Leadership in Anaesthesia: Five Pioneers of the Deadly Quest for Surgical Insensibility 1527555968, 9781527555969

Citation preview

Leadership in Anaesthesia

Leadership in Anaesthesia: Five Pioneers of the Deadly Quest for Surgical Insensibility By

Berend Mets

Leadership in Anaesthesia: Five Pioneers of the Deadly Quest for Surgical Insensibility By Berend Mets This book first published 2020 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2020 by Berend Mets All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-5275-5596-8 ISBN (13): 978-1-5275-5596-9

For my father: Dr. Johann Teunis Mets (1924-2019) (May he rest in peace.) †

Berend Mets M.B. Ch.B. (Stellen), Ph.D.(UCT), F.F.A.R.C.S.(Eng), F.F.A.(S.A.), A.B.A. (U.S.A.).

†

William Morton (1819-1868) "Character is Destiny." †

John Snow (1813-1858) "An anesthetic which might be inhaled with absolute safety, and which would destroy common sensation without destroying consciousness." †

Arthur Guedel (1883-1956) "Maintain Flying Speed." †

Virginia Apgar (1909-1974) “Birth is the most hazardous time of life.” †

Bjørn Ibsen (1915-2007) "I knew I could." †

TABLE OF CONTENTS

Acknowledgements ................................................................................... ix Introduction ............................................................................................... xi 1. Surgery Before Anesthesia ..................................................................... 1 2. A Brisk History of Leadership ............................................................... 5 3. William Morton—The Art.................................................................... 35 4. John Snow—The Science ..................................................................... 85 5. Arthur Guedel—The Practice ............................................................. 133 6. Virginia Apgar—Outcomes ................................................................ 195 7. Bjørn Ibsen—Beyond the Operating Theater ..................................... 245 8. A Leadership Reckoning .................................................................... 295 Notes & Bibliography............................................................................. 315

†

ACKNOWLEDGEMENTS

First and foremost I thank my wife, Ulane, for giving me the time and support to write this book. Meeting at medical school, we embarked on life's adventure together and never looked back. Next thanks go to my colleague and friend, Dr. Pat McQuillan, who helped run the Anesthesiology Department during my Sabbatical in service of researching and writing this book. The Rolling Stones too played their part. Re-energizing me with the best rock and roll music a gentleman can hope for—'Sympathy for the Devil'— is still the all-time favorite. My brother-in-law, deserves specific mention. A Submariner and Rear Admiral (Ret) in the South African Navy, Derek Christian read every page, offering comment and advice on the book's writing. Further thanks goes to Sherry Annibali, and to Judith Robins of the Wood Library Museum in Schaumberg, Illinois. And, Dr. Merlin Larson is thanked for pointing me in the right direction with respect to Dr. Arthur Guedel's life and times, and Mr Xavier Macy and Dr. Polina Ilieva are thanked for hosting me and providing access to the Arthur E. Guedel Anesthesia Collection at the University of California, San Francisco, Archives and Special Collections. Additional thanks are due to Archivists: Leslie Fields, Micha Broadnax and Deborah Richards for access to, and support at, the Mount Holyoke College Archives and Special Collections, South Hadley, Massachusetts. A very special thank you goes to Dr. Thomas Bjørn Ibsen and Dr. Birgitte Bjørn Ibsen Willumsen for meeting with me on a bright beautiful day in Copenhagen, and providing me with much background material surrounding their father's life and career, as well as permission to use a photo of Dr. Ibsen's portrait fronting the first page of his chapter. Dr. Preben G Berthelsen, is also thanked for meeting with me in Copenhagen, much personal communications, and showing me the Kommunehospital and the original 'Observation Room' which has now reverted back to its historical state: a classroom. Dr. Ion Meyer from Copenhagen's Medical Museion also is due thanks for allowing me to visit and sharing original anaesthesia departmental case records from the Kømmunehospital.

x

Acknowledgements

Finally, I hope and trust that I have done the rich history of anesthesia justice in these pages.

†

INTRODUCTION

Leadership is like beauty. Hard to define but obvious when you see it—and manifests differently in differing people. Fascinating to behold, leadership is one of the most studied, yet least understood of all human endeavors. That is because there cannot be just one singular definition of the phenomenon we recognize as leadership—nor does one size fit all. Hence there is great advantage in studying leadership as it presents in different people, disciplines, and contexts. To that end, this book explores five leaders who were important to the historical development of practical anesthesia from the 1840's to the present day. I have chosen these pioneers in the field, not only because they were interesting personae and left their extraordinary mark, but also because sequentially, they had a profound effect on transforming the crude practice of anesthesia to the sophisticated specialty of anesthesiology—extending its reach beyond the operating theatre where it first started. Each leader's vision propelling anesthesia ever forward. All these leaders had the necessary creativity, energy and resilience to be successful, but evidenced charisma, emotional competence, empathy, credibility and the ability to change in differing measure. Some died young, others old. Three married. Two didn't: both having second careers: Dr. John Snow in epidemiology, and Dr. Virginia Apgar in perinatology. Three were excellent musicians, two swimmers, and two aviation enthusiasts. Some might have met: William Morton and John Snow at the Great Exhibition in London of 1851; others definitely did, and corresponded: Dr. Arthur Guedel and Dr. Virginia Apgar; while Dr. Bjørn Ibsen likely met Virginia at the Fifth International Polio Conference held in Copenhagen in 1960. Both, by then, well on their way to becoming famous: Virginia Apgar for the Score that now carries her name, and Bjørn Ibsen as the "Father of Intensive Care." All, however, in very different ways, left their leadership mark in navigating man's deadly quest for surgical insensibility.

xii

Introduction

This book tells their stories through the lens of leadership. Berend Mets

1. SURGERY BEFORE ANESTHESIA

"Time me Gentlemen! Time me!" —Dr. Robert Liston

Before anesthesia, surgery needed to be fast and furious. Take Dr. Robert Liston (1794-1847) as a case in point. Operating at the London Hospital in the 1840's before the introduction of etherization—when speed was prized above all else in surgery—Liston could execute a leg amputation in 25 seconds flat. A command and control surgeon of the time, he was regarded as little more than an armed savage. Famous for his wantonness and showmanship; he played regularly to the crowd of spectators that had gathered in the semi-circular, tiered, amphitheater situated at the very top of the hospital—the following surgical spectacle unfolding once or twice weekly.

2

1. Surgery Before Anesthesia

Standing erect and tall at six-foot-two-inches, the Scottish surgeon led the proceedings. An inebriated patient was shepherded unsteadily into the sky-lit theater and held down on the stout operating table by six solid men. One sitting at the head of the table clasped him around the waist, three others pinned down his arms and leg, while a fourth tied a tight tourniquet around the offending leg; readied for amputation by yet one other. A bell rang out in warning, the theatre door closed firmly (to stem the screams emanating to the rest of the hospital), and Liston would plant his surgeon's stick into the terrified patient's mouth; completing the preoperative preparations. Then. Clenching a sharp knife between his own perfect teeth for rapid deployment should he need it, Liston raised his terrifying surgeon's saw— the multi-notched handle bearing testimony to each amputation he had performed—high above his head; poised for the planned amputation. The assembled audience hushed and rose as one from their tiered seats, some whipping out their pocket watches in anticipation. Then Liston would yell: "Time me gentlemen! Time me!" as he sawed the leg asunder, the patient straining and bellowing with the excruciating pain, as the hellish torture of the operation unfolded—only sometimes relieved by merciful unconscious or unwanted death: from the shock of it all. On one such an occasion before the tempering effect that the discovery of general anesthesia brought on the need for speed in surgery, Liston rapidly cut through a patient's leg, and unknowingly, his assistant's hand: both dying of sepsis. An audience member who witnessed this fright keeled over dead from a heart attack. The only recorded surgery with a 300% mortality. This horror forever changed in 1846 with the news that William TG Morton, a lowly dentist from Boston, had demonstrated that sulfuric ether could be used to render a patient unconscious—allowing painless surgery to be performed at the Massachusetts General Hospital. A report of this new discovery travelling as fast as steam could carry it to London on board the ship Acadia; Dr. Liston resolved to be the first surgeon in England to attempt the new approach—declaring on December 21, 1846: "I am going to do a Yankee Dodge today." Things unfolded not quite as easily as he had hoped. His assistant, William Squire, brandishing a glass bottle filled with the clear sharp smelling ether, festooned by a rubber tube connected to a face-mask (a contraption much like a Turkish water-pipe) entreated the

Leadership in Anaesthesia

3

assembled crowd for a volunteer to go under the knife to test the new technique. Finding none, a portly porter, Shelldrake, was dragooned into service, held down tightly, and told to breathe from the mask—deeply. The stretcher-bearer proved to be a poor candidate for this first demonstration as Shelldrake was a florid drinker with a well-developed liver. Rather than becoming unconscious, ether exhilaration ensued—the porter running screaming and cursing from the room, never to return. Somewhat cowed by this first failure, but nevertheless undaunted, Liston arranged for another volunteer that same afternoon: Frederick Churchill, a resolute butler from nearby Harley Street, hurriedly carried into the theatre on a stretcher at 2.35 p.m. Sanguine about his fate, putting great trust in the unparalleled reputation of Dr. Robert Liston—surgical assistant Squire was again engaged to apply the mask tentatively to Frederick's face—the sharp smell of sulfuric ether permeating the room as Churchill became limp. "Time me Gentlemen! Time me!" Liston slashed through the leg in 28 seconds. Churchill remaining dead-still on the hard-wooden table in no need of restraint. To the quietened audience's evident amazement. Then. Suturing together the remnants of the ragged skin left from the amputation, Liston commanded Squire to remove the ether-soaked handkerchief that had kept Churchill unconscious and pain free. Stirring a little and groaning only lightly as his eyes fluttered open, Churchill looked around at the breathless crowd who were watching the miracle unfolding in front of them. And stuttered: "When are we going to begin?" Dr. Liston, glowing with the elation of the moment, his voice booming above the laughter from the crowd at this sight, yelling: "This Yankee Dodge beats Mesmerism hollow." And it did. A London newspaper announcing the very next day: "We have conquered pain." Dr. Robert Liston, his reputation greatly enhanced by the successful demonstration, going on to popularize general anesthesia in England—turning etherization into a public sensation. And surgery took off: surgeons—considered mere 'saw-bones' at the time—were no longer limited by the need for surgical speed, and could now expand their scope from simple peripheral operations like amputations or bladder stone removals, to penetrate body cavities and perform ever more

4

1. Surgery Before Anesthesia

complex surgeries humanely—anesthetic and surgical techniques advancing in lock-step together over the next 170 years. †

2. A BRISK HISTORY OF LEADERSHIP

William Morton

John Snow

Virginia Apgar

Arthur Guedel

Bjørn Ibsen

Philosophy ĺ Psychology Leadership ĺ Followership "Great leadership—and the need for it—is timeless" —Anonymous

6

2. A Brisk History of Leadership

The concept of 'leadership' is a relatively modern phenomenon. The word first appearing in the Oxford English Dictionary of 1933. In contrast the word 'leader' appeared as early as the 1300's, but the notion of 'leadership' was formerly rather that of 'headship' differentiating the ruler from the ruled. The ruler having been put in charge as the Head of State, King, or more usually, through the process of conquest or usurpation. Historically too, there was no call for studying leadership in order to progress in life. And so really no need to dissect out a leader's characteristics in order to learn from them how to become successful. The general populace just wanting to maintain their assigned 'proper station': a blacksmith, a farmer— fearful more of sliding backwards than interested in progressing forwards. With a knowledge-based economy all of that changed. Many aspiring to progress beyond their station—becoming leaders themselves— hence the study of leadership gathered pace. (Drucker 1999) In this brief prelude to the leadership stories of five pioneers from the history of anesthesia—I wish to bring the reader briskly to the present day by: Providing a brief history tracking key trends from the leadership literature—then progress on to the "the Seven Ages of Leadership" that straddle the pioneers' lives—to conclude with a "leadership primer" of current day concepts, with two important goals in mind: (1) To develop a Leadership Skeleton of key 'body parts' comprised of concepts such as 'emotional competence' and 'resilience'—that will be used to contrast these five leaders' profiles and then: (2) Use this analysis to surface key leadership insights from the protagonists' stories—all suitably underpinned by a working knowledge of the subject supplied in this chapter. †

Leadership History The study of leadership was rooted in philosophy but has migrated to embrace psychology and has shifted from a focus on the leader to one emphasizing the follower. A good starting point in its history is probably with Aristotle (384322 BCE) who proclaimed that three types of leaders were necessary for a well-functioning state: a philosopher statesman to rule the republic with

Leadership in Anaesthesia

7

justice and reason, a businessman to provision the citizens' material and baser needs, and a commander to defend the state and police its will. Plato (427-340 BCE) begged to differ. Claiming that just one, the democratically elected philosopher, was sufficient as long as he was competent in psychology. Plato stressing early a fact which is very much in evidence today: that psychology was the driver of human behavior—the leader being motivated by the loins, heart and head. Respectively: desire, emotion and knowledge. Niccolo Machiavelli (1469-1527) is considered the first student of leadership. (Kellerman 2001) Incarcerated for crimes against the Florentine State, he penned The Prince providing lessons on staying in power—through coercion, deception and manipulation—that have stood the test of time; inaugurating the 'selfhelp' manuals that live on in the leadership literature today. Another student of leadership was Napoleon Bonaparte (17691821). Having undoubtedly read The Prince being of Italian-French origin, he used coercion at first but matured; developing considerable diplomatic, political and interpersonal skills. Famed for having the "common touch" with his troops he engendered deep devotion from his followers who in turn supported him. Banished to Elba, his legacy lives on: his pen proving mightier than his sword—The Napoleonic Code granting civil rights, and in so doing liberating Europe from clericalism and feudalism—living on as testament to his transformative leadership. (MacGregor Burns 2003, Polelle 2008, Pears 1997) Serving as four time-tested historical examples of leadership: Aristotle, Plato, Machiavelli and Napoleon, deliver us to the 1840's when the history of Anesthesia starts—setting us up to briefly review the history of leadership up to the modern era. David McCullough, a noted historian, giving us a salutary warning—lest we fall into the trap of unfairly judging the historical protagonists in this book by present day leadership concepts—pointing out that the demands of leadership change from era to era: "Leaders from the past having experienced their present differently from the way we experienced ours." (McCullough and Bronwin 2008) But why are we so interested in studying leadership in the modern era? One answer has its roots in the rationalist revolution of the late eighteenth century. (Goffee and Jones 2000) At the time, Voltaire (François-Marie Arouet, 1694 –1778), optimistically posited that the application of reason alone could control

8

2. A Brisk History of Leadership

man's destiny—hence two beliefs drove the early nineteenth century: a belief in the perfectibility of man and a belief in unrelenting progress. Beliefs that were then debunked in the late nineteenth century by at least two thinkers: the psychologist Sigmund Freud (1856-1939) and the sociologist Max Weber (1864-1920). Freud, the founder of psychoanalysis, believing that the rational mind was severely compromised by the unconscious, which was in turn responsible for a large proportion of human misbehavior—resulting in man's imperfectability. While Weber had misgivings about the limits of reason to ensure progress. Finding man's ability to reason wanting, he determined that the most destructive force arresting progress was something he named technical rationality; rationality without morality—more specifically pointing the finger at the organizational bureaucracy that prevailed in institutions of his day. The only counter for this bureaucracy in Weber's mind was charismatic leadership. Only this could combat the technical rationality that was stifling progress. The institutionalized bureaucracy that he found truly frightening, not for its inefficiency, but rather for its efficiency in dehumanizing people. It needed leadership to cut through the bureaucratic red tape. Following this anguished thinking, by the early 1900's there were thus legitimate concerns about man's ability to progress relentlessly; given the fact of human fallibility and man's failing powers of reason to save the day. Consequently, for both practical and philosophic reasons, an increasing interest in leadership concepts developed in an attempt to arrest man's inevitable downward spiral. These leadership concepts can be roughly categorized into Seven Ages of Leadership. (Northouse 2018, Clinton 1992) 1

1

This draws heavily on the inspired summaries of Dr PG Northouse and Dr JR Clinton, while liberally adding in my own and other's perspectives.

