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HISTORICAL OUTLINE

A history of the intensive care medicine is closely associated with the age-old dream of mankind to control pain and to come to life of the extremely grave patients and even the deceased, particularly, if healthy people of flourishing age die suddenly. Even ancient Egyptians tried to use the root of mandragora, thorn apple, poppy and other plants to control pain, hereafter they began to add an alcohol to them. However, all these agents proved to be of little effect in surgical operations.

Some attempts to revive injured persons by means of inflation of air into the lungs using a mouth-to-mouth method had been undertaken 3-5 thousand years ago. Paracels suggested special bellows to inflate air into the lungs. A society for revivification of drowned people was founded in the USA in 1767. English physician Bukhan and Russian doctor Nikitin have also tried to resuscitate drowned persons.

An effective surgical anesthesia became possible only after the appearance of substances having properties of general anesthetics.

In 1772 an English priest Joseph Pristly isolated a nitrous oxide in its pure form, narcotic properties of which were described by the chemist Hemphry Devy in 1780. The first narcosis with nitrous oxide was carried out by a physician Horace Wells in Boston, in 1844, though the failure of its public demonstration became the cause of nonrecognition of the significance of this discovery.

A discovery of anesthetic properties of ether that had been received as far back as 1540 gave rise to the onset of triumph of general anesthesia. For the first time an ether anesthesia was applied by Crowford B. Long in 1842, but he reported about this only 10 years later. In 1846, on October 16, William T.G. Morton had publicly demonstrated in the Massachusetts military hospital in Boston a successful ether anesthesia during the operation performed by a surgeon Warren on the patient by the name of Abott, and on the next day he described this anesthesia. Therefore, the palm of being the first had been given to him, and October 16 entered the history of medicine as "the Day of anesthesiologist".

Information of this discovery had spreaded fast and found its followers in Europe. In Russia, an ether anesthesia was, for the first time, applied by F.I. Inozemtsev on February 7, 1847 in Moscow, and 2 weeks later by N.I. Pirogov — in Petersburg. He was the first in the world to use anesthesia in the field surgery, including a war period in Prussia, Crimea and in the Caucasus, he published the first monograph on anesthesia in the world, containing materials of clinical and experimental study of narcosis and development of its new methods.

Then came a prolonged period of search for ideal methods of anesthesia.

After the ether and nitrous oxide, other inhalation agents appeared: chloroform (Simpson, 1847), chlorethyl (Carlson, 1894), ethylene (Lookhard, 1923), cyclopropane (1929), vinitene (1932). To the extent of revealing a toxicity and other harmful side effects, all of them, exept nitrous oxide, were excluded from clinical application and today are not used. They were replaced by halothane (1956), methoxyflurane (1960), enflurane (1973), isoflurane (1981), desflurane (1992) and sevoflurane (1995).

Along with inhalation anesthetics following the invention of a hollow needle (Wood, 1853) and a syringe (Ring, 1845 and Pravats, 1853), the idea of noninhalation anesthesia, suggested by N.I. Pirogov, had found its development. At the early stages, they introduced intravenously chloral hydrate (Ore, 1872), chloroform and ether (Burkhardt, 1909), hedonal (N.P Kravkov and S.P. Fedorov, 1911), a mixture of morphine with scopolamine (Bredenfeld, 1916). They were forced out by barbiturates synthetized in 1903. The first was barbital, then hexobarbital (1927), but only thiopental (Landi and Waters, 1934) and methohexital (Stelting, 1957) continue to be widely used up to the present time. Side by side with barbiturates, diazepam (1959), hydroxybutirate sodium (1960), ketamine (1965), lorazepam (1971), midazolam (1976), ethomidate (1972), propofol (1989) are applied.

In the history of searches for new agents of anesthesia there is another important trend to be visible. In the 40-ties of the XX century French psychopharmacologists Labory and Gougenar have developed some methods of defense of the organism from outward aggression by means of blockade of vegetative impulses. This trend had found its reflection in anesthesiology when they started to use different "lytic cocktails", containing neuroleptics of largactil (aminazine) type causing a profound inhibition of vegetative nervous system,

called as "artificial hybernation". However, so profound areactivity of the patient not so much saved him from aggression, as decreased compensation abilities of the organism and made the patient absolutely unable to respond adequately to the loss of blood, increase of the capacity of vascular bed and other pathological factors. A further development of this trend was "neuroleptanalgesia" (De Castro, 1959), caused by neuroleptics. Ataralgesia caused by ataractics and analgetics is rather close to it.

