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September 1999
Volume 63 |
Number 9
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| James Otis Elam,
M.D.: Respiratory Researcher (1918-1995) |
Robert P. Sands, Jr., M.D
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Unfortunately, James Otis Elam, M.D., is a name that very few
practicing anesthesiologists instantly recognize, but without
this man's hard work and dedication to the profession, anesthesiology
may not be where it is today. Elam contributed to the introduction
of two landmark "improvements" to the field of anesthesiology
and another to medicine in general.
Elam's training began at the University of Texas, where
he earned his bachelor of arts in 1942. In 1945, he received his
medical doctorate from Johns Hopkins School of Medicine. A rotating
internship at the United States Naval Hospital in Bethesda, Maryland,
from 1945 to 1946 was Elam's next stop where he realized that
the field of medical physiology interested him the most. He pursued
a surgical career, believing he would have more time to study
physiology. Fortunately for the field of anesthesiology, he was
wrong!
Realizing the error of his ways halfway through the second
year of his surgical residency, he signed on with Massachusetts
General Hospital as an assistant resident in anesthesiology because
there were no residency spots available in mid-year. In July of
1949, he began his anesthesiology residency at the University
of Iowa Hospital. The mornings were spent administering anesthetics
in the operating rooms, while afternoons found Elam performing
research in the biophysics lab.
Elam's enthusiasm for research was already firmly established.
As time went on, this dedication to the research side of anesthesiology
led some of his contemporaries to comment that he relegated patient
care to a secondary role. His commitment to research also alienated
colleagues because, at times, it came across as aloofness. He
was always thinking about a new project and could be impatient
while trying to solve a clinical problem, but these characteristics
allowed him to push the envelope in anesthesiology, resulting
in the carbon dioxide (CO2) absorption system and the
Roswell Park ventilator.
The groundwork for the development of a system that could
fully absorb CO2 was already laid by Adriani and Rovenstine
in 1941. They had devised a system that could absorb CO2,
but he had difficulty measuring the actual amount neutralized
because the chemical titrations they utilized were prone to error.
Elam believed that a device could be built to absorb CO2
during surgery, but first, a better understanding of CO2
homeostasis during anesthesia was necessary.
In 1951, Elam was on staff in the Department of Anesthesiology
at Barnes Hospital in St. Louis, Missouri. As he was about to
start his research into CO2 homeostasis, a new department
chair was appointed who wanted all research in anesthesiology
to be performed using animals, not humans. Elam realized this
would not be feasible and moved to Buffalo's Roswell Park Memorial
Institute along with his top two collaborators, Elwyn S. Brown,
M.D., and Raymond H. Ten Pas, M.D.
Using a Liston-Becker CO2 analyzer, Elam's
group was able to define three characteristics of CO2
absorption that we now take for granted. First, interstitial space
within the CO2 canister should closely approximate
tidal volume, and secondly, for CO2 absorption to be
maximally efficient, soda lime should contain 20-25 percent water.
Finally, channeling was described for the first time, where expired
gas flowed directly through the canister bypassing any interaction
with soda lime. The amount of channeling depended upon how tightly
the soda lime granules were packed and could be minimized by placing
baffles in the canister.
To obtain reproducible results during his soda lime research,
Elam needed to construct a machine that could mimic human respiration.
The first working model was large and unwieldy, not unlike the
first computers. But, this first model was able to provide continuous
data 24 hours a day for five years. Because the machine ran continuously,
Elam and his colleagues were able to test multiple breathing circuits
and CO2 canisters to ascertain the optimal design.
This first model also was invaluable in calculating physiologic
and anatomic dead space, and with minute adjustments, it could
simulate different human respiratory patterns.
Elam postulated that if the machine could be "programmed"
to breathe like a human being, it could be further modified
to breathe for a human being. A prototype ventilator was
constructed and dubbed the Roswell Park ventilator. Although it
was not the first ventilator introduced onto the market, it was
very versatile. It could work in either volume or pressure modes
and could also cycle in positive-negative, positive-zero and positive
pressure manners. The tests on human subjects validated the work
done during soda lime research, that CO2 homeostasis
was adequate with the Roswell Park ventilator. The ventilator
then became known as the Air-Shields Ventimeter ventilator and
is still in use in many parts of the country today, almost 50
years later.
