesting ritual.
Hemlock
Known to the ancient Greeks. Given to Socrates.
Soporific Sponge
Many recipes have come down from the Middle Ages. Opium, mulberry, hyoscyamus, hemlock juice, mandragora half a lettuce and boil Soaked into a sponge.
Compression Anesthesia
By applying pressure to major nerve trunks, anesthesia can be produced. But the compression itself causes pain!
Refrigeration Anesthesia
Marco Aurelio Severino of Naples introduced it in the 1600. Used extensively during the Russo-Finnish War of 1939!
Humphry Davy and Nitrous Oxide

Began experiments at the Pneumatic Institute in Bristol in 1799. Discovered that nitrous oxide could relieve headaches and toothaches.
Image Courtesy of the Wood Library-Museum Copyright 2003 American Society of Anesthesiologists. All rights reserved.
Humphry Davy and Nitrous Oxide

As nitrous oxide in its extensive
operation appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood takes place.
Davy H. Researches Chemical and Philosophical Chiefly Concerning Nitrous Oxide or Dephlogisticated Nitrous Air and Its Respiration. London: Biggs and Cottle. 1800 p. 556.
Carbon Dioxide
Henry Hill Hickman worked with carbon dioxide in the 1830s. Discovered that animals could be rendered insensible for an operation. Concerns!
Horace Wells
Dentist in Hartford, Connecticut. Needed a way to stop pain to install dentures. By marriage and practice, was one of the leading citizens of Hartford.
Horace Wells in 1844

Laughing Gas
In December 1844, Gardner Quincy Colton brought his Laughing Gas traveling show to Hartford. Wells and his wife attended.
Eureka!
Wells saw a gentlemen cut his leg on a table painlessly. Tried it out on himself for the removal of a molar. Painless dentistry was born!
Horace Wells at Harvard

Tried to publicly demonstrate nitrous oxide anesthesia at Harvard in late 1844. Failed! The patient groaned.
The First Successful Public Demonstration of Anesthesia
Charles Jackson and Ether

Charles T. Jackson, professor of chemistry at Harvard, suggested that ether might have anesthetic properties. Gave the idea to a medical student who also had a dental practice.
W.T.G. Morton and Anesthesia

Took Jacksons suggestion and began to use ether. Anesthetized bugs, worms, his dog, Nig, and even attempted a fish. His assistants at the dental office were next.
October 16, 1846 Triumph

Morton brought Letheon to the operating theater at Harvard. Gilbert Abbott had a jaw tumor. Gentlemen, this is no humbug! J.C. Warren
Spreading the News

First news to leave Boston was in the form of private letters sent by steamship to England. First article appeared in the Boston Medical and Surgical Journal in November 1846.
Ether and the World

By December 1846, ether anesthetics were being given in London, and within a month, general anesthetics were recorded in France and Germany Rev. Dr. Peter Parker gave the first anesthetics in China eight months later. The first Australian anesthetics were given in June 1847.
Success of Ether
Why was ether so successful?
Mortons demonstration was public and dramatic (called it Letheon and had it colored green, inhaler device). Later admitted it was simple ether. Easy to prepare Easy to store in bottles (unlike nitrous oxide) Good physical properties; volatility enabled inhalation Low concentrations meant patients didnt become hypoxic Very little cardiopulmonary depression Slow induction safety margin for new learners Easy to administer (towel soaked in ether; later, drop inhalers)
Photo: Hugh Smith, Courtesy of Wood-Library Museum, Park Ridge, Illinois
The Aftermath!
The Ether Controversy

Morton tried to patent Letheon to make money. Wells claimed that he had invented anesthesia, as did Jackson Congress became involved to compensate Morton for lost
patent revenue!
Power Brokers
Morton refused to tell his colleagues at Massachusetts General Hospital (MGH) what Letheon was! After two weeks, gave MGH the right to use ether without compensation!
Crawford Long and Charles T. Jackson

To destroy Morton's claim, Jackson found Long. Long anesthetized James Venable in March 1842 in Jefferson, Georgia. Long never published his results until 1849.
The Death of Wells (1848)

