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September 2001
Volume 65 |
Number 9
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| Why Celebrate
Ralph Milton Waters? |
Douglas R. Bacon, M.D., Trustee
Wood Library-Museum of Anesthesiology
September 2002 marks the 75th anniversary of the arrival of Ralph
M. Waters, M.D., in Madison, Wisconsin. From 1927 until 1949,
a span of 22 years, Waters was able to revolutionize the practice
of anesthesiology. Remembered most often for starting the first
university-based residency training program, Waters’ contributions
are more extensive than that, but often his work has remained
unknown. In a time when anesthesiology was just being defined
as a medical specialty, Waters worked to ensure that it was set
on an equal footing within the university with surgery, internal
medicine and pediatrics as well as the traditional hospital- based
specialties of radiology and pathology.
Within this NEWSLETTER issue are articles that help define
Waters’ contribution to American anesthesiology. Lucien E.
Morris, M.D., trained by Dr. Waters, writes on Waters’ contributions
to education and the Waters legacy, respectively. Carlos P. Parsloe,
M.D., another “aqua alumnus” writes about Waters’
worldwide impact, while the Wood-Library Museum of Anesthesiology
(WLM) Laureate, Thomas Boulton, M.B., describes Waters’ influence
on British anesthesia. Christopher M. Burkle, M.D., covers Waters’
career as a medical politician, while Robert P. Sands, Jr., M.D.,
writes about Waters and regional anesthesia. John E. Steinhaus,
M.D., covers Waters’ enormous contribution to education in
anesthesiology within the medical school setting. Yet all of this
would not be possible without the support of NEWSLETTER
Editor Mark J. Lema, M.D., Ph.D., and the vast resources of the
WLM, the largest collection of literature and artifacts related
to anesthesiology in the world and whose collections and activities
are available to every ASA member.
Dr. Waters’ career was an interesting one. He graduated
from medical school at Case Western Reserve and established a
thriving private practice in Sioux City, Iowa, and later in Kansas
City. It was in these two cities where Waters established an ambulatory
anesthesia clinic within an outpatient surgical center. 1
Even though his practice was flourishing, Dr. Waters took time
to work on some of the problems of anesthesia. He researched and
wrote on carbon dioxide absorbance 2 and developed
a cuffed endotracheal tube 3 with Arthur Guedel.
Dr. Waters looked to increase his skills, and enrolled as a voluntary
resident at the Mayo Clinic for three months in 1926 to learn
regional anesthesia from John S. Lundy, M.D. Later that year,
Dr. Waters injured his back, and while recovering, he sought a
less strenuous practice. 4
The University of Wisconsin afforded him both a different type
of practice and an opportunity to “…work toward bringing
back anesthesia into the medical profession where it originally
was and where it undoubtedly belongs. The only way I could see
of really basically helping this movement was through the educational
institutions.” 5 The challenge Dr. Waters
accepted in 1927 was to design and implement a residency training
program in anesthesiology. Dr. Waters chose to make the training
three years after the internship, with the first and third clinical
and the second laboratory-based research. Dr. Waters preferred
residents who had already been in general practice for a few years
as these candidates were more mature. 6
Dr. Waters’ reception at the university was warm. Chauncey
Leake, the Chair of Pharmacology and Toxicology, wrote a letter
to Waters on February 2, 1927. In it, Leake states, “I want
to express to you my great pleasure at the opportunity of cooperating
with you. … We should be very happy to have you talk to our
students at the 11 o’clock lecture, Thursday, March 8, on
the general subject of practical anesthesia…” 7
The anesthesia community at large also was very receptive to what
Dr. Waters was doing in Madison. Francis Hoeffer McMechan, M.D.,
the leader of organized anesthesia at the time and a recognized
international figure, was addressing anesthesia meetings and “…talked
most enthusiastically of the work you are doing in Madison. He
described in considerable detail the organization you have worked
out and the plans you have for the future. He also laid great
stress on the actual achievement you have made and in general
held up your work as an example for the whole country to follow.”
