Chapter Two: Anesthesia

Chapter 2 Sub-sections

Why did I choose anesthesia? I cannot explain it, but my choice was correct. My conscious interest began in 1956 with a lecture during my junior year by Herbert Natoff, a senior resident. He discussed cardiac arrest, its various causes during surgery, and how blame – personal or physiological - was assigned. He generated an awareness of the variations in physiology and pharmacology inherent in anesthesia, and the satisfaction in applying these to patients.

But what led me to the study of anesthesia? In 1956-8, my clinical years in medical school, I was intrigued by pediatric cardiology when Dr. Gazul of Chicago's Cook County Hospital demonstrated that improved techniques in cardiac catheterization solved auscultatory puzzles, e.g., heart sounds and murmurs that had confounded clinicians for decades. We medical students roamed the cardiac pediatric ward with him, and he taught us what the various heart sounds and murmurs signified as regards anatomical abnormalities.

I considered anesthesia in my senior year. Although I had anesthetized rats with ether as a research technician in endocrine physiology, this experience did not consciously lead me to anesthesia, and certainly not to surgery. I was open minded, and
undecided, and then anesthesia simply fell in place.

Figure 1a
Fig. 1a. There appears to be an inhalation apparatus at the patient's mouth.

A Bit on Development of Anesthesia

The term ‘anesthesia' or anaesthesia (as spelled in the Commonwealth), a state of insensitivity, was described in a thesis in Rostock, Germany in 1718 by JB Quistorp. His dissertation linked the concepts of anesthesia as mentioned by Greek and Latin authors (Wright et al, 2000). Genesis describes the deep sleep of Adam during which his rib was removed to form woman (Bible, Genesis 2:21). In the 15th century, Sabuncuoglu of Turkey described successful general anesthesia using mandrake root and almond oil (Basagaoglu et al, 2006). In 1513, several monks used what appears to be general anesthesia (Schilling, 1997). Fig. 1a, b. The monks were familiar with the anesthetic action of "sleep"-drinks and were imprisoned by the city council of Berne for defrauding the clerus and the public. At trial, it was determined that the monks had permitted religious frauds to gain

Figure 1b
Fig. 1b. Close up.

money for the monastery from pious people. Among other actions, they had
manipulated a statue of the Holy mother Mary, causing her to apparently shed bloody tears. The city council asked the Pope for his verdict. The papal verdict was the rope around the neck till death occur. (Fig: Schilling, Diebold: Schweizer Bilderchronik, 1513, Wie die Berner Predigermönche dem Laienbruder Hans Jetzer aus Zurzach in einer Narkose die Wundmale Christi mit Säure einätzten, figure 1-30, Seite 45-46. From: Brandt, Ludwig, Illustrierte Geschichte der Anäesthesia; Wissenschaftliche Verlagsgesellschaft Stuttgart 1997, used by permission.)

Ralph Waters, Initiator of Anesthesia Residencies

Dr. Robert Virtue was chair of the department at the University of Colorado, where I served my residency. He loved history and told us of the very first anesthesia residency program, initiated by Ralph M. Waters, about 1927 at the University of Wisconsin. Prior to that, he had been in private practice in Iowa. At Wisconsin, he had had to fight surgeons virtually constantly, with continuing frustrations. His routine fights with surgeon were much greater than our worst ones. Early surgeons were heavily dictatorial and did not take easily to others trying to change things. Waters was introducing applied physiology and pharmacology to anesthesia, training residents to become science-based.

As an example, M. Digby Leigh, who eventually gained fame as a pediatric anesthesiologist, visited Waters from Canada during his training, about 1937. As Leigh told us residents in 1960, Waters had an impressive department, and Leigh, never easy to impress, stayed some months. Surgeons, especially at that time, wanted results with their case now, without performing measurements or doing other things that distracted from or delayed their performance. Waters was so frustrated and disappointed with the surgeons at Madison that, when he retired to Florida to grow oranges, he vowed never to return to the hospital or to anesthesia meetings. When visiting Madison after retirement, he would come to the local drugstore across the street and phone over to the operating rooms so those who wished to see him could come over there. The only anesthesia meeting he ever attended during retirement was in Brazil (Parsloe, 2001).

Waters both started and aided academic anesthesia. When Emery Rovenstine finished Waters' residency, he left Madison to start the anesthesia program at Bellevue Hospital in New York City. Waters split his own group, and shared faculty and residents to begin that program (Morris, 2001) -- incredible unselfish generosity! Academic and private practice anesthesiologists that I met in my early anesthesia years spoke reverently of Waters. At several conferences, I met Rovenstine – modest, quiet, and self-effacing.

Dangerous Application of Nitrous oxide

More from Dr. Virtue: While Waters was establishing quality educational policies, problems with nitrous oxide were occurring. It had been used for decades, but was weak, with borderline potency. It cannot maintain anesthesia deep enough to prevent awareness without also causing hypoxia. It can be used safely as a second gas with more potent agents, and enables use of lower concentrations of the potent agents. In the past, some used nitrous oxide alone, and pushed it so that the oxygen concentration was less than 20%. This was in part erroneously justified by the fact that nitrous oxide (N2O) contains two molecules of nitrogen and one of oxygen. Some believed that this oxygen was available to the patient, but it was too tightly bound to nitrogen. In the 1960s, I recall discussing use of nitrous oxide with an anesthesia friend who admitted that he pushed the nitrous oxide concentration until the patient became slightly cyanotic. But this is asphyxia, which, if prolonged, can result in hypoxic brain damage.

E. I. McKesson, an early anesthesia pioneer, began an anesthetic with 100% nitrous oxide (O'Connor, 1990). The combination of the resulting brief anoxia with nitrous oxide rapidly induced anesthesia. He could then add oxygen and other agents. This approach was dangerous. The use of nitrous oxide in concentrations that limited oxygen to less than 20% was finally deterred after Courville (1939), a pathologist in Los Angeles, demonstrated that this resulted in catastrophic brain damage. Previously healthy patients who had received hypoxic concentrations of nitrous oxide for otherwise minor, safe procedures would suffer severe neurologic damage. Courville demonstrated microscopic areas in the brain of hypoxic destruction. His publication laid to rest arguments about the use of hypoxic concentrations of nitrous oxide.

Enough on early development of anesthesia and on to my early development.