Leadership in Anaesthesia

9

Seven Ages of Leadership

(Bracketed are the names of the historical protagonists.) (1) Great Man Age: 1840-1900 (Dr. William T Morton & Dr. John Snow) Whereas prior to 1840, Plato, Machiavelli, and many others wrote about leadership in theoretical terms—they identified types of leaders and related their actions to what was going on in the society around them, observing what leadership ought to be doing and so conducted a philosophical analysis—by the mid-1800's, Thomas Carlyle, had focused more practically on studying the actual leader: the Great Man—their accomplishments, their acts of heroism, their inventions, their conquests, their origins and the circumstances they faced, writing: "They were the leaders of men, these great ones; the modelers, patterns, and in a wide sense creators, ..all things that we see standing accomplished in the world are properly the outer material result, the practical realization and embodiment, of Thoughts that dwelt in the great men sent into the world." (Clinton 1992) In so doing, encouraging the study of these Great Men and their stories. Considering them superior beings, favored with qualities which differentiated them from their followers, at moments of destiny in shaping

10

2. A Brisk History of Leadership

history—he supposed that emulation of these qualities could in turn create leaders. Hence, this Great Man Age surfaced early the now familiar question: "Are leaders born or made?" Carlyle believing the former; that the leaders themselves created the situation which resulted in the progress for which they were venerated. Others saying no: it was the latter; that circumstances created the opportunity for the Great Man's leadership. (2) Domination Age: 1900-1920 (Dr. Arthur Guedel) In the early 1900's leadership was seen as domination: a Leadership Conference of the time describing leadership as "the ability to impress the will of the leader on those led, and induce obedience, respect, loyalty, and cooperation." (Northouse 2018, Clinton 1992) (3) Trait Age: 1920-1950 (Dr. Virginia Apgar and Dr. Arthur Guedel) Mellowing somewhat, the Domination Age, swung to the Trait Age, where leadership was considered the ability to influence the situation rather than dominate it—surfacing an interest in understanding the leaders themselves: their characteristics and the common traits that went into becoming an influential leader. Trait theorists suggesting that leaders could be made; once leadership traits had been identified they could then be developed into leaders through training. Accordingly research into leadership traits was launched energetically in the 1920's with much fanfare; researchers positing the theory that some people were natural leaders bearing identifiable traits that could differentiate them from others, that, upon emulation, might allow others to lead effectively. The complex research unfortunately falling flat when the conclusion was less than earth shattering: effective leaders were either below or above average in height. (Goffee and Jones 2000) Notwithstanding this set back, the research generated important advances in demonstrating that an individual leader's specific personality traits interacted with that of the follower group: the attitudes and activities of the one, influencing the other, which focused attention on the leadershipfollowership reciprocal path and also established the need for the study of the psychology of leadership—both becoming much better recognized in the future.

Leadership in Anaesthesia

11

(4) Group-Goal Age: 1950-1960 (Dr. Virginia Apgar, Dr. Arthur Guedel, Dr. Bjørn Ibsen) Institutions and Corporation's interest in setting shared Group Goals for their workers drove researchers to study the leadership behavior necessary to relationship building through persuasion—rather than coercion—in the next age. In an attempt to guard against the ever-present threat that the setting of group goals might have in increasing bureaucratic management, Cyril Northcote Parkinson (1909-1993) battled bureaucracy's inexorable growth, with robust ridicule, through writing. A British civil servant of the time, Northcote, echoed Max Weber's fear of growing bureaucracies in a lament—the book—Parkinson's Law or the Pursuit of Progress. (Parkinson 1958) Observing the relentless growth of the Colonial Office of his time, despite the decline of the British Empire—he explained this as due to two factors: (1) "an official wants to multiply subordinates, not rivals" and (2) "officials make work for each other"—distilling this bureaucratic phenomenon to its crux as Parkinson's Law: "work expands so as to fill the time available for its completion." Recognizing the spinning of wheels, inefficiencies, and lack of guiding leadership that this all entailed—he penned a later book entitled: The Law of Delay in which he was one of the first to spell out the six elements that the art of leadership required: imagination, knowledge, ability, determination, ruthlessness, and personal magnetism (the charismatic leadership that Weber had championed as an antidote to bureaucracy almost a century earlier). (Parkinson 1970) 5) Behavior Age: 1960 -1980 (Dr. Virginia Apgar, Dr. Bjørn Ibsen) Responding to the need for ever more effective organizations, that were becoming increasingly more complex to run, Group-Goal theory gave way to a focus on leading improvements in organizational behavior. Whereas here-to-fore trait theory had given way to style theory, with American executives favoring the 'hail-fellow-well-met' democratic style of leadership, now what was painfully obvious for all to see, was the need for leaders who could accomplish complex organizational goals through enhancing its personnel's behavior. The Pulitzer Prize winning, James MacGregor Burns (1918-2014) defining the necessary leadership thus: "Leadership is the reciprocal process of mobilizing, by persons with certain motives and values, various economic, political, and other

12

2. A Brisk History of Leadership

resources in a context of competition and conflict, in order to realize goals independently or mutually held by both leaders and followers." (MacGregor Burns 1978) MacGregor establishing early the difference between transactional leadership: you pay me to do the work you want and I will do it—and transformational leadership: where the leader inspires and motivates the follower. In so doing seeking to engage the "full person of the follower." The resulting transformational leadership becoming: "a relationship of mutual stimulation and elevation that converts followers into leaders and may convert leaders into moral agents." MacGregor also had no truck with mere "power wielders"— regarding these as lesser mortals—instead leaders needed to always keep the goals of their followers in mind and never treat people as things. "Power wielders may treat people as things. Leaders may not." (Kellerman 2004) (6) Leadership vs. Management Age: 1980-2000 (Dr. Bjørn Ibsen) In the early 1980's American companies were on the back heel. Foreign competition, expensive oil, inflation, and excessive regulation were killing profits. Responding to this crisis of confidence in American Business of the time, Professor J.P. Kotter (b. 1947) famously stated, "Most U.S. companies are over managed and under-led." The solution? Corporate America turned to business schools to help solve the problem—the Harvard Business School endowing a Professor of Leadership Chair in 1982 forging the way for others to follow. (Kotter 2001) Kotter and a fellow Harvard Business School professor, Abraham Zaleznik (b.1924) going on to define the differences between leadership and management. In essence, managers ensured stability while leaders pressed for change, but both were considered essential for organizations to succeed in turbulent times. Embroidering further, Kotter proposed that managers cope with increasing complexity, through planning, budgeting, organizing, problemsolving, staffing, controlling and monitoring of the work done—creating predictable order and efficiency. In contrast, leading an organization required, setting direction, motivating, inspiring and aligning people—in so doing keeping people moving in the right direction despite the obstacles—the road to success always under construction.

Leadership in Anaesthesia

13

Underpinning the development of business schools was the strong belief that leadership and management could best be learnt by an increased emphasis on the study of the psychology and psychopathology of leadership—in an attempt to improve managerial performance—provoking an ever-burgeoning industry of leadership coaches, magazines and gurus; all espousing the latest formula for managerial improvement. It is well to note that, impelled by the wish to develop a competitive business advantage, the contemporary leadership and management field is largely American in origin and often in its portrayal. The American national spirit—with its positivity and penchant for self-improvement—suffusing the current-day literature; celebrating corporate titans as being the aspirational leaders one should strive to become. (7) Rapid Change Age: 2000-2020 Today. The only constant that we can truly rely on—is change. In the past—as described at the beginning of this chapter—at a time when knowledge and indeed technology and culture changes occurred at a much slower pace than a human's life-span—the rational thought that philosopher teachings brought, carried the day as the pre-eminent leadership ideas and approaches for use by the populace. Today—in an era of ever accelerating change—knowledge, processes, and equipment, are changing at an almost exponential pace, requiring ever-more rapidly evolving adaptive leadership and management techniques. Pace-setting descriptive words, like 'Agile Management' giving a flavor of what is yet to come from the leadership literature. (Bartleby 2018, Rigby, Sutherland, and Noble 2018) †

Leadership Primer Leadership is like beauty—displayed differently in differing people and different circumstances—and is difficult to define; but immediately recognizable when you see it. At its simplest, leadership is the accomplishment of goals through human endeavor. Distilled to its essence, it requires human relationships to achieve and is contextual: "What works in one era, setting or organization, simply does not apply to any other." (Kellerman 2001) There-in lies the rub, and the challenge for this book, in gaining leadership insights, for the present, from the past.

14

2. A Brisk History of Leadership

Nevertheless, I am hopeful that by providing a brief history of leadership, and presenting a brisk leadership primer that will bring the reader up to date with contemporary theories, neuroscience research, and practice, we may meet the challenge of assessing how the historical protagonists in this book managed their leadership responsibilities.

Psychology and Psychopathology of Leadership and Management Dr. Abraham Zaleznik, a psychoanalyst, brought important psychological insight to the study of leadership. Noting that leaders are often temperamentally disposed to seek out risk and danger—especially where the chance of reward or opportunity seems promising—he added that this rests more commonly with his or her personality, rather than a conscious choice; spearheading the study of the roles of psychology and personality in contrasting leadership with management. (Zaleznik 2004) Pointing out further that business leaders have far more in common with artists, scientists and other creative thinkers—than managers—in not only their struggle with neuroses but also their willingness to accept chaos, states of ambiguity, and, in not seeking premature closure when making an important decision. Premature closure—by a manager in providing a structural solution to a problem—often appearing to give something, but in reality, only limiting options. According to Linda Hill from the Harvard Business School, instead of limiting options through early decisions as managers are wont to do, leaders should rather bring creative agility to their leadership, in imagining a future state different from the status quo. 2 Going on to suggest that they do so in a proactive, rather than a reactive fashion, by active, effective, communication; altering moods, instilling desires and expectations, and evoking images of what is both possible and desirable. (Hill et al. 2014) In other words leading through inspiration and example, in stark contrast, to the manager who fills a more mundane, routine role; requiring a completely different personality type. Consider next the four classic personality types. Three Freudian: erotic, obsessive and narcissistic and one Frommian: marketing. While most people are varying mixtures of all four, those with a prominent obsessive personality make the most effective operational managers; obsessives being inner directed, self-reliant and conscientious, like to create and maintain order. 2

See Dr Bjørn Ibsen (Chapter 7) for a good example of this.

Leadership in Anaesthesia

15

Whereas narcissists, 3—especially productive narcissists, not mired in self-adulation—make the best leaders. Wishing to be admired, but not loved (like the erotics) narcissists are the creative innovators who seek power and glory; providing the vision and charisma for the cause that the obsessive often lacks. (In fact some psychoanalysts state that all leaders need a healthy dose of narcissism to thrive.) (Coutu 2004) What about the marketing personality type? They make poor leaders. Being anxious to please they excel at trying to sell themselves; chameleon like, they emulate the surrounding personalities and lack direction and the ability to commit to projects or people. (Maccoby 2000) Personality type may morph into psychopathology and so into the realm of psychiatry—spawning a cottage industry for the management of leadership dysfunction. Of which there is much: resulting in a burgeoning of Leadership Coaches to address the problems leaders are encountering in managing their work. Psychotherapy becoming de rigeur to coach the dysfunctional narcissist, manic-depressive, emotionally disconnected, or passiveaggressive leader that seem to abound in today's organizations. (Kets de Vries 2014, Morse 2004) Some psychiatrists going on to declare that to be a leader you need to be somewhat unhinged in the first place; pointing out that "to lead is to live dangerously," while other's hope for a "little madness" to ensure creativity. Still others have linked leader's success with their psychiatric problems—pointing to the triumphs of President JF Kennedy, a visionary hyper-manic, and Sir Winston Churchill, a depressed realist. (Heifetz and Linsky 2002b) (Coutu 2004, Ghaemi 2011) To understand leadership and some of the pioneers in this book better, as well as to appreciate the role that psychopathology may play in a leader's successes or failures, we must first define the concept of temperament and how that relates to different personality traits, and in turn, types. The Greek physician, Hippocrates (460-370 B.C.) described four temperaments. Seeking to explain human behavior as the result of either an excess or depletion of bodily fluids, he envisioned, Sanguine (blood), Choleric (yellow-bile), Melancholic (black-bile) or Phlegmatic (saliva) personality types—all generated from varying imbalances of these 'humors' in the body. 3 Which Dr. William Morton (Chapter 3) and Dr. Bjorn Ibsen (Chapter 7) will turn out to be.

16

2. A Brisk History of Leadership

(These could be treated by 'rebalancing' the humors through blood-letting, purging or emesis—the basis for much futile medical therapy of the past.) Individual temperaments, however, are probably better defined as being composed of biologically based, and, relatively independent from learning, interactions of four basic personality traits: neuroticism (anxiousness), sociability (extra/intra-version), impulsivity, and openness to experience (curiosity vs cautiousness). These traits combining to produce different personality types: Some—always a little depressed, introverted, of low energy, and requiring lots of sleep; the dysthymic. Others—the polar opposite, always positive, extraverted, and high energy—no sleep required; the hyperthymic—occurring often in great leaders. Yet others are a bit of both—cycling between lows and highs in mood and energy; the cyclothymic. For some these normal temperaments may stretch within reach of the abnormal; becoming mild versions of depression, mania and bipolar disorders—a matter of degree, and only a diagnosis away from being labelled a psychiatric problem. Thus, mental health and psychiatric disease are not really opposites but a spectrum—or better still—a continuum; often defined by the boundaries of what is normal. And further, mental health does not of course guarantee good leadership. In fact the opposite may often prove to be true: in that psychiatric diseases, like hyper-mania, may confer enhanced resilience and creativity while depression may improve realism and empathy—enriching both President John F. Kennedy and Sir Winston Churchill's leadership capacity respectively. With the added somewhat surprising caveat that when leading in a crisis: "The best crisis leaders are either mentally ill or mentally abnormal: the worst crisis leaders are mentally healthy." (Ghaemi 2011) The Cuban Missile Crisis and the retreat from Dunkirk serving to illustrate the role of mental illness in enhancing leadership capacity, well. † John F. Kennedy (1917-1963) was by all accounts a hyperthymic—a resilient, creative, dynamo. Fast of speech, idea flow, and of visionary

Leadership in Anaesthesia

17

intent, his frenzied, often impulsive activity was common knowledge. Snapping his fingers repeatedly, he was intensely curious, rapidly dictated directives, restlessly pacing and fidgeting in the Oval Office—on one celebrated day receiving over 100 visitors. Sociability to a T, he took risks, had a great sense of humor, ambition, and a legendary libido—all hall marks of hyperthymia if not quite mania. His hyper-manic state often brought on however, by the steroids (and other drugs) he was forced to take to stave off the repetitive Addisonian Crises that he suffered from. 4 By 1962—his physicians having perfected the cocktail of drugs needed to combat his ailments—Kennedy was mentally much improved and on even keel. Not so a year earlier however, when mentally unstable, his own inaction in supporting Cuban exiles upon their landing at the Bay of Pigs had created the well-known fiasco. Kennedy should have provided US Airforce backup against Fidel Castro then, but didn't to his eternal regret, and now: in 1962, the Soviet Chairman, Nikita Khrushchev, was back with a new challenge: placing missiles in Cuba pointing at the United States. This time round, however, Kennedy ignored his generals (who recommended attack) and his diplomats (who counseled against military action) and followed his own lead—organizing a naval blockade of Cuba instead. Threatening to precipitate a nuclear war, Kennedy stared down Khrushchev, who blinked, six days later; Soviet ships turning back on their way to attack the blockade and the missiles quietly removed from Cuba— illustrating well, Kennedy's ability (as a suitably medicated hyperthymic) to lead in a crisis. (Ghaemi 2011) † Winston Churchill suffered terribly from depression. Calling this his "black dog," he was ever fearful of train platforms and unguarded ship's railings—just a "few drops of desperation"—impelling him to commit suicide; by jumping. 4

Addison's disease is a shortage of adrenal steroid hormone release that can have wide ranging detrimental effects on a patient, but can be treated with replacement hydrocortisone which, in turn, may have psycho-active effects. Kennedy suffered hugely from this disease, with multiple hospitalizations and near-death experiences, publicly denying the problem "fit for anything"— speaking to his exceptional resilience in the face of personal adversity.

