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September 2001
Volume 65 |
Number 9
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| Ralph Milton Waters:
His Influence on the World and Me |
Carlos P. Parsloe, M.D.
The purpose of this essay is to present two of my most poignant
memories of “the Chief” and to describe the impact of
his professionalism and leadership on the practice of anesthesiology
throughout the world.
Two revealing personal episodes:
On a cold and wet Saturday afternoon in April 1946, I arrived
in Madison, Wisconsin, for an interview with Ralph Waters, M.D.
I was a candidate for a residency in anesthesiology. Correspondence
from Chicago, where I was an intern, informed Dr. Waters that
my schedule permitted only two opportunities to visit Madison.
His short answer was “Come when you can.” I had no letters
of recommendation and had no idea what to expect. The naivete
of youth generally diminishes eventual difficulties. Once in Madison,
I called him at home. The reply was, “Can you come to the
hospital tomorrow at 1 p.m.?” “Yes,” I said, but
I thought to myself, “Tomorrow is Sunday. How can a professor
leave his home to interview a young unknown candidate from far
away Brazil?”
I found him at his small office smoking a pipe, a relaxed, self-confident
person. After five minutes of conversation, I decided that if
accepted, I would go to Madison. That was the impact of his personality
on a young man with little knowledge of anesthesia. I had given
a number of general anesthetics in Rio de Janeiro with the Ombrédanne
inhaler but without any real knowledge of what I was doing. Thankfully,
human beings are resilient to nonphysiological assaults. That
the world’s first and foremost professor of anesthesia (something
that I did not realize at the time!) left his home on a Sunday
to interview a candidate from a remote country, with no special
gifts of any kind, is testimony to the generosity of his personality.
I was accepted, but I never asked Dr. Waters the basis for his
decision. That one-hour interview literally changed my whole life.
Fifty-five years have elapsed and never for one moment have I
had reason to regret my decision. I went to Madison with no particular
direction in life and left with a rosy future, a finite background
of knowledge, a crowd of life-long friends, a good Wisconsin wife
and the most pleasant memories of two unforgettable years, working
and learning in a most hospitable atmosphere.
The second episode occurred on a fateful morning during my second
year. I started to anesthetize a very young girl with bronchiectasis
for lobectomy. She was frightened, repeating, “I am going
to die.” I did not believe her until her heart stopped. Resuscitation
with an open thorax proved useless, and after an hour, we gave
up. I was extremely upset and did not know what to expect.
Later in the day, I met with the Chief. I had made meticulous
notes of the whole unfortunate accident. I was greeted with, “Carlos,
tell me what happened.” After listening without interruption,
he told me, “Well, those things unfortunately can happen,
you should not blame yourself. We will discuss this death at the
Wednesday conference.”
I was one of the last to arrive at the room. To my surprise,
the professor of thoracic surgery, who was the patient’s
surgeon, was sitting at Dr. Waters’ side. Dr. Waters began,
“There was an unfortunate death on induction. Would the surgeon
describe the patient’s condition?” The patient was a
chronic bronchiectatic with profuse secretions that could not
be controlled. She needed removal of the affected lung to improve
her condition. I then explained how I started giving cyclopropane
to a very frightened girl while she was crying. The heart had
stopped before induction was complete. Profuse secretions prevented
proper ventilation, and all efforts at resuscitation had failed.
Dr. Waters then thanked the surgeon and excused him. While I had
expected the worst, Dr. Waters aimed no recriminations or blame
at me. In retrospect, hypoxia and catecholamine surge combined
with cyclopropane stopped the heart. The lesson was learned. What
could have been a remorseful episode turned out to be a learning
one, benefiting everyone and relieving my guilty feeling.
These two episodes tell a great deal about how Dr. Waters conducted
his training. In an emotionally charged situation, he persuaded
the surgeon to come to the meeting and to alleviate my utter discomfort.
I felt protected and could continue my training without feeling
despair. Those two episodes, which remain vividly clear in my
memory after 55 years, have generated a profound humility and
gratitude for the wisdom and leadership of Dr. Ralph Waters.
I vividly remember seeing the Chief daily in the operating rooms
administering anesthesia. I do not remember hearing him tell me
or anyone else what to do. Residents needed only to imitate his
demeanor and activities. We watched him gently apply a mask and
proceed with a smooth cyclopropane induction. Then we tried as
hard as we could to emulate him, realizing all the time that this
was no small task. Of course, those were the days of a mask, a
to-and-fro canister and a five-liter rebreathing bag. Cyclopropane
and sometimes nitrous oxide with oxygen were the “joy”
of our practice. The “joy” included adapting the mask
to the patient’s face, often over a nasogastric tube and
using controlled manual ventilation assisted by an oropharyngeal
airway.
He gave a few lectures to the student classes. The residents’
didactic teaching consisted of the Monday evening literature review
and the Wednesday afternoon case discussions. In addition to Dr.
