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The Danger of Using a Medical Eponym: Missing the Point of the “Tuohy” Needle

By Jordan Francke, MD

The CSA Committee on the History of Anesthesia congratulates Dr. Jordan Francke, the 1st place winner of the 2023 CSA History of Anesthesia Essay Contest!

Dr. Francke, who was born in Kentucky and raised in Maine, is a CA-2 resident physician at UCLA. He is an avid marathoner, hiker, and lover of history.  

Jordan Francke photo

Epidurals are widely employed as a safe anesthetic modality in countries with a developed healthcare infrastructure. Of the over 3.7 million women who delivered babies in the United States in 2019, nearly 2.9 million (greater than 75%) elected for neuraxial anesthesia at some point during labor.¹ In 2019, the American College of Obstetricians and Gynecologists recommended that any medical center providing inpatient maternal care be capable of administering epidural or spinal anesthesia.2 In addition to its obvious role in labor analgesia, neuraxial anesthesia has significant benefits for operative analgesia, including in Caesarean deliveries. It allows the parturient to remain awake and for her partner to be present during delivery, minimizes transplacental opioids, and may even reduce risk for postpartum depression.3

Although New York-based neurologist Leonard Corning experimentally produced epidural anesthesia in 1885, its first successful use for clinical purposes dates to 1921—when Spanish military surgeon Fidel Pagés used it for an inguinal hernia repair.4-6 But whom do we have to thank for the ubiquitous acceptance of epidural anesthesia one hundred years later? Among the pioneers of neuraxial anesthesia, a single eponym dominates: the “Tuohy,” now associated with the hollow hypodermic needle with a lateral opening that is used to place nearly every epidural catheter in the United States.

Based on this famous eponym, one might expect lumbar epidural anesthesia to have been the brainchild of American anesthesiologist Edward Tuohy. However, the story of continuous lumbar epidural analgesia began long before him. It was an enthralling ballet of refinements in needle design coupled with the development of safer methods to access the intrathecal and epidural spaces.

In August 1896, German surgeon August Bier became the first to administer subarachnoid cocaine successfully, delivering analgesia for the removal of a tubercular joint lesion using a “long…very fine…Quincke needle.”7-8 He subsequently administered it to four more patients for surgical anesthesia, and he and his assistant also tested it on each other. His own experience was marred by an unforgiving post-dural puncture headache (PDPH):

Both of us went to eat after these experiments were performed on our bodies. …The next morning… I went for a one hour morning stroll. At the end of this walk, I felt a slight headache… Around 3 o’clock in the afternoon, I became pale and the pulse became weaker… I felt severe pressure in the skull and became dizzy when I tried to get up from a chair rapidly. All of these symptoms disappeared as soon as I lay horizontally. About 9 PM, I was forced to go to bed, and I remained for 9 days until the upright position ceased to cause the above mentioned symptoms.8

In 1901, two French physicians became the first to discover epidural anesthesia: Jean-Anthanase Sicard and Fernand Cathelin.6 Working independently, Drs. Sicard and Cathelin, within 3 weeks of each other, described cocaine injections into the caudal epidural space. Dr. Cathelin suggested that these injections had value in surgical anesthesia.6, 9-10 Dr. Sicard became the first to suspect that the PDPH arises from dural tears, and also the first to illustrate the “loss-of-resistance” technique using a solution of 40% iodized poppy seed oil to find radiographic evidence of spinal canal masses.11-13

From 1896 to 1906, spinal anesthesia was given only with single-shot injections. However, in 1906, Dr. Henry Dean, an English surgeon, unintentionally stumbled upon continuous spinal anesthesia while using intrathecal amylocaine to anesthetize a 16-year-old patient with appendicitis:14

He was given 0.6 as a first dose, but owing to an accident when injecting the solution we were afraid most of it was lost. We waited for seven minutes… I put in a further dose of 0.4 At the end of seven minutes… I then put in another 0.4

This “graduated dose,” Dean believed, was the only neuraxial anesthetic approach that would minimize the risk of intercostal paralysis.14 However, he also accepted its serious limitation: the need for prolonged retention of a sharp metallic object within the subarachnoid space.14 Dean’s revelation failed to garner significant attention.7