18

2. A Brisk History of Leadership

A classic cyclothymic personality—experiencing severe ups and downs—Winston suffered from hyper-mania and depression. In the manic phase: extroverted, highly productive, creative (in the Dunkirk landings, it was his idea to sink old ships, one on top of each other, to create artificial harbors), gregarious, and an interminably incessant talker. But in the depressive phase: down in the dumps, drinking too much and despondent. Accordingly, having battled with his own despair, he could rally a despairing nation against Hitler—realistically recognizing the lying tyrant for whom he was; depression conferring a greater sense of realism on its sufferers. (Ghaemi 2011) (In contrast, Neville Chamberlain, the then prime minister and mentally healthy, believed Hitler; and sought appeasement rather than resistance to the Nazi menace.) Churchill instead leading his War Cabinet to unleash Operation Dynamo—launched a flotilla of all available water craft to sail to the French coast where the retreating British Expeditionary Force and Allied troops had amassed on the beaches—fearing imminent attack from the German Panzer divisions by land, and the Luftwaffe from the skies. Operation Dynamo, however, was a highly risky proposition at best, because of the ever-present dread of a massive loss of resources in planes and destroyers, that might have been put to better use protecting England at imminent risk of invasion by Hitler's advancing forces. Churchill facing down multiple detractors in the War Cabinet (including the certifiably sane Neville Chamberlain who he had replaced) who questioned his leadership, and demanded that the Government engage in a Peace Treaty or they would resign. Churchill's resolute answer? "We shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and streets, we shall fight in the hills; we shall never surrender." Winston's resounding words, delivered to parliament, and aired on BBC radio, June 4, 1940, rallying the nation against Hitler, as the last of 340,000 troops were evacuated from Dunkirk. If leadership is the art of communication, that rallying address is held to be one of the finest oratorical moments of the war; standing testament to the effective, if cyclothymic, leader that Sir Winston Churchill was. Psychiatrist, Dr. Nassir Ghaemi asserting in A First Rate Madness: "Our leaders need not be perfect: their imperfections indeed may produce their greatness. The indelible smudges on their character may be signs of brilliant leadership."

Leadership in Anaesthesia

19

The presented two classic histories of mentally ill leaders hopefully illustrating more fully the role of psychology and psychiatry in understanding leadership. †

Power shift: Leadership ĺ Followership Starting about four decades ago, imperceptible at first, a power shift from leadership to followership started gathering steam. Kindled by greater demands for support and empowered by communication technology and information, followers had become more demanding and critical of their leaders, often with an attendant decline in respect and a shift, downwards, in leaderships' conferred power. Exploding the 'leadership myth' that leaders were all-powerful and important—slowly, but inevitably, leaders were toppled from their pedestal. (Northouse 2018) Professor Barbara Kellerman noting the change: "Increasingly, followers think of themselves as free agents, not dependent underlings." (Kellerman 2007) This is not to say however, that there is no longer the need for a leader-follower dynamic. There is. For many reasons. For example, the quality of the relationship in this dynamic frequently motivates the follower; either through engaging personally with the leader or with the mission she represents. And then there are the psychological needs of followers. Often, surprisingly, following even bad leaders to ensure them. Freud pointing out that followers need authority, stability, certainty and security as well as the feeling of being special and the nurturing they received (or didn't) from parental figures. Deeply needed too is a sense of belonging to a group. Followers fearing ostracism, isolation, or social death, should they be rejected from a group; sometimes undergoing privation and subjecting to unethical leadership to achieve these psychosocial imperatives. 'Followership' has thus been described as the process whereby an individual accepts the influence of others to achieve common goals. And, not surprisingly, effective followership has also been captured, sliced and diced, and given descriptive names such as: Sheep; Yes People; Alienated Followers; Survivors and the most desirable: Effective Followers. Predictably: Sheep: follow passively, lacking initiative and a sense of responsibility.

20

2. A Brisk History of Leadership

Yes People: often unenterprising, they depend on the leader for inspiration. Alienated Followers: frequently cynical, disgruntled and acquiescent; they may be passive-aggressive in the execution of their tasks. Survivors: repeatedly adept at surviving change, they follow the leader's signals closely, hearkening to the "better safe than sorry" mantra. Effective Followers: however, think for themselves and are risk takers, who take on assignments with energy and vigor. Being responsible adults, they find followership to be an acceptable choice and a source of pride and fulfillment in their lives. (Kelley 1988) In line with this trend in evaluating the role of followership on leadership, current research is now focused on assessing the effect that followers have in supporting and challenging leaders. And studying how follower's behavior in turn affects the leader's behavior in a give and take process—the so called, co-created leadership process. (Now you lead—now I lead). Resulting in two further leadership concepts that will be touched on here. Servant Leadership is what Robert K Greenleaf (1904-1990) called it back in the 1970's. On reading Journey to the East by Herman Hesse, Greenleaf advanced the utopian sounding leadership concept that the prime role of a leader is to serve the follower. A seemingly whimsical contradiction in terms, he moved that a leader be a servant first and foremost; so that follower's highest priority needs are best met to ensure that they grow as persons—inspiring them in turn to become robust servant leaders themselves. Leading to self-actualization of the follower, positive engagement, and enhanced leadership performance. Path-Goal Theory further advanced how leaders motivated followers to achieve designated goals—putting the responsibility squarely on the leader's back to address follower's needs, add what is missing, remove obstacles, and compensate for deficiencies in ability; in so doing creating a healthy and productive work environment. Leaders who trod the path to this goal needed to be particularly adept at discerning a given follower's individual needs: a follower who himself is authoritative and directive— needing leadership that is in turn, directive. Hence the leaders' responsibility rested in clarifying the path to the goal, clearing away ambiguity, and providing more certainty to their followers.

Leadership in Anaesthesia

21

Change Management Perhaps the two most prominent catalysts associated with leadership change management, are the Harvard Business School Professors: John P Kotter and Ronald A Heifetz (b.1951). (Kotter 1996, Heifetz and Laurie 1997, Heifetz and Linsky 2002a) Professor Kotter describing the key leadership ingredients of effective change management, as: x Establishing a sense of urgency x Creating a guiding coalition x Developing a vision and strategy x Communicating the change vision x Empowering employees for broad-based action x Generating short-term wins x Consolidating gains and producing more change x Anchoring new approaches in the culture until they become habit. (Kotter 1996) While Professor Heifetz described the psychological underpinnings of change management as tackling first the fear of change. Called metathesia-phobia, it is the fear of loss. This fear can be readily combatted by leaders providing sufficient trust in their leadership to propel followers to take the veritable leap of faith needed to adopt the change initiative—to a future that would be better than the past—leaders taking care to name the loss incurred. Then following through by defining whether the change needs to be either: adaptive—requiring a behavior change, or: technical—requiring a process or technology change. The so launched change initiative bolstered further by a leaders willingness to act much like a ballroom manager in moving from the center of the action "dance floor" up on to the "balcony" from where the leader— thus removed from the direct action—can see the patterns of the change initiative emerging, while, simultaneously, "orchestrating the conflict"— regulating (adding or releasing) the pressure on the dancer protagonists; in so doing applying the necessary urgency to the situation and moving the change process forward while not overwhelming the participants. (Heifetz and Laurie 1997, Heifetz and Linsky 2002a) Coined Adaptive Leadership, Professor Heifetz urges leaders to be especially certain that they put the work squarely where it belongs; with the follower. Allowing them to grow from the experience. Recognizing that it is often far too easy for a leader to take back the work—figuratively taking

22

2. A Brisk History of Leadership

back the monkey from the follower's shoulder, rather than leaving the monkey where it belongs; the follower learning from the resolution of the problem, allowing her to strengthen her own leadership potential in turn. Underscoring these change management techniques was the seminal work of Professor Daniel Goleman (b.1946) on emotional and social intelligence. First demonstrating that leader's moods and emotions were literally contagious; affecting everyone around them in a positive or negative way, he went on to show that leadership behavior could be learnt— hardwired into the brain's neural tracts—leaders literally connecting with the brains of their followers, through mutual firing of similar 'mirror' neurons in their brains. In so doing inspiring both positive feelings and releasing neurohormones, like oxytocin; making followers feel good about themselves and so motivating them even further. (Goleman and Boyatzis 2008, Goleman, Boyatizis, and McKee 2001) Professor Warren Bennis capturing this beautifully in the timeless quote: "People love leaders, not for who they are, but for how they make us feel." (Bennis and Nanus 2003)

Teamwork Teamwork too has been much championed over the intervening years. The Wisdom of Teams defining: "A team is a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable." (Katzenbach and Smith 2002) Designed to equate to more than the sum of their parts, teams are created to unlock greater value: 1 + 1 + 1 = > 3. Central to effective teams, in creating this added value, is having the necessary skill set within the team as well as mutual accountability, and a collective determination of performance goals. Theory translating into practice as the team works towards a common objective: ticking off "short term wins" along the way, which deepen trust and commitment, producing the enriching rewards of mutual team effort, and so further energizes and motivates the team members in a virtuous positive reinforcing loop—mirror neurons firing in unison in the team participants: releasing oxytocin. Predictably, not everyone agrees with the value of teams. Some citing concerns about the problem of maintaining motivation, clarity of

Leadership in Anaesthesia

23

purpose, and having the right team members to avoid ending up with a fuzzy dysfunctional team. (Coutu 2009) Ultimately putting this responsibility on the team leader to manage—the leader charged with making sure that contrarian voices are heard, and acted upon, so that feel-good group-thinking does not fatally wound the team effort in the achievement of its goals. (Coutu 2009) †

Leadership Skeleton In order that we might flesh out important leadership insights from the five anesthesia leaders presented in this book, we will perform a Leadership Post Mortem concluding each chapter. To equip us for the job, we have hopefully provided an adequate, but brief history of the perpetually expanding concepts that writers have used to describe leadership. Nevertheless, we need something we can "hang our hat on" for this dissection. We need a skeleton that we can perform our post mortem on. A post mortem being a dissection of the dead to find out what ailed them. But historically, post mortems were often used by early anatomists and doctors to establish what kept patients alive or better still, how things worked—just as much as to determine the cause of death. So, in this book, we will perform a leadership post mortem to assess each pioneer's leadership capacity. Pathologists have a set approach to the post mortem. 5 First they do a "Gross Examination." An overall evaluation by looking at the body as a whole—sometimes making a presumptive diagnosis at this stage as to the probable cause of death. "Tumor of the brain." Then they dissect down, removing body parts for further examination. Resecting the liver and then the lungs (amongst other organs), the pathologist might note tumor growth in the lungs and liver as well as in the brain, and, upon further histological examination, establish that the primary cancer came from the lungs. The final diagnosis: not primary brain cancer after all, but rather, primary lung cancer with metastasis to the liver and brain—terminal indeed. Hence the post mortem is the final word in the diagnosis of death. 5

Mortem is Latin for death, hence post mortem is after death. Also known as an autopsy, most pathologists abhor having to perform these.

24

2. A Brisk History of Leadership

Similarly, we will examine seven key 'body parts' of the Leadership Skeleton in an attempt to gauge the leadership capacity of the pioneers described in this book. For this purpose, we propose using seven crucial diagnostic elements for the leadership assessment—best captured by the rubric: Creative LEADER. Leadership Skeleton: Creative LEADER max score: +++, min score: 0.

Pioneer

Creativity/Innovation/Imagination

++

Legitimacy/Authenticity/Credibility

0

Emotional Competence/Psychological makeup/Personality Adaptability to Change

+

Determination/Passion

++

Empathy

+

Resilience

+++

Total Leadership Score

12/21

+++

Example score (out of a possible 21) provided as illustration. In turn we will use the derived rubric scores to compare the leadership profiles of the five pioneers in the final chapter of the book entitled: "A Leadership Reckoning." The reader will be forgiven for questioning the validity of these seven body parts as constituting a sufficient skeleton for a leadership analysis. In motivation for proposing these we offer the above provided leadership history and the following:

Leadership in Anaesthesia

25

Creativity/Innovation/Imagination Creativity is the key to leadership. Without it, or bereft of cultivating this in her followers, a leader is nothing. Be this in science, politics, industry or the arts—nothing new will be created and no constructive change championed. Call it innovation, imagination, a better way, or even a vision of moving forward, leadership creativity is the necessary spark to the leader's success. While it is no longer an academic question that personal creativity, or the leaders' ability to unlock, nurture, and bring to fruition the original ideas of others, is essential to organizational success in the present day—in the past, creative innovation was often spawned by enthusiastic tinkerers. (Scemama and Hull 2012) Witness Thomas Alva Edison (1847-1931) and electricity; the Wright brothers and the development of flight (1903); and Henry Ford (1863-1947) and the Model T motor car. Born into a farming family in Michigan, Henry tinkered with timepieces before training to be an engineer. Working on steam engines by day, he designed gasoline engines by night and eventually created the first mass produced car—using ideas from his factory workers in developing an assembly line to enhance productivity. Ultimately producing more than fifteen million black Model T Ford motor cars as testament to his creative leadership. Creativity is thus not just about solving old problems (steam engines) with new solutions; it is about finding new problems to solve (gasoline engines). (Ghaemi 2011) Or, better still, finding new opportunities to develop. (Drucker 2004) But how does a leader unlock and harness the creativity of others to a common purpose? By providing the intellectual challenge, recognizing and showing appreciation of the goals that are attempted, and embracing, while supporting, the certainty of failure of many of the initiatives endeavored. (Amabile and Khaire 2008) It is all about creating a community that is willing and enabled to generate new ideas. (Hill et al. 2014) And how does a leader develop and foster new ideas? Well, it's not just about how many new ideas you have—it's about how many you can make happen. It's about overcoming the natural human resistance to new ideas, borne of any number of reasons: jealousy, anxiety of usurpation, natural skepticism. It's about embracing these naysayers, in

26

2. A Brisk History of Leadership

so doing lighting a fire of attention on the idea, letting the enemy shoot at the idea, while not shooting back. So winning sympathy from the crowd you are trying to pitch your succinctly presented idea to—while being suitably prepared for the four ways people try to kill ideas: fear mongering, confusion, delay tactics and ridicule. (Kehoe 2010) Once the original, potentially revolutionary ideas are so unleashed, it is then the leaders' job to shepherd them to successful resolution: setting rules of engagement (conflict of ideas not person—question everything!); fostering experimentation while learning; encouraging improvisation; harnessing available resources, and fostering 'creative agility'—adjusting plans and actions based on interim results and incorporating this knowledge in a renewed cycle until a solution to the problem eventually emerges. (Hill et al. 2014)

Legitimacy/Authenticity/Credibility Authentic Leadership is all about the development of trust. Trust engendering greater loyalty and commitment in followers and unlocking altruistic behaviors from them. We are wired to establish early in an encounter who we can trust, are real or authentic as opposed to being fakes, and who have good intentions towards us; so we can put faith in their leadership ability. (This is where Dr. William Morton will become seriously unstuck—as described in the next chapter). Leaders who approach us with genuine warmth (and good intentions) unlock oxytocin 6 release in our brain and so enhance our feelings for them and our willingness to reciprocate and build a positive relationship with them. (Cuddy, Kohut, and Neffinger 2013) However when a leader is faking it, pretending to be someone they are not; we cotton on early—something does not quite ring true about the phony—provoking anxiety in the interaction (raising the stress hormone cortisol and depressing oxytocin levels). We just cannot put our finger on it and so we view the non-authentic leader with suspicion—especially suspicion as to their underlying motives in wishing to establish a relationship with us. Hence the term authentic leadership conveys a leader's ability to project their true selves—nevertheless sometimes acting like chameleons: adapting to the situations they find themselves in and knowing instinctively 6

Oxytocin is released by the pituitary gland in the brain. It is a key bonding hormone: released during lactation when a mother breast-feeds, during sex, and even when you shake someone's hand in greeting.

Leadership in Anaesthesia

27

what to reveal about themselves or not—in order to best develop a relationship. (Goffee and Jones 2005) To engender trust, authentic leaders are consistent in word and deed and know how to get followers to relate to them. To get to this point, the credible leader has sharpened their social antennae—becoming adept at sensing the effect of their leadership style on their followers. They have also honed their levels of self-knowledge and selfawareness in order that they may share of themselves in building these relationships. In so doing releasing copious quantities of oxytocin— unlocking the good feelings necessary to building resilient relationships based on trust. Legitimacy is related to authenticity and probably an altogether better 'catchall' term handily subsuming it. Professor Michael Porter, again of the Harvard Business School, certainly seems to think so. A leader's influence stemming not only from their formal authority but, probably more importantly, from the legitimacy stemming from the content of their character and the trust they earn from their followers. Earning this legitimacy in many ways: through demonstrating strong values, fairness, ethics and commitment to their people—in so doing motivating followers to go far beyond the normal call of duty and achieving extraordinary performance. (Porter and Nohria 2018) Hence in this book we will use Legitimacy to include the concepts conferring authenticity and credibility.

