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September 2001
Volume 65 |
Number 9
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| Ralph Waters’
Visit to Great Britain in 1936 |
Thomas B. Boulton, M.B., F.R.C.A.
Year 2000 Laureate of the History of Anesthesia of the Wood Library-Museum
of Anesthesiology
Figure 1: Ralph Milton
Waters, M.D.,
F.F.A.R.C.S. (1887-1979). |
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Ralph Milton Waters, M.D., (1887-1979) [Figure 1] was appointed
Assistant Professor of Surgery in charge of anesthesia at
the University of Wisconsin at Madison in 1927, and he was
elected as the first university Professor of Anesthesia
in the world at Wisconsin in 1933.1,2
Professor Sir Robert Macintosh (1887-1989) [Figure
2] described Waters as “the outstanding personality
in our specialty over the past hundred years.” 3
Dr. Macintosh was the first physician anaesthetist (anesthesiologist)
outside of the United States to become a professor. He was
elected to the newly endowed professorial chair of the Nuffield
Department of Anaesthetics at the University of Oxford in
1937.4,5
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Dr. Waters visited Great Britain in 1936.1,3,5
He was still the only Professor of Anesthesia at the head of a
clinical and academic department in the world at that time. He
was received with adulation by his British colleagues who fell
under “the spell of his simplicity, his friendliness, his
keenness and his erudition.”1,3,5
Waters spoke on “The Status of Cyclopropane,” then a
novel agent, at the Annual Scientific Meeting of the British Medical
Association at Oxford in July 1936, and he also gave a memorable
demonstration of the agent using minimal improvised apparatus.1,5
The following October, he addressed the Section of Anaesthetics
of the Royal Society of Medicine (RSM) on “Carbon Dioxide
Absorption From Anaesthetic Atmospheres.”1,3,5
Waters prefaced his lecture at the RSM with the sentence, “The
greatest anesthetist was an Englishman — John Snow.”
3 The life and works of the London general practitioner
and pioneer specialist anesthetist John Snow, M.D., (1815-1858)
[Figure 3] were an inspiration to Dr. Waters throughout his career.1,3,6-9
| Figure 2: Sir Robert Reynolds
Macintosh, D.M., F.F.A.R.C.S. (1887-1989). |
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Dr. Waters was elected to honorary membership of the Section
of Anaesthetics and of the Association of Anaesthetists
of Great Britain and Ireland in 1936. In 1944 he was awarded
the Henry Hill Hickman Medal of the RMS [Figure
4] and, in 1948, he was elected to one of the first
Honorary Fellowships of the Faculty of Anaesthetics of the
Royal College of Surgeons of England (F.F.A.R.C.S.). The
Faculty was the predecessor of the Royal College of Anaesthetists.1,5
The reason why Dr. Waters, aside from his known clinical
expertise and his pleasant personality, was received with
such enthusiasm in Great Britain in 1936 is fairly obvious.
British anaesthesia was established as a physician-based
discipline, but it lacked an academic status.
5
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Waters was greatly admired because he had developed a superlatively
well-organized academic department of anesthesia at the University
of Wisconsin.1,5,7
This department integrated the best possible service to the patients
of its institution with undergraduate instruction, postgraduate
clinical and theoretical training (a concept unknown at that time
in the United Kingdom), meticulous record-keeping and first-class
research, particularly in joint projects with related departments
such as those of physiology and pharmacology. 7
This department set a standard that British physician anaesthetists
in 1936 could only dream about.1,5,7
Anesthesia in the United Kingdom in 1936
British anesthesia, although firmly physician-based, was only
just beginning to emerge as a proper professional medical specialty
in 1936. The British Diploma in Anaesthetics had been introduced
in 1935, 5 three years ahead of the American
Board in 1938, 10 but the specialty in the United
Kingdom was still almost exclusively based on practical expertise
and, outside of the university hospitals attached to medical schools,
it was a sideline practiced by general practitioners. Academic
departments did not exist, and consequently, there was little
basic research. 5
The predominant voluntary hospital system in the United Kingdom
expected clinicians to give their services free of charge to public
patients. Therefore, they had to rely for an income on fees from
middle- and upper-class patients operated upon in private hospitals.
