CHAPTER 41 History of Pediatric Anesthesia

Phase I: Pediatric Anesthesia Before 1940

• Early Control of Pain: Ether and Chloroform

Phase II: Emergence of Pediatric Anesthesia, 1940 to 1960

• Factors in the Rapid Development of Interest

• Foundations of Clinical Control and Support

The pediatric anesthesiologist does not generally diagnose or cure patients but rather guides and supports each young patient through the operative experience with the least possible mental and physical stress. The history of pediatric anesthesia is best told by tracing the steps others have taken; steps toward increased precision in regulation and control of neurologic, respiratory, cardiovascular, and other body systems to serve both the surgeon and child (Smith, 1991).

The goals of pediatric anesthesiology as a specialty include the reduction of perioperative morbidity and mortality and the promotion of ancillary resuscitative and supportive fields through teaching, research, and organizational activity throughout the world.

Phase I: pediatric anesthesia before 1940

Primitive Period

Before the introduction of ether in 1846, circumcisions, amputations, tumor excisions, and correction of gross deformities were performed on infants and children without any 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 resulted in predictably poor outcomes for both 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 herb mixture tsu san sen was used successfully for breast cancer operations in 1804 by Seishu Hanaoka. In 1837, Gancho Homma reported a series of general anesthesia procedures with the use of the same herb mixture for children over 5 years of age for harelip repair, but it was withheld from use in younger patients because of its toxicity (Iwai and Satoyoshi, 1992). The conviction that small infants did not need anesthesia was not effectively suppressed until recently (Anand and Hickey, 1987). 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 (Long, 1849), it was not until the famous public demonstration of ether anesthesia at the Massachusetts General Hospital in Boston in 1846 that ether was widely accepted for use during surgery (Morton, 1847). 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 (Bigelow, 1846; Warren, 1847; Pernick, 1975).

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 an orderly or a parent, 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” (Haggard, 1940).

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 (Eckenhoff, 1966). 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 national 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) (Griffith, 1934). Snow first described signs by which a practitioner could monitor and control the depth of anesthesia in patients of all ages (Snow, 1847). 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 guide, Inhalation Anesthesia, published in 1937. Snow explored both ether and chloroform, preferring the latter, which he found well suited to infants and children. However, he warned of chloroform’s danger with excessive depth (Snow, 1858). 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, as well as attempts to increase its safety, such as diluting it with ether (CE) and with alcohol and ether (ACE). The introduction 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 (Kopetsky, 1903; Schwartz, 1957). Progress was made by trial and error, with little communication among those using anesthesia. Most literature in the United States concerning anesthesia for children was written by surgeons before 1900.

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 practiced 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 by 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 stemmed from his experience in caring for children injured in a massive explosion in Halifax, Nova Scotia in 1917, led the development of pediatric surgery in North America (Goldbloom, 1917; Steward, 1983; Smith, 1959). His work at Children’s Hospital Boston 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.*

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,^† an enterprising nurse anesthetist, 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 as well as for Robert Gross’ widely heralded division of a patent ductus arteriosus in 1938—without endotracheal intubation (Fig. 41-1).

FIGURE 41-1 Ms. Betty Lank served as chief nurse anesthetist at Children’s Hospital Boston from 1935 to 1969.

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 (Smith, 1959). 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 (Ayre, 1937). Although Robson of Toronto had described intubation of children using digital guidance rather than a laryngoscope, it had received little attention (Robson, 1936).

Phase II: emergence of pediatric anesthesia, 1940 to 1960

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 Smith’s The Physiology of the Newborn Infant (1945), Taussig’s Congenital Malformations of the Heart (1947), and Nelson’s Textbook of Pediatrics (1950). The practice of adult anesthesia had become established, providing fresh information on new agents and techniques easily adaptable to children. As yet, the only established pediatric anesthesiologist in North America was Charles Robson in Toronto; in England, it was Robert Cope at London’s Hospital for Sick Children. Among those interested in pediatric anesthesia, M. Digby Leigh made himself well known (Fig. 41-2). Trained by Waters in Wisconsin, Leigh was appointed head of anesthesia at Montreal Children’s Hospital, where he taught and (with his invaluable associate Kathleen Belton) authored Paediatric Anaesthesia (1948) 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 (Conn, 1992).

FIGURE 41-2 Dr. M. Digby Leigh.