Emotional Competence/Psychological make-up/Personality Emotional Competence is an assessment of a leader's ability to execute with intestinal fortitude—stomaching the emotional responsibilities thrust on her; reliant often on the leader's personality, psychopathological frame of mind, and state of emotional intelligence. Emotional intelligence can be developed and serves a leader well in motivating and inspiring followers—recent neuroscience having demonstrated that humans have an open loop limbic system allowing empathetic leaders to become entuned to their followers' moods—resulting in the transmission of positive emotions and self-regard. (Goleman, Boyatizis, and McKee 2001, Goleman and Boyatzis 2008) Emotions being literally contagious, the leader needs to control his mood to be optimistic, supportive and energetic—setting the tone for followers to be more able to achieve their goals and enhance their creativity and efficiency. (Mets 2016) The influence of psychological make-up, personality and psychopathology on emotional competence have been addressed previously.

28

2. A Brisk History of Leadership

Importantly we expect leaders (vs. managers) to be more temperamentally disposed to take on risk and face danger and will often have narcissistic personality types. And if leaders are hyper-manic we expect them to be more resilient and creative—and if depressed: more realistic and empathic.

Adaptability to Change Change is the new constant. And Adaptability to Change a constant requirement—leader's role through the ages being to produce constructive change; either through their leadership or as a consequence of their teachings, art, discoveries, inventions, penmanship, or conquests. The key elements essential to the successful change management have been enumerated above.

Determination/Passion Determination and Passion speak to the leader's advocacy for the higher purpose of the cause she is championing. Impassioned, for example, by religious fervor or the zealotry of a worthy cause—it is the leader's cultivated ability of communicating (pitching) and so motivating for the cause at hand. In a word persuading. Leadership, after all, is considered the management of meaning and the mastery of communication. (Bennis 1994) Professor J.P. Kotter champions the astonishing talent of the great leaders of the 20th century in their ability to persuade by communicating in simple and clear ways; often through story-telling, engaging people and finding the best way for individuals to grasp the issue or cause; in so doing impelling it ever forwards—applying energy and passion to the task at hand. (Kehoe 2010) Determination and Passion also speaks to the constant energized momentum required of leadership—focused on success without the fear of failure. Karl Wallenda (1905-1978) headed the famous tight-rope walking family—the Flying Wallendas. Famously stating that: "The only time I feel truly alive is when I walk the tight-rope." Falling to his death while traversing a 121-foot-high tight-rope in San Juan Puerto Rico, in 1978. His wife, also an aerialist, remarking about her 73-year-old husband: "All Karl thought about was falling.... It seemed to me he put all his energy into not falling, not in walking the tight-rope."

Leadership in Anaesthesia

29

Professor Warren Bennis remarking that when Wallenda put all his energies into not falling—he was destined to fail. Coining the term the "Wallenda Factor," he emphasized that leaders need to have an orientation towards success, without the fear of failure. (Bennis 1994)

Empathy Empathic leadership is a relatively new concept, but rapidly gaining traction—the German word for empathy appearing in the 1850's, refined to Einfühlung at the turn of the century, and, incorporating the word pathos in the English translation in 1910, became empathy: the feeling of suffering with another fellow-human. (Ghaemi 2011) Empathic Leadership is fast becoming a popular concept—fueled by a fuller understanding of the neuroscience that explains empathic feelings: the neuronal architecture underpinning this, and the effect of the neurohormones like oxytocin in the limbic system of the brain. Oxytocin, considered a social glue, is released especially during sex, breast feeding, and during a hand shake; in short, during social interactions that need to be repeated to build relationships. Mirror neurons in the brain providing the supporting neuronal architecture: they mimic or mirror what another human being does, or even feels, through lighting up corresponding insula and cingulate gyri in the other person's brain. "I feel your pain" is thus a true statement: one person's open loop limbic system literally reaching out to the other with empathy for the sufferer. And this 'social guidance' system can be developed to bolster a leader's ability to lead. Often called intuition, or leading from the gut, the system rests within neurons called spindle cells—which have extra-long dendritic branches—connecting feelings and thoughts from learned emotional experiences throughout the brain. These spindle cell neurons come into play whenever we are faced with choosing the best response amongst many; or when we are judging how we feel about a person—literally "thin slicing" whether we feel we can trust them or not; the social guidance system having proven to be highly reliable, especially when we are "attuned" to the person in question. The attunement often being physical; followers experiencing resonance with their leaders—unconsciously through mirror neurons and spindle cell circuitry, but also through oscillator neurons—their body

30

2. A Brisk History of Leadership

movements corresponding to the leader's in rhythmic empathy (nodding their heads or rocking their bodies in tandem). Intertwined and released in sympathy with these neural circuits are the neurochemicals that affect and reinforce behavior: Dopamine release bathing reward centers for a job well done. The more difficult the job, the more dopamine released. A leaders' praise releasing cortisol and adrenaline which at low levels facilitate a follower's thinking ability; but if the leader vehemently criticizes the follower instead (causing overwhelming release of these chemicals), memory, planning, and creativity suffer, and attention fixates on the threatening boss instead of focusing on the work at hand. Oxytocin release further cementing and reinforcing relationships; building empathy and trust, while serotonin is released when we feel respected—and both foster the empathic relationship between leader and follower. (Ghaemi 2011, Goleman and Boyatzis 2008, Goleman, Boyatizis, and McKee 2002) So, empathy is a neurobiological fact; humans are primed and wired to feel the emotions, movements, and pain of others—Empathic Leadership leveraging this fact. Consistent with the recent interest in Empathic Leadership an empathy triad demonstrating three distinct kinds of leadership engagement have been described: Cognitive empathy—used to understand others by curious questioning; and then piecing their thought processes together to help explain the situation back to them and so help enhance their performance. Emotional empathy—springing from ancient parts of the brain; allows us to feel quickly (while not having to feel too deeply) and arouses the emotional state of others in ourselves—and has been found to be essential in effectively reading group dynamics or mentoring. Empathic concern—mediated by oxytocin release, is the leader's ability to sense, not just how follower's feel, but also what they need from them—in for example nurturing support. (Goleman 2013) Knowing these neurophysiological responses, the empathic leader can use herself as an instrument; using empathy to learn from and effectively control a clinical situation. As an example lets follow an aspirant doctor who learns as a medical student that on interviewing a patient who is agitated or suffering pain; she perceives these sensations as personal irritation or pain.

Leadership in Anaesthesia

31

Having learnt in the past how this patient interaction made her feel, she has learnt to be attuned to the situation and when faced with a similar scenario automatically deploys an "attentional anesthetic" neural circuit, through her pre-frontal cortex, blocking out the agitation and boosting her cognitive concentration, allowing her to tune out negative emotions, stay emotionally calm, and focus on the critical situation at hand. Having learnt to calm herself, in emotionally charged situations, she is better able to sooth the patient while deliberately focusing on the critical task at hand—which might be a precise surgical intervention or making a difficult diagnosis and explaining exactly to the patient what is wrong with him. The doctor having learnt to switch from heart-to-heart emotional empathy—to head-to-heart cognitive empathy; in the better care of her patients. (Goleman 2013) Henry Ford probably described empathic leadership best (before the term had been coined), pointing out that if there is any great secret to success in life, it lies in the ability to put oneself in another person's place and to see things from his or her point of view—as well as from one's own. (Riordan 2014)

Resilience Resilience, the old-fashioned 'hardiness', is about getting up when you get knocked down or experience a set-back. "It's not how many times you get knocked down—It's how many times you get up that counts" is how a colleague put it once. Resilient people, have three defining characteristics: a firm grip on reality an unwavering belief that life has meaning and purpose and, a resolute ability to improvise. (Coutu 2002) Consider Viktor Frankl (1905-1997) a Viennese psychiatrist who studied suicide prevention. Incarcerated in the Auschwitz concentration camp in 1944, he had every chance of losing hope and dying, under the brutal conditions that a slave laborer in the camp endured. Yet he found meaning and purpose in the suffering he bore—through planning to study the experience and write about it should he be freed. Believing that man strives primarily to seek meaning in life, and upon being freed in 1945, he wrote Man's Search for Meaning. Describing there-in his newly developed discipline of Logotherapy, and the three main avenues to meaning in life: creating work or doing a deed; experiencing something or loving someone; and turning a personal tragedy into a

32

2. A Brisk History of Leadership

triumph—he demonstrated how the incurable suffering patient might be ennobled (rather than degraded) from the experience of illness. (Frankl 1984) Resilience is not solely optimism however. Witness the Stockdale Paradox. Admiral Jim Stockdale, imprisoned by the Viet Cong at the Hanoi Hilton in the 1960's, observing that the pure optimists did not survive. Those that believed they would be out by Christmas, didn't make it. Those that confronted the brutal reality and retained faith that they would prevail; survived to tell the tale. (Collins 2001) Nor is resilience either moral or amoral; concentration camp survivors doing whatever it takes to survive—brutal or not—having lost all scruples in their fight for existence. (Coutu 2002) Resilience is the capacity to improvise—through creativity and inventiveness—to use whatever is available to find a way to bounce back from adversity. Resilience work's like a vaccination—it is not simply something that one is born with but an attribute that can be developed and is strengthened from duress; some people becoming stronger from the stress— protecting them in the future. As Friederich Nietzsche wryly observed; what does not kill you makes you stronger. Found to be more prevalent in hyperthymic personalities, there is evidence that repeated psychological trauma can actually improve psychiatric well-being, enhancing resilience. The main factor determining this paradox of psychological trauma—termed the "steel effect"—being how an individual felt about the traumatic episode: positive or negative. Called "cognitive reappraisal," when a positive light is shone on a negative event, like incarceration, as Viktor Frankl did—the individual becomes psychologically more resilient to stress in the future, having been inoculated against it in the past. (Ghaemi 2011) Resilience can thus be built through life's experiences and will prove most important in many of the pioneers' successes in advancing the history of anesthesia. †

Leadership in Anaesthesia

33

Post Mortem In this chapter we have set the stage for this book. Hoping to provide the reader with a working knowledge of the history of leadership, we have focused on present day concepts in order that we may build on these in performing a Post Mortem analysis of the five leaders of anesthesia here presented. To provide structure for this analysis we have characterized seven key ingredients to successful leadership in a rubric entitled Creative LEADER. Composed of Creativity, Legitimacy, Emotional competence, Adaptability, Determination, Empathy and Resilience—we will use these concepts as the 'body parts' of the Leadership Skeleton that will be dissected at the conclusion of the forthcoming chapters—laying bare the protagonist's successes or failures in order to create a putative leadership score, and expose the insights that can be learnt from the five historical protagonists that populate this book. This, in the hope that we may learn to better understand leadership—notwithstanding Dr. James MacGregor Burn's quote: "Leadership is one of the most observed and least understood phenomena on earth." (MacGregor Burns 1978) †

3. WILLIAM MORTON

The Art "Character is Destiny" —Heraclitus

36

3. William Morton

The Discovery

A trouble maker and narcissist! That is what we would call William T.G. Morton today. Not so on Friday October 16, 1846. Poised to publicly demonstrate sulphuric ether as a practical anesthetic, the swashbuckling charmer, Morton, was merely known as a raw dentist, a mendacious huckster, a swindler, a confidence trickster and a counterfeiter extraordinaire as he made his way confidently, but anxiously, and hurriedly, along the straight gravel path past the halfconstructed Harvard Medical School on his way to the three-storied Massachusetts General Hospital—looming up in front of him. He was late. Very late. Forestalled by needed adjustments to the newly invented, never used, glass-globed-apparatus held tightly under his right arm—while the left cradled a demi-john filled to the brim with the deadly explosive ether he was planning to administer. He looked the part though. A fine top hat cresting curly thick hair, groomed side burns, and a considerable moustache, gracing a chiseled charming face, with an all too ready winning smile; he proudly wore a fine alpaca suit and quilted linen waistcoat, as he side-stepped a dead dog—not yet cleared from the path—at 10.15 a.m., reminding him what his wife Elizabeth had just said this very morning when he got up from bed in their Needham cottage: "You will fail, and kill the patient and be tried for manslaughter." Agitating him even further were the screeching seagulls wheeling and diving above—flown over from Boston's back bay. Looking up to follow their progress he noted a favorable sign: a sunlit clear cloudless sky, knowing full well that the hospital's only operating theatre, where a patient had been readied for the demonstration, was on the top floor, and, having a domed sky-light—the surgeon, Dr. J.C. Warren, could rely on ambient light to see his patient clearly and would not need candle-light: the flame causing ether to explode. Nevertheless, Morton was late. Not a good thing for the publicity that William wanted to generate by demonstrating practical anesthesia with sulphuric ether (a distilled liquid known to mankind for over 500 years) whose signature smell Morton had hoped to disguise by adding orange oil essence and had hastily patented as Letheon—wishing to gain a fortune from the discovery of anesthesia; providing painless surgery with no memory of the event.

Leadership in Anaesthesia

37

Publicity that would surely flow from the first public demonstration of painless surgery at the venerable Massachusetts General Hospital performed by one of the best known surgeons in the world, should Morton be successful and the patient not run screaming out of the theatre at the first slash of the surgeon's knife, or die an untimely death in the operating chair. To this end, a few days before, Morton, who was attending as a Medical Student at the Harvard Medical School at the time, had approached his erstwhile lecturer, Dr. J.C. Warren, and bodaciously asked if he might demonstrate practical anesthesia, rendering the patient pain free from surgery. Receiving word, yesterday, that a patient would be ready at 10 a.m. sharp, Morton went into a panic—all he had was the sulphuric ether poured on a towel and clasped over the face to render a patient anesthetic for toothpulling—really nothing new; just a new purpose for the old liquid. He needed much, much more to make a sure profit from his endeavor. He needed an invention, a piece of apparatus that could be used to concentrate the ether sufficiently to allow deep anesthesia; that he could then demonstrate and market as a practical anesthetic device. Hence he had turned to a glass maker and conchologist, Dr. Augustus Gould, who had rapidly fashioned a glass-globed-retort containing a sea sponge. Much like the letter Y—at 10 o'clock a beer-barrel spigot protruded from the one side for the patient to breathe from; while at two o'clock, a glass tube opening had been fashioned—allowing in air—drawn over the sponge saturated with ether liquid; vaporizing with every inhaled breath. Being careful not to drop his precious cargo, Morton tightly clasped the retort under his right arm as he leapt off the gravel path and up the ten steps to the front entrance of the hospital, asked someone to open the front door, and tore up to the three flights of stairs leading up to the sky-lit, tiered, Bullfinch amphitheater, where he had so recently himself watched agonizingly painful surgical proceedings as a medical student. On fire now, and breathless, clasping his anesthetic equipment tightly, Morton paused to catch his breath, focus and compose himself, before making an entrance. He knew what he would see, hear and smell as he nudged open the door to the small operating theater. Overhead, the vast domed glass skylight, a wonder of cast-iron and glass construction, bathing the planned proceedings in a shaft of bright but dusty light. Reaching up on high, a semicircular tiered amphitheater, six levels of seats filled to capacity with the who's who of the day: medical students, doctors, a few scientists, a journalist, a pharmacist and even a daguerreotypist, Josiah J. Hawes, ready to memorialize the planned event. Filled to capacity,

38

3. William Morton

there wasn't even standing room available, many spectators planning to crowd around the surgical chair—all the better to see unfolding events. On his right as Morton entered the theater, hip-height, the entire back wall was outfitted with glass cabinets filled with the sharp knives, saws, cleaving hooks and hammers that were the tools of the surgical trade, ready to be extracted at a moment's notice should the readied surgical instruments prove insufficient for the planned surgery. Standing erectly on either side of the cabinets was a full human skeleton on the left, and at the right, a larger than life statue of Apollo; the Goddess of medicine and healing reminding all of the balance between life and death, that would be about to be played out before them. The general hubbub quietening somewhat. Morton glanced anxiously to see the patient—was he solid and a drinker (and so difficult to anesthetize) or slim, temperate, and tubercular, and so unduly sensitive, making it easier, but more dangerous, to provide the anesthetic. (Woodward 1962) There, in the center of the room, displayed for all to see was his answer: Edward Gilbert Abbott, a sickly twenty years of age, probably tubercular, shabbily dressed in a white shirt and drawers but resolute nevertheless, having suffered from a neck tumor since birth, lying back in the plush red operating chair, hyper-alert, his eyes fixed straight ahead and his arms and legs tightly held down by leather straps—just in case. Saw dust, not yet saturated with blood, crunched underfoot as Morton advanced to the operating chair, pleased to see a crowd of coated men gathered around anticipating his every move. (Wolfe 1993) Ebenezer Hopkins Frost, a rotund mirthful sawyer, smiled encouragingly, showing the gapped tooth that Morton had so recently extracted, painlessly, under ether anesthesia at his Tremont Row Dental Office late on the night of Sept 30th—a defining moment that had been captured the very next day in the Boston Transcript: "A new and valuable discovery." Dr. Henry Jacob Bigelow (1818-1890), a young house surgeon who had witnessed 37 of Morton's subsequent successful ether anesthetics for tooth-pulling—eventually becoming Morton's greatest champion in promoting practical anesthesia. Dr. Charles Frederick Heywood (1823-1893), who, unbeknownst to Morton struggling up the stairs at the time, had wanted to start the surgery without him—for he was late—but was arrested in that attempt by the diminutive but magnetic ramrod figure termed the "Iron Duke"—ice-water running through his veins—at the center of the crowd:

Leadership in Anaesthesia

39

Dr. John Collins Warren (1778-1856). Small in size but large in stature—the Iron Duke was Boston's pre-eminent surgeon. Long in the field of surgery and sickened by the pain he had caused over the years, he was ready to wait a few minutes longer in the hope that a solution to this intractable problem could be demonstrated declaring, as he stayed Heywood's knife from cutting into Abbott's pale scrawny neck: "Stop, we have promised Mr. Morton a chance. We will give him a few more minutes." Then turning his face up to the "Mountain" of medical students and other on-lookers around the semicircular auditorium he announced loudly and with a nasal twang, "There is a gentleman who claims that he has discovered that the inhalation of a certain agent will produce insensibility to pain during surgical operations, with safety to the patient. I have decided to permit him to try the experiment." (Fenster 2001) A hush fell as Morton took center stage next to Abbott, reclining fearfully in the operating chair, lashed down in case he changed his mind and bolted. "Your patient is ready" said Warren with some irritation: it was 10.25 a.m. His hands shaking a little, bright blue eyes flashing, Morton poured ether from the demi-john held in his right hand down into the glass apparatus in his left, dousing the sponge fully with volatile sulphuric ether, the pungent smell suffusing the room immediately. (This was serious stuff, he was about to experiment, in public, using a lethal concoction and a device he had never tested, that could kill and explode, ruining his reputation and future prospects, and in all likelihood Morton being tried for manslaughter should Abbott succumb.) Turning to Abbott, Morton took him by the hand and speaking quietly to calm him, he pointed out Ebenezer Frost who so recently had received the anesthetic successfully, to reassure him and then asked: "Are you afraid?" "No, I feel confident and will do precisely as you tell me." Morton then fiddled with the glass retort, as he saw the Iron Duke pick up a particularly vicious knife out of the corner of his eye, and proceeded to place the wooden spigot in Abbott's mouth: "breathe in deep and slow." (Vandam and Abbott 1984) Gilbert did, coughing a bit; Morton encouraged Abbott on: "breathe deep and slow" as his limbs twitched and moved, restrained only by the leather straps, an expectant silence reigned in the amphitheater; some in the auditorium forgetting to breathe themselves at the sight of an apparently unconscious patient displayed before them.

40

3. William Morton

Five minutes later, Morton removed the wooden-mouth piece, stood back, turned to Warren, and with a flourish stated in his customary course irritatingly loud voice: "Your patient is ready sir." The Iron Duke raised his knife, planning to cut into the 20-yearold tumor pulsing in Abbott's neck. † William Thomas Greene Morton was born into a common-place, God-fearing, Massachusetts farming family on 19 August 1819. First and only son of Rebecca Needham and James Morton, his first two names were family names but the "Greene" remains forever a mystery. As much a mystery as why "Willie" with such constrained humblyhonest beginnings, would become the lying, conniving, manipulative promoter of etherization that would eventually convince the world of sulphuric ether's practical use as a general anesthetic. It is true that he had very little consistent school education (despite his poorly educated father's best efforts); James first enrolling Willie in the local Charlton Academy, and then (probably because Willie got caught with his fingers in the till at a local bar where he was bar-tending) sending him to the nearby Oxford Academy. To no avail. Morton was expelled for breaking school rules. Refusing to confess, Morton received an 'ill-judged and outrageous punishment,' returning home where he was laid up for many months becoming 'a sufferer in health and unfit for action or thought.' (Rice 1859, Perley Poore 1856) It is also true that at this time James Morton suffered financial ruin, forcing the sale of their house, and to make ends meet, father and son repaired to Boston to make a living for the family, while tearing it asunder— to the everlasting regret of Becky, his mother (who Willie was very attached to, would outlive him, and be an avid apologist for his actions). Morton just 16, becoming an errand boy and a copy-runner for the first American Ladies Magazine, a periodical devoting itself to Ladies' fashion; and probably where Morton learnt his foppish dress sense. Not finding this to his liking, Morton returned home to Charlton, but didn't stay long; forced for undisclosed reasons to set out further afield— far further afield—to Rochester, to Cincinnati, to St Louis, to New Orleans and then to Baltimore on various mercantile endeavors. All failing—Willie branded a swindler, trickster, impersonator, counterfeiter and imposter besides—and only just escaping the long arm of the law; almost certain arrest by Constable George Riggs of Baltimore—

Leadership in Anaesthesia

41

Morton having fled there to escape the public vilification meted out in the St Louis Daily Evening Gazette of September 30, 1840 entitled: BEWARE A VILLAIN "An utter, abandoned, and block hearted scoundrel, capable of perpetrating any atrocity not requiring personal courage for execution" The Gazette going on to chronicle meticulously each geographical misstep by misstep that sullied Morton's reputation from the age of 17 to 21. It is a wonder he was never locked up, although it was often a close thing—Morton's glibness, artful beguiling manipulation, and deceptive, but persuasive charm, keeping him one step ahead of the law through Houdinilike trickery. (Wolf 2001)

Rochester, New York (Pop. 20,000: 1836-1839) Travelling by stage-coach to Albany and then to the Erie Canal, Morton, aged just 17, likely took a steam boat to Rochester arriving with his small trunk of belongings in one of the early boom towns of the "West" to start his first job. Disembarking in his usual hurried fashion, he took lodgings in a boarding house, enrolled as a clerk in a General Store owned by Timothy Chapman, and generally busied himself in learning the tricks of the trade. As it turned out, more tricks than trade, unfortunately—upon Willie's exit from his employment, Chapman not having much good to say about Morton's business conduct: "I watched his course in business & as a citizen, and it was such in both respects as to deprive him of all confidence of all honest and honorable men, he violated his engagement to those with whom he formed business connections." 1 Undaunted, Morton forged on. Literally. Taking up with a new business associate, Loren J Ames, buying and selling West India Goods, and signing both a business contract and admitted to communion privileges at the Rochester Brick Church on the same day: April 1, 1838. April Fool's Day. Fooling both:—Ames with fraudulent notes of credit, and the Church—of his Christian religiosity (Morton having been circumcised earlier to win favor with a rich Jewess). 1

Such statements were gleaned from depositions that were subsequently recorded, almost a decade later, for the purposes of contesting Morton's primacy claims for the "Invention & Discovery" of sulphuric ether as an anesthetic.

42

3. William Morton

Nevertheless, the business opened on Main Street fronted by the name: "Ames & Morton" after Willie had secured $1500.00 of West India goods for sale, and established lines of credit with the New York Loan Company—Loren Ames unfortunately soon discovering that this fine sounding company was "a swindling concern without capital." The credit notes and bills Morton had proffered for payment, proving spurious and rejected by creditors; Loren Ames was soon forced to provide security using goods from the firm instead. Undeterred, Morton went off to New York again, with no funds save those he needed for travelling expenses, and returned with $2000.00 worth of ill-gotten goods. Again, to Ames's dismay, Morton purchasing solely on the credit of the now increasingly creaky firm of Ames & Morton. Protesting vigorously at Morton's bent business practices, Ames sought dissolution of the partnership without further delay. Morton refused. Things came to a head however when Ames ascertained that Morton had crooked the books—writing in $500.00 as bogus credit to his name; Ames later deposing that "Mr. Morton never at any time paid any cash whatsoever into the concern." Seeing no honest future in it, just five months into the joint venture, Ames closed the partnership in September and left the concern—Morton agreeing to pay all partnership debts. Valued at over $5000.00 in goods and services, mostly purchased on counterfeit credit, young Morton had a serious problem on his hands—resolving this in typical fashion. Ames, to his consternation, learning in November that Morton was selling the dissolved companies' belongings; not at cost, but instead, for firesale prices at auction—trousering the proceeds—and siphoning off other goods and trucking them away by rail-road. Amounting to almost $1500.00 in diverted supplies, to stop the bleeding; Ames had Morton served with an injunction; stopping him from any further sale of the merchandise. Nonplussed—stealing under cover of night was Morton's next approach to restitution. Ames catching him red-handed. Forewarned by his attorney and suitably disguised as a nightwatchman, Ames waited patiently outside his Main Street store on a cold November night. Peering through the cracks between the closed blinds he could just see Willie and an accomplice—holding aloft a guttering candle lighting the way—selecting salable silks and laces from the packed shelves; then packing them into a trunk, which Morton then stealthily removed to his boarding house.

Leadership in Anaesthesia

43

Morton caught secreting the goods in his boarding house that very night, a court ordered Receiver was appointed the next day. The business of Ames & Morton immediately closed for good, and the creditors paid off with the proceeds. Unsurprisingly, these proved to be insufficient. Forcing Morton to provide further reparations, which he did by providing the forged deeds to five tracks of land; a fact that only came to light many years later. The Brick Church—which Morton had so deftly joined to seal his contract with Ames on April Fool's day—also had their day of reckoning in store: Church records detailing the excommunication of William Morton from the Church of Christ at large, for the sin of profanity and dishonesty in his dealings with his fellow man—a testimonial stating that he remained incorrigible and more hardened and non-repentant than ever before. 2

Cincinnati, Ohio (Pop. 46,000: 1839-1840) Declared Person-non-grata in Rochester, Morton now all of 20, hastily packed his trunk, put on his coat and top-hat, straightened his neck tie, boarded a steamer, and headed down the Erie and Ohio canals on his way to Cincinnati, hoping to leave behind his tarnished reputation and start a new life in this busy port-city known as the "Queen of the West." Morton knowing that opportunity abounded as Cincinnati boasted five banks, seven insurance companies, and a college, while its bustling populace was productively engaged in manufacturing and trade craft. Arriving in the late fall of 1839, the tree-leaves all turned to golden brown in the brisk cold, Morton repeated the suspect business practices he had refined so recently, forming a partnership with Charles S Pomroy: a grocery business known as Pomroy & Company—which too was soon to be put into receivership from his nefarious actions. Misrepresenting that he was the son of Governor Marcus Morton 3 of Taunton, Massachusetts—Morton sought to win confidence by using forged promissory notes to establish credit; presenting fraudulent letters of introduction, and through providing glowing testimonials—he hoped to expunge any whiff of past transgressions and gad about that if any errors had been committed in the past, these were undoubtedly "of the hand & not the heart."

2

Important to note here in 1839, that Morton was want to celebrate his successes and very likely attended 'ether frolic' parties conducted by William Clarke, a nominal dentist, who reputedly, later, used ether liquid (not vapor) to still the pain of tooth-pulling. 3 Governor Marcus Morton had no son. Only daughters.

44

3. William Morton

The inevitable failure of Pomroy & Company thus assured—it came early in 1840, just 6 months after it's inauspicious launching—an auditor J.J.B. Carpenter was appointed to examine the books and to prosecute Morton as a swindler. But, inexplicably, greatly taken in by the narcissistic troublemaker, Carpenter reported that Morton "Threw himself on my sympathies.... &.... gained them. I used my influence to prevent the prosecution." And, upon finding that the partners had only deposited cash in the amount of $250.00—while a sum of over $6000.00 had been entered in the books; Carpenter reluctantly had to conclude that the Company was running on "fictitious capital" and was finally swayed to concede that: "Morton's manner was flexible, persuasive & gentlemanly." After impoundment of Pomroy & Company's goods—true to form—Morton, having retained a back-door key to the store, was once more apprehended stealing goods—again in the dark of night. The thief immediately compelled to leave Cincinnati post haste— just nine-months after arrival—and criminal prosecution only stayed, because his creditors believed Morton might use the situation to his political advantage; and the money had been lost any way.

St Louis, Missouri (Pop. 36,000, 1840) Feeling unwanted and unloved, Morton who was known for his slouching gait, stood himself up to his full five-foot-eleven and hastened on; packing his trunk carefully with counterfeit letters, forged stamps, printing stencils and ill-gotten silks; tightening his new silk bow-tie, but loosening his increasingly threadbare coat as the warming Spring weather of May was in the air—he disembarked on a steam boat headed down the Ohio river, past the port city of Cairo, straddling the two massive rivers' confluence, and back up northwards along the great Mississippi River and onto St Louis, the Capitol of Missouri—then the largest state of the Union. A bustling frontier city, St Louis, Mo. was a gateway to the West; a rambunctious supply point for fur-traders and migrants on their way to Oregon and beyond—ripe for Morton's manipulations. Finding suitable lodgings in a boarding house, Morton met his comeuppance, one Mordicai D' Lange, the bookkeeper for the venerable firm of J.B. Sickles and Co., dealers in saddlery and its hardware. Soon presenting fraudulent letters of credit to Sickles & Co, in the value of $6000.00, Morton was sent to the New Orleans branch of the company, letters in hand, to purchase goods on behalf of the St Louis based firm. Contriving to secretively ship these away for his own purposes, the

Leadership in Anaesthesia

45

goods were unloaded from the steamboat just in time, as Mordicai, armed with information of Morton's nebulous past, and smelling a rat, frantically sent letters to New Orleans begging the company there to stop Morton from perpetrating a fraud. Perforce, forced back to St Louis to be confronted for his past misdeeds by Mordicai at his boarding room, Morton armed himself for the planned altercation—placing a pair of pistols on the mantlepiece in readiness. Taken by surprise at the meeting to find two visitors—Mordicai and Mr. Benj Dayton—Morton was relieved of the pistols and threatened with public exposure in the St Louis Daily Evening Gazette, should he fail to immediately leave the city—within 24 hours. Greatly downcast by the threat of public exposure, Morton, beseeched the accusers, wept and cajoled, threatening to commit suicide, but stayed. Prompting the very public unmasking entitled: BEWARE A VILLAIN, of Sept 30, 1840, which propelled Willie back to Cincinnati and on to Baltimore for his next foray in misadventure. 4

Baltimore, Maryland (Pop. 102,300, 1840) Travelling with a Cincinnati acquaintance, Mr. N.S. Jacobs, Morton made his way post-haste, on the 500-mile trip to Baltimore—via steamboat along the Ohio river to Pittsburgh and then for three and one-half days by stage coach to Baltimore—the intermittent snow falls of December slowing their journey. Upon arrival the pair took lodgings together at the somewhat ramshackle private boarding house of Miss Beeman in Monument Square. Sharing a room with Morton—Jacobs, after becoming suspicious of his travelling companion's clandestine activities, took the liberty of inspecting Morton's trunk, finding all the accoutrements necessary to a swindling operation: forged post office stamps for the cities of Rochester, New York and Boston; fraudulent letters of credit, and certificates from a fictitious bank in Seneca, New York—he reported his findings to the local police for fear of being implicated. Gaining an arrest warrant, Constable George Riggs planned to apprehend Morton the very next day. But arrived at Miss Beeman's too late. Morton had just escaped, leaving behind his incriminating trunk, but taking Jacobs brand new broadcloth coat to replace his threadbare one. Riggs searching Baltimore high and low but ultimately concluding that Morton 4 Mordicai D' Lange stating dismissively in deposition later, against Morton's claims

for primacy in the discovery of ether: "in Morton I had discerned a degree of general ignorance which would make a scientific discovery by him, appear to me to be no less than miraculous."