In 1879 V.K. Anrep being on a practical training in Germany and studying anesthetizing properties of cocaine put forward an idea of local anesthesia. Koller (1884) gave rise to the realization of this idea putting with an eye dropper a cocaine solution into the eye for anesthesia. The other methods of local anesthesia became to be applied in clinics — spinal (Bier, 1897), conduction (Brown), intravenous under a tourniquet (Bier, 1908), epidural (Pages, 1921; Doliotti, 1931), continuous epidural (Curbello, 1949) anesthesia. A.V. Vishnevsky worked out in detail the method of "creeping infiltrate" that remained for a long time as a predominant one in Soviet surgery. Novocaine (Aichgorn, 1904) came to replace a toxic cocaine, then dibecaine (1930), tetracaine (1932), lidocaine (1947), chlorprocaine (1955), mepivacaine (1957), prilocaine (1960), bupivacaine (1963), etidocaine (1972), ropivacaine (1996) had been introduced into medical practice.

Simultaneously with the invention of new anesthetics new methods and equipment for their application are being designed.

One of the most important auxiliary methods ensuring patency of respiratory tracts and a possibility to support respiration in the most traumatic operations and critical conditions of patients is the endotracheal intubation. For the first time, an oral intubation, applied earlier to resuscitate newborns, was used for anesthesia by a Scotish surgeon Mackiwen (approximately in 1878). Kuhn, from Germany, described in his classic monograph oral and nasal intubation with metal tubes, suggested a blind intubation with the help of fingers and a rubber tube. A British anesthesiologist Megill, using the oral and nasal intubations since 1919, proposed a number of improvements including rubber tubes that had been in use in the world for many years until plastic ones appeared. Gwedell provided them with tracheal cuffs, and together with Waters designed one-lumen and double-lumen endotracheal tubes.

A prototype of laryngoscope for tracheal intubation was a direct laryngoscope (Krishtein, 1845). After a number of improvements (Jackson, Janway, Dorrance, Megill) a laryngoscope has acquired a usual L-shaped form, and Miller and Mackintosh provided it with a curved blade.

In 1942 the important event took place in anesthesiology, by its significance it may be compared with the discovery of ether anesthesia: on January 23, 1942 a Canadian anesthesiologist Griffit and his assistant Johnson have used curare and intubated the trachea during anesthesia of the patient subjected to appendectomy. By 1948 a number of new nondepolarizing myorelaxants (gallamin, decamethonium, metubin) were created, and in 1949 a Nobel Prize winner Bove obtained succinyl-choline — a depolarizing myorelaxant gained the wide popularity in the whole world. A search for new myorelaxation agents is being continued. The principal significance of myorelaxation agents application in anesthesiology is that with their help the need in profound anesthesia is eliminated for all time.

For more than one and a half century the evolution of anesthesia apparatuses is being continued. From the simplest anesthetic masks they have turned into complex units equipped with all necessary for supplying a gas mixture into the respiratory tracts in spontaneous and controlled respiration, electronic systems of monitoring and control of the organism's functions.

Parallel to the methods of anesthesia some techniques of resuscitation and intensive care had been developing and improving.

Attempts of cardiac massage in order to renew a cardiac output had been undertaken as back as the end of XIX century (Shiff in experiment in 1874, Nigauz in man, in 1899). For the first time a successful massage was implemented in clinic in 1901 (Ingelsrud), but a wide recognition it gained significantly later.

A defibrillation of the heart with the aid of electric current was carried out experimentally by Batelli and Prevo in 1899, and with a chemical method — in 1929-1948, with an alternating current — in 1947-1955. However, they started to use it widely in clinical practice only after M.L. Gurvich and G.S.Yunyev (1939, 1946-1955) have developed a technique with the use of capacitor discharge.

In 1958 Safar developed in detail a method of mouth-to-mouth artificial breathing and proved in practice the advantages of the insufflation method of artificial respiration over the methods of Silvester, Sheffer, Laborde et al., applied earlier.

Methods of hemotransfusion and transfusion of blood substitution solutions have undergone a long way of development: Harvey (1628) — a scheme of blood circulation; Borde (1895) — heteroagglutination; Landsteiner (1901) and Yansky (1907) — isoagglutination; Landsteiner and Winner (1940) — Rh factor. In 1936 Gamble has made a great step forward in the problem of studying a water-salt metabolism in the organism ("Chemical anatomy, physiology and pathophysiology of intercellular space"). A further development of this problem has led to the creation of hemodialysis method; Able, Roventry and Turner (1914) — "artificial kidney" in experiment, Kolf (1943) — in clinic.

Scientific achievements, established a physiologic role of adrenocortical hormones (1934-1948), aldosterone (1954), potassium and sodium pump (the 50-ties), discovery of the role of vegetative nervous system in the organism's response to stress (Labory, H. Selye, 1933-1951), development of the methods

of neuroplegia and artificial hybernation to protect the organism in shock (Hamburger, Labory, Gugenar), have played a great role in the development of modern methods of intensive care.

