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September 2001
Volume 65 |
Number 9
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| The Investigator
and His ‘Uncompromising Scientific Honesty’ |
John E. Steinhaus, M.D., Ph.D.
Ralph M. Waters, M.D., began a general medical practice in Sioux
City, Iowa, in 1912. After a short time, he limited himself to
anesthesia and obstetrics. A year or so later, after returning
from a year’s military service in Mexico, he found serious
conflicts in scheduling obstetrics and anesthesia practice, and
he further limited himself to anesthesiology. Although he was
a self-trained specialist, a common medical practice in those
days, he recognized the serious shortcomings and inadequacies
of early 20th century medicine, especially anesthesiology. He
constantly raised questions about the scientific fundamentals
of anesthesia practice and sought answers to these questions and
problems by his own recorded observations and available medical
publications. During his time in Sioux City, he published 10 papers
and, after he moved to Kansas City in 1924, he published another
four.
One of his major interests was the role of carbon dioxide during
anesthetic administration. The Heidbrink and other early anesthesia
machines were designed with a yoke for a tank of carbon dioxide
because some anesthesia authorities believed that this gas was
necessary for good anesthesia. Dr. Waters was concerned about
excesses of carbon dioxide as well as the wasteful partial rebreathing
technique in common use. In 1924, he published his first paper
on carbon dioxide filtration using the “Waters” canister
1 [Figure
1]. Dr. Waters maintained a strong interest in carbon dioxide
during his career in anesthesia with publications in his last
year before retirement. Two fascinating case reports in 1921 describe
attempted resuscitations of two patients with high-pressure oxygen.
In both instances, peripheral oxygenation was established and,
in one, both pulse and spontaneous respiration, although both
patients died. In his discussions, Dr. Waters suggests —
many years before this cardiac compression became established
— that the mechanical pressure of the gas in the chest could
re-establish circulation.
| “Dr.
Waters realized that the medical school center with its cadre
of basic scientists as well as skilled clinical faculty was
needed to solve these problems.” |
Although private practitioners of anesthesiology can raise many
questions concerning their observations during the administration
of anesthetics, they are limited in their effort to find answers.
Dr. Waters realized that the medical school center with its cadre
of basic scientists as well as skilled clinical faculty was needed
to solve these problems. In 1927, Dr. Waters joined the medical
school faculty at the University of Wisconsin as director and
assistant professor of anesthesia. Although patient care, education
of medical students and training of residents were listed as the
first three objectives of his program at Wisconsin, the fourth
objective was “the encouragement of as much cooperative investigation
as is consistent with the first three objectives.” 2
A strong basic science faculty at Madison was part of the attraction
to the University of Wisconsin. Among the nationally recognized
experts in pharmacology and physiology were Drs. Loevenheart,
Leake, Tatum, Meeks and Eyster whose research was on or related
to anesthetic drugs and physiological change during the administration
of anesthesia.
Ralph Waters was very modest about his role as a medical researcher,
and yet, his name appeared with Leake and others in 1927, his
first year at Madison. His interest in carbon dioxide continued
in his work with Chauncey Leake on the anesthetic properties of
carbon dioxide and with Dr. Loevenheart (pharmacology) and Dr.
Lorenz (psychiatry) on its cerebral stimulation. In his paper,
“Carbon Dioxide: Its Place in Anesthesia,” 3
Dr. Waters urges conservative use of both rebreathing and
the addition of this gas to the breathing mixture until more was
known about fundamental physiological changes that were involved.
Dr. Waters’ research interests expanded as his program became
more established. His studies with Guedel in 1928 reported on
a new technique with cuffed endotracheal tubes. 4
A few years later, however, they published a historical paper
on these catheters in which they gave credit to Torrance, who
first reported inflatable cuffs in 1910. The introduction of cyclopropane
popularized the closed system and the cuffed endotracheal tube
because this new gas was expensive and in short supply. Dr. Waters’
children earned their pocket money making cuffed tubes. An interesting
letter to the Duvall catheter company elicited a response that
they saw no commercial future in cuffed endotracheal tubes.
In keeping with his original objectives, Dr. Waters was most
productive in collaborative investigations with the pharmacology
and physiology faculty. Studies were reported on a new anesthetic,
tribromethanol, with Seevers and several surgeons. A new barbiturate,
thiopental, was employed in an investigation with Tatum in 1934.
This new anesthetic was reported to be satisfactory for short
surgical procedures but lacking good analgesic properties.
Dr. Waters was widely known for his clinical introduction of
cyclopropane, which had been investigated by studies in animals
by Henderson from Toronto. His investigations led to extensive
clinical studies 5 as well as basic science studies.
The electrocardiac changes that were observed led to a number
of basic science studies culminating in Meek’s (physiology)
Harvey lecture in 1941. 6
Waters also reported studies on local and regional anesthesia.
