Terra Sigillata

Arlenna baby.JPG

In discussing the Christmas birth of a son to ScienceBlogs launcher and science journalist Christopher Mims and his wife, I neglected to note another addition to our tribe of science, from a science blogger specifically.

ChemicalBiLOLogy blogger, Arlenna, gave birth on Christmas Eve to a beautiful girl, pictured here with Mr. Arlenna. In her brief post, “I had a baby!,” Arlenna posited:

. . .whoever invented epidurals and started using them in childbirth should win the Nobel Prize.

Despite my lack of training in anesthesiology or obstetrics, I thought I might look into this a bit. I had pondered this question before on behalf of PharmGirl, for whom epidural anesthesia played a prominent role in the Caesarian delivery of the PharmKid.

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Epidural anesthesia involves an injection, usually a continuous infusion, of drugs around the covering of the spinal cord in the lumbar region of the back. This is overly simplified but there is an anatomical space around the dura that protects the spinal cord where sensory nerve from the periphery transmit impulses to the spinal cord to be interpreted in the brain or as part of reflex responses at the level of the spinal cord. This page at the Australian website, myDr.com.au, is where the illustration to the left is derived and provides a nice, lay description of the procedure.

My labor & delivery colleagues can comment on current drugs, but epidurals usually consist of an anesthetic such as lidocaine or bupivicaine and an opioid analgesic such as fentanyl or sufentanil. The anesthetic decreases the transmission of all nerve impulses while the opioid reduces the activity of nociceptive pathways, those which transmit pain impulses. There may also be a vasoconstrictor such as epinephrine to restrict distribution of the drugs to the local area and prolong their duration of action. The main point of an epidural is to anesthetize the pelvic or abdominal area without impairing consciousness.

As with any drug or procedure, there are side effects and potential risks such as the prolongation of labor, a hypertensive episode, or post-procedure headaches from leakage of cerebrospinal fluid. Some women also prefer no analgesia in order to “more completely participate in the birth experience.”

Most original accounts of epidural anesthesia in obstetrics are from 1942 and 1943 and trace to a group led by Dr. Robert A. Hingson at the Public Health Service Marine Hospital at Stapleton on Staten Island, NY. However, a 1942 Canadian veterinary journal article from the 38th annual meeting of the Central Canada Veterinary Association (Ottawa, January 21, 1942; Can J Comp Med Vet Sci 1942:102-6) on torsion of the uterus in cattle revealed to me that epidural anesthesia had been practiced for years earlier in the veterinary setting. (Note: the reference to “caudal” anesthesia is an injection into the epidural space, or caudal canal, lower on the spinal column. Hence, more precise terms used define the site of injection: caudal epidural vs. lumbar epidural.).

Caudal or epidural anaesthesia
It may be said that caudal anaesthesia is one of the most useful methods made available to practising veterinarians in recent years. It is relatively safe and simple when properly performed and the results are usually very satisfactory. Caudal anaesthesia seems to have been introduced by Siccard of France about 1901. Since then, numerous veterinarians at home and abroad have described its use in domesticated animals. However, it is only within the last five or six years that it has come into general use and is yet practised more widely in cattle than in other animals.

In humans, however, it is the team of Hingson and Waldo B. Edwards, together with James L. Southworth, who are largely credited with introducing caudal and epidural anesthesia in childbirth.

Hingson RA and Southworth JL (1942) Continuous caudal anesthesia. American Journal of Surgery 58: 92-96.

Hingson RA and Edwards WB (1942) Continuous caudal anesthesia during labor and delivery. Anesthesia and Analgesia 21: 301-311.

Southworth JL, Edwards WB, and Hingson RA (1943) Continuous caudal anesthesia in surgery. Annals of Surgery 117: 321-326.

Hingson RA and Edwards WB (1943) Continuous caudal anesthesia in obstetrics, Journal of the American Medical Association 121: 225-228.