Wells became despondent after his failure and Mortons success. Several failed businesses. Went to New York City as an anesthetist.
The Final Tragedy

Wells made his own agents in his apartment. Became increasingly psychotic. Threw acid in the face of a prostitute. Sent to the Tombs. Lacerated his femoral artery under anesthesia in 1848.
The Death of Morton

Spent the next 22 years seeking compensation for his discovery. Gave anesthetics during the Civil War. Died of brain congestion on July 15, 1868 in New York City.
The Death of Jackson

Continued to fight Morton for years. Suffered a stroke June 22, 1873. Committed to an insane asylum where he died in 1880.
Death of Long
Gave anesthetics in the Civil War for the Confederacy. Died June 16, 1878 of a stroke after helping to deliver a baby.
Other Inhaled Anesthetics

Effective surgical anesthesia had profound medical and sociological implications: surgical pain put to sleep, birth of anesthesiology as a specialty. Subsequent development of better inhaled anesthetics: chloroform, cyclopropane, ethyl chloride, divinyl ether. Fluorination offered stable, volatile hydrocarbons Charles Suckling, 1951, began attempting to prepare the ideal anesthetic gas, which resulted in clinical introduction of halothane. Enflurane, isoflurane, desflurane, sevoflurane and methoxyflurane followed.
Airway
Control of the Airway

Early anesthesia: No definitive airway control
Mask anesthesia, inhalers, drop mask techniques were all equally capable of producing an unconscious patient but offered no airway protection or control against apnea or emesis.
1877: Joseph Clover describes jaw-thrust technique for opening airway. Performs surgical airway with metal canula (first cricothyrotomy by anesthesia provider).
Frederick Hewitt developed a device for preventing the tongue from obstructing
the airway in the unconscious patient. He called this device the air-way restorer. Device was a direct precursor to modern oral airways.

Development of anesthesiologist-inspired laryngoscopes
occurred just prior to the introduction of muscle relaxation, which dramatically improved intubating conditions. After WWI, Ivan Magill introduced rubber endotracheal tubes; enormously popular 1926: Arthur Guedel began experimenting with animal tracheas, trying to devise a cuffed endotracheal tube. Glued rubber from surgical gloves, etc., to endotracheal tubes, tested above and below the cords. Demonstrated success with his dunked dog airway. 1981: Dr. A. I. J. Archie Brain begins work on the laryngeal mask airway (LMA). Completes extensive study of airway anatomy in cadavers and perseveres to create an effective airway device now used extensively.

