Koch 2015-anesthesia &-analgesia

March 2015 • Volume 120 • Number 3 www.anesthesia-analgesia.org 653

Copyright © 2015 International Anesthesia Research SocietyDOI: 10.1213/ANE.0000000000000618

Because of the frequent mortality associated with both anesthesia and surgery, the 50 years after Morton’s demonstration of ether anesthesia in 1846 were some-

times called the “period of the failed promise.”1 “With surgery, the main culprit was infection… With anesthesia, problems arose from unskilled administration by ‘occa-sional anesthetists’.”1

Nurses collaborated with surgeons to solve both these problems. First, surgeons depended on nurses to minimize the transmission of infection.2 Before the acceptance of asep-tic practice in the late 1890s, nurses followed Joseph Lister’s prescription to spray carbolic acid over the operating room. At Johns Hopkins Hospital in Baltimore, surgeons and nurses dipped their hands in permanganate, oxalic acid, and mercuric acid in a multistep cleansing process. Mercuric acid so irritated the hands of the scrub nurse for Chief Surgeon William Halsted (1852–1922), Caroline Hampton, that he commissioned the production of high-quality gloves from the Goodyear Rubber Company, thereby protecting Hampton’s hands and inci-dentally further decreasing the incidence of infection. “The introduction of rubber gloves to surgery began as simply and unremarkably as protecting a nurse’s skin from irritation.”3

With infections reduced, surgeons turned their attention to the need for quality anesthesia. In 1953, Virginia Thatcher, the first historian of nurses as anesthetists wrote: “Finally, opera-tions could be performed without fear of fatal surgical infec-tion, and …no longer could surgeons afford to tolerate the consequences of hit-or-miss anesthesia when the whole human body lured them to new adventures in surgical therapeutics.”4

The Civil War greatly increased the number of surgeries and thus anesthetics. The demand for anesthesia was filled, at least in part, by recruiting nurses. Thatcher quotes a report from an 1866 publication. “On July 4, 1863, after the Battle of Gettysburg, a Mrs. John Harris ‘taking some chloroform and stimulants…left Baltimore…and penetrated as near as possible to the scene of the conflict, administering as much as in her power to the stream of wounded…”5 We do not know if Mrs. Harris was a trained nurse. A second report is of an unnamed “nurse in attendance” who also admin-istered chloroform to a wounded soldier.6 A third report is specific. Catherine S. Lawrence, a native of Skaneateles, New York, had undergone nurse training under Dorothea Dix (of mental health fame) and administered chloroform at the Kalorama Hospital in Washington, DC, around the time of the Second Battle of Bull Run (1862). It is not known who the surgeon was, and Lawrence mentioned only once in her autobiography that she “tied arteries and administered chloroform.”7,8 Thus, it is unlikely that anesthesia formed more than a small part of her duties, but Lawrence was the earliest known nurse who practiced anesthesia.

After the Civil War, nurse anesthesia was born out of the need, as Thatcher aptly put it, for anesthetists who would: “1. be satisfied with the subordinate role that the work required; 2. make anesthesia their one absorbing interest, 3. not look on the situation of anesthetist as one that put them in a position to watch and learn from the surgeon’s

To meet the need for qualified anesthetists, American surgeons recruited nurses to practice anesthesia during the Civil War and in the latter half of the 19th century. The success of this deci-sion led them to collaborate with nurses more formally at the Mayo Clinic in Minnesota. During the 1890s, Alice Magaw refined the safe administration of ether. Florence Henderson continued her work improving the safety of ether administration during the first decade of the 20th century. Safe anesthesia enabled the Mayo surgeons to turn the St. Mary’s Hospital into a surgical pow-erhouse. The prominent surgeon George Crile collaborated with Agatha Hodgins at the Lakeside Hospital in Cleveland to introduce nitrous oxide/oxygen anesthesia. Nitrous oxide/oxygen caused less cardiovascular depression than ether and thus saved the lives of countless trauma victims during World War I. Crile devised “anoci-association,” an outgrowth of nitrous oxide/oxygen anes-thesia. Hodgins’ use of anoci-association made Crile’s thyroid operations safer. Pioneering East Coast surgeons followed the lead of the surgeons at Mayo. William Halsted worked closely with Margaret Boise, and Harvey Cushing worked closely with Gertrude Gerard. As medicine became more complex, collaboration between surgeons and nurse anesthetists became routine and necessary. Teams of surgeons and nurse anesthetists advanced thoracic, cardiovascular, and pediatric surgery. The team of Evarts Graham and Helen Lamb performed the world’s first pneu-monectomy. Surgeon-nurse anesthetist collaboration seems to have been a uniquely American phenomenon. This collaboration facilitated both the “Golden Age of Surgery” and the profession we know today as nurse anesthesia. (Anesth Analg 2015;120:653–62)

Surgeon-Nurse Anesthetist Collaboration Advanced Surgery Between 1889 and 1950Bruce Evan Koch, CRNA, MSN

From Kootenai Health, Coeur d’Alene, Idaho.

Accepted for publication November 20, 2014.

Funding: Self funded.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Bruce Evan Koch, CRNA, MSN, 30899 N. Nautical Loop, Spirit Lake, ID 83869. Address e-mail to [email protected].