46

3. William Morton

"had been a swindler along the western lines from Cincinnati to New Orleans" and had left the city for good. 5 And so ended Morton's 'mercantile career' as noted in William's self-edited, self-serving, sanitized, biography, written by Dr. Nathan Rice. Contractually bound to cohabit with Morton, in his farm-house, during its writing, in 1858—Rice was commissioned to write the: "Trials of a Public Benefactor" to bolster Morton's claims for primacy in the Ether Controversy which is about to be related here. 6 Never fully paid for the writing of the 460-page book, Rice was incensed by Morton's commandeering of his final and only manuscript. The fruit of two months of arduous labor—Morton hanging around to supervise the writing—upon its completion, the manuscript was spirited away from Rice under false pretenses; Morton likely editing the final text without permission before submitting the book (sight unseen by Rice) to the New York Publishers of Pudney and Russell; entreating them to get 100 copies published urgently to further his claims for primacy—Morton asserting that the competition, in the form of Horace Wells' ancestors, and Dr. Charles Jackson in person—were hard on his heels with counter claims and publications supporting their positions for primacy in the discovery of anesthesia. Rice, not knowing at the time what was about to happen to his book, and completely silent about the period of 1836-1840 described above, innocently summarized Morton's business escapades from the age of 17 to 21, thus: "With a natural dislike to the bustle, annoyance and drudgery of his present mode of life, his knowledge of routine business ... not ... very great, nor his powers for protecting himself from the cunning designs of others sufficient to assure him a profit. ... and duped by his partners, his mercantile career terminated in decided disaster, and its abandonment forever." (Rice 1859) Interpretation. Character is destiny. Character compels action and is molded from birth; shaped by an interplay of nature (genetics) and subsequent nurture (parenting) into behaviors that repeat themselves— becoming habits that are set early in youth but reprise interminably though out life. Character sometimes strengthens; creating adaptivity, resilience, and rigorous persistence. Sometimes character wanes. The person being 5

Giving the lie to the later claim by Morton that he had attended the newly opened Baltimore College of Dental Surgery, in furtherance of his claims that he was trained as a dentist; there being no records of Morton's attendance or graduation. 6 The illustration of William Morton fronting this chapter also graced the first page of this book and was undersigned: William G. Morton, M.D.

Leadership in Anaesthesia

47

easily overwhelmed, making them slippery, evasive, and unreliable, and often not learning from their inevitable mistakes—'thin skinned' because learning from others implies criticism, which they cannot give credence too. Character is sometimes well camouflaged. Becoming aware of their own flawed character traits, usually in late adolescence, the individual seeks to hide them—should they be timid, poorly educated, and anxious, they learn to disguise this with a front; appearing confident even boisterous, making it all the more difficult to establish the true content of their character. Most have a certain 'tone' to their character: anxious and avoidant; confident and secure; enmeshing and needy; and/or hostile and aggressive. Abundantly clear however is that one's character is deeply ingrained at an early stage, compelling us to act, often beyond our awareness and our control. (Green 2018) Thus Morton was compelled by his dubious character, complicated further by sociopathic tendencies and tinges of narcissism; that would manifest throughout his vivid life. Such complicated people move among us—chameleon like—they cleverly camouflage their intent to manipulate, deceive, and beguile— blending in consciously to gain advantage from the situation at hand; showing a stunning lack of conscience and emotion in their maneuverings. This is because—brain scans have shown—in such individuals there is an abnormal dissociation between the thinking brain (cortex) and the emotional brain centers (para-limbic system) which normally assures the 'affective resonance' necessary to empathetic relationships. (Persons with sociopathic tendencies learn to copy empathetic responses—faking these in their own demeanor—to fool their targets.) Hence, unsurprisingly, the so afflicted are often emotionally flat, appearing supremely confident, even callus, while impulsively taking immense risks for personal gain. (Possibly also because they are easily bored and need excitement to energize themselves.) Witness Morton's willingness to experiment with the deadly sulphuric ether in public. Never having practiced the use of the just created anesthetic apparatus, he was quite willing to put Gilbert Abbott at mortal risk to gain a possible fortune from the patent rights he had taken out for the thinly disguised 'Letheon' that he was about to administer—notwithstanding his wife's admonishments: "You will fail, and kill the patient and be tried for manslaughter." Exhilarated no doubt by the troublemaker's need for excitement, having just rendered Abbott unconscious—full of pent up bravado—he declared loudly "your patient is ready sir." Not knowing whether this was true or not!

48

3. William Morton

Witness also Morton's disastrous 'mercantile endeavors.' People with sociopathic tendencies lack remorse, a sense of responsibility, do not learn from their mistakes, and repetitively conduct antisocial behaviors; not feeling constrained by the rules of society. Morton showing little or no remorse for the people he had swindled, the goods he had stolen, the mistakes he repeatedly made and the unpaid debts he held— save for providing fake letters to would be creditors attesting to errors "of the hand & not the heart." There is one other story from Morton's youth that supports concerns of sociopathic tendencies—early behavior problems being a hallmark of the condition. (Ghaemi 2011) 7 Apart from being caught with his hands in the till, and multiple school expulsions for incorrigible behavior, Morton was banned from further experimenting "with a battery of elder-tree vials and bread pills" nearly causing the death of his infant sister Elizabeth, "by forcing some unearthly compound down her throat, as she lay asleep in her cradle." (Rice 1859) Troublemakers do not bond well; with their sisters or anybody else. This is again rooted in neurophysiology and the separation of the thinking cortex and the emotionally important, but primordial, limbic system. In normal conversation two humans have at least two levels of communication; at the cortical level which is conscious, and at the limbic or emotional level, which is unconscious but nevertheless, our two limbic systems are connecting—feeling each other out for shared emotions such as happiness, calmness, fear—attempting to mirror these in each other and so literally bonding at a subliminal level; creating feelings of empathy, or trust, or love. This emotional bonding does not occur in those diagnosed with sociopathy, because of the disconnection described earlier. Hence, they fake it—instead exciting attraction by their well-practiced charm, flamboyant appearance, and entertaining and nimble conversational style, borne of a narcissistic self-inflated view of their own self-importance. While sociopaths invariably have some narcissistic tendencies, narcissism can be erratically expressed in different individuals. Narcissism or 'self-love' is much misunderstood. Everybody has some; of necessity we are all self-absorbed—otherwise we could not motivate ourselves to get things done. Born of our youthful upbringing, we learn to balance selfregard and self-appreciation with empathy for others. We build a self-image, 7

Psychiatrists like Dr. Nassir Ghaemi will invariably tell you that no diagnosis should be made without examining the patient—hence absolutely no firm conclusions can be made about William Morton's motivations, frame of mind, or personality traits based on the historical detail that is available.

Leadership in Anaesthesia

49

learning to console and appreciate ourselves—becoming a 'Functional Narcissist.' The 'Toxic Narcissist' is where things go wrong. Usually materializing in their 20's or 30's, such individuals have failed to develop a cohesive sense of self that they can love and depend on. Hence, they need constant attention. Often exhibitionistic, they need to be in the limelight, instigating constant drama, thirsting for a validating audience, to support their feelings of self-worth. Habitually displaying extreme self-confidence, they lack true self-esteem and so when challenged—having no internal mechanism to validate their worth—are "thin-skinned;" reacting with rage and self-righteousness, declaring themselves victims. Relationships with narcissists is another trouble spot: they tend to see others as extensions of themselves or self-objects; seeking to control them and isolating them from others so that there is no competition for their attention. They are also masters at making others feel guilty so forcing them to do their bidding. (Green 2018) The narcissistic leader can be a particular problem. (Maccoby 2000) Yes, they attract followers to a grand vision and yes, they have the ambition and drive to see the vision realized, and so good leaders need a healthy dose of narcissism—the associated assertiveness, tenacity, ambition, and persistence essential to success. (Coutu 2004) Problems arise however when the attendant grandiosity and selfaggrandizing behavior become the leader's undoing as they lose focus on their goals, seeking instead, ever greater outside validation to support their fragile self-image, and, mistrustful of others, plagued by paranoia—their inner turmoil and drama seeking behavior, creates problems for the organization—the business at hand spinning out of control; their neediness destroying their creation. William Morton will turn out to be such an individual—having narcissistic tendencies he will be seen to trigger powerful emotions in others, both of attraction and repulsion, causing people to act irrationally and often beyond reason; repeatedly leading to extreme action from those he came into contact with; either as a devoted follower or as an implacable enemy—dogging Morton's claim for primacy in the Ether Discovery: Dr. Charles Jackson, an initial promoter, becoming his eventual nemesis. (Green 2018) †

50

3. William Morton

Dr. Nathan Rice's commissioned (and Morton-edited) biography is silent on the years of 1840 to 1842 as to William Morton's exact whereabouts and activity—save the false claim that Morton attended and graduated from the newly opened Baltimore College of Dental Surgery; there being no independent record of William's attendance, nor matriculation from this school. This bogus assertion was surely made to falsely burnish Morton's credentials as a fully trained dentist—rather than the unschooled dentist that he really was. It is much more likely that he apprenticed to Horace Wells, a highly regarded, honest, and trusted dentist who had long practiced in Hartford Connecticut. (Archer 1944) So, what do we know of Morton for the years 1842-1846 leading up to the fateful sulphuric ether demonstration in the Bullfinch Amphitheater on the bright sunny Friday of October 16th? x 1842: Together with Horace Wells, Morton opened what would prove to be, at least initially, a highly profitable dental practice in the top floor offices of the fashionable Tremont Row building, No.19—a stone's throw from the Boston Common. x 1843: Horace Wells exits the partnership—amicably but sententiously; concerned about Morton's grandiose business practices. x 1844: Morton meets and marries Elizabeth Whitman, a lovely diminutive lady, from an excellent family, with wide hazel eyes, feathered by long lashes—brown hair curling to her soft pale shoulders. x His new father-in-law—Edward Whitman Esq., insisting, that as a condition of his hand in marriage, Morton enrolls at the Harvard Medical School to better educate himself and become a doctor. 8 x The newlywed couple taking residence with Dr. Charles Jackson (31-Somerset Street), a storied, but stern doctor, scientist, and geologist, who reluctantly and upon substantial pressure, offers to serve as Morton's mentor—the couple leaving within three months; Jackson expressing outrage at Morton's crass behavior. Morton remarking: "You have to drive ahead in this age of steam, or you will be run over and no one will pick you up." 8 Morton never graduated from medical school, but nevertheless signed his name with the suffix 'M.D.' Such actions are typical of those with sociopathic tendencies: grand educational schemes, never realized, because they are too lazy to execute on them.

Leadership in Anaesthesia

x

x

x

51

1845: Morton continues building his Tremont Row dentistry adding at least seven assistants, becoming quite the promotor; his dental office having a set of mechanical teeth displayed—kept in motion by springs—clicking open and shut; an exact imitation of natural teeth. Developing a patented gold tooth inlay, and setting up a lucrative 'Tooth Mill' factory to create quartz and porcelain teeth, he encountered a major impediment to substantial profits; the excruciating pain caused by the fact that to fit the new improved device required the pulling of all of his patient's teeth. 1845: Attending Medical School Materia-Medica lectures, some given by the Iron Duke, Dr. J.C. Warren himself—Morton's ears perked up when he heard the annual 'Will of the Wisp' lecture: a pitiful accounting of the inadequate medications available to combat pain, and a lament, that while chloric ether might be applied to teeth, to still tooth ache, it should never be inhaled to unconsciousness, as certain death would ensue. Warren going on to contend that a solution to the surgical pain problem needed to be found, lest, surgery as a discipline, atrophy—noting the black despair that descended on patients when surgery was ordered; patient's preferring suicide to the insufferable pain from cutting and sawing through skin and bone. Dr. Warren concluding his lecture dissolutely with the famous quotation of the French Surgeon, Alfred Velpeau (1795-1867) warning that the relief of surgical pain is all but a 'Chimera' never to be found. 9 1845: Morton secures an invitation from Dr. J.C. Warren for Horace Wells—his former dental instructor, erstwhile business colleague, and future challenger for the primacy of the invention of practical anesthesia—to demonstrate the use of nitrous oxide gas to en-numb a willing volunteer; hopefully rendered unconscious to alleviate the pain from a tooth extraction. On the fateful day, in front of the 'Mountain'—tiers of medical students, assembled doctors and hanger's-on (that Morton now also faced)— Wells administered the nitrous oxide gas by means of a bladder bag, and, upon the tooth extrication, the patient cried out in pain and catapulted out of his seat—the Mountain rising in unison; hissing and booing with cries of humbug, humbug, humbug— ringing in his ears: Wells hastily slunk out of the amphitheater,

9 Velpeau would go on to comment, when the use of ether and chloroform as practical anesthetics had become established, that: "On the subject of ether, it is a wonderful and terrible agent, I will say of chloroform, that it is still more wonderful and more terrible."

52

3. William Morton

going on to close his dental practice in shame, and applying his talents to developing a shower stall instead. (Only to return much, much later to dog Morton in the Ether Controversy.) x 1846, September 30. Here is where it gets murky. How did Morton think of using ether as an anesthetic? Had he heard of ether frolics, the inhalation of ether for merriment back in Rochester during his party days? Had he read up about it in the chemistry books housed in the medical school library—which uniformly warned of the dangers of ether: "death in three hours" "lowered pulse" "apoplectic condition?" In any event he appeared largely ignorant on the subject when he visited Dr. Charles Jackson in his laboratory that day, a gas bag in hand—not knowing whether ether was a liquid (it is) or a gas (it becomes a vapor). Sounding out Jackson about the different kinds of ether (chloric and sulphuric) that might be used in dentistry. The august doctor, turned chemist, responding—that highly rectified sulphuric ether was best, handing him a flask with a glass tube sticking out, suggesting he try it on a willing patient, but unwilling to certify that this lethal substance was in any way safe. (In effect directing the lowly dentist, and unenthused first year medical student, to try the ether—the root of Jackson's later contention for primacy in the Ether Controversy and the reason for his name's inclusion in the subsequent Letheon patent application.) x Having purchased, some sulphuric ether from Burnett's Apothecary, conveniently, three doors down from his offices in Tremont Row, that very afternoon, and wanting to try the experiment without delay, Morton sent out a dental assistant to the Boston wharves around Quincy market to enlist a subject keen to earn $5.00 to be rendered insensible and so, hopefully, undergo a painless tooth extraction using the planned freshly prepared liquid—taking care to invite a journalist, Albert G. Tenney, to document and so publicize the event. Finding no paid volunteers whose "mouths would have readily opened to take any amount of bad rum, [but] could not be induced to take anything for experiment, even on the assertion of a medical man."—Morton was well satisfied when later that evening, as the clock struck nine, Ebenezer H. Frost appeared with an excruciatingly painful bicuspid molar decaying in his lower jaw, begging for relief. Happy to oblige, Morton sat the robust wood sawyer down, asked him to remove his hat and loosen his collar, poured a

Leadership in Anaesthesia

53

healthy dose of the pungent vaporizing liquid on to a readied handkerchief, told Dr. G. Hayden to stand by with the forceps, and clasped the sodden cloth to Eben's be-whiskered face. Thirty seconds or so and the sawyer went limp, his pale skin only illuminated by the fluttering candles arranged around the dental office, as his mouth gaped open. Hayden gripping the molar firmly and yanking it out; Morton, sprinkling arousing water on Eben's face who started awake; looked down in surprise to see his tooth on the wooden floor just next to the carpet edge, and sprang up yelling "Glory Hallelujah!" at the miracle of relief. Remaining for just 20 minutes longer he left for home, and reported no untoward effects from the general anesthetic the next day, when Morton visited him at home, conveniently just a few blocks away on Prince Street. Morton remarking later how scared he had been: "I never saw a body with breath in it look more like a corpse." (Rice 1859, Woodward 1962, Wolf 2001) x October 1, 1846 (the very next day), Morton visited the Offices of the Boston Daily Evening Journal in order to assure that the announcement of the first successful anesthetic experiment for teeth-pulling performed on Ebenezer Frost would be published immediately, hoping to secure this by reassuring AG Tenney, the journalist present at the event, that Dr. Charles Jackson had declared sulphuric ether perfectly safe and harmless, when Dr. Jackson had done nothing of the sort—in fact the contrary; refusing to sign a certificate declaring it safe—not wanting his august name to be associated with the dangerous venture. x Future financial success firmly fixed in his mind, Morton's next stop was at the offices of Richard Dana Esq. The famous author of Two Years Before the Mast, a seafaring saga, Dana's offices were at the Boston wharves where he represented seaman and their interests. Morton requesting the eminent attorney's help in drafting a patent application to J.C. Eddy Esq. for the practical use of ether as an en-numbing agent, but full-well knowing that there was nothing new about the 500-year-old substance, he attempted to disguise its signature smell by adding in a dose of oil of orange essence and called it 'Letheon' 10 in the patent application, referring to it as a "secret substance" until this application had been secured. (For good measure, knowing that Jackson had given advice on the 10

Morton had named the 'secret substance' after the Hadic river 'Lethe,' as, reputedly, all who drank of its waters suffered oblivion and forgetfulness. Probably not realizing that the name of the dark river was also the base for the word: lethal.