A decade later, in 1921, Spanish surgeon Fidel Pagés Miravé published the first description of a lumbar approach to the epidural space.5-6 The needle he used was described as “a regular spinal-puncture needle with a very short bevel that is not very sharp”15 and was likely a variation of the Quincke needle.5-6 Unfortunately, in September 1923, Dr. Pagés died in a motor vehicle collision in the Spanish countryside while returning from vacation with his family, and his work was soon forgotten.16

Due to Pagés’ untimely death and lost work, in 1933, an Italian cardiac surgeon, Dr. Achille Mario Dogliotti, initially received credit for using an 18-gauge short-bevel needle to deliver the first single-shot lumbar epidural injections, used to anesthetize patients for abdominal surgery.6,17 While Dogliotti was not actually the first to discover lumbar epidural anesthesia nor the loss-of-resistance technique, he has been credited with popularizing both ideas by giving a widely publicized presentation of their safety and efficacy at the 11th Annual Congress of Anesthetists in 1933 in New York City.

Prior to the 1930s, neuraxial anesthesia was exclusively used to anesthetize surgical patients. Its usage began to evolve in 1931, when Romanian obstetrician Eugen Aburel became the first physician to block the lumboaortic plexus in a laboring woman with chinocaine through a silk ureteral catheter in the caudal epidural space.6,18 Aburel is credited not only with the first administration of epidural anesthesia for a parturient, but also with the first use of an epidural catheter for continuous labor analgesia.6

American anesthesiologist William Lemmon simplified the ability to deliver continuous neuraxial anesthesia with his development of the “Lemmon Mattress” in the 1940s.19 He designed an operating-table mattress with a large hole in the lumbar region and inserted a spinal needle while the patient was positioned laterally. He used his own self-designed needle, a sharp 17- or 18-gauge nickel/silver “malleable” needle with a cutting bevel and a small aperture to enable free flow of cerebrospinal fluid (CSF).11, 19 Once CSF was visualized, the needle was connected to rubber tubing attached to a syringe. The patient was then repositioned supine, and a procaine solution was infused. However, much like Dean’s discovery, this approach also required a retained metallic needle in the patient’s back.

Dr. Edward Tuohy was an anesthesiologist at Mayo Clinic in the 1940s. He was inspired by the work of a Mayo Clinic neurologist named Grafton Love, who developed the use of ureteral catheters for continuous subarachnoid drainage in meningitis.7, 20 Tuohy was initially interested in the concept of continuous spinal anesthesia and proposed threading a similar ureteral catheter intrathecally to obviate the need for a retained metallic needle in the subarachnoid space.21-22

Initially, Tuohy used a 15-gauge Barker spinal needle with a cephalad bend, but a year later, he published his findings using a “needle with a Huber point.”21-25 The Huber needle, patented by Seattle-area dentist Ralph Huber in 1946, possessed a lateral opening and was initially designed to minimize tissue coring during phlebotomy.6,25-26 Tuohy suspected the needle’s design would encourage cephalad advancement of the catheter and reduce lumen occlusion from cored tissue. To decrease this risk even more, Tuohy proposed inserting a stylet during placement.6,22

A few additional refinements created the epidural needle as we know it today. Charles Flowers, a prominent obstetrician at Johns Hopkins University, used a 15-gauge needle with a blunter, shorter bevel and a sharp stylet that protruded beyond the needle to facilitate the traversing of tough ligament.6,27 Robert Hustead, who in 1954 was a first-year anesthesia resident at Yale, modified the Tuohy-Flowers needle by using a stone to sand off the needle’s sharp tip to reduce the likelihood of accidental dural puncture or trauma.6 He also reduced the size of the bevel opening to prevent dural straddling and minimized the bevel angle to 12-15º to prevent catheter kinking.6 Peter Cheng, a California-based physician, was the first to propose adding centimeter markers to the needle design in 1958.28 Finally, Jess Weiss, an anesthesiologist at Brigham & Women’s Hospital, who utilized a hanging drop method to find the epidural space, added wings to the epidural needle in 1961 to allow for slow advancement through the ligament.29-30

The “Tuohy” needle poignantly illustrates the danger of medical eponyms. The story of epidural anesthesia is wholly incomplete without the acknowledgement of the contributions of so many other pioneers. It would perhaps be more reverential simply to refer to the Tuohy needle as an “epidural needle” to be more inclusive of the work of so many other innovators.


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