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September 2001
Volume 65 |
Number 9
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| The Influence
of Ralph Waters on Regional Anesthesia |
Robert P. Sands, Jr., M.D.
1998 Fellow of the Wood Library-Museum.
| Ralph M. Waters, M.D.
[Figure 1], professor and founder of the University of Wisconsin
Department of Anesthesiology, is a key figure in anesthesiology
for many reasons. His keen interest in the effects of general
anesthesia on the human body is well represented in his impressive
list of publications. He authored a landmark article in 1926
on carbon dioxide (CO2) absorption. 1 He
followed this up by publishing his paper on the physiologic
and pharmacologic effects of cyclopropane on the human body.
2 Finally, as his piece de resistance, he
penned the book on chloroform anesthesia in 1958. 3 |
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Figure 1: Ralph M. Waters, M.D.
(circa 1945)
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All of these accomplishments are known to most of those who have
even a passing interest in the history of anesthesiology. However,
many of those who consider themselves well-versed in the career
of this great man are unaware that he had strong interests in
regional anesthesia.
To say that Dr. Waters was an unknown in the field of regional
anesthesia would be to do the man a disservice. Although his list
of publications is not nearly as long in this area as it is in
topics pertaining to general anesthesia, he did publish important
work. In 1933, he authored a comprehensive paper dealing with
the prophylaxis and treatment of procaine toxicity. 4
Procaine had already been in use for about 30 years when Dr.
Waters published his paper. He believed that even though the drug
was utilized regularly by many nonanesthesiologists and considered
to be the safest, most reliable local anesthetic, it was still
important to review the side effects and treatment of toxicity.
He outlined the five conditions that determined the potential
for toxicity: susceptibility of the patient, total weight of drug
injected, strength of the solution, rate of injection and vascularity
of the body part injected.
As with his other published work, he went into much detail concerning
signs and symptoms that could be exhibited by the patient who
had received a toxic dose of procaine. A comprehensive treatment
and prophylaxis section followed that outlined the risks/benefits
of the addition of epinephrine to the procaine solution and delineated
the advantages of using a barbiturate as a premedication.
Another paper by Waters, “Drugs and Methods for the ‘Occasional’
Anesthetist,” 5 also had a section dealing
with local anesthetics, specifically procaine. The section dealt
with the administration of the drug into the subarachnoid space.
He cautions those using procaine in the subarachnoid space: failure
may create the temptation to supplement with inhalational drugs,
which may be dangerous in the hands of nonanesthesiologists. He
goes on to say, “Anyone can inject through a hollow needle.
Knowledge and experience are nevertheless necessary to foresee
the physiologic and pharmacologic changes that may result in a
patient following such injections.”
The aforementioned publications can be obtained with a little
digging and make for some interesting reading, but they do not
tell the whole story. To bring this other facet of Dr. Waters’
professional life into focus, one must closely examine his glass
lantern slide collection housed at the Wood Library-Museum of
Anesthesiology (WLM). The WLM has slide collections from many
of the anesthesiologists who shaped the field: John S. Lundy,
M.D., Albert M. Betcher, M.D., and Paul M. Wood, M.D., to name
a few. Dr. Waters’ collection, donated after his death by
his son Darwin, contains more than 350 slides. The majority of
the slides pertain to the topics most readily associated with
Dr. Waters: cyclopropane, chloroform and CO2 absorption. Approximately
10 percent of the slides are devoted to the practice of regional
anesthesia.
Of the 36 slides dealing with regional anesthesia, a little more
than one-third depict topics and techniques of subarachnoid block.
There are basic anatomy slides demonstrating ligaments, bone and
dura from different views, thus permitting Dr. Waters to stress
to the audience the anatomic relationships that need to be understood
in order to deliver the drug to the correct area. Three of the
anatomic diagrams contain German text [Figure
2]. These were probably chosen over English versions because
of the superior anatomic illustrations. 6
| Figure 3: Sterile spinal
kit from Waters’ slide collection. |
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A subset of the slides deals with the clinical aspects of
the subarachnoid block.Two of the three demonstrate the effect
of procaine administration on peripheral temperature control
by graphing the skin temperature of the patients’ feet
versus time since procaine was administered. Another slide
lists the frequently utilized local anesthetics of that era
and the ratio of effectiveness when compared with the gold
standard, procaine [Table
1]. The table also lists where the local anesthetics can
safely be injected, what other solutions with which they can
be mixed, the specific gravity compared to cerebrospinal fluid
and the average dose administered. The last slide of the series
depicts a sterile spinal kit that would have been utilized
during that era [Figure 3]. |
A slide series pertaining to epidural and caudal blockade is
also included in Waters’ glass lantern collection, but it
is smaller. The anatomic and clinical slides correlate with those
from the spinal series. Of note is the slide which demonstrates
the technique utilized to locate the caudal space along with the
proper hand and needle placement to correctly perform the block.
The final slide in this series is the sterile epidural kit used
by practitioners at that time.
The other 18 slides depict miscellaneous topics that Dr. Waters
believed were important for regional anesthetists to understand.
They include the dermatomes of the body, anterior and posterior
views (10 slides) and hand placement to correctly perform a myriad
of other nerve blocks, including brachial plexus, intercostals,
abdominal field, anterior and posterior tibial and sacral (eight
slides).
Although Dr. Ralph Waters is best known for his work with CO2
absorption and chloroform, he also was an adept regional anesthetist,
as can be corroborated by perusing his glass lantern slide collection
and his publications in the area. Because of this facility with
both general and regional techniques, Dr. Waters was able to offer
all of his patients a highly personalized anesthetic that would
optimize their surgical outcome.
References:
1. Waters RM. Advantages and technique of carbon
dioxid filtration with inhalation anesthesia. Anesth Analg. 1926;
5:160-162.
2. Waters RM, Schmidt MR. Cyclopropane anesthesia.
JAMA. 1934; 103:975-983.
3. Waters RM. ed. Chloroform — A Study After
100 Years. Madison, WI: George Banta Publishing Co; 1951.
4. Waters RM. Procaine toxicity: Its prophylaxis
and treatment. J Am Dent Assoc. 1933; 20:2211-2215.
5. Waters RM. Drugs and methods for the “occasional”
anesthetist. Postgrad Med. 1948; 2:77-84.
6. Sands RP, Bacon DR. Ralph Waters as a regional
anesthesiologist. Reg Anesth and Pain Med. 1999; 24:252-254.
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Robert
P. Sands, Jr., M.D., is Assistant Professor of Clinical Anesthesiology,
State University of New York at Buffalo, and Staff Anesthesiologist
at Roswell Park Cancer Institute, Buffalo, New York. |
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