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technique, 4. accept comparatively low pay, and 5. have the natural aptitude and intelligence to develop a high level of skill in providing the smooth anesthesia and relaxation that the surgeon required.”9

Catholic nuns, who worked for free in frontier hospi-tals, were drafted and formed the first group of identifiable nurse anesthetists. The earliest known example was Sister Mary Bernard who entered St. Vincent’s Hospital in Erie, Pennsylvania, in 1877 to take up nursing and “within the year was called upon to assume the duties of anesthetist.”10 One Sister, Secundina Mindrup (1868–1951), lived long enough to tell her story directly to Thatcher. “The doctors would come with their assistants to give the anesthesia, but then they would need the assistant for something else and would teach the Sister how to give the anesthesia.”10

A booming economy and gender bias drove this devel-opment as well. Westward expansion of the 1870s and 1880s led to the establishment of many small hospitals, an absence of physician anesthetists led surgeons to rely on just about anyone as an anesthetist, and they tended to favor women. Marianne Bankert, whose book Watchful Care: A History of America’s Nurse Anesthetists, expanded Virginia Thatcher’s work, made these points convincingly: “early discussion on the need for professional (medical) anesthetists returned again and again to the economic factor…talented physi-cians and interns had no (financial) incentive to concentrate on the giving of anesthetics.”11 Bankert found that bed-side manner mattered too: “what was fundamentally an economic issue was resolved by utilizing talented, trained women, frequently was veiled, unconsciously and/or con-sciously, in a romantic aura praising the ‘natural’ appropri-ateness of women as anesthetists, labeling their expertise and concern for patients as uniquely ‘feminine.”11

THE FIRST SURGEON-NURSE ANESTHETIST PAIRSIn 1889, the Sisters of St. Francis opened St. Mary’s hospi-tal in Rochester Minnesota. There the Mayo brothers (Dr. William W. Mayo [1819–1911], Dr. William J. Mayo [1861–1939], and Dr. Charles H. Mayo [1865–1939]) distinguished themselves as surgeons. From the outset, “the Drs. Mayo saw no reason why an intelligent nurse could not be an able anesthetist, and Dr. W.W. Mayo undertook to teach Miss (Edith) Graham how to administer chloroform.”12 Edith and her sister Dinah Graham were graduate nurses (not nuns). “(F)rom the beginning, (they) administered the anesthesia, in addition to acting as the Mayos’ office nurse, general book-keeper and secretary.”12

Then in 1893, Alice Magaw came to St. Mary’s. She replaced Edith Graham who left nursing to marry Charles Mayo. Magaw had trained at the Women’s Hospital of Chicago under Mary Thompson, a physician. It is not known if anesthesia formed a part of Magaw’s nursing education. Two researchers Jeff Nelson and Steve Wilstead speculated that Thompson, who was said to have “opened many doors for the future medical training of women,” inspired Magaw to “make a mark in her role as a nurse anesthetist through commitment to details, expert clinical practices, and a pio-neering spirit.”13 Magaw would indeed make a mark on anesthesia.

Two surgeons, Albert Ochsner of Chicago and James Moore of Minneapolis, had brought to the United States the German practice of inducing anesthesia by gradu-ally increasing the dripping of ether onto a gauze-covered mask. Magaw adopted this technique. Dripping ether was a significant advance over the popular custom of pouring ether onto a sponge wedged inside a paper cone. Patients breathed from the cone and often became hypoxic. In 1 of her 6 publications, Magaw argued that ether should “not be combined with asphyxia, as has been recommended and is now practiced in many hospitals, the so-called ‘choking or smothering method’.”14

Magaw induced anesthesia by gradually increasing the application of ether onto the gauze while slowly bringing the mask to the patient’s face. She complimented this tech-nique by speaking to her patients, continually reassuring them throughout the induction of anesthesia. Because a patient’s inhibitions might disappear before they lost con-sciousness, they might become fearful and struggle. But because the patient could still hear, Magaw used verbal reassurance to “do away with their fear.”15 Magaw elabo-rated: “Suggestion is a great aid in producing a comfort-able narcosis. The anaesthetist (sic) must be able to inspire confidence in the patient, and a great deal depends on the manner of approach…. The subconscious or secondary self is particularly susceptible to suggestive influence; therefore, during the administration, the anaesthetist should make those suggestions that will be most pleasing to this particu-lar subject. Patients should be prepared for each stage of the anaesthesia with an explanation of just how the anaesthetic is expected to affect him: ‘talk him to sleep,’ with the addi-tion of as little ether as possible.”15 With this method, Magaw reduced the amount of ether given for a typical operation and decreased the incidence of struggling to nearly zero. Her exemplary work prompted Charles H. Mayo to name Magaw “The Mother of Anesthesia.”16 Magaw listed and described many of these principles in articles she published between 1899 and 1904. She amassed a remarkable record of more than 14,000 anesthetics without a fatality. Nelson and Wilstead asserted that Magaw developed sound anesthesia principles that remain true today.14

Training in anesthesia was a part of nurses’ basic edu-cation at the turn of the 20th century. Isabel Hampton Robb’s text “Nursing: It’s Principles and Practice For Hospital and Private Use” contained a chapter entitled “The Administration of Anesthetics” that discussed local and general anesthetic drugs, airway management, the signs of anesthetic depth, and other aspects of caring for a patient during surgery.17 My own great aunt, Mabel Pfefferkorn graduated from Johns Hopkins Hospital School of Nursing about 1907. She left a series of 5 notebooks containing lec-ture notes. All the lectures were given by physicians. A section entitled Materia Medica contains 30 pages of notes from lectures by a Dr. Fort, who began with descriptions of the local use of ethyl alcohol (“greatly used for bathing purposes for its refrigeration”), chloroform, ethyl chloride, and cocaine. Writing of the general anesthetics ether and chloroform, Aunt Mable quoted Dr. Fort: “Ether is by far the less dangerous of the two, but in obstetrical cases and under certain conditions chloroform is preferable. Ether is highly inflammable and cannot be used near an open fire as on a

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battle field, nor where there are lamps or flame”(Pfefferkorn M, unpublished manuscript, 1906).

