The History of Anesthesia

O2 and CO2
In order to understand anesthesia. We need to understand where it started. Although volatile and gaseous anesthetics have changed over the past 150 years, there are two gases that will always be a part of anesthetic practice: oxygen and Carbon Dioxide. Because of the importance that carbon dioxide and oxygen have in the practice of anesthesiology, it is worthwhile to consider how our understanding of respiration came about. How oxygen and carbon dioxide are consumed and produced and how they interact with the body has been the subject of intense research over the past 400 years. Because of the importance that carbon dioxide and oxygen have in the practice of anesthesiology, it is worthwhile to consider how our understanding of respiration came about.

Hx of Respiration
Galen and Aristotle (384-322 BC)
Thought that the air moving in and out of the lungs served merely to cool the heart, which otherwise became overheated in working to sustain life.

Robert Hook (1635-1703)

Attached a bellows to the trachea of a dog with an open chest and demonstrated that the animal could be kept alive by rhythmic and sustained contraction of the bellows. He proved that movement of the chest wall was not the essential feature of respiration, but rather it was exposure of fresh air to the blood circulating through the lungs.

Richard Lower (1631-1691)

Who was also the first to transfuse blood from one animal to another Demonstrated in 1669 that the blood absorbed a definite chemical substance necessary for life, that it changed the venous blood from dark blue to red, and that the process was the chief function of the pulmonary circulation.

Phlogiston Theory
The nature of the process of respiration was misunderstood until the 1780s because of the generally accepted, but erroneous, phlogiston theory promoted by Georg Ernst Stahl (1660-1734). Stahl theorized that combustible substances were composed of phlogiston (Greek for burnt ash ) and that the phlogiston was released during burning and respiration. Joseph Priestley (1733-1804)
A complex individual who was a dissenting minister in Leeds, England, observed that respiration and combustion had many similarities, because a candle flame would go out and an animal would die if left within a closed space.
He thought this was because the air was putrefied with phlogiston.

Priestley discovered photosynthesis by showing that placing plants in confined spaces could remove the phlogiston and purify the air. By heating mercuric oxide, he generated a gas that could make flames brighter and keep mice alive longer in a closed space. Priestley thought this process absorbed phlogiston and informed the French chemist Antoine-Laurent Lavoisier (1743-1794) of his discovery.

Oxygen
Lavoisier realized that heating mercuric oxide released a new element and called it oxygen. Lavoisier s greatest contribution was to outline the great facts of respiration: absorption of oxygen through the lungs with liberation of carbon dioxide. He, however, thought respiration/metabolism was accomplished in the lungs.

 But, Humphry Davy (1778-1829), a young English teenager who dropped out of school at the age of 16, read the works of Lavoisier and designed his own experiments to study the site of metabolism.
He heated blood and collected the gases that were produced.
By showing that these gases were oxygen and carbon dioxide, he surmised that metabolism takes place in the tissues. A conclusion confirmed by Wilhelm Pfluger (1829-1910) 60 years later. Davy also estimated the rates of oxygen consumption and carbon dioxide production, and he measured the total lung and residual volumes.

Advances with Oxygen

John S. Haldane (1860-1936)
was a pioneer investigator in the study of respiration. He was the first to promote oxygen therapy for respiratory disease. In 1905, he discovered that the carbon dioxide tension for blood was the normal stimulus for respiratory drive.

Carl Gustav von Hufner (1840-1908)

Showed that the presence of Hemoglobin in the blood greatly enhanced its oxygen carrying capacity, quantifying that 1g of hemoglobin carried 1.34 mL of oxygen.

Leland C. Clark (1918-)

Developed the oxygen electrode 1956.
The electrode made it capable to calculate the gradients for inspired, alveolar, and arterial oxygen partial pressures.

Polio Epidemic
Further understanding of respiratory physiology arose because of the worldwide polio epidemic that occurred roughly between the years of 1930-1960. Thousands of afflicted patients were kept alive with mechanical respirators, but the adequacy of ventilation could not be assesed without some measure of carbon dioxide tension in the blood.

 The problem was solved in 1958, when John W. Severinghaus (1922-) improved the accuracy of a prototype carbon dioxide electrode produced by Richard Stow (1916-). Severinghaus and A.F. Bradley (1932-) constructed the first blood gas apparatus by mounting the Carbon dioxide electrode and Clark s oxygen electrode in cuvettes in a 37 degree bath. A pH electrode was added in 1959. Blood gas analysis made possible the rapid assessment of respiratory exchange and acid-base balance.

The Pulse-Ox
Until the mid-20th century, the saturation of hemoglobin could be determined only by directly measuring a sample of arterial blood, a technique that required an arterial puncture. Oximetry achieves the same measure noninvasively through a finger or ear probe by using optical measures of transmitted light. Glenn Millikan, devised the first ear oximeter in 1942, and it was used to detect hypoxia in pilots, who flew in open cockpits during World War II. Its introduction into anesthesia practice was delayed until the discovery of pulse oximetry by a Japanese engineer, Takuo Aoyagi. Pulse Oximetry added the additional measure of heart rate, and it provided assurance that the signal was actually measuring a biologic parameter. A highly successful commercial product, the Nellcor pulse oximeter, was introduced in 1983 and had the unique feature of lowering the pitch of the pulse tone as the saturation dropped.