In 1932, Seevers and Waters reported a study on spinal anesthesia.
7 Influenced by Loevenheart and Tatum, both authorities
on local anesthetic toxicity, he reported on the toxicity of procaine
and its treatment. His interest in pain therapy, which he considered
to be an important part of anesthesiology, is shown in his papers
on labor pains and pain in children. 8
A number of investigations and reports by Dr. Waters included
oxygen deficiencies and the therapeutic use of oxygen both in
the operating rooms and the wards. As a consequence of his interest
and concern for the hypoxic patient, the Wisconsin General Hospital
installed piped-in oxygen into the patient rooms on the surgical
ward. 9 The nasal catheter for oxygen delivery
was introduced and used routinely for patients recovering from
anesthesia.
Since the skills of the anesthesiologist are very useful in resuscitation,
he not only emphasized techniques of artificial respiration to
medical students but also studied the accepted methods as to their
effectiveness.10 He emphasized the need for
an unobstructed airway and a method of moving the oxygen into
the lungs. He points out that the most simple and always available
method is mouth-to- mouth, which became the most recommended technique
35 years later.
Dr. Waters’ impact on laboratory research related to anesthesia
at the medical school is demonstrated by comparing the resulting
publications for the 15 years before his arrival, 1912 to 1926,
during which time there were 15 publications predominantly from
pharmacology. From 1927 to 1941, there were 90 laboratory publications.
Dr. Waters was primary author on one and co-author on 13. In addition,
there were 15 papers that had other anesthesiologists as co-authors.
The index of all publications from the department of anesthesiology
from 1940 to 1948, his last years of practice, listed 65. Waters’
name appeared on 30 of these, many as the sole author.
In a sense, Dr. Waters in his career was a lot like Tom Sawyer,
who was adept at getting others “to paint his fence.”
He had questions about anesthesia and anesthetic drugs, and he
stimulated other researchers to pursue the answers. He was very
modest about his contributions and often gave priority to his
residents and junior colleagues. Always ready to challenge currently
accepted medical knowledge, he encouraged and eventually edited
the centennial re-evaluation of chloroform (1947) in his final
two years. 11 It was concluded in this study
that chloroform was a reasonably safe agent, provided there was
careful maintenance of oxygenation and other physiological variables.
In contrast to several national and international medical scientists
of my acquaintance who had little tolerance for findings that
did not fit their own significant contributions, Dr. Waters was
modest and seldom pushed his own claim for priority and would
question even medical knowledge that he had published.
An impressive description of Ralph M. Waters appears in the “Brief
Biography” by Noel A. Gillespie, M.D., an anesthesiologist
faculty colleague of his. Included is a statement from the late
Geoffrey Kaye, M.D., of Melbourne, Australia, who had visited
the department of anesthesiology at Madison. He stated that the
department reflects the personality of one man. He followed with
the comment: “The salient characteristic of Ralph Waters
is his uncompromising scientific honesty.” He goes on to
write “that he has inspired in his department a high tradition
of the inquiring mind, the scientific approach and absolute honesty
as to the results.” 12
References:
1. Waters RM. Clinical scope and utility of carbon
dioxide filtration. Anesth Analg. 1924; 3:20-21.
2. Waters RM. Pioneering in anesthesiology. Postgrad
Med. 1948; 4:265.
3. Waters RM. Carbon dioxide and its place in anesthesia.
Can Med Assoc J. 1929; 17:1510.
4. Guedel AE, Waters RM. A new intratracheal catheter.
Cur Res Anes & Anal. 1928; 7:238-239.
5. Waters RM. Present status of cyclopropane. Brit
Med J. 1936; 2:1013-1017.
6. Meeks WJ. Some Cardiac Effects of the Inhalant
Anesthetics and Sympathomimetic Amines. Harvey Lecture Series. 1940-41;
36:188.
7. Seevers MH, Waters, RM. Respiratory and circulatory
change during spinal anesthesia. JAMA. 1952; 99:961-963.
8. Waters RM, Harris LW. Factors influencing the
safety of pain relief in labor. Am J Surg. 1940; 48:129-134.
9. Waters RM, Buerki RC, Hathoway HR. Oxygen therapy
at the Wisconsin General Hospital. Hosp. 1936; 10:1-4.
10. Waters RM. Methods of Resuscitation. J Lab
Clin Med. 1942; 26:272-277.
11. Waters RM. ed. Chloroform, A Study After 100
Years. Madison: University of Wisconsin Press. 1951.
12. Gillespie NA. A brief biography. Brit J Anaesth.
1949; 21:198-215.
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John E. Steinhaus,
M.D., Ph.D., is Professor Emeritus, Department of Anesthesiology,
Emory University School of Medicine, Atlanta, Georgia. |
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