In the meantime, in Liverpool, G. Jackson Rees (Fig. 41-3) 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), proceeded to carry out this concept with astounding success. With minor alterations this technique was to survive through years of short-lived, complicated types of apparati. Rees’ 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 barotrauma (volutrauma) and surfactant inactivation.

FIGURE 41-3 Dr. G. Jackson Rees.

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 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, C. Everett Koop recruited Margo Deming to head the Department of Anesthesia at the Children’s Hospital of Philadelphia as a teacher and investigator. Dr. Koop is currently a Professor at Dartmouth Medical School.

Little had happened in the field of anesthesia on the home front during World War II. After the war, numerous problems, many not even envisioned at the outset, were resolved by the exceptionally harmonious cooperation between pediatric surgeons and anesthesiologists. Whereas the success of individual operations is the natural goal of the surgeon, and improved supportive measures are the steps noted by anesthesiologists, all are interdependent and are considered together.

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 (Smith, 1959). 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 and the endotracheal intubation being reserved for emergency use during 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” (Smith, 1959). 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. 41-4). Fluids and blood were administered via a 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.

FIGURE 41-4 Smith’s latex blood pressure cuffs: newborn and infant sizes.

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.

Herniorrhaphy and Pyloromyotomy

During this time period, herniorrhaphy and pyloromyotomy could be performed with a patient under local anesthesia by the average surgeon, but open-drop divinyl ether (Vinethene) was definitely preferable. The problem most often encountered in infants with inguinal hernia was whether to cancel the operation when the infant’s hemoglobin was 9.8 g/dL instead of the “required” 10 g/dL, or to transfuse. Transfusion commonly was chosen. Before 1912, attempts to correct pyloric stenosis by gastroenterostomy had resulted in a 50% mortality rate. The Ramstedt pyloromyotomy effected one of the great achievements of pediatric surgery in creating a simple procedure for this common lesion, thereby saving the life of an otherwise normal child. Anesthetic management after early diagnosis was centered on the prevention of aspiration of the accumulated stomach contents and was best accomplished by drainage via a large-bore urethral catheter immediately before operation. In Boston, trachea intubation was not considered necessary unless contrast medium had been used for diagnosis, whereas intubation was routinely used in other centers. In cases of delayed diagnosis, the operation was postponed for rehydration and correction of electrolyte disorders or anemia.

Early Attempts to Control Fear

It soon became evident that for the small child, the fear of needles and the horrors of anesthetic induction were deeply upsetting and of long duration. Concern about this most unfortunate anesthetic by-product was voiced by psychologists, pediatricians, anesthesiologists, and others, as well as numerous mothers reporting prolonged night terrors, bed-wetting, and dependence (Levy, 1945; Jackson, 1951; Eckenhoff, 1953).

Some attention had been paid to premedication shortly before this time. French Armand-Delille (1932) recommended morphine, and Waters (1938) promoted the combination of morphine and scopolamine, but the response to the outburst of concern came in a flood of reports on a variety of ineffective agents. The basic error in most studies was, and still is, the use of age or weight for estimation of drug dosage, when neither reflects the child’s state of mind. General use of intramuscular barbiturates plus morphine mixed with either atropine or scopolamine resulted in severe horror of needles, an uncomfortably dry mouth, and an unpredictable degree of sedation, seldom better than 65% successful. Attempts to improve this record continued to play a large part in the activities and literature of pediatric anesthesiologists with only slight improvement with regard to the effectiveness of sedative drugs. However, the concentration of attention of numerous investigators on this problem did result in the development of close personal interest in each child studied, possibly responsible for much of the benefit credited to the drug being promoted.

Methods of induction showed somewhat more success than those of sedation. Thiopental replaced rectal tribromoethanol, providing greater ease of administration via either the intravenous or the rectal route, whereas induction with nitrous oxide, cyclopropane, or divinyl ether eliminated much use of the dreaded ether (Weinstein, 1939). With the repeated failure of sedative agents, greater skills were developed by caring anesthetists to gain the confidence of children in preoperative visits and then to divert their attention at induction by telling them stories or by simply lulling them to sleep. Hypnosis was used for induction by Betcher (1958), Marmer (1959), and a few others for the total operation in short procedures. It was particularly valuable for the repair of facial lacerations in small children who had recently eaten. Unfortunately, this potentially useful and harmless method gained only limited acceptance.

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) or by means of a centrally operated pipeline.