Intravascular Pressures
The first measurement of blood pressure was made by Stephen Hales (1677-1761) He fixed a brass pipe to the carotid artery of a mare and noticed that the blood rose in the tube. Then he bleed the mare, and recognized that the height of blood in the tube decreased. He also discovered that the resistance of a vascular bed would change by mixing alcohol in the blood. Jean L. Poiseuille (1799-1869) In 1828, he repeated these experiments and devised a hemomanometer that used mercury instead of the long blood-filled tubes used by Hales. He also showed that the blood pressure varied with respiration.

The Sphygmomanometer
Karl Vierrordt (1818-1884) Invented a sphygmograph in 1854, acting on the principle that indirect estimation of blood pressure could be accomplished by measuring the counter pressure necessary to obliterate the arterial pulsation. Scipione Riva Rocci (1863-1937) Invented a sphygmomanometer in 1896, using Vierrordt s same principle but used a rubber cuff that occluded a major arterial vessel and then slowly deflated Nikolai Korotkov (1874-1920) Described the sounds produced during auscultation over a distal portion of the artery as the cuff was deflated. Korotkov sounds resulted in more accurate determinations of systolic and diastolic pressures. Automatic blood pressure devices based on the oscillometric method described by H. von Recklinghausen in 1931, were developed in the 1970s and have become the standard noninvasive measures of arterial pressures.

Central Venous Pressure

Venous pressures were of less interest to anesthesiologists until convenient methods for placing cannulas into central vascular structures were described 50 years ago by Sven Seldinger. The introduction of plastic catheters gradually made it possible to measure central pressures in the clinical setting.

PA Catheterization
Pulmonary artery catheterization with a ballontipped, flow directed catheter was described in 1970 and has been used extensively since to measure cardiac outputs using the Fick principle and pulmonary wedge pressures. The pulmonary artery catheter also allowed the clinician to use the well-known pressure-volume relationships of the heart described by Ernest H. Starling (1866-1927) in 1918 to maximize cardiac outputs and oxygen delivery to the tissues.

TEE
Transesophogeal Echocardiography was described in 1976 and used in anesthesia practice a few years later. With experience and training in TEE, the anesthesiologist can quickly evaluate filling pressures of the heart as well as obtain measures of myocardial contractility and valvular function. TEE has become a routine monitor for certain surgical procedures.

Autonomic Nervous System

Even though the first practitioners of anesthesia had essentially no knowledge of adrenergic or cholinergic transmission, it would be difficult to administer anesthetics today without a thorough understanding of the ANS and its neurotransmitters. Many modern surgical and neurovascular techniques require strict control of arterial and venous pressures, and this control is performed through interventions that alter autonomic tone.

The early days

Robert Whytt (1714-1766)
The first to describe the reflex nature of many involuntary activities.

Thomas Willis (1621-1675)

Described the sympathetic chain as early as 1657. He called it the intercostal nerve because it received segmental branches from the spinal cord at each level.

Pourfour du Petit (1664-1741)

Observed that there was a corresponding miosis when this nerve was unilaterally cut in the neck of the cat.

Winslow
Gave the intercostal nerve the name of grand sympathique, stressing that this nerve brought the various organs of the body into sympathy (greek sym together , pathos feeling )

Claude Bernard (1813-1878)

Observed vasoconstriction and pupillary dilation that followed stimulation of the same intercostal (now called the sympathetic) nerve.

John N. Langley
Langley (1852-1925)
In 1889, began his classic work on sympathetic transmission in autonomic ganglia. He blocked synaptic transmission in the ganglia by painting them with nicotine and then mapped the distribution of the presynaptic and postsynaptic autonomic nerves He observed the similarity between the effects of injection of adrenal glands and stimulation of the sympathetic nerves.

John J. Abel
The active principal of adrenal medullary extracts was called epinephrine by John J. Abel (1837-1938) in 1897. With his discovery of the hormone epinephrine, he uncovered one of the most commonly used lifesaving agents in the anesthesiologists pharmacopoeia.

Hx of Sympathetics
Thomas R. Elliot (1877-1961)
Postulated that sympatheitc nerve impulses release a substance similar to epinephrine and considered the substance to be a chemical step in the process of neurotransmission.

George Barger and Henry H. Dale

Studied the pharmacologic activity of a large series of synthetic amines related to epinephrine and called these drugs sympathomimetic.

Walter B. Cannon and Ulf Svante von Euler

Studied the different effects on end organs produced by adrenal extracts and sympathetic stimulation They demonstrated that the sympathetic nerves released NE, whereas the adrenal gland released both Epinephrine and NE.

Hx of Parasympathetics
Walter E. Dixon (1871-1931) Henry H. Dale
Investigated the pharmacological properties of acetycholine and was impressed that its effects reproduced the same Observed that the alkaloid muscarine had the same effect as stimulation of the vagus nerves on various end organs. He proposed that the nerve liberated a muscarine-like chemical that acted as a chemical mediator.