In 1903, the Mayos recruited Florence Henderson, a graduate of the Bishop Clarkson Hospital School of Nursing in Omaha Nebraska, to replace Dr. Isabella Herb. Florence Henderson’s training seems to have been similar to Mabel Pfefforkorn’s training. Henderson said she learned to administer chloroform and ether “in the taking of my nurse’s training and the three years following that, when I was the Superintendent of the Bishop Clarkson Memorial Hospital after my graduation.”18 According to Nancy Harris and Joan Dean, authors of a biography of Henderson, “The physicians taught as much nursing as the nursing super-intendent did, offering instruction in physiology, chem-istry, and pathophysiology.” But despite her education, Henderson initially served as “a nurse or nursing super-intendent until the position of anesthetist was vacated …” and was thought of as Magaw’s star pupil “in anticipation of her upcoming position.”19

Nurse anesthesia had not yet become formalized, but Magaw’s adept and innovative practice and Henderson’s training and practice set them apart. They were examples of what Thatcher identified as “the beginning of a new type of nurse, whose function was not restricted to providing food, cleanliness and comfort, but encompassed scientific skills that required knowledge of physics, chemistry and bacteri-ology.” Thatcher concluded that “it was inevitable that into her hands should fall more and more functions for which the physician, occupied with the application of new scien-tific learning in his practice, found he had no time.”20

Another factor contributing to the hiring of nurses as anesthetists was physician neglect of anesthesia. The Mayos recruited Miss Graham and then Miss Magaw “in the first place through necessity; they had no interns. And when the interns came, the brothers decided that a nurse was better suited to the task because she was more likely to keep her mind on it, whereas the intern was naturally more interested in what the surgeon was doing.”21 Between 1889 and 1910, the Mayos employed a complement of “anesthetizers.” Jean Pougiales listed 8 (Table 1).22 Only 2 were not nurses: Drs. Isabella Herb and Leda Stacy. Each anesthetist was associ-ated with a specific surgeon in a specific operating room.

With consistent and safe anesthesia, the Mayos pros-pered as surgeons. William Mayo Sr. wrote that throughout history, “Surgeons like (Ambroise) Pare could amputate a

leg or could take off an arm at the shoulder joint in the twin-kling of an eye, because the bulk of the anesthesia was pro-vided by strong men and ropes.”23 But his sons, the younger Mayos did not have to be speedy. They learned what they could by watching their father and visited clinics on the East Coast to observe other surgeons. They became respected for “sureness, soundness, and thoroughness,” not for speed.24

As their confidence grew, so did the number of opera-tions they performed. The trend is unmistakable (Fig. 1). From 655 in 1893 to 23,622 in 1919, the numbers then decreased slightly, perhaps due to World War I before level-ing off until 1924.25

Their operations also grew more complex. Once profi-cient with gynecologic operations, the Mayos learned about appendectomies. “One of the bitter classic battles of medical history” concerned whether to treat appendicitis medically or surgically. Drs. Will Mayo and Charlie Mayo adopted Albert Ochser’s “starvation treatment” of patients with a ruptured organ. “Put the patient at rest and give him abso-lutely nothing to eat or drink, above all no cathartics. In a few days the acutely dangerous phase will pass and appen-dectomy will be safe.” And it worked. “Probably nowhere in the nation did the number of operations for appendici-tis mount so quickly or so high as in Rochester. In 1900 the number for the year was one hundred eighty-six. In 1905 it passed the thousand mark.”26 This was revolutionary.

The Mayos were not averse to risk taking. In their era, thyroid operations were thought of as dangerously “fool-hardy performances” due to the risk of uncontrollable blood loss. Charles Mayo reported in 1912 that he had per-formed 278 successfully.27 This prompted one British author to write: “All in all, in his time, Mayo remained unmatched in his continent for the highest number of thyroidectomies and the lowest operative mortality, hence his other title, the ‘Father of American Thyroid Surgery’.”28 The Mayos even performed some neurosurgical procedures, the first in 1891. “The cases mainly involved trauma to the head, spine, and peripheral nerves, although abscesses and tumors were also described.”29

With success and numbers like these, wrote Professor Roy Porter of the Wellcome Institute for the History of Science,

Table 1. Anesthetists and Surgeons to Whom They Were Assigned at the Mayo Clinic, 1889 Through 1910, with Year of Termination

Anesthetists YearsOperating

rooms SurgeonsEdith Graham 1889–1893 2 Drs. W.J. Mayo and

C.H. MayoAlice Magaw 1893–1918 2 Drs. W.J. Mayo and

C.H. MayoDr. Isabella Herb 1899–1904 2 Dr. C.H. MayoFlorence Henderson 1904–1917 2 Dr. C.H. MayoMary Hines 1905–1936 3 Dr. E. Starr JuddDr. Leda J. Stacy 1908–1910 4 Dr. Emil BeckmanMary Shortner 1909–1949 4 Dr. Emil BeckmanAnn Powderly 1909–1950 4 Dr. C.H. Mayo

Figure 1. Growth of operative work at the Mayo Clinic between 1889 and 1920, from Mayo Clinic Division of Publications. Adapted from: Sketch of the History of the Mayo Clinic and the Mayo Foundation. Philadelphia, WB Saunders, 1926.25


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the Mayos “turned the local Minnesota hospital, St. Mary’s, into a surgical powerhouse.”30 Due to their influence, “sur-gery developed a scope and achieved a popularity hitherto unthinkable; the Mayos became household names and mil-lionaires.”30 Asked to name the better surgeon, William Halsted reportedly said: “Dr. Will is a wonderful surgeon. Dr. Charlie is a surgical wonder.”31 Paul Starr the historian of American medicine called the Mayos the “Midwestern virtuosos.”32