As one might suspect from their area of practice in a Marine Hospital and the years of the publications, these techniques were likely stimulated by a need to better manage pain in the World War II battlefield. In my own field, the subdiscipline of alkylating agent cancer chemotherapy was founded by biological observations of lymphatic destruction by mustard gas. In this case, popularization of epidural anesthesia owes some of its origin to application in the war theatre. Southworth et al. note in the 1943 Annals of Surgery paper:

Further, it would seem that this method is adaptable for use in the treatment of casualties both in civilian and military practice where it would be desirable to have a safe, prolonged analgesia during the transportation and the physical and roentgenologic examinations of the injured. One anesthetist with several trained corpsmen or medical attendants could block a large number of patients at one time. It may be possible in some instances to block certain casualties on the field and transport them painlessly to a base for treatment, thus, perhaps reducing the instances of shock. On theoretical grounds it would seem that this method might be of value in the prevention of the delay shock condition usually referred to as the “crush” syndrome.

Robert Andrew Hingson, MD
While trying to dig up some information on Hingson, Edwards, and Southworth, it was Hingson that most seemed suited for a Nobel Prize, perhaps for Medicine or Physiology or, interestingly, for Peace.

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Hingson followed his work in anesthesiology with a great deal of humanitarian work, developing the “jet” injection system that allows for mass vaccination of hundreds of patients per hour. This device is credited with, among other things, the global eradication of smallpox. (Hingson, second from left, is shown instructing a young medic on the proper use of the “peace gun” – photo courtesy of the Brother’s Brother Foundation.)

Hingson also developed the Western Reserve Midget, a portable, anesthetic gas machine that could be used for general anesthesia in the field or remote areas (JAMA 1958; 167:1077-1082).

Hingson was a Southerner, born in 1913 in Anniston, Alabama, and earned his bachelor’s in 1935 from the University of Alabama. For medical school, he went to Emory University in Atlanta. Following his work with the Public Health Service, he went on to academic posts at what is now Jefferson Medical College in Philadelphia, the University of Tennessee and Johns Hopkins, with the bulk of his career split subsequently between Case Western Reserve University (hence, the name of the Midget gas machine) and the University of Pittsburgh.

While Arlenna wants to give a prize to Dr. Hingson for epidural anesthesia, the doctor, who died in 1983, is perhaps best remembered as founder in 1958 of the interfaith, Pittsburgh-based international relief organization, Brother’s Brother Foundation. The BBF notes on their statistical information page that they have provided educational, humanitarian, and medical assistance to over 140 countries on five continents over the last 50 years.

In 1987, President Reagan recognized Hingson with a President’s Volunteer Action Award.

For his collective work “a humanitarian, inventor, pioneer of epidural anesthesia for childbirth, inventor of jet injection for mass immunization, professor at the University of Pittsburgh Medical Center, and founder of The Brother’s Brother Foundation in Pittsburgh,” Dr. Hingson was inducted in 1999 into the Alabama Healthcare Hall of Fame.

When Hingson died in 1996 at age 83 in the VA Medical Center at Lake City, Florida, his obituary appeared in the New York Times.

No Nobel Prizes, Arlenna, but a pretty remarkable career of accomplishments.

Comments

  1. #1 k8
    December 28, 2009

    So would it be out of line for me to mention that epidurals were used on ANIMALS in labor and on MEN in the battlefield before they were used on WOMEN in labor? I find that fascinating.

    I didn’t nominate anyone for the Nobel Prize, but when I finally got on antibiotics for a sinus infection last year, I was willing to grant all types of favors and throw money at all the dead people who invented them.

  2. #2 DVMKurmes
    December 28, 2009

    @k8;
    If it’s any consolation, those epidurals on animals 100 years ago were probably more motivated by concern for the veterinarian’s personal safety than the animal’s comfort. It has taken us a long time to take the pain and suffering of animals as seriously as we should have. On the other hand, not getting kicked or trampled by a large dairy cow was a good enough reason to relieve the pain associated with calving. ;)

  3. #3 Arlenna
    January 12, 2010

    What a cool post Abel! Thanks for the story of Dr. Hingson, what an interesting dude. I thank him again!

  4. #4 Abel Pharmboy
    January 12, 2010

    Thanks, Arlenna – it was a lot of fun to read up on this and find out some of the unexpected other accomplishments of Hingson.

    Congratulations again to you and Mr. Arlenna and welcome to your lovely daughter!