Endotracheal Intubation

The greatest advance in pediatric anesthesia between 1940 and 1960 was in control of the airway by tracheal intubation. Early use in England and Canada met with little resistance. In the United States, however, opposition by surgeons raised the first major obstacle to progress in the new specialty. (It must be admitted that reasonable concern had been aroused in those who had witnessed the traumatic attempts of inexperienced individuals to perform unnecessary intubations.) It was the efforts of Rees in England; Leigh, then in Canada; the British-American Gillespie (1939); Americans Deming (1952), Pender (1954), and others; and their supportive younger surgeons that brought forth grudging acceptance of tracheal intubation of infants and children in the United States in the 1940s and 1950s.

The ongoing development of this technique led to an increased understanding of laryngeal anatomy; replacement of the “classic” hyperextension of the head by use of the “sniffing” position for intubation; a succession of different types of tracheal tubes, including the tapered tube of Cole (1945) that enjoyed more than a decade of popularity; a variety of tube materials progressing from coarse rubber to nonreactive plastic; and laryngoscopes of several types and sizes (Eckenhoff, 1951).

As with ether and other major advances, the advent of tracheal intubation brought a host of disadvantages and a few real dangers that in turn led to a glut of literature concerning complications, including subglottic stenosis, laryngeal irritation from large tubes, and tracheitis caused by contamination (Baron and Kohlmoos, 1951; Flagg, 1951; Smith, 1953a; Colgan and Keats, 1957). This proved to be just the beginning.

“Total Control” of Respiration: The Muscle Relaxants

After the first clinical use of d-tubocurarine by Griffith and Mitchell in Canada in 1942, Canadians and British accepted it readily and began extensive use in both children and adults, to be followed by much investigation in later years (Anderson, 1951; Stead, 1955; Leigh et al., 1957; Rees, 1958). Again, in the United States there was much opposition, this time by anesthesiologists as well as surgeons, to whom the concept of total “takeover” of an essential body function, termed controlled respiration, appeared to be a dangerous and unacceptable “physiologic trespass” (Gross, 1953; Beecher and Todd, 1954). Beecher threatened one of the authors of this chapter that “heads would roll” if he and others persisted in support of its use. In the meantime, Cullen (1943) had found it quite safe for adults and children, using it as a sole agent for infant surgery. This practice was abandoned after Scott Smith of Utah was tested under total curarization and suffered acutely on painful stimulation (Smith, 1947; Smith et al., 1947). As with tracheal intubation, the total acceptance of neuromuscular blocking agents in the United States required many years. By 1960, however, the terms controlled respiration and assisted respiration had gained widespread use.

Pediatric Breathing Systems: Assisted and Controlled Respiration

With the stimulating effect of ether on respiration in light surgical planes, assisted respiration was seldom needed. Open chest surgery, cyclopropane, and particularly muscle relaxants definitely changed this picture and led to a succession of considerably diverse devices (Dorsch and Dorsch, 1975). The to-and-fro absorption method, using soda-lime canisters of graduated sizes, was particularly adaptable to infants but caused heat retention and the aspiration of lime dust. For larger children, the canisters were bulky and heat retention was even more troublesome.

Special interest was taken in infant circle absorption systems. The Leigh, Ohio, and Bloomquist models were not only difficult to handle but also introduced the problems of valve resistance and dead space (Leigh and Belton, 1948).

To eliminate problems of carbon dioxide accumulation, several nonrebreathing valves were designed by Leigh and Belton (1948), Stephen and Slater (1948), and others. Although compact in design, they were not easy to manage and were definitely ill-suited for use with explosive agents.

The saga of apparatus variously called rebreathing (British), nonrebreathing (United States), and partial rebreathing (general) is complicated and involved numerous studies and modifications of the basic Ayre T system over 30 years (Fig. 41-5) (Ayre, 1937). After the Rees elongation of the expiratory limb with an attached breathing bag, the addition of exhaust valves placed either proximal (Mapleson A) or distal (Mapleson D) to the face brought intensive examination, as did the estimation of proper flow rates of incoming gases. Evaluation by Mapleson (1954) and Inkster (1956) did much to clarify these issues at the time, but more problems lay ahead.

FIGURE 41-5 Original Ayre T-tube nonrebreathing system.