In the 60-ties new methods of intensive care had been suggested — hyperbaric oxygenation (Borema, 1960), plasmapheresis (1963), hemosorption (Yatzidis, 1964).

With a particularly fast rate the intensive care medicine is being developed at the boundary of XX and XXI centuries. Improved technologies of general and regional anesthesia including those with the administration of psychotropic agents according to a target concentration, with the use of xenon and others are being worked out. New techniques of intensive care are being created — an invasive monitoring and a temporary support of central hemodynamics, in particular by means of intra-aortic balloon counterpulsation, extracorporal membrane oxygenation and blood ozonization, thrombolysis with the use of new highly effective agents and others.

Development of intensive care medicine was accompanied by the organization of special service. The first professional anesthesiologists appeared in Europe (Snow, since 1847, and a little later Clover and Hewett, all in London). The first society of anesthesiologists was set up in England (1893), and then in the USA (1905). The first department of anesthesiology was organized in 1937 in Oxford University under the guidance of Robert Mackintosh.

In the USSR and Germany at that time, a position of a nurse in charge of anesthesia was introduced in the staff, and it was planned to introduce the position of anesthesiologist by 1939-1940. However, the war postponed these plans and these positions have been officially adopted in 1947-1948.

Anesthesiology and resuscitation service had been forming in the USSR in the course of the 60-70-ties of the XX century. A. A. Bunyatvan comments in this connection: "Fortunately, for the domestic anesthesiology a group of the outstanding surgeons CN.M. Amosov. A.N. Bakulev. A.A. Vishnevsky. I.S. Zhorov. P.A.Kuprivanov. G.P. Zaitsev. T.P. Makarenko. U.N. Meshalkin. B.V. Petrovskv et a\.) succeeded bv virtue of their authority, prestige, example and great personal labour to create all necessary conditions so that a new medical discipline had passed rapidly through a dangerous period of the "neonatal state".

In Ukraine as in other countries, methods of anesthesia had been applied since ancient times. The first data of this was found during archeologic excavations of Pazirsky berial mounds formed in Scithian state (VII century B.C. — III century A.C.). In Kiev Russ (X-XIII centuries) the "cutters", i. e. surgeons used ointments, cauterizations, snow, vodka, poppy extract, belladonna etc. In old Kiev ancient doctors recommended a high-calorie diet for the operated patients, those who lost a lot of blood they administered abundant drink. Numerous recommendations on anesthesia were in the handwritten "herbals" and "manuscripts of doctor's advices" of the VIII century, but they are in no way comparable to the discovery of anesthesia.

T.L. Vancetti on February 12, 1847 in Kharkov and V.A. Karavaev on February 12, 1847 in Kiev were the first to apply ether narcosis in Ukraine.

In studying the influence of ether and chloroform upon the organism the great is the role of Russian narcosis committee, in the work of which the graduates of Kharkov University A.M. Filomafitsky, the natives of Chernigovskaya province P.O. Noromovich and O.M. Orlovsky took an active part.

A graduate of Kiev University V.F. Voyno-Yasenetsky (a future archbishop of the Crimea — Lucas) defended his doctor's dissertation "Regional anesthesia" in 1897, that contained a description of his own techniques allowing to operate painlessly practically on all regions of human body.

As a rule, in those times professional anesthesiologists were absent on the territory of Russian empire. Of more interest is the fact that N.I. Kefer had taken the position of the doctor-anesthesiologist in Odessa Evangelical hospital in 1891.

In 1924 in Odessa at the II All-Russian Congress of surgeons the principal was a debatable problem — whether to follow West-European surgeons, preferred general anesthesia, or to develop simple, inexpensive local anesthesia, more available under the conditions of economic difficulties of the postwar period. Professor V.L. Pokotilo from Odessa, a surgeon Ya.A. Galperin from Dnepropetrovsk and presiding Professor S.P. Fedorov came out in favor of the first variant. But the advocates of local anesthesia overcame. Only after the Great Patriotic War it became clear that without introduction of the up-to-date methods of general anesthesia on the professional basis a further development of surgery is impossible.

At the end of the 40-ties — beginning of the 50-ties in Ukraine as well as in the USSR, on the whole, the first enthusiasts-anesthesiologists from the number of young surgeons appeared, but soon an increasing interest to this problem demanded to single out specialists-professionals, capable not only to anesthetize, but in all other regards to secure the patient in the time of operation, particularly in thoracal and cardiosurgery. The training of such specialists started in leading clinics of P.A. Kupriyanov, A.M. Bakulev, N.M. Amosov, B.V. Petrovsky, I.S. Zhorov et al.

A foundation of Department of thoracic surgery and anesthesiology, organized and headed by Prof. N.M. Amosov at the Kiev Institute for doctor's advanced training in 1957 in Ukraine was of particular significance for development of anesthesiology. At the same department a 4-month course of anesthesiology was organized and headed by Assistant-Professor A.I. Treshchinsky.