Quality anesthesia, no less than asepsis, drove this devel-opment. Edward Ochsner was one of the many surgeons to visit Rochester Minnesota. In 1905, he claimed that the: “lack of mortality [at the Mayo Clinic] is due to the fact that they have competent anaesthetists.”33 Surgeon Lawrence Littig of Iowa City wrote: “Many of us have had the plea-sure and privilege of seeing that peerless anesthetist, Alice Magaw, and also Miss Henderson, who anesthetizes for Dr. Charles Mayo, ‘talk their patients to sleep,’ and we have been charmed and instructed by the manner in which these ladies do their work. The lessons they have taught, and are teaching, practitioners have been carried far and wide, and (are) practiced by men throughout Iowa and many other states.”34 S. Griffith Davis was a physician anesthetist to Harvey Cushing at Johns Hopkins Hospital in Baltimore. In 1907 (more than 10 years after its inception!), Davis wrote “About a year and a half ago I first saw the drop method, during a visit to St. Mary’s Hospital in Rochester, Minn., where it was so skillfully administered by Miss Alice Magaw and her assistant.”35 And finally surgeons from England witnessed the Mayo nurse anesthetists and pub-lished similar testimonials.36,37

If the Mayos’ nurse anesthetists encountered anesthe-sia-related complications, they were not examined as such. Charles Mayo wrote “The difficulties which arose were from shock, which usually meant loss of blood…”38 (Blood trans-fusions were pioneered later, see below). Describing stomach operations, Magaw wrote that “it is with these cases that we have most of our pneumonias…”39 But she pointed out that the medical community believed that “many of the pneu-monias are probably due to infection from within or to auto-infection. They occur after local anesthesia as well as after general.”39 In fact, the anesthesia outcomes at the St. Mary’s Hospital were considered quite good. The numbers exceeded 14,000 anesthetics without a death related to anesthesia.40

The advent of safe anesthesia during this era lessened the public’s fear of hospitals. When St. Mary’s opened its doors in 1889, “Miss (Edith) Graham remembered that: We almost had to lock some of the first patients in their rooms; they were so sure they were going to die if they came to a hospi-tal.”41 But, in tracing the evolution of rural community hos-pitals, Charles Rosenberg, an eminent Professor of History and Sociology at the University of Pennsylvania, found that safe surgery renewed people’s faith in hospitals, making “institutional treatment seem both necessary and proper—a sign of family devotion and not neglect…Minnesota’s Mayo Clinic was only the most famous and atypically suc-cessful of small-town enterprises.”42 Although some people remained skeptical of “surgeons and their willingness to solve diagnostic problems with their scalpels,” they were in the minority. “Most communities looked on their local

hospitals with pride and hope.”42 The nurses who practiced anesthesia during this era contributed to this success.

Collaboration Between Nurse Anesthetists and Surgeons Spreads Across the CountryNurse anesthesia was born in the Midwest in the latter decades of the 19th century. But Thatcher provides examples to show that by the second decade of the 20th century even “conservative” surgeons in Massachusetts, Rhode Island, Philadelphia, and New York “had capitulated to nurse anes-thesia.”43 William Halsted’s adoption of nurse-administered anesthesia at Johns Hopkins Hospital is a specific example. Halsted developed techniques to repair hernias, anasta-mose bowel, and treat breast cancer. His radical mastectomy became the treatment of choice for decades. And Halsted’s model of teaching formed the basis of modern surgical resi-dency training.

But Halsted resisted nurse anesthesia. According to Thatcher as late as 1908, “interns were giving ether by the cone and struggle method” because William Halsted believed that all interns should learn how to give ether. “To Harvey Cushing (1869–1939), the father of neurosurgery, this kind of anesthesia had nothing to recommend it in operations for brain tumors, and Cushing employed (physician) S. Griffith Davis to administer anesthesia for him. Private patients paid for this service; for public (charity) patients Cushing paid Davis out of his own pocket.”43 In 1912, Cushing left Hopkins for Harvard University and Samuel Crowe was placed in charge of the otolaryngology service. “Crowe did not want house officers to administer anesthesia to his patients, nor could he afford to pay Davis, as had Cushing. He found the answer to his problem in Margaret Boise, (a nurse) whom he employed in 1913 as a private anesthetist with the reluctant consent of Halsted. When Hugh H. Young (1870–1945), with whom Crowe shared an operating room on alternate days, saw how well the anesthesia was managed on Crowe’s ser-vice, he asked to get in on the deal, and an arrangement was made whereby each would pay half Margaret Boise’s sal-ary… Halsted could not help but observe how the problems of anesthesia were being handled on the services of Crowe and Young, and when Margaret Boise had been at Hopkins for only a few months, he asked to borrow her for the admin-istration of anesthesia for a difficult thyroid operation. The upshot was that she was soon employed by the Johns Hopkins Hospital as the head anesthetist for the surgical department, and she gave anesthetics to most of Halsted’s patients until his death in 1922.”43

By 1913, Halsted was 61 years old. He “operated only a day or two each week, and rarely did more than a single case each day.”44 Yet, during this period, when Boise admin-istered Halsted’s anesthetics, he reported “650 cases of exophthalmic goiter,”44 and he “devised a method for drain-ing the common bile duct through the stump of the cystic duct.”44 Then in 1918, when members of Johns Hopkins Hospital deployed as Base Hospital 18 to France, Halsted “resumed a more arduous teaching and surgical sched-ule.”44 The arrangement with Boise paid off for Halsted and his patients. Furthermore, “while working for Crowe and Young, (Margaret Boise) devised a simple machine for the administration of anesthesia to patients undergoing



tonsillectomy and, in collaboration with Young, invented a gas-ether machine later known as the Boise-Young appara-tus.”45 Whether Boise enjoyed any proceeds from the sale of her anesthesia machinery is not known.