Both the general practitioner anesthetists and the few practitioners
who specialized in anesthesia, who were usually attached to university
hospitals, were dependent on fees collected by the surgeon and
passed on to them. These relatively small fees were a welcome
supplement to the income of provincial general practitioners,
but were usually inadequate to enable a physician to limit his
practice to anaesthesia. 5 The Association of
Anaesthetists of Great Britain and Ireland had been inaugurated
in 1933, primarily to improve the status of between 100 and 150
physician anesthetists who held appointments in university hospitals
and who were exclusively eligible for membership. 5
Anesthesia in the United States in 1936
No one can detract from the great achievement of Dr. Waters in
developing the University of Wisconsin Department of Anesthesia,
but it was unique at the time. 7 Waters had seen
the variable standard of anesthesia practiced in Sioux City, Iowa,
during his gradual transition between 1913 and 1927, from general
practice to the very unusual status for that time of “physician
with practice limited to anesthesia.”1,7
In his first paper published in 1919, he described how anesthesia
was generally administered by nurses or even by an “office
girl.” This was either for convenience or because of cost
or (most importantly) because of the “lack of proficient
anesthetists among available physicians.” 1
He did not decry nurse anesthetists as technical administrators
but recognized that a physician anesthetist should have some postgraduate
training or, at the very least, should have a self-taught interest
in anesthesia. His mission on taking up his post at the enlightened
University of Wisconsin in 1927 was to train anesthesiologists
on a proper scientific basis who would go out and found departments
of anesthesia and teach others.1,2,7
He did just that. “Hundreds of academicians throughout the
world and more than 80 departmental chairmen in medical schools
in the United States alone have been of the Waters lineage.”
2 in 1936, however, his first disciples were
only just leaving Wisconsin, and the general provision of anesthesiologists
throughout the United States had only improved marginally.1,7,10
It was not until after World War II (1939-1945) that the demand
for qualified medical anesthesiologists really accelerated in
the United States. 10
| Figure 3: John Snow, M.D.
(1813-1858) |
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Ralph Waters and John Snow
Dr. Waters referred to Dr. Snow as “my idol, the more
I try to do various things, the more respect I have for
him.” 3 Dr. Waters wrote a biographical
paper on Snow in 1936. 6 This contains
an excellent review of Dr. Snow’s extensive scientific
investigations and his clinical work. Dr. Waters concludes,
“We need not hesitate to say that John Snow was and
remains the greatest anesthetist as well as the first.”
6
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Dr. Snow was 33 years old in 1846 and was enjoying a rising reputation
in the medical circles of the capital when the news of Dr. Morton’s
successful demonstration of ether anesthesia at the Massachusetts
General Hospital reached London in December 1846. 6,8,9
Snow was intrigued by the early reports of successful ether anesthesia
in London by the dentist James Robinson and by the eminent surgeon
Robert Liston, M.D., (1794-1847) and he attended a demonstration
of ether anesthesia by Dr. Robinson on December 28, 1846. 8,9
However, by the early weeks of 1847, it was evident that some
attempts by Dr. Robinson and others to produce anesthesia sometimes
resulted in partial or total failure. Such failures occurred so
frequently that Dr. Liston himself and many other leading surgeons
in the United Kingdom ceased to use anesthesia in the early months
of 1847. 9 Dr. Snow also tells us that “considerable
opposition was made to etherization in America soon after its
introduction and it seemed that it was likely to fall into disuse.”
9
Dr. Snow quickly deduced that the failures were “due to
imperfections on the apparatus employed and in the method of administration.”
9 Dr. Snow realized that the empirically manufactured
inhaler employed by Dr. Morton, as well as those used by Dr. Robinson
and Dr. Liston, had proven to be unreliable because they were
not scientifically designed, even though they had been initially
fortuitously successful. 9 Dr. Snow, after careful
laboratory and animal studies, constructed an inhaler that delivered
a known and constant concentration of ether. It incorporated a
water jacket for temperature stabilization. 8,9
John Snow’s results were such that he had established himself
as the leading exponent of ether anesthesia in London by May 1847.
The confidence of Dr. Liston and other surgeons was restored,
and anesthesia became firmly established in the United Kingdom.
Dr. Snow published his first monograph, “On the Inhalation
of the Vapour of Ether in Surgical Operations,” in September
1847. 8 There is little doubt that news of the
successful and established use of ether in Great Britain did much
to revive its use in America. 9
Dr. Snow, like Dr. Waters three quarters of a century later,
insisted that for anesthesia to be successful and safe, administration
should be by medical practitioners.1,7,9 Dr.