54

3. William Morton

subject, and because the eminent physician and chemist had national and even international standing as an inventor, Morton received counsel that he should add Dr. Jackson's name to the patent application as the co-discoverer.) x Seeking to publicize his efforts for profit, Morton experimented— loose and fast—on many of his patients now queuing up at his Tremont Row office for hopefully painless tooth extractions. Some exhilarated patients running screaming from the room; others docilely acquiescing; while still others started vomiting and were terribly ill—never to return for more. Nevertheless convincing Dr. Henry Bigelow, house surgeon at the Massachusetts General Hospital to Dr. J.C. Warren, of its usefulness. Bigelow, having read about Eben Frost's painless tooth extraction in the Journal report, had come to see for himself whether this new secret agent, put to practical use to en-numb patients from the agony of teeth-pulling, might also be used to alleviate the torturing pain limiting progress in surgery. Suitably convinced of Letheon's utility, Bigelow felt strongly that Morton needed to perform a very public demonstration. A public demonstration at the Massachusetts General Hospital, one of the greatest hospitals in the world. This would ensure the necessary attention to this new technique—and incredible profits to Morton— should the publicly held experiment visited on Edward Gilbert Abbot— now lying-back motionless and corpse-like in the plush-red operating chair at the center of the Bullfinch amphitheater, the Mountain of spectators expectantly holding their collective breath—prove a triumphant success. † Morton said it again: "Your patient is ready sir." The Iron Duke plunging his knife, cutting a three-inch incision to extirpate the 20-year-old tumor pulsing in Abbott's neck. Not a movement. Not of the patient. Nor of the breathless onlookers crowding in to see better, as Warren deftly cut out the tumor, closed the wound quickly and mopped up the remaining blood. Completing the operation, he stood back, straightened his stiff back and tight black knee-length frock, tossed back his mane of white hair, peered through his glasses, and stated loudly and clearly: "Gentlemen this is no Humbug."

Leadership in Anaesthesia

55

The Mountain erupting in applause and congratulations. Morton; immensely pleased and relieved. Abbott; on slowly awakening declaring: "I felt no pain, just at the end, a feeling of scraping, like that of a hoe." 11 Interpretation. Morton had been hijacked by young Dr. Henry Bigelow's ambitious aspirations. A simple dentist with very little formal education, 12 Morton had really only wanted to make money from his dentistry: using ether to alleviate the pain associated with the teeth-pulling necessary to fitting his newly improved, patented, dentures, and so grow his already prospering business. But Henry—a charming man in his own right from an excellent surgical family: his father, Dr. Jacob Bigelow, one of the founding members of the Massachusetts General Hospital and the President of the American Academy of Arts and Sciences—had other ideas. Seeing the potential that practical anesthesia with sulphuric ether would bring in expanding the surgeons limited, in fact, atrophying role, in medicine, he was further motivated, as the house surgeon to one of the pre-eminent hospitals in the world, to expand his own fame in an attempt to replace Dr. JC Warren, all of 68 years old, should he retire from his elevated position as the Surgeon in Chief. Thus, exceedingly ambitious, Henry pandered to Morton's narcissistic need for grandiosity, by enlisting him as his agent to expand surgeries' potential by demonstrating and actively promoting practical surgical anesthesia. 13 Morton was of course, utterly out of his depth. Getting in over his head being his first big mistake—a mere, relatively untrained dentist, and not a man of science at all. Not knowing the world of scientific discovery that he was stepping into that Henry Bigelow had thrust on him. Completely understandable however, because Morton must have been exceedingly impressed by the elegant Dr. Henry Bigelow who had trained in medicine 11

This seminal event was not memorialized as planned. The daguerreotypist, Josiah J. Hawes, more used to photographing deceased corpses for portrait purposes, fainted at the sight of the bloody incision. Two famous paintings: by Robert Hinkley (1893) hanging in the Francis A Countway Library of Medicine at the Harvard Medical School; and by Lucia and Warren Prosperi (2000) hanging on the front wall of the Historic Ether Dome amphitheater at the Massachusetts General Hospital, do this grand event adequate justice however. 12 He could not read or write very well and "his crass ignorance was noted by the general silliness of his remarks." 13 In 1847 an esteemed Professor of the Harvard Medical School and poet-physician, Dr Oliver Wendall Holmes, would coin the word "Anaesthesia" together with Morton and Bigelow to describe the state of insensibility that ether produced.

56

3. William Morton

in Paris and Boston, recently started a novel out-patient clinic, and was on the lookout for innovative approaches to medicine, and so had offered to support etherization and become Morton's scientific champion to promote the cause of surgical insensibility. His next mistake, was taking out a patent on Letheon. Accepted practice in dentistry, the application for a patent was totally unacceptable in the medical science of discovery of the time, where reputations were built on the free flow of information, and fame the only just reward for invention. A mistake that would generate enormous controversy, a lack of trust and credibility in William's business practices, and eventually prove to be Morton's undoing. His third mistake, was to give up his day job as dentist, as the evolving story will relate. †

Promotion & Publicity: Courting Controversy Not everyone was immediately convinced. For one, Abbott, had moved a bit, especially at the end of the operation, and announced that the bite of the knife had felt a little like the scraping of a hoe on his skin. For another, if it was really true that insensibility from the agony of surgery could be produced; then much more evidence would need to be presented to convince the doubtful surgeons, the public, and the world at large of this breakthrough. Sir Benjamin Brodie of St George's Hospital, London (who had experimented with ether in guinea pigs finding that it killed them) declaring that very month (October 1) that there was no greater desideratum, than to have a means of allaying pain for surgical operations, "for which all physicians and surgeons have been looking in vain, from the days of Hippocrates down to the present time." If the search for insensibility from surgical operations was truly at an end, more compelling evidence would be needed; hence Morton was invited back the very next day for another demonstration—the young lady, operated on by Dr. G. Hayward with Dr. Henry Bigelow standing by, remaining completely stupefied and having no memory or recall of the operation, while a fatty tumor was resected from her arm, just below the deltoid—Morton using an inhaler with newly fitted valves; allowing continuous inhalation for the full duration of the procedure. Still not fully convinced—the surgeons of the Massachusetts General Hospital needed more evidence and were deeply dissatisfied with

Leadership in Anaesthesia

57

the fact that Morton refused to tell them his secret formula for Letheon. They could smell that it was ether; Warren noting in his surgical notes of Oct 16: "First the young man was put under the influence of sulphuric ether by respiration, which so benumbed his feelings, that he did not complain on the first incision, but did so afterwards." But they could not be sure that Morton hadn't added alcohol or another substance in addition to the orange oil essence that he had admixed in attempts to disguise the clear liquids true nature. Hence, the august surgeons of MGH refused to permit the absolutely essential test of the new anesthetic agent's true worth: the demonstration of a "capital" operation. An amputation. Only the successful amputation of a limb without the agony of pain would fully convince any lasting doubters of the merits of practical anesthesia; re-assuring a disbelieving surgical fraternity and a wary public. Upon hearing from Dr. Henry Bigelow that an above knee amputation was to be performed on Alice Mohan, 20, who had been plagued by a gangrenous leg for over a year—Morton promptly wrote a letter to Dr. Hayward (who had in the interim become the Chief Surgeon) for permission to provide a practical demonstration of insensibility using Letheon— attesting therein that the preparation was in fact pure sulphuric ether, and that he would permit free use of the patented solution at the hospital, should the surgeons accede to his request. Receiving no reply by the date of the planned operation on 7 November 1846, Dr. Henry Bigelow accompanied Morton to the Hospital, walked him up the three flights of steps to the now familiar Bullfinch amphitheater, and stopped him just outside the door. Going in, alone, to personally seek permission from his surgical colleagues for Morton's crucial demonstration. Morton, his ear pressed to the door, hearing his letter to Hayward read out aloud, followed by a heated debate; anticipated rejection. But instead, he was cordially invited in to perform the third experiment— Alice's leg amputation: performed quickly, and painlessly as she lay unconscious and unaware; rendered insensible by Morton's ether administration. Discharged from the hospital, and back home, on crutches, six weeks later to wide acclaim—Alice Mohan' successful amputation offered the necessary living-proof that practical anesthesia could provide surgical insensibility for a capital operation.

Publicity Dr. Henry Bigelow, considered the "third man in the discovery" of ether by many historians, sprang into action: Publicizing the new and thrilling discovery of the use of sulphuric ether for insensibility from

58

3. William Morton

surgical operations at meetings of the American Academy of Arts and Sciences and the Boston Society for Medical Improvement to name but two—and publishing his ground breaking, seminal report, in the world renowned, Boston Medical and Surgical Journal 14 entitled: "Insensibility during surgical operations produced by inhalation" that would take the world by storm. (Wolf 2001) (Bigelow 1846) This article, first printed on November 18, would explode across the world—heralding a transformational era in medicine: Through reporting the successful cases of Morton's ether administration while recounting the unhappily long and sorry history of previous attempts to provide insensibility from the agony of surgery. The article going on to describe how ether could be administered, and what side effects Bigelow had observed in the many administrations he had witnessed in Morton's dental office on Tremont Row—cautioning the reader all the while as to the potential lethal effect of the vapor. Confirming in the landmark article that a patent had been taken out on the invention, by Dr. Morton and Dr. Charles Jackson as joint discoverers, Bigelow went on to endorse this arrangement by providing two reasons to do so: "1st: It is capable of abuse, and can readily be applied to nefarious ends. 2nd: Its action is not yet thoroughly understood, and its use should be restricted to responsible persons." The article then making its way as fast as steam could carry it aboard the Cunard steamer RMS Acadia; a copy of the "insensibility paper" included by Dr. Jacob Bigelow, Henry's proud father, in a letter to Dr. Francis Boott of London, who soon published the ground-breaking article in its entirety in England's Lancet, the foremost of medical publications, and spoke of it to Dr. Robert Liston, England's leading surgeon, who, true to his swashbuckling nature, acted promptly and fearlessly; amputating Samuel Butler's leg on the afternoon of December 21—using the "Boston ether inhaler"—in an astounding 28 seconds flat and exultantly declared: "This Yankee dodge beats mesmerism hollow" to the crowd of astounded spectators. And, in so doing, readily attached his considerable prestige and reputation to the promotion of what would turn out to be the greatest medical innovation of the 19th century and probably of the age— the development of anesthetic techniques propelling the then atrophying practice of surgery to the muscular, life enhancing, medical discipline that 14 This Journal would become the New England Journal of Medicine which is still housed at the Countway Museum of the Harvard Medical School.

Leadership in Anaesthesia

59

exists today. Advances in anesthesia inexorably intertwined with advances in surgery, the two specialties progressing in lock step together. 15 William Morton, also took immediate action: not for the sake of scientific advancement; not for the sake of the suffering of his fellow man; nor for fame—but in the interests of the stupendous monetary rewards that Dr. Henry Bigelow had convinced him would be the result of his public demonstration and promotion of practical anesthesia for surgical operations. (Recall that Morton only wanted to deaden the pain from teeth-pulling in furtherance of profits from his dental practice.) Morton embarked on an accelerating play-book of business management practice, publicity, and promotional activities to advance the cause and practice of practical anesthesia, locally, nationally and internationally, with one goal in mind—to profit from the endeavor. Leaving aside Morton's utilitarian profit motive, he evidenced great organizing ability and a highly strategic approach in the brilliant execution of the plan. A plan which would bring everlasting fame but end in personal misery and misfortune. Morton, who probably suffered from hypomania, 16 wasted no further time after the successful amputation. Always in a hurry, usually a hurry to make money, he had a highly disciplined approach to launching practical etherization: 1. He handed over his dental practice to Dr. Granville G. Hayden (who had been present that fateful night; extracting Eben Frost's paining tooth after Morton had administered ether), drawing up papers to this effect with his attorney, Richard Dana, in order to focus entirely on the new enterprise. 2. He hired a business manager, his brother in law, Mr. Francis Whitman, to run the 'practical anesthesia' enterprise. 3. He hired a secretary to organize his affairs, as well as a publicist to execute most of his personal writing; Morton being poorly educated could not read or write very well. In short order, these two individuals in Morton's employ: x Dispatched and received almost 2000 letters of correspondence over the ensuing 9 months.

15 Following, Robert Liston's lead, Dr. John Snow (Chapter 4) would introduce ether at St George's Hospital in London on January 28th 1847—the Royal Surgeon, Sir James Clark remarking: "It is really a marvelous thing." 16 And occasional depression, the psychopathological implications for leadership are explained in greater detail in Chapter 2.

3. William Morton

60

Published a monthly pamphlet, 'The Letheon' which was widely circulated to describe successes with etherization. x Advertised "practical anesthesia with etherization" in all the major newspapers of the day using the catchy trade name of "Letheon". x Generated a 'Manual of Etherization' ostensibly written by Morton, describing key considerations in achieving safe etherization with a sponge or Morton's Inhaler. (Morton 1847) x And conducted the necessary correspondence, drafting of documents, licenses and contracts, in conjunction with Richard Dana Esq. 4. He developed and manufactured more than 1000 Morton Inhalers to be sold for $25.00 each. 5. Morton going on to hire agents to staff defined territories around the United States where, for a percentage, the agents would extract licensing fees from doctors for the right to use the patented Letheon and Morton's Inhaler—based on the number of patients they served; a Doctor in Salem was charged $850 for a five-year license and a steep $2380.00 for 14 years (the duration of the patent). 6. Wishing to promote anesthesia far and wide he advertised: 'To Surgeons and Physicians' the services of 'practical anesthesia' at any location where operations were to be performed and where the patients were desirous of being rendered insensible to pain. Stating that trained personnel would be provided—trained in the vicissitudes of administering safe and reliable ether anesthesia, no matter the state of the patient. (In essence the first advertised Locum Tenens Anesthesia Service which would promote practical anesthesia administration far and wide—for profit of course.) 17 7. And, because he remained ever wary as to the provenance of his income, Morton, in an attempt to shield his assets from the inevitable creditors (that he would reliably fail to pay) usually bought his assets and speculative properties in his families' name—either his father's or father-inlaw's. 8. Contriving to extend the reach of practical anesthesia internationally, William arranged the distribution of his Letheon Inhalers and 'Manuals of Etherization' far and wide—to the many Emperors and Monarchs who then reigned across the Atlantic: – The Emperors: Nicholas of Russia and Ferdinand of Austria and x

17

Published as paid advertisements in the November 25 and December 2 (1846) issues of the Boston Medical and Surgical Journal, the forerunner of the New England Journal of Medicine.

Leadership in Anaesthesia

61

– The Kings: William of Holland, Leopold of Belgium, Charles Jean of Sweden, Christian VIII of Denmark, Frederic Augustus of Saxony, Louis of Bavaria, Ernest of Hanover and Louis Phillipe of France. The latter, an impassioned amateur surgeon, sending a special letter of thanks appreciating the sentiment that obliged the communication from Dr. Morton. Hoping to influence many prominent physicians around the world, Morton also dispatched his promotional Letheon manuals and inhalers to Europe and beyond—being especially careful to include Drs. Alfred Velpeaux and Paul Dubois of France, the latter administering the first anesthetic with ether on December 22nd; and in celebration of the landmark discovery, the French Academy of Sciences (the premier arbiter of anything medical at the time in the world) devoting the January 1847 meeting in Paris to a discussion of the merits of etherization for surgical insensibility. 9. Morton stoking controversy in order to fan the flames of opportunity concluded the frantic first year (December 28th) by submitting a "Memorial" to the United States Congress in the first of four claims seeking Primacy in the "Ether Controversy," with a request for considerable compensation for the discovery of practical anesthesia with ether— justifying this request by using the historical precedent of Edward Jenner's discovery of smallpox vaccination and his compensation of £30,000 by the English Parliament. The Memorial however, already a hot potato, was immediately referred to a Senate Select Committee composed of physicians, where it was effortlessly rejected as preposterous; one man of science opining "I cannot consider any agent generally useful that unquestionably subjects the patient to the risk of losing his life." (Perley Poore 1856)

Bad Press Not all were enamored with ether and rendering patients insensible. Particularly vociferous against it were Morton's brethren, the dentists of Boston. (They found his patenting of ether especially galling and mercenary.) Gathering together in early December (1846) at a suitably large meeting, they appointed Dr. Josiah F. Flagg to head a 12-man committee to make a formal protest to the public in opposition to anesthesia, by creating a "Manifesto" against etherization. Published in the Boston Daily Advertiser, the Manifesto attested to the many failures and complications of the new anesthetic—calling Morton's 'sucking bottles' a 'humbug' and dangerous quackery.