Harvey Cushing (1869–1939) expressed great interest in and concern for the quality of anesthesia. Cushing, together with the Boston surgeon Amory Codman (1869–1940), developed and implemented the first anesthetic record, to “focus the anesthetizers attention” on the patient rather than the surgery.46 A harrowing anesthetic death that Cushing contributed to as a third year medical student at Harvard and his experiences using a nurse anesthetist in Europe during World War I may have influenced his thinking.47,48 In 1912, Cushing employed the physician Walter Boothby as his anesthetist in Boston. The appointment proved to be temporary. Gertrude Gerard was a 1915 graduate of Peter Bent Brigham Hospital School of Nursing. She told histo-rian Thatcher that “Walter Boothby, the hospital’s chief anesthetist at the time, trained her (to administer anesthe-sia), and when he became head of the section on metabolism at the Mayo Clinic in 1916 she took his place as anesthetist for Harvey Cushing.”49

The working lives of Cushing and Gerard together have not been extensively investigated. It is known that, dur-ing World War I they deployed to France with the Harvard University medical unit as Base Hospital 5. Base Hospital 5 replaced a British medical team in Camiers, just south of Ypres where the fighting was intense. According to Cushing’s biographer Michael Bliss, the “Canadians and Australians told Cushing that the British had given the Americans the worst site for a hospital in all of France and warned him to expect indolence and indifference when he suggested reforms or innovations.”50 Nevertheless, Cushing, with Gerard, performed hundreds of operations on patients with “the most serious” head injuries.46 His debridements “were so effective that his mortality rate for wounds that penetrated the dura fell from 54.5 percent in the first month of the battle to 28.8 percent in the third.”46

In the American South, Another Category of Anesthesia Provider Is BornThe Midwest and East Coast were relatively well off finan-cially and could afford to build hospitals with state-of-the-art operating rooms. “In the South, which was making a slow recovery from the ravages of the Civil War, there was neither incentive nor funds to provide the hospital accouter-ments necessary to the new (aseptic) surgery. A concomi-tant lack of house officers and interns required surgeons to depend on one another to administer anesthesia and inci-dentally brought into existence a new category of admin-istrator, the private nurse anesthetist.”51 One example was Ethel Baxter who described to Thatcher her work between 1901 and 1913 for the surgeon Eugene J. Johnson. “Johnson’s practice took him throughout the impoverished sections of rural Mississippi, and with him went Ethel Baxter, traveling by any available means of conveyance, even ox cart, steril-izing instruments in the kitchen oven, scrubbing floors and dousing the furniture in the operating room with antisep-tic solution, and on one occasion constructing an operating table from two planks pulled off a barn and laid across two casks, the operation being performed on the porch since

the flies swarmed less viciously there than in the house.”51 Thatcher asserted that “such arrangements originated inde-pendently throughout other parts of the South and became so well established that the private nurse anesthetist attend-ing her surgeon and acting as an independent agent in pro-viding her equipment and obtaining fees, is a familiar figure in Southern hospitals today.”51 Surgery was thus extended by nurse anesthetist-surgeon pairs to those who might not otherwise receive it.

GEORGE CRILE (1864–1943) AND AGATHA HODGINS (1877–1935)George Crile was a leading American surgeon and a founder of the Lakeside Hospital in Cleveland. Like many surgeons, Crile wanted to learn about the shock that sometimes resulted from surgery. That led him to pursue laboratory and clinical experiments with blood loss and transfusions. He published a 553-page book called Hemorrhage and Transfusion in 190952 and is credited by Seymour Schwartz and other historians of surgery, with having pioneered our understanding of transfusion therapy.53,54

Crile believed that ether anesthesia “if deep or pro-longed, produced a condition identical with that of surgi-cal shock.”55 He had been taught the use of nitrous oxide by the dentist C.K. Teter. “A few administrations of this anesthetic by him for patients of mine were sufficient to indicate to me its clinical possibilities in my field, so I undertook a research in 1906 to ascertain if nitrous oxide gave better protection to the central nervous system than ether or chloroform.”55

However, Crile also knew that the person at the head of the table needed special skills to safely blend nitrous oxide with oxygen. He wrote “The nitrous oxide expert, for instance, must develop an anesthetic intuition. Oxygen is a pilot light to keep the flame of life burning safely. If the light burns too high, the patient immediately comes out from the anesthesia, if too low, the patient is too deeply submerged; if it is turned out, the patient dies. Yet with a steady flow of gas under constant pressure, the patient is carried eas-ily through the narrow zone of anesthesia.”56 When it came time to extend his experimental work from animals in the laboratory to human patients in the operating room, Crile surveyed the nurses at Lakeside for “one who had the ideal qualities to undertake a great responsibility.”56 He listed intelligence and intuition as those qualities and selected the Canadian nurse Agatha Hodgins.