1878: First endotracheal tubes were devised for use in drowning victims; not used in anesthesia until 1878 by William Macewan. 1885: Joseph ODwyer performed multiple blind intubations with flexible metal endotracheal tubes during a diphtheria epidemic. ODwyer later developed a rigid tube with a conical end piece that could be attached to a bellows to provide positive pressure ventilation. Early laryngoscopes designed by Alfred Kirstein, Chevalier Jackson, Henry Janeway and others. Cumbersome, dental trauma, poor visualization, difficult conditions without muscle relaxants.
Laryngoscopes
1941: Robert Miller and Sir
Robert MacIntosh simultaneously develop laryngoscope blades designed to maximize visualization of the vocal cords.
Anesthesia Equipment: Photo Montage
Photos: Hugh Smith; Images Courtesy of Wood-Library Museum, Park Ridge, Illinois
Regional Anesthesia
Regional Anesthesia
Carl Koller (1857-1944), Viennese ophthalmologist, friends with Sigmund Freud, experimented with cocaine gave Koller a sample. In 1884, no fine sutures to close open globe procedures. GAs PONV and extrusion of eye contents. Koller inadvertently licks his fingers after touching cocaine sample, tongue goes numb. In his lab, creates cocaine soln, anesthetizes corneas of animals. Then tries on himself and lab assistant, sticking pins in their eyes to test the anesthesia. Koller is too poor to attend Congress of German Ophthalmologists. A friend presents his article; within a year, over 100 papers published supporting use of cocaine in Europe and North America.
Carl Koller
Sigmund Freud
Spinal Anesthesia
1885: Leonard Corning attempts spinal anesthesia (coins term as well) using cocaine on a dog, and then on patient afflicted with chronic masturbation. Dog likely had spinal, patient had epidural injection legs gradually became sleepy. 1899: First spinal anesthetic using cocaine for surgery performed by August Bier in Kiel, Germany. Used Quincke technique (obtain CSF from lower lumbar interspace before injecting). Bier performed six spinal anesthetics, some patients cried out during surgery. Bier felt greater study was needed.
Spinal Anesthesia
Bier permitted his resident, Dr. Hildebrandt, to perform a spinal on him. Hildebrandt couldnt attach the syringe to the needle, and a large volume of CSF spilled. Ready to abandon their research when Hildebrandt volunteered. Bier performed the spinal, and 25 minutes later, Hildebrandt could not feel a blow with a hammer on the tibia or strong pulling on a testicle. Celebrated into the night with wine and cigars. Both developed violent postdural postural headache. Biers headache took nine days to resolve. Smaller needles, reduced cerebral spinal fluid loss, sterile gloves, refined technique, discovery of baricity and better local anesthetics all eventually led to continued popularity of spinal anesthesia.
(Bier 1861-1949)
Regional Anesthesia
1908: Bier introduces IV regional block placed between two tourniquets ( not really used for 50 yrs). Known as the Bier block. 1928: G.P. Pitkin uses hypobaric nupercaine in lumbar spinals to produce thoracic anesthesia. 1940: William Lemmon popularizes continuous spinal technique using malleable silver needle left intrathecally throughout procedure (placed in lateral position, stabilized and threaded through hole in table and mattress while patient turned supine). 1943: Lidocaine (amide local anesthetic) synthesized by Lofgren and Lundquist in Sweden. 1944: Edward Tuohy (from Mayo Clinic) introduces Tuohy needle for passing lacquered silk catheters for continuous spinal. 1949: Martinez Curbelo (Cuba) performs first continuous epidural using Tuohy needle and fine ureteral catheter. Many infections before plastic catheters developed.
Muscle Relaxants
Muscle Relaxants
Introduction in 1940s revolutionized anesthesia practice. Muscle relaxants facilitate safe tracheal intubation, which led to profound advances in airway management. Enable skeletal muscle paralysis and relaxation important to a wide variety of surgical procedures. Decreases anesthetic requirements needed to achieve similar muscle relaxation; greater hemodynamic stability, less PONV, etc. Used to prevent trauma in ECT therapy for psychiatric disorders. Used to facilitate patient-ventilator synchrony in intensive care units (ICUs).
Chondrodendron tomentosum
Muscle Relaxants
Explorers of South America in the 16th century returned with tales of Native Indian arrow poisons that could kill enemies and animals during hunting. Poison was called curare. By the 18th and early 19th-century explorers brought home small quantities of curare. In early experimentation, discovered that curare caused muscular paralysis, including respiratory muscles. Found that animals could be kept alive by tracheostomy and ventilating with a bellows until recovery (B. Brodie, 1811). Late 19th and early 20th century, sporadic but unsuccessful attempts to use curare in tetanus, rabies, epilepsy and choreiform disorders. Impure samples, limited quantities, unsafe in significant doses without mechanical ventilation/intubation.
History of Curare: Ruth and Richard Gill
Images courtesy of Wood-Library Museum, Park Ridge, IL
Clinical Use of Curare