8
Once established, Dr. Waters’ next greatest challenge was
to transplant the residency training program to another site while
keeping his program alive. A unique opportunity arose in 1934,
and Dr. Waters’ most experienced resident who had remained
on the faculty after completing his training, Emery A. Rovenstine,
M.D., accepted the position as director of anesthesia at Bellevue
Hospital beginning in 1935. While Dr. Rovenstine had a difficult
time changing surgical practice in the first few months, his results
spoke for themselves. Mortality on the surgical service plummeted.
Dr. Rovenstine then developed his own training program, molded
after Waters’. Soon the two were sharing residents and looking
for universities that wanted to develop academic programs in the
specialty in which to place their graduates. 6
| Had establishing an academic department in
anesthesia been Dr. Waters’ only contribution to the
field, his career would be worthy of study. Yet he was much
more involved. In the years before arriving at Madison, he
had become enmeshed with the new professional anesthesia societies
and had become a close personal friend of Dr. McMechan. He
presented numerous papers and published the results of his
work long before he became associated with the basic scientists
at the University of Wisconsin. Once established in Madison,
however, Dr. McMechan relied on Waters to have papers for
meetings and to keep a steady flow of young physicians interested
in anesthesia coming to the meetings. 9 |
Ralph M. Waters, M.D. (circa 1957) |
When Dr. McMechan proposed certification for specialists in anesthesia
Dr. Waters supported the initial proposal. Yet when Dr. Waters
learned that physician anesthetists who worked with nurses were
to be excluded, Dr. Waters broke with Dr. McMechan, strained their
20-year friendship and suffered virulent attacks by Dr. McMechan’s
close associates. In many ways, it was Dr. Waters who added the
imprimatur of academic excellence to the founding of the American
Board of Anesthesiology. 10 Dr. Waters also
played a key role in the difficult mending of the relationship
between organized anesthesia and the American Medical Association
(AMA). Dr. Waters and his department developed exhibits at the
AMA annual meeting that displayed for the professional medical
community the importance of physician anesthesia. 11
In 1938, Dr. Waters’ expertise was added to the 1939 New
York World’s Fair Exhibition Committee. Several of Dr. Waters’
ideas were critical to the final exhibit, one that brought anesthesia
to the general public. 12
Why celebrate Ralph Waters’ arrival in Madison, Wisconsin?
It has been suggested that Henry K. Beecher, M.D., was responsible,
more than any other, for introducing anesthesia into the university.13
Yet Dr. Beecher was appointed in 1936 as anesthetist-in-chief
at the Massachusetts General Hospital (MGH), nine years after
Dr. Waters’ appointment and a year after Rovenstine’s
appointment at Bellevue. Dr. Waters was considered a candidate
for the Henry Isaiah Dorr Chair at Harvard. Waters proposed that
he would be the departmental chair and that there would be a “first
assistant” at the various hospitals, with Beecher being designated
at the MGH. Both finances and Chair of Surgery Edward Churchill
prohibited such an arrangement, and Waters declined the position.
If Beecher, the great basic scientist, and Dr. Waters, the leading
educator and clinical investigator, had pooled their talents in
Boston, where would anesthesia be today? 14
In historical writing today, the careers of outstanding individuals
have been de-emphasized. Many authors argue that these individuals
are no more than the product of their times and circumstances.
Yet there is a fallacy in that argument because it negates the
influence of the individual in changing his or her own destiny.
Dr. Waters was an active clinical investigator before ever considering
his move to the university center. When the right opportunity
arose, Waters grabbed at it. Was it because his youngest sister
lived in Madison, being married to a professor in the department
of agricultural bacteriology, 15 or was it because
Waters wanted to do more for the specialty than simply being a
sound practitioner? Did Waters share McMechan’s vision of
postgraduate medical education in anesthesiology?
Whatever the case, Waters’ move to Madison was at some personal
financial cost. Dr. Waters wrote: “…I persuaded my wife
to forego the possibility of having anything in the way of finances
other than bare living for the rest of my days in order that I
might spend the rest of my life, if possible, in attempting to
further the interest of anesthesia and to do my little bit to
help to make the future [of] anesthesia professional anesthesia.”