Born in Toronto, Hodgins emigrated to Massachusetts in 1898 to attend the Boston City Hospital Training School for Nurses. Classmates described her as “quiet and self-possessed in manner,” “intelligent, amiable, and well bred,” “happy in her work and…well adapted to the care of chil-dren.”57 After graduation, Hodgins settled in Cleveland and went to work as the head nurse in the private pavilion at Lakeside Hospital. Crile wrote that one morning in 1908 he “drew Miss Hodgins aside and presented to her what amounted to an annunciation. She had received no warn-ing whatever about the plan to make her my special anes-thetist, but she told me promptly that she would undertake it if I would remember always that she was giving her best.”58 With that admonition Agatha Hodgins entered into a relationship with George Crile that included both clinical


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laboratory and didactic work. It lasted until her retirement in 1933. Crile felt that “Miss Hodgins made an outstanding anesthetist for she had to a marked degree both the intel-ligence and the gift.”58

When World War I started, the surgery departments of 33 prominent American hospitals were transplanted to Europe to care for wounded soldiers. “The most publi-cized American Ambulance (hospitals were called “ambu-lances”) using nurse anesthetists and nitrous oxide-oxygen anesthesia was that organized at the Lakeside Hospital in Cleveland.”59 These hospitals and the huge organizational effort behind them were led by surgeons, for “warfare is overwhelmingly a surgical affair-requiring removal of the wounded from battle, well organized distribution sys-tems, and prompt and ingenious operative techniques.”60 Orthopedic and plastic surgery developed in particular; the phrase “physical medicine and reconstruction” came into general use; and knowledge about surgical shock, blood transfusion, splints, and operating techniques boomed.60

The effect of gas-oxygen anesthesia on battlefield surgery was dramatic. Lieutenant Colonel Katherine Baltz of the Army Nurse Corps wrote that “92% of wounded soldiers who reached Army hospitals alive were saved,” a “bril-liant testimony of the service record of the Army Medial Department and the Army nurse anesthetist…”61 It is not known where Lt. Col Baltz found this information, but she may have been referencing L.F. Pilcher, President of the American Surgical Association, who in his 1919 presidential address noted: “more than 93% of all casualties who lived to come under surgical care recovered from their wounds and that between 70% and 80% of all casualties returned to duty within 2 months.”62 Whatever the source, anesthetic morbidity and mortality during World War I was far less than in previous wars.

British surgeon Berkley Moynihan sent his anesthe-tist to Miss Hodgins to be trained, and she trained several Frenchmen in its use. According to Thatcher, “many sur-geons returned to the United States sold on the method and looking for anesthetists adept in its administration.” And she asserted that a “booming demand” for trained nurse anesthetists grew directly from that experience.59

A NEW ANESTHETIC METHOD FOR THYROID SURGERYHodgins work with Crile did not end with the 1918 armi-stice. After the war, Crile, like his contemporaries Charles Mayo and William Halsted, pursued thyroid surgery. Crile had observed how patients with hyperthyroidism become excessively frightened when faced with the stress of sur-gery. “The importance of the emotions in this disease was impressed upon me over and over again.”63 From those impressions, Crile inferred that to “conquer exophthalmic goiter, fear itself must be eliminated.”63 He theorized that a total blockade of peripheral noxious stimuli would pre-vent the brain from ever generating fearful symptoms. Crile devised an anesthetic method that he termed “anoci-associ-ation”64 to completely block noxious stimuli from reaching the brain.

Anoci (noninjurious) association (stimulus or memory) was produced by the inhalation of nitrous oxide and/or ether along with oxygen, plus the injection of intramuscular

morphine and scopolamine, and local anesthetics at the sur-gical site. In certain instances, brief inhalations of nitrous oxide were begun days before the surgery to condition the patient to wearing a mask. Some contemporary historians of anesthesia and pain therapy think of anoci-association as a premodern version of pre-emptive analgesia.65,66

The nurse-patient relationship was integral to the suc-cess of anoci-association. Patients with exophthalmic goiter Hodgins wrote: “are hypersensitive to any external stimuli, their sense of fear is exaggerated, and they make a marked response to even slight physical injury. These patients, therefore, must be approached with great caution.”67 For “several consecutive days before the day of operation the nurse anesthetist would administer inhalations of oxygen, with perhaps a very small amount of nitrous oxide.”67

On the day of surgery, the most severely anxious patients would be anesthetized in bed using “analgesia plus local anesthesia.”67 Stable patients were given nitrous oxide to the point of analgesia and then transported to the operating room on a wheeled stretcher. Some patients were even kept partially awake throughout an operation. Hodgins wrote “it devolves upon the anesthetist to guide the patient through the analgesic stage and to interpret to him comfortably the happenings of the operation.”67 During periods of increased surgical stress, “it may be necessary for the anesthetist to explain to the patient that she knows he is not comfortable, and that she is going to let him have a little sleep for a few minutes.”67 Anoci-association could be manipulated to pro-duce a less than a complete anesthetic, but it worked. “We have found that, unless there is an utter lack of self-control, patients respond very well indeed to the suggestion that they can co-operate with the anesthetist.”67 Because anoci-association sometimes produced less than a complete anes-thesia, Crile felt like we “stole the glands of hundreds of patients.”63

COLLABORATION BECOMES A NECESSITYAn initial shortage of physician anesthetists forced sur-geons to collaborate with nurses who practiced anesthesia. Collaboration enabled or facilitated surgery. But Thatcher makes the case that as medicine grew more complex during the middle decades of the 20th century, collaboration (she called it interdependence) became a requisite part of prog-ress, and no longer just an innovative stopgap. “Neither medical nor surgical practice could prosper without the host of attendants and tons of apparatus that the hospi-tal provided….”68 Inevitably, large institutions and highly organized provider groups evolved to support this type of practice. And medicine became “a graphic illustration of science as a co-operative pursuit in which an accepted interdependence of many classes of workers (dentists, surgeons, obstetricians pharmacologists, physiologists, engineers, anesthesiologists, and nurse anesthetists) was a vital necessity.”68 Dentists, surgeons, obstetricians, phar-macologists, physiologists, engineers, anesthesiologists, and nurse anesthetists led to advancements in medica-tions, equipment, and clinical techniques, which were then turned over to commercial enterprises and marketed. Inevitably some excellent pairs emerged. The recognized outstanding surgeon-nurse anesthetist teams from this era are listed in Table 2.68,69 I consider Evarts A. Graham



and Helen Lamb below. Other pairs deserve our attention. Further investigation would surely advance our under-standing of history. It might also enhance our appreciation of collaboration.

