History of pediatric anesthesia

Primitive period

Before the introduction of ether in 1846, circumcisions, amputations, tumor excisions, and correction of gross deformities were performed on infants and children with little relief of pain. Struggling was controlled by use of force, but pain was accepted as an unavoidable part of life. Crude attempts were occasionally made with alcoholic “spirits,” nerve compression, or even brief strangling, coupled with headlong surgical speed. However, these attempts often resulted in a poor outcome for both the operation and patient. Harelip repair had been attempted without pain relief measures in many parts of the world for hundreds of years. In Japan, general anesthesia with the herbal mixture tsu san sen was used successfully for breast cancer operations in 1804 by Seishu Hanaoka. In 1837 Gancho Homma reported a series of procedures with the use of the same herbal mixture for children over 5 years of age for harelip repair, but it was withheld from use in younger patients because of its toxicity ( ). The conviction that small infants did not need anesthesia was not effectively suppressed until modern times ( ). For many years, the “whiskey nipple” had been used widely as a sedative supplement to local anesthesia in infants undergoing abdominal procedures, and wine has been given for ritual circumcisions for millennia.

Early control of pain: Ether and chloroform

The introduction of ether was the first giant step in the history of anesthesia. Although Crawford Long used ether in his rural practice in Georgia beginning in 1842, and his third ether anesthesia procedure was for a toe amputation in a 7-year-old boy ( ), it was not until the famous public demonstration of ether anesthesia at Massachusetts General Hospital in Boston in 1846 that ether was widely accepted for use during surgery ( ; ). The discovery that sensation, or pain, and along with it consciousness and motion, could be abolished temporarily by ether was widely acclaimed; however, little was known about ether’s actions, how to use it, or what its dangers might be. Ether was accepted only gradually over several years, with many surgeons retaining the belief that ordinary men (the wealthy excluded) should be able to tolerate surgery without anesthesia! However, for children and ladies, who were considered to be “more sensitive,” anesthesia was considered appropriate, although Morton himself was reluctant to administer it to young subjects because of the high incidence of nausea and vomiting in this population ( ; ; ).

It was soon found that pouring ether onto a handkerchief or small cloth was a practical method of administration with small children. One simply pressed the cloth to the patient’s face until the child was quiet and limp. The cloth was then withdrawn, and the surgeon was granted 3 or 4 minutes to operate as the child regained consciousness. The use of continuous administration of ether caught on slowly with gradual familiarization with the new agent. The early impression that ether was easy to administer, effective, and safe led to the belief that it was a trivial service that any inexperienced person, often a student or orderly, could perform. The unfortunate result was that throughout the rest of the century, the administration of anesthesia continued to be held in poor repute as a medical activity, rarely attracting physicians with special interest or ability in the field. Nurses eventually began to assume increasing responsibilities for providing anesthesia care ( ). As late as 1940, a physician, in the lead article published in the first edition of the new journal Anesthesiology , noted, “During my internship I was trained by a nurse. I was given a cone, a can of ether, and a few empirical tricks” ( ).

In England, chloroform was accepted more readily because of its smoother and more rapid action. Soon, however, the incidence of deaths became so alarming that the British established a dictum that only physicians should be allowed to administer anesthesia ( ). The fortunate result was that throughout the British Empire, anesthesia flourished as a medical specialty, and its workers gained equal status with other physicians and became early leaders in the field.

Another great advantage for the British in the early development of anesthesia was the presence of the astounding John Snow (1813 to 1858), who made epidemiologic advances of international importance, ran an active medical practice, and kept notes on hundreds of anesthesia experiences and research experiments, mostly in the last 10 years of his life (1846 to 1856) ( ). Snow first described signs by which a practitioner could monitor and control the depth of anesthesia in patients of all ages ( ). His five stages of anesthesia (excitement, loss of consciousness, relaxation, eye movement, and depth of respiration) served as a guideline throughout the remainder of the century and formed the basis of Guedel’s important text, Inhalation Anesthesia , published in 1937. Snow explored both ether and chloroform, preferring the latter, which he found well-suited for infants and children. However, he warned of chloroform’s danger with excessive depth ( ). His record of successfully anesthetizing 147 infants for harelip repair is hardly conceivable in view of the mortality that this operation continued to bear well into the next century.

After the remarkable advances made by Snow, anesthesia in England progressed at a slower pace. For nearly 20 years, chloroform and ether remained the only anesthetic agents available, and progress consisted mainly of developing methods of administration, comparing advantages and dangers, and simply studying how to keep children asleep and still for longer periods of time. Despite its recognized danger, chloroform remained the principal agent in England and throughout Europe. Efforts to reduce the complications associated with chloroform included many warnings and attempts to increase its safety, such as diluting it with ether (CE) and with alcohol and ether (ACE). The introductions of nitrous oxide into general use by 1870 and ethyl chloride shortly after 1900 were important advances because they reduced or replaced the use of chloroform in many operations. Both of these agents were nonirritating and relatively acceptable, making them particularly adaptable for induction. Because induction had been seen as a troublesome stage of anesthesia, the use of these agents generated much interest.

