A Brief History of Early Neuroanesthesia
The dramatic improvement in anesthetics over the course of the 19th century was perhaps the biggest driving force for the advances in neurosurgery that followed. Carbon dioxide, hydrogen, and nitrogen were discovered toward the end of the 18th century and set off a new era of exploration and experimentation with the properties and uses of various chemicals, including oxygen and nitrous oxide. Sir Humphry Davy (1778–1829), who established the Pneumatic Institute in Bristol, England, in 1799, and is known to have been one of many at the time who inhaled nitrous oxide and ether for pleasure, suggested that these gases had the ability to relieve the pain of surgical operations.
However, the relatively slow implementation of anesthesia in neurosurgery had to do with the prevailing reluctance of surgeons of the era to perform cranial operations; indeed, Sir Astley Cooper (1768–1841), consulting surgeon to Guy's Hospital in London, England, published a series of lectures on the practice and principles of surgery in 1829, reporting that "trephining in concussion is now so completely abandoned that in the last four years I do not know that I have performed it once, whilst 35 years ago I would have performed it five or six times a year." Rather than trephine, Cooper's recommendation was instead to use leech therapy to the temporal arteries, calomel purging, and frequent venesection. Any anesthesia necessary was achieved with liberal quantities of wine. Even in 1869, Dr. John Erichsen (1818–1896) of the University College Hospital in London wrote of anesthesia in neurosurgical trauma: "in the treatment of injuries of the brain, little can be done after the system has rallied from the shock, beyond attention to strict antiphlogistic treatment, though this need not be of a very active kind. As much should be left to nature as possible, the surgeon merely removing all sources of irritation and excitement from his patient and applying simple local dressings."
At the beginning of the 19th century, if relaxation was desired, the patient might be intoxicated with alcohol or drugged with opium. Sir Humphry Davy, though, noted that nitrous oxide could produce a state of insensibility. Wells, a dentist of Hartford, Connecticut, in 1844, experimented with nitrous oxide on several patients in quick succession but stopped abruptly when one of his patients succumbed to the toxicity of the gas and died. This anecdote, relayed to his close friend and colleague William Morton, became the inspiration for Morton's own experimentation with anesthetic agents.
Although William Morton popularized the use of ether as an anesthetic agent, the credit for its initial use in the surgical setting belongs to another American physician, Dr. Crawford W. Long (1815–1878). On March 30, 1842, Long removed a small tumor from the neck of a patient, who noted that he was amnestic to the events of the surgery; Long, however, did not publish his results until much after Morton's public demonstration of ether anesthesia on October 16, 1846, at the Massachusetts General Hospital, when Dr. John C. Warren (1778–1856) removed a vascular tumor from the submaxillary region in a patient anesthetized with sulphuric ether. Although the use of ether and chloroform as modern-day anesthetics quickly became routine the world over, its implementation in neurosurgery only came several decades later.
At the turn of the 20th century, there were great debates regarding the relative merits of chloroform and ether. Victor Horsley (1857–1916) performed a series of experiments in animals from 1883 to 1885 and concluded that, although ether was safer, it was not to be recommended in favor of chloroform because it produced a rise in blood pressure and an increase in blood viscosity, with a consequent potential for hemorrhage. Additionally, because morphine constricted blood vessels, he suggested that a combined morphine and chloroform narcosis be used. Of note, however, he later recommended abandoning the use of morphine when its depressant effect on the respiratory center became widely recognized. The anesthesia preferences of many of the pioneers in neurosurgery varied: Fedor Krause (1857–1937) used chloroform alone, while Emil Theodor Kocher (1841–1917) hesitated to do so because of its tendency to lower the blood pressure. Harvey Cushing (1869–1939), on the other hand, was impressed with chloroform's efficacy but preferred a cautious approach to anesthesia, favoring ether and restricting his use of chloroform to children. He frequently employed ethyl chloride in inducing the first stage of anesthesia and may well have been the first to introduce the concept of induction in anesthesia.
Around the same time, the use of local anesthesia gained prominence. Cocaine had been formally discovered in 1860 and was introduced into surgery in 1884. Use of procaine, which was first synthesized in 1905, immediately became commonplace among surgical anesthetics. Most neurosurgeons used local infiltration anesthesia for select cases, but beginning in 1913 with its popularization by de Martel, it became a common practice to use it for all craniotomies. By 1917, Harvey Cushing recommended the use of local anesthesia for all neurosurgical cases. The field of anesthesia quickly began to develop and by the time World War II, several agents had come into routine use, including tribromoethanol and pentothal sodium. Anesthesia as a specialty grew exponentially in the years that followed.