EVARTS A. GRAHAM (1883–1957) AND HELEN LAMB (1899–1979)Helen Lamb grew up in Butler, Missouri, a rural town of about 5000 people close to the Kansas border. She was the daughter of a physician who taught her as a child to administer ether in the homes of his patients (!), so that he could perform procedures and small operations. Helen’s brother went to medical school, but Helen obtained a nursing diploma and then formal anesthesia education at the Lakeside Hospital School of Anesthesia under Agatha Hodgins. There she studied “efficiency, practical work, executive ability, and anesthesia theory” (D. O’Malia, per-sonal communication, June, 2013) Her anesthesia educa-tion was the best available in the United States in the 1920s. Lakeside graduates were in high demand.

Evarts Graham (1883–1957) was the Chief of Surgery at Barnes Hospital in Saint Louis. He was a rising surgical star. Graham pioneered the physiology of thoracic surgery during and after World War I. Much later, Graham linked cigarette smoking to lung cancer. He chaired the American College of Surgeons and played key formative roles in the American Board of Surgery and the Joint Commission on the Accreditation of Hospitals. Graham’s biographer called Graham the “Surgical Spirit of St. Louis” and said he domi-nated nearly every aspect of American surgery during the middle decades of the twentieth century.70

In 1927, Graham hired Lamb to be his anesthetist at Barnes. Before her arrival, anesthesia was “administered by many individuals with varying degrees of training and competence—an occasional nurse who was self-trained, medical students or interns, dentists, general practitioners, and referring doctors ….”71

This changed with the arrival of Lamb. Between 1927 and 1951, she performed or oversaw all Graham’s anes-thesia needs. She introduced and taught the practice of endotracheal intubation.71 Lamb served as president of the American Association of Nurse Anesthetists and chaired its powerful Education Committee. In that post Lamb spear-headed the 20-year effort that culminated in the upgrading and accreditation of all nurse anesthesia schools, and the certification by examination of all graduates. Lamb is cred-ited with 14 publications,72 including a chapter on “intra-tracheal” anesthesia in Graham’s 1935 textbook Surgical Diseases of the Chest.73 Within 2 years of her arrival at Barnes, Graham had the hospital open a school of nurse anesthesia, and he placed Lamb in charge.

In 1933, nitrous oxide/oxygen was the only nonflamma-ble anesthetic available. Graham used a hot cautery, which excluded the use of the inflammable ether. But nitrous oxide had to be given in hypoxic doses. Helen’s teaching notes on nitrous oxide oxygen make clear that she understood very well its dangerous pharmacology. She wrote that mix-tures as extreme as: “83% Nitrous Oxide and 17% Oxygen will maintain surgical anesthesia, when proper pre-medi-cation has been given, and (the) patient will exhibit good color, with absence of other asphyxial symptoms. As con-trasted with that, it is to be noted that when a mixture of 90% Nitrous Oxide and 10% Oxygen is used, cyanosis and other asphyxia symptoms develop. From this it will be seen that in Nitrous Oxide Oxygen anesthesia (without Ether) the margin is very narrow between the percentages which just suffice to maintain anesthesia, and those which intro-duce asphyxia effects which would be injurious if persisted in” (Lamb H, unpublished manuscript) Helen emphasized further in her teaching notes the need for paying breath-to-breath attention to the quality of the respirations. “During the induction period respirations do not vary greatly from normal, but their change in character with loss of conscious-ness and supervention of the second stage must be studied critically if the characteristic increase in rate and in depth that is typical of entry to that stage is to be identified. This change is easily noted when the anesthetic agent is ether, but it is less noticeable when the anesthetic agent is one of the quicker acting gaseous agents, nitrous oxide-oxygen or ethylene-oxygen.”74

Graham believed that advances in anesthesia equipment and technique made thoracotomies possible. Magill, Gale, and Waters had designed tracheal and bronchial tubes. Chevalier-Jackson and Flagg had made workable laryngo-scopes. Machines with gases, a rebreathing bag, and a carbon dioxide absorber had been developed by Dennis Jackson, Ralph Waters, and Brian C. Sword. These developments meant the mediastinum could be immobilized to provide a stable surgical field. But, to remove an entire lung all at once was not thought possible because it left such a large void.

In April 1933, without at first intending to, Graham performed the world’s first 1-stage pneumonectomy. With Helen Lamb providing the anesthesia, Graham began the operation intending to perform a simple lobectomy. He opened the chest, removed a few ribs, and, according to Mueller’s account, easily found the nodules that he had noted earlier by bronchoscopy in the upper lobe. But when he explored the remainder of the lung, Graham found “that the main stem bronchus was involved and that there was no uninvolved area in the upper lobe bronchus…”75 Consequently, the only option for saving the patient’s life from lung cancer would be a pnuemonectomy. But this had never been done successfully.