British physician anesthetists began to publish articles and texts in increasing numbers. Buxton alone produced five editions of his Anaesthetics: Their Uses and Administration between 1888 and 1912. Many texts related to adult care contained advice on pediatric problems, of which harelip continued to attract the most attention. Numerous references to pediatric anesthesia could be found in The Lancet , Britain’s premier medical journal, and in 1923, C. Langton Hewer wrote Anaesthesia for Children , the first text on pediatric anesthesia to be written in English.

In the United States the special needs of children were given slight consideration for many years. The child was treated as “a little adult”; surgeons operated with large instruments, and all equipment was adult sized. Ether remained the principal agent. Although criticism of chloroform became more vehement, its use was advocated in the United States as recently as 1957 ( ; ). Progress was made by trial and error, with little communication among those using anesthesia. Most literature in the United States before 1900 concerning anesthesia for children was written by dentists or surgeons.

Interest grew slowly around the turn of the century, and nurses and surgeons began to develop skills sufficient to carry children through longer and more difficult procedures. Thousands of tonsillectomies were being performed by 1900, and appendectomy was an accepted, although often dangerous, procedure. Orthopedic surgery was the most active type of pediatric surgery during this time, and most procedures were easily managed with simple ether techniques. One of the first signs of concern for the child’s anxiety when undergoing anesthesia was voiced by James Gwathmey in 1907. He recommended that one should “add a few drops of the mother’s cologne to the ether mask and induce the child in the mother’s arms.” Another step toward easing induction came in 1928 with the introduction of tribromoethanol, the German Avertin, which was used widely as a rectal agent. It provided almost certain sleep in 7 to 8 minutes and was of special value before ether induction because, unlike the barbiturates used later, it had a bronchodilating effect that facilitated rather than retarded induction. However, the drug required preparation immediately before use. That, in addition to the repeated occurrence of fecal incontinence, led to its abandonment.

Between 1925 and 1940, activity in both pediatric surgery and anesthesia began to accelerate. William Ladd, whose interest in caring for children was enhanced by his experience treating pediatric patients injured in a massive explosion in Halifax, Nova Scotia, in 1917, led the development of pediatric surgery in North America ( ; ; ; ). His work at Boston Children’s Hospital, where he became chief of surgery, was devoted to the correction of neonatal defects, including harelip. Ladd performed harelip repair seated, with the infant held facing him in the lap of a nurse. The anesthetist stood behind the nurse, directing ether from a vaporizing bottle into the infant’s mouth via a metal mouth hook. *

* An accurate description of the first anesthetic agents given by one of the original writers of this chapter (Robert M. Smith) for Dr. Ladd at Boston Children’s Hospital in 1946.

The introduction of cyclopropane in 1930 proved particularly helpful for pediatric anesthetists in the management of infants, although it required assembly of a closed-system apparatus. Lamont and Harmel developed a miniaturization of the to-and-fro canisters Waters described in Wisconsin, and they used this technique for Blalock’s “blue baby” (tetralogy of Fallot) operations at Johns Hopkins Hospital. In Boston, Betty Lank ( Fig. 61.1 ), the chief nurse anesthetist at Boston Children’s Hospital from 1935 to 1969, further redesigned the miniature to-and-fro apparatus with less dead space and shrank adult celluloid masks to infant size, enabling her to provide anesthesia, relaxation, and controlled respiration for Ladd’s infants and for Robert Gross’s widely heralded division of a patent ductus arteriosus in 1938—without endotracheal intubation ( ).

By 1940, considerable progress had been made in the ability of minimally trained anesthetists to provide satisfactory operating conditions for the surgeons of that time ( ). Ladd strenuously corrected the previous concept by establishing the dictum “The child is not a little man.” Supportive warming, preoperative correction of electrolyte balance, and intraoperative charting became standardized. Clinical signs of anesthetic depth, described by Guedel in 1937, served well. This might be termed the height of the art of pediatric anesthesia in the United States, where simple expedients still prevailed.

In England, there had been more progress in airway control. After World War I, Magill and Rowbotham popularized tracheal intubation for adult procedures, and in 1937, Philip Ayre of Newcastle-Upon-Tyne reported his classic method of endotracheal intubation with a T-tube device for harelip repair in neonates ( Fig. 61.2 ) ( ). Although Robson of Toronto had described intubation of children using digital guidance rather than a laryngoscope, it had received little attention ( ).

Factors in the rapid development of interest

Before and during this period, activity accelerated in related fields, and much information became available, defining normal and abnormal infants in such texts as Clement , , and . The practice of adult anesthesia had become established, providing fresh information about new agents and techniques easily adaptable to children. Before that time, the only established pediatric anesthesiologist in North America was Charles Robson in Toronto; in England, Robert Cope was at London’s Hospital for Sick Children. Among those interested in pediatric anesthesia, M. Digby Leigh made himself well known ( Fig. 61.3 ). Trained by Waters in Wisconsin, Leigh was appointed head of anesthesia at Montreal Children’s Hospital, where he taught a course on anesthesia. Along with his invaluable associate Kathleen Belton, he wrote the book , the first North American text on this subject. Leigh and Belton described the use of spinal anesthesia for intrathoracic procedures, an original pediatric circle absorption apparatus, and a nonrebreathing valve. Leigh moved to Vancouver, British Columbia, in 1947 and then to Los Angeles in 1954, where he started the first annual pediatric anesthesia teaching conference in America. He was a brilliant technician and a stern teacher, and he delighted his audiences with his stinging repartee. His foresighted attempts to monitor exhaled carbon dioxide in 1952, however, were rebuffed by incredulous scoffers ( ).

