Skin Deep: A Brief History of Hypodermic Hardware

Do you remember the first time you stuck a needle in a real person, on purpose? I don’t mean for IV practice on your least-favorite classmate; I’m talking about putting a legitimate, Johnny-18-Gage line in a sick patient who assumed you knew what you were doing.

I remember my first stick. I wish I could forget it, plus the next two.

Point of No Return

I was doing my second ALS rotation as a paramedic student on a Brooklyn ambulance in 1994. Three calls on that November day involved cardiac patients who needed IVs. Guess who got to try them.

I missed every one. What a bloodbath. I was a walking hazmat incident. Medics who rode with me added Tyvek suits to their checklists.

One of my victims, an elderly woman with overworked veins, was so distressed by my fishing for flashback in her blotchy arms, she wept. My wise-ass preceptor embraced the teachable moment: “Don’t cry, Mami. I know he’s hurting you. I would never do that.”

Thanks, John. I wouldn’t have felt worse if I’d blown both A/Cs on Mother Teresa.

That evening, shortly after I decided not to transfer to truck-driving school, I opened a few angiocaths and tried to figure out what I was doing wrong. As I became preoccupied with the design of those gadgets, I wondered how they compared to pre-EMS appliances. You could say my messy introduction to invasive procedures inspired this article about the finer points of fine points.

Hypodermic Horrors

The first syringes were developed three millennia ago—not to dispense medication but to extract pus. If you were a citizen of ancient Greece and didn’t want to wait 2500 years for aseptic technique, you could have your festering spear wound drained by anyone with a pyoulkos (Figure 1). Notice how modern it looks compared to the twisted relic in Figure 2, which was used around 900 AD in an unspeakable manner. I’ll speak of it just enough to give you a hint: “I’d rather stick needles in my eyes.”

If you guessed cataract remover, you’re correct. I am in awe of your imagination and suggest you seek therapy.

Fast-forward to 17th-century Europe. It was a time of bold ideas and philosophical discourse. Scholars call it the Age of Enlightenment, but to the sick and injured it was the age of disfigurement, which is what many suffered after seeking compassionate medical care that hadn’t been invented yet.

One big step in the right direction was the use of hypodermic instruments for more than incisions and drainage. Take Christopher Wren’s intravascular apparatus of 1656 (Figure 3). Wren used his quill-and-bladder set to bolus a dog with ethyl alcohol, then infused a second mutt with blood from the first. Besides discovering an economical way for hounds to party, Wren inspired Paris physician Jean Baptiste Denis to orchestrate the first lamb-to-unwilling-psych-patient transfusion (Figure 4) followed by the first fatal transfusion reaction. 

What happened next smacks of bureaucratic CYA: Animal-to-human transfusions were banned in France for 100 years, and the patient’s wife was charged with his murder.

In 1662 Dr. Johann Major recorded the first intravenous injection in a human. The subject didn’t survive, possibly because he got a mixture of opium, sulfur, and arsenic. Ongoing experiments with life-limiting cocktails made IV medications relatively unpopular for two centuries, but hypodermic hardware continued to improve.

Invention Is the Mother of Injection

I’m not sure if I hold the US paramedic record for most times vaccinated against smallpox. Multiple employers and long life leave me in the running, at 3, because I was never able to prove to any personnel department that I’d already been inoculated. I’ve had several MMRs and Tdaps for the same reason. I’m thinking of listing my plasma on eBay.

Being hypervaccinated makes me want to credit Edward Jenner not only for his role in eradicating smallpox but also for the hybrid instruments he inspired that helped reignite interest in parenteral medication. Look at the remarkable tool Jenner and other vaccination pioneers favored (Figure 5). The blade in the background was used to lance a cowpox lesion on a donor (cowpox was similar to smallpox, but milder) and transfer exudate to the vaccine recipient, where it would be scratched into the skin using the prongs in the foreground. My inoculations were similar, except for the cowpox donor.

The next major development was injections with hollow needles invented by Francis Rynd and Gabriel Pravaz in the 1830s. Figures 6 and 7 show syringes incorporating that innovation. Daniel Ferguson enhanced those designs in 1853 with a silver-and-glass model customized for narcotics (Figure 8). That was a celebrated improvement over subcutaneous morphine-soaked pellets inserted with RBNs (really big needles).