Table 2. Other Outstanding Surgeon-Nurse Anesthetist Pairs, Their Institutional Affiliation and ContributionSurgeon Nurse anesthetist Institution ContributionGeorge Crile Agatha Hodgins Lakes Hospital, Cleveland Nitrous oxide/oxygen, trauma and thyroid operationsEvarts A. Graham Helen Lamb Barnes Hospital, Saint Louis Pulmonary operationsClaude S. Beck Gertrude Fife University Hospitals, Cleveland Cardiac operationsAlfred Blalock Olive Berger Johns Hopkins Hospital, Baltimore Cardiac operationsWilliam Ladd and Robert Gross Betty Lank Children’s Hospital, Boston Cardiac operations


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Graham wanted to proceed. But he stopped long enough to consult with the others in the room. According to Mueller, “One doctor asked if such an operation had ever been done before. Graham replied that it had been performed success-fully in animals, in fact, he had even done it himself, but he knew of no case of a successful one-stage removal of the lung in a human being.”75 Mueller conceded that the details of this discussion “may well have been embellished by fre-quent repetition.”75 However, Mueller found no evidence that Graham consulted with his anesthetist. If correct, this is neither the first nor the last time a critical surgical decision was made without consulting the anesthetist charged with keeping the patient alive.

Graham pressed on: “A rubber catheter was placed around the hilum to constrict the arterial and venous flow for 2 or 3 minutes. No cardiovascular collapse occurred. Graham then applied two clamps, cut between them, and removed the lung with one clamp. The stump was then cauterized with heat and silver nitrate, radon seeds were implanted, and aghast at the size of the cavity, Graham removed seven more ribs to let the chest wall collapse onto the mediastinum and bronchial stump.”75 The pneumonec-tomy was accomplished without a hitch.

The anesthetic too was remarkably unremarkable, con-sidering it had never been done before. Lamb’s notes read: “Uneventful anes. Pulse good volume, color good. Glucose given when BP fell. Pt responded. At completion of opera-tion blood transfusion was given.”76 The key to this success was that Helen Lamb judiciously compressed the breath-ing bag throughout the 165-minute operation. Spontaneous respirations would not have adequately ventilated the patient’s lungs but would, on the contrary, have precipi-tated the deadly combination of paradoxical respirations and mediastinal flap associated with a surgically induced pneumothorax. Even though the principles were under-stood, pressure ventilation was rarely used.77 Helen Lamb was ahead of her time.

Lamb understood the importance of positive pressure ventilation in patients with an open chest. “The practical significance of this (pneumothorax) phenomenon to the anesthetist, lies in its indication for administering the anes-thesia under sufficient positive pressure to counterbalance the contralateral pressure that has been introduced by the pneumothorax, and to thereby prevent encroachment of the mobile mediastinum upon the unoperated lung at a time when its fullest respiratory integrity is vitally needed.”78 Graham considered the first pneumonectomy to be his greatest achievement.79 Helen Lamb made it possible, and her anesthetic was an equally great accomplishment.

Graham and Lamb (the only notable surgeon-nurse pair with rhyming names), were considered by Thatcher the foremost outstanding surgeon-nurse anesthetist team.68 I interviewed several of Lamb’s colleagues. Jim Cuddeford, a Certified Registered Nurse Anesthetist in Nebraska, met Helen when he worked at Barnes Hospital between 1969 and 1971. His comments were typical. According to Jim, “Helen lived during an era when there were few anesthe-sia textbooks. Some of them were unreliable, and caused Helen to be skeptical. She filled notebook after notebook with her comments on results published in anesthesia journals” (Cuddeford J, personal communication, April

4, 2013) Graham’s biographer Mueller described Helen as “brilliant,” and possessed of a “good understanding of physiology and pharmacology, especially as it related to anesthesia.”80 Lamb, because of her knowledge, her clinical accomplishment with endotracheal anesthesia, her pursuit of specialized training, accreditation of schools, and exami-nation of graduates, can be thought of as the “The Mother of Nurse Anesthesia Education.”

Surgeon/Nurse Collaboration as a “Yankee Dodge”Surgical progress through collaboration between surgeons and nurse anesthetists appears to have flourished only in the United States. The necessary ingredients existed else-where: there was a shortage of anesthesiologists worldwide until the mid-20th century,81 nurse anesthesia existed in England decades after it was thought extinct,82 and nurses administer anesthesia in at least 106 of the world’s coun-tries.83 American nurse anesthetists impressed the French, British, and Canadian surgeons, during World War I, suf-ficiently to train their own nurses in anesthesia.84 But the practice did not survive. “A British nurse anesthetist ‘might (barely) be acceptable in times of war but definitely not in peacetime’” (Pearce D, unpublished dissertation, 1988:41). Nurse anesthesia is scarcely mentioned in the (physician-written) histories of anesthesia in Mexico, the Caribbean Islands, and Central America,85 France,86 Germany,87 the Nordic countries,88 and South America.89 That is not to say that there were no nurse anesthetists in these countries dur-ing the first half of the 20th century. However, there is no documentation that they played any role in the advance-ment of surgery.

The Americanness of nurse anesthesia brings to mind the famous words of the Scottish surgeon Robert Liston (1784–1847). Throughout his professional life, Liston had endured the screams of patients under hypnotism and other failed methods of producing painless surgery. Shortly after the discovery of ether anesthesia in America in 1846, 1 year before his death, Liston operated on an etherized patient for the first time in London. He is said by many writers to have exclaimed (though an original source escapes me): “This Yankee dodge beats mesmerism hollow.” Like ether, nurse anesthesia was a “Yankee dodge:” an efficient and effective strategy that beat the competition hollow and advanced the practice of medicine.

ACKNOWLEDGMENTSThe author thanks Dr. Lawrence Saidman and Dr. Edmond Eger for editing this account, and Joan Wilson, Kootenai Health Library and Information Center, Coeur d’Alene, ID, for refer-ence assistance.

DISCLOSURESName: Bruce Evan Koch, CRNA, MSN.Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript.Attestation: Bruce Evan Koch approved the final manuscript.This manuscript was handled by: Steven L. Shafer, MD.



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