Cardiovascular and Thermal Control

Between 1940 and 1960, revolutionary advances were made in several areas involving the combined efforts of anesthesiologists and surgeons. The intentional reduction of arterial blood pressure, extensively explored by Enderby (1950) and others in England, was cautiously extended to pediatric use by Anderson (1955) with trimethaphan camphorsulfonate (Arfonad). This served as a reasonably safe agent. It was the initial step in induced hypotension to reduce surgical blood loss in major pediatric surgery and to prevent excessive blood pressure elevation during correction of coarctation of the aorta. However, the agent was unpredictable and soon was replaced by more controllable agents and techniques.

Controlled Reduction of Body Temperature and Cardiopulmonary Arrest

After Gross’ ligation of a patent ductus arteriosus in 1938, correction of coarctation of the aorta, repair of vascular rings, and shunt procedures for tetralogy of Fallot were successfully performed under closed or semiclosed inhalation anesthesia, usually with cyclopropane (Harmel and Lamont, 1948; Harris, 1950; Smith, 1952). McQuiston, endeavoring to reduce the oxygen requirements of Dr. Potts’ cyanotic infants, cooled them 3° to 4° C on a simple ice-water mattress, thereby introducing the practice of hypothermic control of body metabolism into pediatric anesthesia (McQuiston, 1949). Efforts to reduce oxygen demand by further lowering temperatures to 30° C with immersion in ice water provided surgeons time for simple intracardiac aortic or pulmonary valvotomy (Lewis and Taufic, 1953; Virtue, 1955).

The drive to bypass both the heart and lungs initiated by Gibbon in 1937 became exciting in the early 1950s, with competing surgeons Lillihei, Kirklin, and Kay and their respective anesthesiologists Matthews et al. (1957), Patrick et al. (1957), and Mendelsohn et al. (1957) all contributing toward the first practical use of the pump oxygenator in 1955, 2 years before publication of the articles cited.

The supplementation to bypass perfusion by moderate hypothermia (30° C) and different methods of induced cardiac arrest produced the greatest “takeover” of body function to date and the means of performing intracardiac surgery on all but small infants.

Mild and moderate hypothermia techniques were also used in this period for neurosurgery, orthopedic surgery, and harelip repair (Kilduff et al., 1956).

Control During Maintenance of Anesthesia

As more extensive procedures were developed and surgeons began to prefer accuracy to speed, 4-hour operations became more common and the methods of maintenance and support grew more demanding. Experience, skill, and constant observation were still primary factors that were assisted by a few simple devices (Fig. 41-6). During this time the precordial stethoscope became essential for use with every infant or child throughout the field of anesthesia (Smith, 1953b). A precordial or esophageal stethoscope served first to keep the anesthetist in direct contact with the child at all times, providing unaltered information as to the clarity and strength of breath sounds and the rate, rhythm, and strength of heart sounds (Smith, 1991). Strength of heart sounds was an important guide to the degree of blood loss at that time. Arterial blood pressure could be obtainable with standard apparatus for larger children and with a specially constructed latex cuff with an inflatable bladder for infants (the Smith cuff). During this phase, the electrocardiograph was occasionally brought into operating rooms, encased in antiexplosive shielding (shaped like a torpedo) and serving relatively little purpose. Body temperature was measured intermittently at oral, nasal, or rectal sites, the standard glass thermometer giving way to the safer but less accurate thermostat devices. The anesthesia chart was considered a necessary item, gaining in importance as procedures grew increasingly complex and legal suits more common.

FIGURE 41-6 Smith’s teaching precordial stethoscope with a single chest piece and two headpieces.

Control of Blood Loss

Methods of estimating blood loss at the time consisted of assessing blanching of conjunctivae, evaluating the strength of heart sounds, measuring arterial blood pressure, and weighing bloodied sponges, purposely used without moistening. Whereas speed was still considered essential in pediatric surgery during the excision of Wilms’ and other large tumors, massive hemorrhage might exsanguinate small infants before replacement was possible. Attempts to restore the loss with cold, acidified blood brought failing hearts to irreversible cardiac arrest. A major advance to controlling these situations occurred when surgeons were persuaded to time their work by the advice of the anesthesiologist rather than by the clock. Although the cautery soon reduced blood loss drastically when used, it was not adopted immediately by all.

Progress in Local Anesthesia

Ladd had used local infiltration for abdominal procedures in premature infants in the late 1930s, and Leigh wrote of spinal anesthesia for open chest work in the 1940s, but improved inhalation methods outmoded both. Except for brachial plexus block, little attention was paid to these methods in the United States (Small, 1951; Eather, 1958; Smith, 1959). In many other countries, however, where inhalation anesthesia was less advanced, there was considerable dependence on regional and spinal anesthesia for both infants and children.