5 It is through this example of personal integrity
and the desire to give back to the specialty which allowed Waters
to make a living that makes him such a compelling figure. Waters
did many things well and often was among the first to do them,
including establishing residency training in a form well recognized
today, integrating basic science and clinical research, administrating
in both the department and national arenas and helping to establish
specialty certification for physicians that is recognized around
the world.
Waters was without doubt a product of his time, yet his career
teaches that being involved in and chasing a vision for the specialty
can and ought to be done. His example will be remembered on June
6-8, 2002, in Madison when the world gathers to pay tribute to
Dr. Waters. The meeting is jointly sponsored by the Anesthesia
History Association, the History of Anaesthesia Society of Great
Britain, the University of Wisconsin Department of Anesthesiology
and Continuing Medical Education, the Wisconsin State Society
of Anesthesiologists and the Wood Library-Museum of Anesthesiology.
References:
1. Waters RM. The downtown anesthesia clinic.
American Journal of Surgery. Anesthesia (Q) (suppl). 1919; 33:71.
2. Waters RM. Clinical scope and utility of carbon
dioxide filtration in inhalation anesthesia. Current Researches
in Anesthesia and Analgesia. 1924; 3:20-22. [This article is particularly
interesting because it has the first description of what would
become the Waters to-and-fro anesthetic apparatus.]
3. Guedel AE, Waters RM. A new endotracheal catheter.
Current Researches in Anesthesia and Analgesia. 1928; 7:238-239.
4. Letters between John S. Lundy, M.D., and Ralph
M. Waters, M.D., The Collected Papers of John S. Lundy, Mayo Foundation
Archive, Rochester, Minnesota.
5. Letter from Ralph M. Waters, M.D., to Frederick
W. Clement, M.D., February 3, 1933. The collected papers of Ralph
M. Waters, M.D., Steenbock Library, University of Wisconsin Archives,
Madison, Wisconsin.
6. Bacon DR, Ament R. Ralph Waters and the beginning
of academic anesthesiology in the United States: The Wisconsin
template. J Clin Anesth. 1995; 7:534-543.
7. Letter from Chauncey Leake, Ph.D., to Ralph
M. Waters, M.D., February 2, 1927. The Collected Papers of Ralph
M. Waters, M.D., Steenbock Library, University of Wisconsin Archives,
Madison, Wisconsin.
8. Letter from Chauncey Leake, Ph.D., to Ralph
Waters, M.D., May 23, 1929. The Collected Papers of Ralph Waters,
M.D., Steenbock Library, University of Wisconsin Archives, Madison,
Wisconsin.
9. Multiple letters between Ralph M. Waters, M.D.,
and Francis Hoeffer McMechan, M.D. The Waters Collection, Guedel
Memorial Library, San Francisco, California.
10. Bacon DR, Lema MJ. To define a specialty:
A brief history of the American Board of Anesthesiology’s
first written examination. J Clin Anesth. 1992; 4:489-497.
11. Exhibit on Anesthesia 1938, 1939. The Collected
Papers of Paul M. Wood, M.D., The Wood Library-Museum Archive
Collection, Park Ridge, Illinois.
12. Bacon DR, Lema MJ, Yearley CK. For all the
world to see: Anesthesia at the 1939 New York World’s Fair.
J Clin Anesth. 1993; 5:252-258.
13. Gravenstein JS. Henry K. Beecher: The introduction
of anesthesia into the university. Anesthesiology. 1998; 88:245-253.
14. Bunker JP. Henry K. Beecher. In: Volpitto
PP and Vandam LD, eds. The Genesis of Contemporary American Anesthesiology.
Springfield: Charles C Thomas; 1982:106-109.
15. Gillespie NA. Ralph Milton Waters: A brief
biography. Br J Anaesth. 1949; 21:197-214.
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Douglas R. Bacon,
M.D., is Associate Professor of Anesthesiology, Mayo Clinic,
Rochester, Minnesota. |
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