Waters, Sidney Orth, M.D., from pharmacology always had answers
to many questions about drug effects, and Noel A. Gillespie, M.D.,
originally from England, had dissenting views on just about every
clinical situation. The frank and lively exchange of opinions
provided for a rich learning ambiance.
Dr. Waters’ International Projection
The international stature of Dr. Waters at the time was most remarkable.
Madison was the mecca of anesthesia during the 1930s and 1940s.
Travel was difficult, and correspondence by mail was the best
available means of communication. The Waters archive at the Department
of Anesthesiology, University of Wisconsin, is full of revealing
letters. Most notable, perhaps, is the correspondence with Arthur
E. Guedel, M.D., and Geoffrey Kaye, M.D., from Australia. It conveys
insight into important problems of the time, such as arrhythmias
with cyclopropane.
The Anesthetists Travel Club was formed early and provided an
opportunity to gather the few anesthesiologists in the United
States and Canada to meet and exchange opinions. Large congresses
did not exist. As a consequence, Waters did not travel much. Instead,
colleagues from many countries came to Madison to imbibe the Chief’s
simple and basic teachings. These are expressed in the book that
he edited, Fundamentals of Anesthesia, published by the American
Medical Association. The book, which was my first source of information,
emphasizes airway and ventilation as fundamental to patient safety.
| Ralph M. Waters, M.D., right,
with Torsten Gordh, M.D., from Sweden at the
Third World Congress of Anaesthesiology, September
20-26, 1964, in São Paulo, Brazil.
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Sir Robert R. Macintosh, D.M., visited with Dr. Waters
prior to becoming the first professor of anesthesia in the
United Kingdom and starting a new department at Oxford.
He came to exchange ideas with Dr. Waters and to absorb
the concept of a triad of clinical practice, teaching and
research as the basic tenet of a university department.
M. Digby Leigh, M.D., from Canada was a resident with Dr.
Waters before establishing the subspecialty of pediatric
anesthesia and becoming a professor in Montreal. The first
four Swedish anesthesiologists were trained by Dr. Waters,
who received the Vasa Medal from the Swedish government
for this achievement in 1948. Eric Nilsson, M.D., from Lund
and Karl-Gustav Dhuner, M.D., from Gothenburg were fellow
residents with me. Torsten Gordh, M.D., and Olle Friberg,
M.D., finished before I started.
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We residents learned about the Vasa Medal by reading the local
newspaper the day following the presentation by the Swedish Consul
in Chicago. This reveals the modesty of Dr. Waters. Jone Wu, M.D.,
a pharmacologist from Shanghai, became a resident during my time
and returned to China to establish a department in Shanghai. He
is the father and grandfather of all Chinese anesthesiologists.
He, like Dr. Gordh in Sweden, was the first professor of anesthesiology
in his country. Professor Juan Nesi from Buenos Aires was a notable
visitor. Martinez Curbello, M.D., from Havana, Cuba, who had introduced
continuous peridural anesthesia with a ureteral catheter in 1947,
demonstrated the technique in Madison. Professor Edward Pask from
the United Kingdom also visited. Olive Jones, M.D., from Oxford
spent one year mostly engaged in neurosurgical anesthesia, her
specialty. Colleagues from India, Brazil, Mexico, Peru and Uruguay
learned the safe conduct of anesthesia with Dr. Waters in Madison.
As a result, anesthesiology in Latin America became physician-based
and well developed since 1940.
Waters did travel to England in 1936 at the invitation of the
British Medical Association to lecture on cyclopropane and to
receive honorary membership in the Royal Society of Medicine.
That was the only time he left the United States during his professorship.
After retirement in 1950, he traveled to Copenhagen to become
a teacher in the World Health Organization training center for
anesthesiologists. He then moved to Orlando, Florida, and refused
all invitations to travel. Nevertheless, in preparation for the
Third World Congress of Anaesthesiology in São Paulo, Brazil,
in 1964, I was determined to have Dr. Waters give the opening
lecture. Repeated invitations were nicely declined. Desperate
to achieve my desire, I discussed the problem with Perry P. Volpitto,
M.D. He advised me to invite Mrs. Waters. The Chief came to São
Paulo and gave a short but incisive opening speech, which was
later published in Survey of Anesthesiology. It illustrates his
knowledge of the history of anesthesia as well as his concern
for the training of physicians as anesthesiologists throughout
the world.
The golden days of the new specialty of anesthesiology produced
many memories for those who were privileged to have met and worked
with the Ralph Waters in Madison. The genealogical tree of Waters
alumni prepared by Lucien E. Morris, M.D., (see pages 22-23) depicts
the solid trunk and branches into most states in the United States
and four continents of the world. This was the extent of the influence
of this great pioneer in anesthesiology.
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Carlos
P. Parsloe, M.D., is an anesthesiologist practicing at Hospital
Samaritano, São Paulo, Brazil. |
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