Halothane Opens a New Era

Although anesthesia with relaxants and nitrous oxide permitted the use of electrical instruments in the operating room, explosive gases were still popular until the introduction of halothane. After its first use in England by Johnstone in 1956 (in 10% concentration), this nonflammable, nonirritating, and potent agent was promptly introduced in Canada by Junkin et al. (1957) and in the United States by Stephen and colleagues (1958). Subsequently, flammable anesthetic agents were totally abolished in the United States, thus opening the way to revolutionary changes, first in the control of blood loss by cautery and then in the development of electronic devices for monitoring and physiologic control.

Supportive Care and Oxygen Therapy

Related fields brought important aid to pediatric anesthesiologists during this period. The time-honored rule developed by Holliday and Segar (1957) for pediatric fluid administration based on metabolic requirements serves to this day. Also of great importance, particularly in reducing the morbidity and mortality of small infants undergoing surgery, was the control of infection by the use of antibiotic agents.

The interest of pediatricians caring for neonates led to the development of enclosed incubators with regulated oxygen, warmth, and humidification for infants with respiratory distress syndrome. Improved oxygen tents were developed for older children, including those with cystic fibrosis. The poliomyelitis epidemics of the 1950s in Europe and North America initiated a succession of ventilating devices to replace the enclosed “iron lung” in use since 1929. Pediatric anesthesiologists and pediatricians shared responsibility for this work, which opened a new field for anesthesiologists.

The first pediatric intensive care unit was established in Goteburg, Sweden, in 1955.* Similar units were established in Stockholm (Feychtung), Liverpool (Rees), and Melbourne (MacDonald and Stocks) between 1960 and 1964. In North America, the first pediatric intensive care unit was established by Downes at the Children’s Hospital of Philadelphia in 1967, followed by Children’s Hospital of Pittsburgh (Kampschulte), Yale-New Haven Hospital (Gilman), Massachusetts General Hospital (Todres and Shannon), and the Hospital for Sick Children in Toronto (Conn) within the next 4 years (Downes, 1992).

Teaching and Research

Throughout Europe and North America, communication among anesthesiologists began to accelerate. The Great Ormand Street Hospital for Sick Children in London and the Alder Hey Hospital in Liverpool became teaching centers in England; the Hospital for Sick Children in Toronto in Canada and the Children’s Hospitals of Boston and Los Angeles in the United States became centers to which various novice and experienced anesthetists came from all parts of the world for clinical training. Residents on affiliation from teaching hospitals were rotated through brief training periods for instruction in basic, safe, and practical methods of anesthetic control of children undergoing standard operations and in special methods for those at higher risk.

On the heels of Leigh and Belton’s Pediatric Anesthesia (1948), Stephen’s Elements of Pediatric Anesthesia (1954) and Smith’s Anesthesia for Infants and Children (1959) were published, with details of advances to date. Articles on new agents and techniques steadily increased in the anesthesia-related literature. Whereas some reported personal early experiences based on limited numbers, many were of lasting value, including those involving tracheal abnormalities by Eckenhoff (1951) and Colgan and Keats (1957), tracheoesophageal repair by Zindler and Deming (1953), and the important warning of Leigh et al. (1957) concerning bradycardia after the intravenous administration of succinylcholine.

Research, on the other hand, was still in its infancy, there being little space, time, or funds for sophisticated investigation. As previously mentioned, many clinical studies offered practical current value concerning new agents and techniques. Whereas those concerning preoperative sedation outnumbered others, many reports covered airway resistance, valves, and dead space (Macon and Bruner, 1950; Mapleson, 1954; Orkin et al., 1954; Hunt, 1955; Inkster, 1956). The introduction of muscle relaxants initiated other studies, including those of Hodges (1955), Stead (1955), Telford and Keats (1957), and Bush and Stead (1962). The addition of halothane led to a more critical analysis of this agent than had been done for previous anesthetics.

This period established such fundamental techniques and basic concepts that Rees subsequently (1991) stated, “Paediatric anaesthesia in Great Britain and Ireland shows that by 1950 it had reached a point at which current practice is recognizable…. Future pediatric anaesthetists are therefore unlikely to experience the great excitement their predecessors enjoyed between 1930 and 1950, but will derive satisfaction from changes less dramatic as the curve of improvement approaches perfection.”