1938: Gill learns of his Multiple sclerosis. Collects 12 kg of raw curare in Ecuador and delivers it to Squibb pharmaceuticals. 1939: A.E. Bennett uses curare to prevent trauma from chemical ECT. 1942: H.A. Holaday devises rabbit head drop assay for standardizing dosing (0.1 ml aqueous curare soln q 15 sec). 1942: Harold Griffith and Enid Johnson report successful use of curare during appendectomy. Later that year, published report of 25 patients having abdominal surgery.
Muscle Relaxants
1900: Jacob Pal describes antagonism of curare with physostigmine. 1906: Sux first prepared but relaxant properties not recognized. 1931: Neostigmine synthesized (10 times more potent than physostigmine). 1949: Sux synthesized by Nobel winner Daniel Bovet. 1956: Distinction is made between depolarizing and nondepolarizing neuromuscular blockers. 1964: Pancuronium released. 1979: Vecuronium released. 1993: Mivacurium released. 1994: Rocuronium released. 2004: Savarese JJ. Preclinical pharmacology of GW280430A (AV430A) in the rhesus monkey and in the cat: A comparison with mivacurium. Anesthesiology. 2004; 100(4):835-845.
Intravenous Anesthetics
1657: Christopher Wren injects opium into a dog using a goose quill and pig bladder. The dog becomes stupefied. 1845-1855: Development of hypodermic syringe. Alexander Wood is usually credited with the discovery, but earlier syringes were described.
1875: Pierre Or of Lyons publishes report of 36 cases in which chloral hydrate was injected immediately preceding incision. Several postoperative deaths occurred, few people emulated his technique.
Photo: Hugh Smith, Courtesy of Wood-Library Museum, Park Ridge, Illinois
1932: Hexobarbital used clinically for the induction of anesthesia. 1933-34: Pentothal (thiopental) introduced, tested extensively by John Lundy at the Mayo Clinic. During WW II, Pentothal used extensively. Cardiovascular effects learned the hard way in burn and hypovolemic patients. 1962: Ketamine synthesized by Parke Davis Labs. Only drug among group of PCP-like compounds that gained clinical use. 1964: Etomidate (hypnomidate) synthesized by Paul Jannsen, not released for clinical use until 1974. Great acceptance in the hemodynamically unstable patient. 1977: Propofol released. Anaphylactic reactions when synthesized with Cremophor EL. Taken off market, then re-released stabilized in egg lecithin, soybean oil and glycerol.
Organized Anesthesia
Anesthesiology Organization
ASA: The Society was founded on October 6, 1905, when nine physicians from Long Island, New York, organized the first professional anesthesiology society. The Society expanded to 23 members in 1911 and named itself the New York Society of Anesthetists. The group met to advance the art and science of anesthesia. In 1911 the group moved from Brooklyn to Manhattan and was renamed the New York Society of Anesthetists. In 1912 the group petitioned the American Medical Association to create a Section on Anesthesia.
The Importance of an AMA Section

A section was necessary before the AMA would sponsor a specialty board. At the AMA annual meeting, sections presented papers in their areas, which made the meeting program
Anesthesiology as the Practice of Medicine

Resolution was brought before the AMA House of Delegates in 1912 requesting a Section on Anesthetics. The motion failed. Led to the formation of the AAA.
Image courtesy of the Wood Library-Museum Copyright 2003 American Society of Anesthesiologists. All rights reserved.
The Result
Physician anesthetists are organized nationally. Begin to meet yearly Small regional societies were organized. Concerted political action possible.
The McMechan Organization

Francis Hoeffer McMechan controlled the AAA and the national meetings in the 1920s and 1930s. Editor of Current Researches in Anesthesia and Analgesia from 19221939.
The McMechan Organization in 1933
International Anesthesia Research Society
Associated Anesthetists of the United States and Canada
Eastern Society
Canadian Society of Anaesthetists
Southern Association
Pacific Coast Association
Mid-Western Association
The Concerns About Anesthesiology in the Early 1930s

Multitude of providers gave anesthetics Family doctors supplemented their income during the depression by giving anesthetics. Increases in technology made giving the anesthetic more challenging, and mortality was a concern.
McMechans Answer
Organize an international college to certify specialists. Began to develop the idea in 1932. Did not want the AMA to play a role.
Internal College of Anesthetists

Clinical criteria weak. Physicians who worked with nurses were excluded. Began a rift within organized anesthesiology. Had little or no standing in the United States.
1933 Section
It would, of course, have been much better if the National Board could have organized two years ago (1933) when the opportunity could have afforded. Unfortunately, the old organization of anesthetists did not approve of such action and in order to avoid a split in the only representation of organized anesthesia at that time, nothing was done about it.
Letter from Ralph Waters to Paluel Flagg, November 12, 1935, Carbon Copy, the Collected Papers of John Lundy, Mayo Foundation Archive, Rochester, MN
An Alternative Approach
Needed a group independent of McMechan to act as sponsoring body. Needed the AMAs agreement for national acceptance. Needed to be open to all who specialized in anesthesiology. Needed to be accomplished in the next several years.
The New Plan

