Mere Amateurs: Early Interest in Physician Anesthesia in the U.S., 1880-1920

Mere Amateurs:Early Interest in Physician

Anesthesia in the U.S., 1880-1920

A. J. Wright, MLSDepartment of Anesthesiology LibraryUniversity of Alabama at Birmingham

Ralph Waters, M.D. (1883-1979)

• Began anesthesia career care in 1915• Arrived in Madison in 1927• Created "Wisconsin model"

"Wisconsin Model" of Academic Anesthesia

• Clinical care• Education (2 yrs clinical, 1 yr research)• Research (involve basic scientists)

"Wisconsin Model" Early Departments

• Rovenstine: Bellevue, 1935• Cullen: University of Iowa, 1938• Dripps: University of Pennsylvania, 1941• Papper: Columbia University, 1949

Other Anesthesia Milestones

• 1890s: Cushing/Codman anesthesia record• 1890s: Nitrous oxide/oxygen mixture• 1904: Procaine synthesized by Einhorn• 1914: Gwathmey publishes textbook• 1923: Lockhardt & Carter/Herb use ethylene

clinically

Journals

• Am J Surg Anesth Suppl 1914-1926• Am Yearbk Anesth Analg 1916-1920• Curr Res Anesth Analg August 1922

Societies

• 1905: Long Island Soc Anesthetists • 1911: Became NY Soc Anesthetists • 1919: Am Assoc Anesthetists • 1923: Am Soc Reg Anesth • 1925: IARS founded

Developments in the U.K.

• 1850s-60s: Physician anesthetists join staff of several hospitals

• 1892: Frederick Silk makes case to BMA for better anesthesia education

• 1893: Society of Anaesthetists founded by Silk

• 1923: British Journal of Anaeshesia begins publication

• 1937: First U.K. academic department, Oxford

Mayo Clinic (Minnesota)

• Alice Magaw, nurse anesthetist • beginning early 1890s

• John Lundy, M.D. • arrived 1924 • set up section on anesthetics • by 1936 majority of anesthetics

given by physicians

Lahey Clinic (Massachusetts)

• Frank Lahey, M.D., surgeon• Lincoln Sise, M.D., administered anesthesia for

30 yrs• Philip D. Woodbridge, M.D., also gave

anesthesia beginning late 1920s

• 1880: Springfield, Illinois• 1891: Chicago• 1891: Seattle• 1893: Baltimore• 1896: Portland, Oregon; Denver• 1897: Troy, N.Y.

Some Early Nurse Anesthetists

• "By 1915 [nurse anesthestists] had essentially replaced all but a few of the part-time, occasional physician anesthetists. The technical skills of nurse anesthetists were considerable...They were, however, professionally unable to advance the field in academic terms, and their dominant role...reduced even further the professional appeal of the field to physicians."

Greene, Anesthesology & the University, p. 32

• Thomas D. Buchanan: NYC, 1899• Thomas L. Bennett: NYC, 1899• S. Ormond Goldan: NYC, ca. 1900• James R. Dawson: Birmingham, ca. 1910

Early Physician Anesthetists

American Medical Education 1865-1910

• 1869: first academic hospital, Univ of Michigan• 1870s: President Charles Eliot begins reforms in

medical school• 1893: JHU Medical School opens• 1904: AMA creates Council on Medical Education• 1910: Flexner report published

Effects of Flexner Report I

•Medical Schools 1910: 148•Medical Schools 1919: 85

•Medical Students 1910: 21,526•Medical Students 1919: 12, 930

Effects of Flexner Report II

• Medical education standards established after 1910 did not allow room for new disciplines such as anesthesia.

• Since physician anesthesia was rare in 1910, decades passed before the specialty could establish itself.

Greene, Anesthesology & the University, p. 31

• Anesthesia administration is complex and often risky to the patient.

• Specialists should administer anesthesia.• Anesthesia training should be a part of the medical

curricula.

Arguments for Change 1880-1920

• "For the operator to charge $100 or $200 for performing a simple uncomplicated operation and give the anesthetizer $5 for conducting a difficult and complicated anesthesia...is an injustice which is not calculated to increase the number or efficiency of anesthetizers."

Galloway DH. Phila Med J May 27, 1899, 1175

• “That the administration of an anaesthetic by a physician for any purpose whatever, except in obstetrics and cases of emergency, without the presence of another physician, when such can be procured, is to be condemned.”

JAMA 16:347, 1891 [editorial]

• "In a large city like Indianapolis, where the services of an expert in anaesthesia can always be procured, the physician who does not avail himself of such services should be held to a strict accountability for any disastrous results that may occur."

JAMA 16:347, 1891 [editorial]

• "So far as we are informed in the matter, there exists in this great city no physician who makes a specialty of administering anaesthetics. There would seem, however, to exist a demand in that direction."

