NEEDLES AND SYRINGES

The syringe was known in ancient Greece and appeared sporadically as an aid in various medical treatments before the mid-19th century, when it was popularized by the addition of the fine hollow needle. As one example, a piston syringe used to inject mercurial salts transurethrally for syphilis is on display in the Mary Rose Exhibit in Portsmouth, England. The battleship Mary Rose sank in Portsmouth harbor in 1542, under the shocked gaze of Henry VIII. These early syringes ( Fig. 1-8 ) probably were unreliable and cumbersome to use. Although Christopher Wren experimented with the

Figure 1-8 Drawing by unknown artist appearing in Clysmatica Nova, a book written by Johan S. Elsholtz (1623–1688) and dated 1667. The artist clearly shows that syringes and rudimentary hollow intravenous tubes were used before the 19th century. Although this book was published in Cologne, Germany, most historians credit the first intravenous injections of pharmaceuticals to Christopher Wren and Timothy Clarck in England. (Courtesy of the National Library of Medicine, Bethesda, MD.)

During the first few decades of the 19th century, chemists were active in isolating a number of potent alkaloids from plants. In 1830, Magendie's Formulary for the Preparation and Employment of Several New Remedies^[170] lists the following newly discovered alkaloids: brucine, morphine, emetine, quinine, piperine, quinine, cinchona, strychnine, and veratrine. The agents were administered to patients for various ailments, often with little or no prior animal experimentation. Strychnine, for example, was used for palsies and paraplegias, often with "temporary relief." Of the alkaloids, morphine ( Fig. 1-9A ), isolated by the pharmacist Friedrich W. Sertuerner^[171] (1783–1841) in 1817, held the most promise for therapeutic success. Syrups, pills, draughts, and tinctures were used to deliver these drugs because no other effective method of administration was known at the time.

In an attempt to find another route of drug administration, some physicians raised blisters or excoriated the skin and then deposited drugs on the exposed surface of the wound. Francis Rynd^[172] (1801–1861) used a lancet to pierce the skin and devised a syringe to insert medication into the wound by gravity. Alexander Wood^[173] (1817–1884) invented a hollow needle that would fit on the end of a piston-style syringe made for him by Daniel Ferguson, an instrument maker from London. Wood used the syringe and needle combination to successfully treat painful neuralgias by local morphine injections. The syringe and needle combination became a popular item after these reports, and many practitioners used the device to inject morphine subcutaneously for pain relief. The term hypodermic injection was coined by Charles Hunter, who argued with Wood that morphine could be injected any place in the body and achieve the same analgesic effect as that obtained through injection at the site of pain.^[174]

The early syringes were inadequate for the work of the developing specialty of regional anesthesia. The rubber or leather plunger cracked or deteriorated after repeated sterilization. During use, the drug contents accumulated proximal to the plunger, or the plunger itself jammed inside the glass barrel. To achieve the fine control required for identification of the epidural space, a more carefully tooled instrument was required. H. Wulfing Luer of Paris introduced the first all-glass syringe in 1896. He sold the patent to Becton, Dickinson and Company in 1898. The Record syringe was made by Dewitt and Herz of Berlin, Germany in 1906,^[175] and it consisted of an all-metal plunger with a finely ground glass barrel. The fit between the barrel and plunger was precise and sturdy, and Record syringes nearly 100 years old can still be used for identification of the epidural space.^[174]

The first hypodermic needles were made from tempered steel, a metal that rusted easily when in contact with water. A small rusted area might not be observed visually, and defective needles sometimes broke below the skin. Meticulous care was taken to dry each needle after steam sterilization. Specially designed introducers, called rimmers, were used for storage of the needles to prevent rust from developing inside the needle. To avoid

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Figure 1-9 Botanical origins of adjuvants used in anesthesiology. A, Papaver somniferum, from which opium is obtained. Opium is the ancient Greek word for juice because the active alkaloids, which include morphine and codeine, are obtained from the juice squeezed from the unripe seed pods. The first undisputed reference to poppy juice is from the writings of Theophrastus (372–287 BC) in the third century BC. B, Erythroxylon coca, a shrub native to Peru and Bolivia from which cocaine was isolated in 1856. Although the native people of Peru have used the drug for centuries to increase endurance, they may have also used it as a local anesthetic. C, Strychnos toxifera, a source of curare, as drawn by Robert Schomburgk in 1841.^[484] Schomburgk traveled into Guiana following the maps drawn by Waterton and obtained several species containing the active drug. Richard Gill's curare was obtained primarily from Ecuador, and the arrow poisons there were made from Chondodendron tomentosum. (Courtesy of the National Library of Medicine, Bethesda, MD.)

The bevel of the needle was a topic of great discussion in the early 20th century. A long bevel produced less trauma to the tissues, but it allowed a small portion of the needle to lie in the intrathecal space with the proximal portion of the bevel in the epidural space. To increase the success of spinal anesthesia and minimize side effects, short-beveled needles and pencil-point needles were developed by several regional anesthesia specialists, a process that continues to this day. Fine, 25-gauge spinal needles, designed to produce minimal trauma to the dura, reduce the incidence of post-spinal headache.