The "Discovery"
The dramatic improvement in anesthetics over the course of the 19th century was perhaps the biggest driving force for the advances in neurosurgery that followed. Carbon dioxide, hydrogen, and nitrogen were discovered toward the end of the 18th century and set off a new era of exploration and experimentation with the properties and uses of various chemicals, including oxygen and nitrous oxide. Sir Humphry Davy (1778–1829), who established the Pneumatic Institute in Bristol, England, in 1799, and is known to have been one of many at the time who inhaled nitrous oxide and ether for pleasure, suggested that these gases had the ability to relieve the pain of surgical operations.
However, the relatively slow implementation of anesthesia in neurosurgery had to do with the prevailing reluctance of surgeons of the era to perform cranial operations; indeed, Sir Astley Cooper (1768–1841), consulting surgeon to Guy's Hospital in London, England, published a series of lectures on the practice and principles of surgery in 1829, reporting that "trephining in concussion is now so completely abandoned that in the last four years I do not know that I have performed it once, whilst 35 years ago I would have performed it five or six times a year." Rather than trephine, Cooper's recommendation was instead to use leech therapy to the temporal arteries, calomel purging, and frequent venesection. Any anesthesia necessary was achieved with liberal quantities of wine. Even in 1869, Dr. John Erichsen (1818–1896) of the University College Hospital in London wrote of anesthesia in neurosurgical trauma: "in the treatment of injuries of the brain, little can be done after the system has rallied from the shock, beyond attention to strict antiphlogistic treatment, though this need not be of a very active kind. As much should be left to nature as possible, the surgeon merely removing all sources of irritation and excitement from his patient and applying simple local dressings."
At the beginning of the 19th century, if relaxation was desired, the patient might be intoxicated with alcohol or drugged with opium. Sir Humphry Davy, though, noted that nitrous oxide could produce a state of insensibility. Wells, a dentist of Hartford, Connecticut, in 1844, experimented with nitrous oxide on several patients in quick succession but stopped abruptly when one of his patients succumbed to the toxicity of the gas and died. This anecdote, relayed to his close friend and colleague William Morton, became the inspiration for Morton's own experimentation with anesthetic agents.
Although William Morton popularized the use of ether as an anesthetic agent, the credit for its initial use in the surgical setting belongs to another American physician, Dr. Crawford W. Long (1815–1878). On March 30, 1842, Long removed a small tumor from the neck of a patient, who noted that he was amnestic to the events of the surgery; Long, however, did not publish his results until much after Morton's public demonstration of ether anesthesia on October 16, 1846, at the Massachusetts General Hospital, when Dr. John C. Warren (1778–1856) removed a vascular tumor from the submaxillary region in a patient anesthetized with sulphuric ether. Although the use of ether and chloroform as modern-day anesthetics quickly became routine the world over, its implementation in neurosurgery only came several decades later.
At the turn of the 20th century, there were great debates regarding the relative merits of chloroform and ether. Victor Horsley (1857–1916) performed a series of experiments in animals from 1883 to 1885 and concluded that, although ether was safer, it was not to be recommended in favor of chloroform because it produced a rise in blood pressure and an increase in blood viscosity, with a consequent potential for hemorrhage. Additionally, because morphine constricted blood vessels, he suggested that a combined morphine and chloroform narcosis be used. Of note, however, he later recommended abandoning the use of morphine when its depressant effect on the respiratory center became widely recognized. The anesthesia preferences of many of the pioneers in neurosurgery varied: Fedor Krause (1857–1937) used chloroform alone, while Emil Theodor Kocher (1841–1917) hesitated to do so because of its tendency to lower the blood pressure. Harvey Cushing (1869–1939), on the other hand, was impressed with chloroform's efficacy but preferred a cautious approach to anesthesia, favoring ether and restricting his use of chloroform to children. He frequently employed ethyl chloride in inducing the first stage of anesthesia and may well have been the first to introduce the concept of induction in anesthesia.
Around the same time, the use of local anesthesia gained prominence. Cocaine had been formally discovered in 1860 and was introduced into surgery in 1884. Use of procaine, which was first synthesized in 1905, immediately became commonplace among surgical anesthetics. Most neurosurgeons used local infiltration anesthesia for select cases, but beginning in 1913 with its popularization by de Martel, it became a common practice to use it for all craniotomies. By 1917, Harvey Cushing recommended the use of local anesthesia for all neurosurgical cases. The field of anesthesia quickly began to develop and by the time World War II, several agents had come into routine use, including tribromoethanol and pentothal sodium. Anesthesia as a specialty grew exponentially in the years that followed.
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