Medical Record (NYC) 51:522, 1897

• "The post at the head of the operating-table is an honorable one, and at times everything depends upon how ably it is filled."

Medical Record (NYC) 51:522, 1897

• "The fault in this country is for the most part limited to the administration of ether, where the most inexcusable indifference to the patient's comfort is often demonstrated."

JAMA 31:613, 1898 [editorial]

• "No operator should permit any man to administer his anesthetics unless he is competent to do so and willing to direct his undivided attention to the patient."

JAMA 31:613, 1898 [editorial]

• "Nor is it sensible to continue the foolish custom of allowing the most inexperienced intern [sic] to narcotize instead of having a professional anesthetist in every hospital..."

Gwathmey JT. JAMA 47:1361, 1906

• "Dr. J. Montgomery Baldy, of Philadelphia, said that a perfect solution of the problem of giving anaesthetics would be a medical man of a high grade of intelligence, with a well-grounded medical and surgical education, an especial education in anaesthetics, supplemented by a natural inclination in this direction as any other. "

Baldy JM. SGO 8:545, 1909

• Baldy went on to note the lack of such medical men due to "the disadvantages of the scientific narrowness and lack of opportunity for distinction and income to hold a sufficient number of men of this type.."

Baldy JM. SGO 8:545, 1909

• "To the nurse, anaesthesia will prove a stepping-stone to something better than she had originally chosen, a higher and more dignified position...In this way may be secured a sure method of always having the anaesthetist on hand, as she lives in the institution and is ready for an emergency."

Baldy JM. SGO 8:545, 1909

• "Dr. Herman J. Boldt of New York, said the competency of the anaesthetizer is more important to the surgeon in many instances than the competency of his first assistant."

Boldt HJ. SGO 8:545, 1909

• "In light of recent discoveries, no surgeon is justified in adopting some one anaesthetic and method of administration exclusively. There are four general anaesthetics in common use, and there are three methods of administration."

Gwathmey JT. SGO 8:545, 1909

• "The problem today is not the matter of life and death upon the table, but what methods and combinations will give the best results and leave the patient just as we found him."

Gwathmey JT. SGO 8:545, 1909

• "...in our opinion, there exists no more forceful argument in favor of the regular employment of a trained anesthetist than the fact that once the operation is under way, the responsibility as to whether the patient is going to be able to endure the complete procedure is almost entirely in the hands of the anesthetist."

Lahey F. Am J Surg 35:108, 1921

• "In some cases Dr. M. had seen chloroform administered by young gentlemen, rather in a careless manner...In fact, he believed that most of the fatal cases can be traced to a careless administration of the remedy."

Hosp Pract 3:305, 1859

• "...this important part of the procedure is carried out by a novicus just out of the medical school. In almost all institutions it is the junior on the staff, who is going through the process of gaining knowledge and skill...."

Medical Record (NYC) 51:522, 1897

• "...in most hospitals one of the younger internes is...selected to administer the anesthetic. The operator accustomed to having a novice give chloroform or ether for him is kept on the qui vive while performing the operation and watching the administration of the anaesthetic. Such a condition of affairs is not conducive to the best work of the surgeon."

Simon S. Medical Record, February 12, 1898, 230

• "Then it became a positive disadvantage to a young man to get a reputation for skillful administration of anesthetics, for he was called upon oftener, his opportunities for learning surgery were lessened, and still no one thought of offering him adequate pay for the time and skill required."

Galloway DH. Phila Med J May 27, 1899, 1173

• "A patient...requested that the most experienced anesthetizer available be obtained..The surgeon informed the patient that that would cost $25 additional, and the patient said he would gladly pay it. The surgeon employed a student to give the anesthetic, collected $225, gave the student $5..."

Galloway DH. Phila Med J May 27, 1899, 1175

• "If the desire, voiced so frequently, for a safe anesthetic, means an agent which would be without danger in unskilled hands, I seriously question whether such an anesthetic ever will be secured; for the production of unconsciousness in itself has, and always will have, an element of danger..."

Goldan SO. Am Med 1901

• "I consider it unjustifiable for nurses to administer anesthetics, or for anyone to permit them to do so, excepting, of course, in emergencies. This is an abuse which exists in this country to a considerable extent even to this day."

Goldan SO. Am Med 1901

• "Were I to require an operation I would have no difficulty in selecting any one of a number of surgeons. The same, however, is not equally true regarding the anesthesia."

Goldan SO. Am Med 1901

• "The fact that some surgeons receive fees of from hundreds up to, in some instances, thousands of dollars, and expect the anesthetist's account to them to be from $10 to $25 seems incredible; it is nevertheless in my experience true."

Goldan SO. Am Med 1901

• "A word as to the future of anesthetization, instead of the haphazard methods of administering anesthetics they will be properly taught by those competent to teach, not by any means the surgeon. He is not an anesthetist but a surgeon. To follow his teaching in this subject would certainly be decidedly bad for the patient in many instances."