At that time in Liverpool, G. Jackson Rees ( Fig. 61.4 ) had been named anesthetist at the Alder Hey Children’s Hospital by his mentor and teacher Cecil Grey. Together they conceived the idea that practically all surgery could be performed under the simple and nonexplosive combination of nitrous oxide and curare. Rees, adapting the Ayre T-tube system by adding an expiratory limb and breathing bag (the well-known Jackson-Rees system) ( Fig. 61.5 ), proceeded to carry out this concept with astounding success. With only minor alterations, this technique was to survive through years of short-lived, complicated types of apparatuses. Rees’s conviction that respiration should be controlled in infants with reduced tidal volumes and rates of 60 to 80 breaths per minute also met with criticism, but it proved to be rational when increased tidal volumes were found to cause volutrauma and surfactant inactivation.

The new field of pediatric surgery, spearheaded by Gross, was calling for more skilled anesthetists, and at the end of World War II large numbers of young physicians were released from military service, many of whom chose the uncharted field of pediatric anesthesia. McQuiston and Smith ( Fig. 61.6 ) found posts at children’s hospitals in Chicago and Boston, respectively, and Rackow worked at Columbia Presbyterian Hospital in New York, each to participate in early advances. In 1946 surgeon C. Everett Koop recruited Margery “Margo” Deming, Robert Dripps’s first resident in anesthesia at the University of Pennsylvania, to head the Department of Anesthesia at the Children’s Hospital of Philadelphia as a teacher and investigator. Before this, anesthesia was administered there by nurses ( ). Dr. Koop later was named the surgeon general of the United States from 1982 to 1989.

Foundations of clinical control and support

Neonatal surgery and anesthesia

Among the surgical challenges in the beginning of the 1940s, three congenital defects were dominant: tracheoesophageal fistula (TEF), omphalocele, and congenital diaphragmatic hernia (CDH). Both Leven and Ladd performed secondary multiprocedure repair of TEF in 1939 ( ). Primary repair, first accomplished by Haight in 1941, then became the most important challenge in pediatric surgery, each case demanding all-day and all-night efforts of all participants. In Boston, the operation was carried out with the patient under the influence of cyclopropane via mask with a to-and-fro apparatus, endotracheal intubation being reserved for emergency use during the operation. Control of the exposed pleura during esophageal anastomosis required complete immobility, and the operation, in the words of Ladd, was “like stitching the wing of a butterfly” ( ). Supportive management played a large part in the survival of these infants, both during and after the operation. Warmth was maintained by heating and humidifying the operating room, wrapping limbs in sheet wadding, and using a semiclosed to-and-fro absorption technique. Blood pressure was measured by a locally introduced cuff with a latex bladder encircling the arm ( Fig. 61.7 ). Fluids and blood were administered via an open-top burette with rubber tubing and “cut-down” metal cannula in the saphenous vein. Postoperative survival depended largely on the remarkably able services of one or two very special nurses.

Repair of omphalocele posed different problems. Here the forceful closure of the abdomen over the extruded viscera often caused severe compression of the lungs and abdominal blood vessels. The challenge to the anesthetist was that of providing adequate relaxation while preserving ventilation and circulation. Skin closure was possible only rarely, leaving the alternative of delayed closure, which often failed. The use of muscle relaxants facilitated closure but increased the risk of postoperative hypoventilation. Mortality was appreciable.

Of the three defects, CDH at first appeared to be the easiest to correct, and anesthesia often was managed with open-drop ether without mortality. By 1950, however, postoperative deaths became an obvious and unsolved problem. It later became evident that the CDH-related deaths occurred in the sickest of infants, who in an earlier time would have died before repair could be attempted. The management of CDH subsequently became, and still is, one of the most engrossing problems of neonatal surgery.

Control of the airway

The importance of airway management became evident with the first anesthesia procedures, and after years of progress it still presents formidable difficulties. For patients of all ages, hypoxia resulting from laryngospasm, oral secretions or blood, abscesses or tumors, aspiration of vomitus, or simply blockage by the tongue has been an ever-present danger. Many deaths from early harelip procedures resulted primarily from hemorrhage, as did later deaths from tonsillectomy.

By 1940, two simple but extremely fundamental aids had been introduced. To prevent obstruction by the tongue, metal and rubber oral airways had been used successfully for a decade and were often fitted with a metal nipple for insufflation of vaporized ether. Suction apparatus was first available in the form of bulb syringes used alone or fitted with rubber catheters and then later as portable motorized pumps situated at the head of the operating table (ether and cyclopropane notwithstanding) ( Fig. 61.8 ) or by means of a centrally operated pipeline.