A.I. Treshchinsky had been building systematically for many years the edifice of Ukrainian anesthesiology together with his team of accomplices and

disciples. Enthusiasts of new speciality — L.P. Chepky, L.V. Usenko, R.I. Novikova, G.A. Mozhaev, Yu.P. Svirgunenko, I.D. Timchuk, I.S. Yurchuk, A.Ya. Malovichko, Yu.M. Vedutov, V.D. Zhabo, Yu.P. Butylin, I.V. Khalaturnik et al. have actively participated in this noble work.

After Kiev Department of surgery and anesthesiology an analogous department was organized in Kharkov (Head of Department — Prof. A.A. Shalimov), where such anesthesiologists as V.A. Arkatov, N.I. Obolentsev, A.Yu. Pashchuk also worked.

Since 1958 anesthesiology and reanimatology are being taught in the Odessa medical institute at the Department of surgery (Prof. I.Ya. Deyneka), and since 1969 — in the L'vov medical institute (Prof. M.V. Danilenko).

In 1967 Prof. A.I. Treshchinsky organized, the first in Ukraine, Department of anesthesiology in the Kiev Institute for doctor's advanced training, that, at present, is headed by Prof. LP Shlapak, and in 1969 the same Department was headed by Prof. V.A. Arkatov in Kharkov.

In 1970 Prof. L.N. Aryaev organized and headed the Department of anesthesiology and reanimatology of the Odessa medical institute (later it was headed by Prof. V.P Stasyunas, Ass.-Prof. A.I. Bakhar, Prof. A.S. Vladyka). Starting from 1973 when the order of the USSR Ministry of Public Health No.696 "On organization of departments of anesthesiology and reanimatology in medical institutes of the country" was issued, the analogous departments were set up in Donetsk (Head — Prof. R.I. Novikova, Prof. E.P. Kurapov, Prof. V.I. Cherniy), in Dnepropetrovsk (Head — Prof. Corresponding member of AMSc. and NASc. of Ukraine L.V. Usenko), in the 80-ties the Department of anesthesiology and HBO of the faculty for doctor's advanced training was founded — Head -Ass.-Prof. Yu.S. Petrenko, later Prof. E.N.Kligunenko, in L'vov (Head — Prof. I.D. Timchuk), in Lugansk (Head — Prof. G.A. Mozhaev), in Kiev (Head — Prof. L.P. Chepkiy, Prof. A.E. Dubitsky, and at present — Doctor of Med. Sc, F. S. Glumcher), in Kharkov (Head — Prof. N.I. Obolensky, later Doctor of Med. Sc, A.A. Khizhnyak), in Simferopol — a closely related by its speciality Department of first and emergency medical aid (Head — Prof. Yu.P. Svirgunenko), in Chernovtsy (Head — Prof. VF. Stashchuk) and in Vinnitsa (Head — Prof. I.I. Mishchuk).

In 1976 the Department of anesthesiology and reanimatology was organized in the Zaporozhye Institute for doctor's advanced training (Head — Ass.-Prof. V.A. Ekzarkhov, later Prof. G.A. Shifrin) and courses (Prof. V.P. Stasyunas), and since 1985 the Department of anesthesiology and reanimatology of the faculty for doctor's advanced training was founded in the Odessa medical institute (Head — Prof. P.N. Chuev).

An important stage in the development of intensive care medicine was a creation of departments of extreme and military medicine (medicine of catastrophies) that were headed by anesthesiologists: in the Lugansk medical university — Prof. O.N. Spitsin, in the Crimean medical university — Prof. VI. Molchanov.

The work of all organized departments provided a training of the number of anesthesiologists, sufficient to form in Ukraine a branched service of anesthesiology in all medical institutions including every district hospital. Without participation in the process of treatment of the representatives of this service today neither surgeons, nor other specialists do not manage, when it is a question of operation or treatment of patients being in the critical or terminal state.

A need to exchange with experience and scientific developments has led to a setting up of anesthesiologic sections in surgical and scientific-and-practical societies. The first such section was organized in Kiev in 1960, then they have appeared in Kharkov, Donetsk, Simferopol, L'vov, Odessa and by 1963 they were already in the half of the Ukrainian regions. Later these sections were reorganized into independent societies. And in 1964 a Republican society of anesthesiologists of Ukr.SSR — the first such society in the Soviet Union — was established at the conference in Simferopol. For the period of 1969-1988, 5 conventions of this society were being held, and after a creation of the Association of Anesthesiologists of Ukraine (AAU) in 1991, under its aegis 3 more congresses were held (Zaporozhye, 1992; Kharkov, 1996; Odessa, 2000; Donetsk, 2004). In June of 1992 AAU is admitted to the World's Federation of Anesthesiologist's Societies.

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