Goldan SO. Am Med 1901

• "The anesthetist will not be considered a mere satellite of the surgeon, but recognized as one of a distinct class. There will be an incentive to men to give their best energies to the perfection of anesthesia..."

Goldan SO. Am Med 1901

• "No more is the occasional necessity for a layman or a nurse to administer an anesthetic argument that we physicians should not fit ourselves to do the best work that can be done in that line and help to develop the science, to make it better."

Waters RM. Journal-Lancet 1919

• "I wish especially to appeal to the physicians...in every town who occasionally give anesthetics, to wake up, get busy, and make anesthesia a part or all of your business."

Waters RM. Journal-Lancet 1919

• "Do it the best you know how every time you officiate at the head of the table. Learn all there is to find out about it, and help the rest of us to do it better by adding to the developments already made."

Waters RM. Journal-Lancet 1919

• "The anesthetist should examine the patient the night before, and take the blood-pressure on the evening before and in the morning. He should know exactly what condition the patient is in."

McCauley CE. Journal-Lancet 1919

• "The position of the anaesthetist is not an easy one. Upon him depends not so much the success of the operation (for every operation is successful and beautiful even though the patient die), but the recovery of the patient."

Simon S. Med Rec February 12, 1898

• "An excellent solution of the problem, and what ought to be the desideratum of every surgeon, would be the professional anaesthetist. It is doubtful, however, whether one taking the work up as a specialty could make a living at it alone; and especially is this true in the smaller cities."

Simon S. Med Rec February 12, 1898

• "Anesthesia should cease to be regarded as merely an adjunct of surgery....It should be in charge of those whose principle aim is, not to see as much of the operation as possible, but to administer anesthesia in such a manner as to bring the patient through with the least possible loss of vitality."

Committee on Anesthesia report to AMA House of Delegates, June 1912

• "As the success and progress of surgery depend in a large measure upon the safety of anesthesia, it is evident that too much study can not be given to this subject. An operation may be practically devoid of danger, while an anesthetic is never administered without imperiling the life of the patient."

Heinick, General and Local Anesthesia, 1901, p.8

• "Never should the surgeon administer chloroform or ether, and operate at the same time. It is false economy. There is no scarcity of physicians. It is unsafe. Deaths have been caused by this practice."

Heinick, General and Local Anesthesia, 1901, p.10

• "....and though [America is] the birthplace of modern anaesthesia, the discovery of which has brought relief to countless thousands, we permit the administration of anaesthetics by any Tom, Dick or Harry who can be pressed into service."

Barnesby, Medical Chaos and Crime, 1910, p. 176

• "There are many reasons why anaesthetics should be administered only by experts, not the least of which is the greater freedom with which the surgeon can work when he is not troubled about his patient's condition."

Barnesby, Medical Chaos and Crime, 1910, p. 177-8

• "...were a public investigation called for at the present time, the employment of trained anaesthetists, or the adoption of adequate measures for the safety of the patient, would be found to be the exception rather than the rule."

Barnesby, Medical Chaos and Crime, 1910, p. 181

• "During a recent visit in a metropolitan medical centre I was shocked at the reckless manner in which general anaesthetics were given. Observations during my surgical life in some ten or more hospitals...has convinced me that a protest against the methods...is urgently needed."

Roberts JB. " The Anaesthesia Peril in Ameican Hospitals."Therap Gaz February 1908

• "I have sat on clinic benches and stood near operating tables more than once with thankfulness in my heart that the safety of no friend of mine was then in the hands of operators and anaesthetists so indifferent, or so oblivious, to the risk of ether and chloroform."

Roberts JB. "The Anaesthesia Peril in Ameican Hospitals."Therap Gaz February 1908

• "Yet the majority of doctors treat anaesthetics lightly, and some delegate the giving of chloroform in obstetrics to the husband or the nurse while they use forceps in the delivery. Is there anything in the practice of medicine where we are as careless as in this one of anaesthesia?"

Porter M. "The Trained Anaesthetist."Lancet-Clinic June 18, 1910

• "The general administration of anaesthetics as performed to-day is the shame of modern surgery, is a disgrace to a learned profession, and if the full, unvarnished truth concerning it were known to the laity at large it would be but a short while before it were interferred with by legislative means..."

Baldy JM. Am J Obstet July 1908

• "For some years past I have felt that we were not doing our duty toward the undergraduate in sending him forth upon his life's work with little or no experience in the practical administration of anaesthetics."

Peterson R. SGO 8:525-7, 1909

• "...it is only by such a systematic course of instruction in the theory and practice of administering anaesthetics that we can ever hope to deal with the problem we have under consideration."

Peterson R. SGO 8:525-7, 1909

• "The faculty of the department of medicine and surgery for the University of Michigan have only this spring placed themselves on record in favor of such a course..."

Peterson R. SGO 8:525-7, 1909