Snow was further confirmed in this view when he began to employ
chloroform as his main anesthetic after it was introduced by James
Young Simpson of Edinburgh (1811-1870) in November 1847. 9
Chloroform was a more potent and potentially more dangerous anaesthetic
than ether and consequently required more skill for its administration.
Dr. Snow felt justified in using it, however. 9
It is interesting that one of the last clinical publications edited
by Dr. Waters in 1951 (before halothane was introduced in 1956),
was the report of an investigation by the Wisconsin department
titled “Chloroform: A Study After 100 Years.” Rightly
or wrongly, the report concludes: “Chloroform does not deserve
to be abandoned as a surgical anesthetic” but added “no
one can administer chloroform safely when he is not keenly aware
of what he is doing.” It also is possible that nurse anesthesia
developed in the United States rather than physician anesthesia
partly because the less elegant but safer ether remained the predominant
agent in New England for many years.
Snow continued to publish a prodigious amount of outstanding
anesthetic-related research during his lifetime. 6,8,9
His animal and self-experimental studies included the use of carbon
dioxide absorption. 8 This was a technique that
Dr. Waters developed for practical reasons in his Sioux City,
Iowa, days before he took up his appointment at the University
of Wisconsin.1
Dr. Snow suffered a fatal stroke as he was writing the last sentence
of his major work, “On Chloroform and Other Anaesthetics:
Their Action and Administration.” 9 This
volume records the work of a lifetime. His friend Benjamin Richardson,
M.D., edited the book and added a valuable and moving account
of Dr. Snow’s life. 9
There are many parallels in the careers of Dr. Snow and Waters;
for example, both were clinicians as well as research workers,
both kept meticulous records of their cases and both advocated
trained physician anesthesia.1-9 It is therefore
easy to see why Dr. Waters admired Dr. Snow. Circumstances dictated
that Dr. Snow could only promote his ideas as an individual to
a relatively small audience. Dr. Waters, on the other hand, was
able to organize a prestigious department both clinically and
academically that could introduce undergraduates to anesthesia
and train postgraduates. Many senior physician anesthetists from
all over the world also came as visitors to learn from his experience.
Postscript
Robert R. Macintosh, D.M., was rather unexpectedly appointed to
the newly endowed Nuffield Professorship of Anaesthetics at Oxford
in 1937, from a nonacademic background. 4,5 He
wisely, almost immediately, took academic leave to spend time
with Dr. Waters, who became a life-long friend. Macintosh subsequently
incorporated many of the concepts developed by Dr. Waters into
the structure of his department at Oxford. 3,4,5,7
References:
1. Gillespie NA. Ralph Milton Waters: A brief
biography. Br J Anaesth. 1948-49; 21:197-214.
2. Morris LE. The continuing influence of Ralph
M. Waters on education in anesthesiology. In: Rupreht J, van Lieburg
MJ, Lee JA, Erdmann W, eds. Anaesthesia: Essays on Its History.
Berlin: Springer-Verlag; 1985:32-35.
3. Macintosh RR. Ralph M. Waters Memorial Lecture.
Anaesthesia. 1970; 25:4-13.
4. Beinart J. A History of the Nuffield Department
of Anaesthetics, Oxford 1937-1987. Oxford University Press; 1987:1-40.
5. Boulton TB. The Association of Anaesthetists
of Great Britain and Ireland 1932-1992 and the Development of
the Specialty of Anaesthesia. London: Association of Anaesthetists
of Great Britain and Ireland; 1999:1-61.
6. Waters RM. John Snow, First Anesthetist. Bios
1936; 25:40-45.
7. Waters RM. Pioneering in anesthesiology. Postgrad
Med. 1948; 4:265-270.
8, Snow J. On Narcotism by the Inhalation of Vapours.
Ellis RH, ed. London: Royal Society of Medicine; 1991:1-112.
9. Snow J. On Chloroform and Other Anaesthetics:
Their Action and Administration. Richardson BW, ed. London: John
Churchill; 1858:1-443.
10. Betcher AM, Ciliberti BJ, Wood PM, Wright
LH. The jubilee year of organized anesthesia. Anesthesiology.
1956; 17:226-264.
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Thomas B. Boulton,
M.B., is Honorary Consultant Anaesthetist at Oxford and Reading,
England. He is past President of the Association of Anaesthetists
of Great Britain and Ireland and the History of Anaesthesia
Society in the United Kingdom, former editor of Anaesthesia
and well-known author and lecturer. |
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