Use the New York Society of Anesthetists, the largest group outside McMechans control. Make a new form of membership called Fellows. Make the Fellow designation mean something by making the criteria conform to AMA guidelines.
1933 Section
they wished to get some scheme which would at a later date be acceptable to the Advisory Board for Medical Specialties, which serves as a gobetween with the American Medical Association.
Letter from Ralph Waters to Paluel Flagg, November 12, 1935, Carbon Copy, the Collected Papers of John Lundy, Mayo Foundation Archive, Rochester, MN
Success!
Fellowship was very popular. New York Society membership skyrocketed. Members joined from across the country. Others began to notice.
Conflict
McMechan was not pleased. Physicians loyal to McMechan did not apply for Fellowship.
Change!
February 13, 1936, the New York Society changed its name to the American Society of Anesthetists to demonstrate to the AMA that a national organization supported specialization. Needed to show that a national organization supports specialization.
Erwin Schmidt: Surgeon and Friend

Chairman of Surgery at Madison. Member of the group founding the American Board of Surgery. Invited Ralph Waters and Paul Wood to the ABS meeting at the Palmer House, January 10, 1937.
Birth of a New Board

Four sponsors. Incorporated in 1938 as a sub-board of surgery.
A Note of Thanks
On behalf of the entire committee of the ASA and for all they represent, I am sending this note of appreciation and thanks for your persistent, skillfulefforts for the proper recognition of a neglected but important field in modern medicine. Thus [by] your courageous and dignified insistence you prepared the way for the elevation of the highest standards of modern anesthesia
Letter from Paul Wood to Erwin Schmidt, June 3, 1937.
June 26, 1939

Death of Francis Hoeffer McMechan. AMA became more receptive to an independent ABA since McMechan could not control it. Surgeons feel the need to rid themselves of the responsibility.
The American Society of Anesthesiologists

On April 12, 1945, the American Society of Anesthetists became the ASA. Became the voice of American anesthesiologists in the United States and across the world. Membership has risen from the original nine physicians of the Long Island Society to more than 39,000 today.
Resources in the History of Anesthesiology
Resources in Anesthesiology History

There are many resources in the history of anesthesiology. The Wood Library-Museum of Anesthesiology (an affiliate of ASA) stands ready to help. The Anesthesia History Association is a national group that supports research in anesthesiology history. Bulletin of Anesthesia History.
Conclusions
Conclusions
The history of anesthesiology is rich and full of interesting characters and surprises. There is much yet to be discovered and documented. The Wood Library-Museum of Anesthesiology remains the best repository of information and artifacts on the history of anesthesiology in North America.

8 - 8-04 History of Anesthesiology

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8 - 8-04 History of Anesthesiology

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The History of Anesthesiology

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Surgery Before and After Anesthesia

After Oblivious, painless surgery (i.e., total joint protocol)

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Humphry Davy and Nitrous Oxide

Humphry Davy and Nitrous Oxide

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Horace Wells in 1844

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Horace Wells at Harvard

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

The First Successful Public Demonstration of Anesthesia

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Charles Jackson and Ether

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

W.T.G. Morton and Anesthesia

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

October 16, 1846 Triumph

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Spreading the News

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Ether and the World

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Photo: Hugh Smith, Courtesy of Wood-Library Museum, Park Ridge, Illinois

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

The Ether Controversy

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Crawford Long and Charles T. Jackson

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

The Death of Wells (1848)

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

The Final Tragedy

The Death of Morton

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

The Death of Jackson

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Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Other Inhaled Anesthetics

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Control of the Airway

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Control of the Airway

Control of the Airway

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Anesthesia Equipment: Photo Montage

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

Copyright 2003 American Society of Anesthesiologists. All rights reserved.

History of Curare: Ruth and Richard Gill

Copyright 2003 American Society of Anesthesiologists. All rights reserved.