You could say syringes paved the way for intravenous meds, but the first physician to demonstrate the true value of IV therapy was Thomas Latta. In 1832, after he saved the life of a hypovolemic cholera patient by administering a saline infusion, cholera became a treatable disease.

Another fatal illness, polio, was partly responsible for development of disposable sharps in the mid-1950s. I remember getting my Salk vaccine with one of those plastic plungers. It wasn’t as scary as older autoclaved models, but it hurt just as much.

In 1933 the Baxter Travenol Company originated sterile solutions in glass bottles (Figure 9). IVs started to resemble the setups we saw in M*A*S*H, Emergency!, and other ’70s TV dramas with gallant doctors who told nurses in hats to do things stat! 

Baxter switched from bottles to bags shortly after a 1970 recall of contaminated fluid. Nurses stopped wearing hats around the same time, due to concerns about hygiene and how Nurse Kenneth would look with a white cap.

That brings us to the ubiquitous angiocath, which was a catheter inside a needle (Figure 10) before it became a needle inside a catheter. Today it’s a spring-loaded, push-button marvel that guards against everything except pushing that button too soon. Perhaps we need a second button to unlock the first one. Or maybe we should simply accept the limits of technology. As my friend Rob Bowen asks, are sharps containers really improvements over bench seats?

Mining for Marrow

As much as I dislike some colleagues’ cavalier references to “drilling” patients, intraosseous drug delivery has certainly been a game-changer for EMS.

Introduced in 1922 by Dr. Cecil Drinker, IO techniques were refined in the 1930s mainly for pediatrics. World War II changed that; roughly 4000 soldiers received IO infusions. Figure 11 shows a collection of devices that predate the use of power tools to access bone marrow. The Jamshidi needle in the center is what I carried. You just twisted and pushed hard below the tibial tuberosity and tried not to hit any of your own tuberosities. I did one manual IO, on a kid. That was enough.

I never worked in a system where drills were used for anything except putting ambulances back together. I do recall seeing presentations in the early 2000s by IO sales reps who swore their hardware didn’t hurt. One even offered to try it on himself. Talk about dedication. Talk about mental illness.

Pharma Karma

Writing all this has been therapeutic. I wish I hadn’t started my paramedic career with three missed sticks, but at least I know my clumsy attempts at cannulation were relatively harmless compared to clinical bloodletting during the Age of Enlightenment. Back then there was so much to learn about injectable drugs, about invasive procedures, about not dying as often. Going to the doctor must have been super scary for people, not to mention dogs and sheep.

As for the patients I’ve punctured during the past 27 years, they’d be happy to know I get stuck pretty regularly these days for one reason or another. I deserve a little discomfort, no doubt, but I draw the line at arsenic IVs.  

Resources

A Brief History of the Syringe and Injectable Medication. Aplus Corp. Published February 6, 2019. www.aplususapharma.com/blog/brief-history-of-the-syringe-and-injectable-medication/ 

Craig R. A history of syringes and needles. University of Queensland. Published December 20, 2018. Accessed March 15, 2022. https://medicine.uq.edu.au/blog/2018/12/history-syringes-and-needles

Foex BA. Discovery of the intraosseous route for fluid administration. J Accid Emerg Med. 2000; 17: 136–7. doi: 10.1136/emj.17.2.136

The History of the Syringe: from Glass Tubes to Microneedles. Bulk Syringes. Published January 31, 2014. Accessed March 15, 2022. www.bulksyringes.com/the-history-of-the-syringe-from-glass-tubes-to-microneedles/ 

Intraosseous Access–History, Method and Automated Devices. Safeguard Medical. Published January 5, 2022. Accessed March 15, 2022. https://safeguardmedical.com/intraosseous-access-history-method-and-automated-devices/ 

Rivera AM, Strauss KW, Van Zundert A, Mortier E. The history of peripheral intravenous catheters: How little plastic tubes revolutionized medicine. Acta Anesthesiologica Belgica. 2005; 56: 271–82. PMID: 16265830

Riedel S. Edward Jenner and the history of smallpox and vaccination. Proc (Bayl Univ Med Cent).  2005: 18(1): 21–5. doi: 10.1080/08998280.2005.11928028

Nashville paramedic Mike Rubin is the author of Life Support, a collection of EMS-oriented essays, and a member of the EMS World editorial advisory board. Contact him at mgr22@prodigy.net.