The CO2 absorption system and ventilator have
helped to make the practice of anesthesiology easier and safer,
but Elam's contributions to the field of medicine transcend even
that achievement. Elam was intimately involved in the process
of bringing rescue breathing, or cardiopulmonary resuscitation
(CPR) as it is known today, to the attention of the medical community
and the general public.
Elam also had two powerful allies in this battle: Peter
Safar, M.D., and Archer S. Gordon, M.D. Gordon initially did not
support rescue breathing until he performed a study of his own
using pediatric patients, reproducing Elam's results. Safar had
also been working on the feasibility of rescue breathing, so they
agreed that a concerted effort would be much more valuable than
each working separately and possibly reproducing each others'
work.
Prior to the 1950s, the accepted method of resuscitation
was the chest-pressure and arm-lift technique that was shown to
be ineffective by Safar and Elam. In 1954, Elam was the first
to demonstrate experimentally that exhaled air ventilation was
a sound technique. Elam and Safar (and later Gordon) performed
many experiments demonstrating the superiority of the rescue breathing
technique. The problem then became one of popularizing the method.
To do this, Elam enlisted the assistance of then New York
State Health Commissioner, Herman Hilliboe. Hilliboe was impressed
with the technique and commissioned Elam to write the instructional
booklet titled "Rescue Breathing," which was distributed nationally
in 1959. The success of the booklet spurred Elam to produce films
demonstrating this new life-saving technique.
By 1960, rescue breathing had been adopted by the National
Academy of Science, American Society of Anesthesiologists, Medical
Society of the State of New York and the American Red Cross as
the preferred method of resuscitation. For changing forever the
face of emergency medicine, Elam was recognized by the United
States Army with a Certificate of Achievement, and in 1962, the
Medical Society of the state of New York presented him with its
highest honor, the Albert O. Bernstein Award.
James Elam has left an indelible mark on the practice
of anesthesiology and medicine with his scientific contributions.
True to his legacy, he continued working to improve the field
of anesthesiology until his untimely death on July 10, 1995. Detractors
argue that his work was never original and that he only finished
what others had begun. Even if this is partially true, it still
requires an impressive amount of intelligence and perseverance
to solve a problem that others could not. Elam always strived
to provide the best and safest anesthetic for his patients. Because
of his scientific commitment, the clinical practice of anesthesiology
became significantly safer.
Robert P. Sands, Jr., M.D., is Clinical
Assistant Professor, Department of Anesthesiology, State University
of New York at Buffalo, and Attending Anesthesiologist, Roswell
Park Cancer Institute, Buffalo, New York.
References:
- Adriani J, Rovenstine EA. Experimental studies on carbon dioxide
absorption for anesthesia. Anesthesiology. 1941; 2:1.
- Sands RP, Bacon DR. An inventive mind: the career of James
O. Elam, M.D. Anesthesiology. 1998; 88:1107.
- Flower RC. Rapid infrared gas analyzer. Rev Sci Instrum.
1949; 20:175.
- Luft K. Methode der registrieren gas analyse mit hilfe der
absorption ultraroten Strahlen ohne spectrale Zerlegung. Z Tech
Phys. 1943; 24:97.
- Brown ES. Factors affecting the performance of absorbents.
Anesthesiology. 1959; 20:198.
- Brown ES, Bakamjian V, Seniff AM. Performance of absorbents:
Effects of moisture. Anesthesiology. 1959; 20:613.
- Elam JO. Channeling and overpacking in carbon dioxide absorbers.
Anesthesiology. 1958; 19:403.
- Elam JO, Brown ES, Janney CS. Ventilator. Anesthesiology.
1956; 17:504.
- Gordon AS, Frye CW, Gittelson L, Sadove MS, Beattie EJ. Mouth-to-mouth
versus manual artificial respiration for children and adults.
JAMA. 1958; 167:320.
- Safar P, Escarraga L, Elam JO. A comparison of the mouth-to-mouth
and mouth-to-airway methods of artificial respiration with the
chest-pressure arm-lift methods. N Engl J Med. 1958; 258:671.
- Safar P. Failure of manual respiration. J Appl Physiol. 1959;
14:84.
- Elam JO, Brown ES, Elder JD, Jr. Artificial respiration by
mouth-to-mask method. A study of the respiratory gas exchange
of paralyzed patients ventilated by operatorŐs exhaled air.
N Engl J Med. 1954; 250:749.
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