62

3. William Morton

Further damaging to Morton's increasingly damaged reputation was fellow dentist, Dr. Nathan Keep's, refusal to continue to practice with him at his Tremont Row dental office—he felt that Morton was practicing dangerously with ether (and likely to kill someone soon) and was as much asphyxiating his patients as anesthetizing them; suggesting applying oxygen which Morton capriciously refused. Of the same mind were Dr. Charles Jackson 18 and his dental tutor, the rotund, red-headed, Horace Wells, who had given up dental practice, for furniture design, but on hearing of Morton's claim for primacy of practical anesthesia with ether, responded early and often in counterclaims for Primacy in the Ether Controversy. Hastily publishing a rebuttal to Morton's claims in the Hartford Courant (December 9th) stating that Morton was not the real discoverer of general anesthesia at all—for he was—having used nitrous oxide for toothpulling on 15 patients at least a year earlier in his practice at Hartford, which Morton had indisputably witnessed; William undergoing his apprenticeship there. The physicians of Philadelphia were even more scathing (if it were possible) of the "humbug and quackery" visited on them by Morton's claims. Dr. Robert M. Huston writing in the Philadelphia Medical Examiner, in further confutation of Bigelow's "insensibility paper" thus: "the surgeons of Philadelphia will not be seduced from the high professional path of duty, into the quagmire of quackery, by this "Will-o-the-wisp." And vilifying, Dr. Henry Bigelow, his fellow Bostonian surgeons, and Dr. Robert Liston as follows: "We are sorry to see many of our brethren, at home and abroad, stooping from the exalted position they occupy in the profession to hold intercourse with, and become the abettors of, quackery in any form." (Perley Poore 1856) 19 Feelings also ran high against Morton's manipulations in his local community of West Needham 20 connected by rail track to nearby Boston. The local populace eventually tiring of his shenanigans: someone arranged for a likeness of Morton to be hung in effigy; swinging from a high branch of the taller of two buttonwood trees centered in the town square. Bearing an uncanny resemblance to the dentist, the perpetrator nevertheless furnished a hat-band with 'Morton' emblazoned across it to be doubly sure; leaving absolutely no doubt as to the object of vilification. Coming upon 18

Jackson initially said he would have nothing to do with ether, because he thought Morton would kill someone, but would eventually claim co-discovery, becoming Morton's nemesis, in the primacy question. 19 Charles A. Lee M.D. editor of the New York: Journal of Medicine. 20 1859, Wellesley today.

Leadership in Anaesthesia

63

"the buttonwood effigy" which had drawn a crowd one Sunday morning; Morton mingled with crowd, shrugged, pulled out a fat cigar, lit it, puffed a few times, and then nonchalantly circled the tree and sauntered off— apparently the effigy was of no consequence. Interpretation. Morton, if not a great writer or reader was a superb organizer. He knew too that if he wanted to turn his new finding of practical, reliable, anesthesia with Letheon into a profitable business venture, he needed to publicize this to the disbelieving scientific world. So, Morton the anesthetist, and Bigelow the surgeon, needed each other. 21 The untrained dentist street-fighter and the sophisticated doctor-scientist, who had all the right connections at the Harvard Medical School and the ability to promulgate the new findings to the world, were mutually dependent to achieve different ends. One money. The other fame as a surgeon. Knowing Morton's motivation for the monetary reward that a patent for Letheon would likely bring, Bigelow must have taken the Faustian Bargain of supporting this agreement in the "insensibility paper" that shook the world. On purpose never actually documenting that the substance used was in fact simply sulphuric ether—mentioning this only as a 'preparation' or 'vapor' instead—and supporting the highly controversial fact that a patent had been taken out to ensure that the dangerous unnamed substance did not fall into unskilled hands. (Bigelow 1846) 22 Morton however did not have the fine sensibilities that Bigelow displayed and so very quickly struck out on his own—courting controversy at every step—in an attempt to realize expeditiously the profit-taking that Henry had held out as the potential of his involvement. Morton, an adept if corrupt businessman, honed by his previous 'mercantile endeavors,' showing himself equal to the task by implementing the necessary steps to develop licensed anesthesia practice throughout the northeastern states; heralding a second era to that of simple medical discovery—one where business concerns outstripped the holy ground of medical advancement: "compromising it's spirit but also accelerating it's pace." (Fenster 2001)

21

This truism had its origin on October 16, 1846. Bigelow did however hold forth extensively in the paper on the use of agents including sulphuric ether that had been tried up to this point in time; hence it was relatively easy for anyone reading the paper carefully to conclude that the substance in question was indeed sulphuric ether. Bigelow was the only named author of this paper, but publication was delayed because he had to have Morton's approval of the final wording. 22

64

3. William Morton

According to Sir Isaac Newton, and the laws of nature, for every action there is an opposing reaction. To the proposition of etherization to secure insensibility for surgery there was a particularly robust and forceful one. This was partly because it seemed unbelievable that a mere untrained dentist (from America no less) could come up with the idea, 23 when sophisticated medicine had not—despite searching for a solution since the advent of surgery. Hence, unsurprisingly, a storm of disagreements was unlocked by the Ether Controversy: the claims of primacy for, utility of, and compensation due to the discoverer of the concept of practical anesthesia. We have introduced three claimants. Horace Wells and William Morton the dentists, and Dr. Charles Jackson, the chemist doctor, and now include a fourth: Dr. Crawford Long (1815-1878), a physician from Athens, Georgia, who first administered ether using a handkerchief on 30 March 1842 to painlessly excise a neck tumor from James M. Venables—reporting on this only publicly in 1849 to combat Morton's claims for primacy. Calling the Ether Controversy a mere storm in the national mind and press, would be to grossly understate the magnitude of the polemic which raged for 28 years till Morton's death (and beyond) in the public's consciousness (it could not be entered in polite conversations and created fist-fights at dinner tables). The Ether Controversy would require intermittent upgrading to hurricane and tornado strength storms or downgrading to just a dull roar in the public's consciousness and, eventually, with respect to claims for compensation, would be brought to President Pierce's desk in the White House, for final adjudication. †

Claiming Compensation Franklin Pierce (1804-1869) looked dubious. His sturdy chin jutting out, eyes set a little too narrow in his pained face, his trademark forelock falling over a bold forehead, he knew well why Morton was yet again supplicating for compensation. Like last time, March 1854 (two years earlier), just after his inauguration; President Pierce again had much more important things on his mind. Then, his 11-year-old son had just been decapitated in a rail-road accident and he had a new cabinet to form; and now, May 1856; he was dealing with the political fall-out from the ill23

He didn't, it is most likely that Dr. Charles Jackson did.

Leadership in Anaesthesia

65

advised Kansas-Nebraska bill, and here again was Morton seeking a handout from the government. Why wouldn't Morton just give up and go away? Brought into the President's office by Congressman William Barksdale, Morton made himself comfortable at the imposing table centering the office facing the 14th President, who liked to sit with his back to the fire-place; coals still smoldering from last-nights wood-fire under the grate. Behind him, a wall of books and to the left, morning light streamed through the two massive White House casement windows, playing across the secretary's desk who was busily penning down every word of the conversation. A conversation that would decide Morton's financial fate; creditors circling—held at bay only by the well-publicized promise of compensation that the President could give; the purpose of the well-worked out pitch that Morton had prepared to deliver. Morton, for a change, not that confident that he would prevail; had nevertheless prepared well for the Presidential pitch, having developed a vast experience in his four applications to Congress for restitution that spanned the last 10 years. He had to. He was desperate—he had racked up considerable debt lobbying in Washington; his dental and anesthesia practice neglected in the effort had fallen apart, and his many ill-advised land speculations were coming home to roost. In essence he was bankrupt and living on the smell of an oil rag and could not keep up the pretentious and expensive life-style he had accorded himself and his family: grown to five children strong. He had a lot to recall as he prepared to deliver his pitch to Franklin Pierce, now hunched before him ready to give a verdict—up or down. 1846: The year of his ether discovery and Morton's first unsuccessful application to Congress was also the year when his dental partners (who he had handed his Tremont Row practice too) deserted him—his tooth manufacturing company similarly falling into disarray. And the year that Morton's generous, if self-serving offer to allow the army to use the patented Letheon and Morton's Inhaler (for just a small licensing fee and discounted manufacturing cost of the vaporizer) was roundly rejected by the Government. In essence sanctioning the free use of sulphuric ether by its surgeons and in so doing breeching Morton's patent rights; all to ensure that painless surgery could be provided to the wounded of the war, launched that year against Mexico. In one fell swoop the Government, in allowing free use of ether by its surgeons, had voided the value of Morton's licenses: disenfranchising the contracted licensing agents arrayed around the

66

3. William Morton

northeast; while the licensees who had paid good money for them, now clamored for restitution from Morton's business to defray the cost of their expensive licenses—rendered completely useless and unnecessary by the Government's action. 1847: A Memorial documenting William Morton's role in the Ether Discovery was created by eleven prominent Massachusetts General Hospital Trustees—including Doctors J.C. Warren and Henry Bigelow— and sent to Congress to ask for $100,000.00 in compensation for Morton. This got nowhere. But was exceedingly necessary as William's money had run out and creditors had impounded his West Needham house, Etherton, so Morton and family were forced to move to Boston; taking up rooms at 7 Bowdoin Square. 1849: The second application to Congress. Morton was energized. He had been entreated by Dr. Henry Bigelow to make personal representations in Washington—by January—and to get the Memorial acted upon before President Zachary Taylor was inaugurated; now that the Mexican War was over and Congress had an appetite for other pressing matters. Oliver Wendall Holmes, the famous poet and doctor, writing a letter to Congressman Isaac Morse on his behalf—who in turn suggested putting together a persuading portfolio of evidence in favor of Morton's claim to the discovery (in addition to the Memorial) for referral to Dr. T. O. Edwards, Chairman of the house committee on patenting compound medicines. To this purpose, Richard Dana Esq., Morton's attorney, coordinated putting together a trove of articles, pamphlets and charts (documenting the increased use of surgery after the ether discovery) as well as Morton's 'Miscellaneous Notes' (20,000 letters of correspondence)—but wanted just one more piece of evidence: a precedent for the bestowment of a reward for America's first great contribution to the science of medicine. Finding this in the fact that Congress had compensated Samuel Morse in the handsome sum of $30,000.00 for the electromagnetic telegraph some years back, he was quietly confident that this second time they might prevail. Correspondingly, the select committee hearings progressed steadily in favor of Morton; until its Chairman, Dr. Edwards, invited Dr. Charles Jackson to present any counter claim that he might wish to bring. This in order that the committee might consider all the evidence laid before them in one sitting. Jackson enthusiastically bringing forth plentiful documentary evidence for his own primacy in the Ether Discovery as well as submitting the contrary depositions that his attorney, the notorious J.L. Lord Esq., had garnered around the country—documenting in devastating detail Morton's previously documented infamous character lapses; his 'mercantile endeavors'—from the age of 17 to 21 that would never have seen

Leadership in Anaesthesia

67

the light of day; but for Jackson's energetic pursuance of Morton's malfeasance, and in turn, his determined efforts at Morton's character assassination to further his own claim for primacy. Despite this unflattering evidence, the select committee nonetheless found in favor of Morton, summarizing in their House Report number 114 that they had arrived at the same conclusion that the Board of Trustees of the Massachusetts General Hospital had come to: that Morton was the discoverer—but, unhappily for Morton, did not recommend specific remuneration as this was for Congress to deliberate and act upon. Not them. Sadly, Congress didn't; no action was taken, leaving Morton in the same destitute state, despite his best efforts; Congress having more important things to consider than the pecuniary claims of the dentist. Nonetheless the year ended well: Morton despite never completing his medical studies at Harvard, nor any other medical school for that matter, was admitted to the Degree of Doctor of Medicine at the Washington University of Baltimore and could forever more be called Dr. William Morton; which he used to great advantage. 1850: After three years of deliberation, much to Dr. Morton's chagrin, the French Academy's Ether Commission, having wrestled with the problem of who to credit with the discovery, decided to share the award between Morton and Jackson, both receiving the Institute National de France Prix Montyon Medals as well as having to share the FF 5000.00 award. 1851: The third application to Congress. Importantly, Morton decided to change his strategy for this third attempt at remuneration. Rather than present mounds of seemingly incontrovertible evidence, he would lobby and politic (and likely bribe politicians) to further his end. But this was an expensive proposition to implement so, seeking to defray personal costs, he sought a sponsor—befriending William S. Tuckerman, who, as the upwardly mobile treasurer of the Eastern Railroad, had ready access to money. Tuckerman very likely providing Morton with more than a $100,000.00 of ill-gotten funds to support the application. 24 Offered a percentage of the reward that Morton was sure to get, Tuckerman was asked to support Morton in secret; lest the fact adversely affect Congress's decision, but the truth was eventually out as the Eastern Railroad treasurer 24

It should be noted that at this time, and for most of the rest of his life, Morton, using these and other funds, embarked on innumerable complex speculative land purchases, acquiring and sometimes rapidly selling large acreages of farmland, usually putting this property into his father's or father-in-law's name to shield him from the inevitable creditors.

68

3. William Morton

was later incarcerated for the embezzlement of twice that amount—at least; Jackson putting Morton's ill-fated pecuniary association with the now disgraced railroad treasurer, Tuckerman, to good effect in fanning his claims for primacy in the Ether Controversy. Nevertheless, Morton was not so easily dissuaded from pursuing the matter; promptly bringing to bear his new-found politicking strategy of entertaining Congressmen and their wives lavishly with fine wines, cigars, and oyster-laced-suppers at Washington's well known Brown Hotel; he was soon able to have a new Select Committee convened in the House of Representatives to examine a "proposition to appropriate $100,000 to enable the President of the United States to purchase from the patentee his patent..... ." Packing the committee with four out of five Congressmen favorable to his cause, Morton was overheard to observe: "you have to watch members of congress like a cat would a mouse" ready to pounce and take your kill. Matters apparently moving in the right direction, and his compensation almost assured, until an article timeously appeared in the National Police Gazette (circulation 40,000)—a mass circulation broadsheet read by every politician of the day—entitled: "The Great Ether Question and It's Pretended Discoverer." No doubt aided and abetted by someone on the Jackson team, the article opposed the excessive noise and false claims that Morton's petition to Congress was making, using his past history with respect of "His Circumcision and His Excommunication" to destroy his character and, for good measure, included a complete reprinting of Mordicai D'Lange's: "Beware a Villain" article. (Wolf 2001) Not surprising then, that despite the Select Committee having passed off the "Proposal" to the Senate floor for a final vote on a hot summers night—Morton observing matters from the gallery—after a three hour heated debate till the edge of midnight, during which time Morton's character was repetitively impugned; only 17 senators voted in favor, and 28—"no." Again; there would be no compensation this time. 1854: The fourth application to Congress. Morton was relentless and desperate; he had expended a fortune on profuse entertainment and politicking, using Tuckerman's funds, and had nothing to show for it. Moving again to Washington from Boston, he took up residence in the National Hotel knowing full well that President Pierce held regular Friday evening parties there—hoping to rub shoulders with him and so influence matters to his better advantage.

Leadership in Anaesthesia

69

On 19 April 1854, Dr. Edward Everett the former Governor of Massachusetts and President of Harvard College introduced: "A bill to recompense the practical discoverer of anesthesia (SB No 210)" on the Senate floor. Amended to include the names of William T.G. Morton, Charles T. Jackson and Horace Wells as co-discoverers 25 it was opened to the floor of the Senate for further discussion. No sooner than that, and the Senator from Georgia wanted to add a further claimant. One Dr. Crawford Long of Athens who had administered ether for anesthesia as early as 1842. Positing that he could motivate for Dr. Long's claim for primacy as he had papers in his possession which he would submit in due course. A further two claimants, Dr. Samuel Guthrie and Dr. J.G. Dickinson were also added and the bill was still further amended to reflect that, as the patent no longer referred to the original patentees (Morton and Jackson) this should be "annulled" in favor of the multiple claimants now added, instead. Put to the vote in the Senate, it was easily passed and moved to the House. Where, lamentably for Morton's cause, "on the second morning after its passage in the Senate, and without any intimation, the Speaker of the House of Representatives called it up and laid it before the House." A Congressman moving immediately that it be laid on the table. A motion that if approved would defeat Senate Bill 210 once and for all. Rancorous debate ensued and confusion reigned, one Congressman declaiming "If either of these gentlemen has a right to this agent as the original discoverer, let him maintain the right under the patent laws of the United States." Another eventually calling the question and the vote held: 82 "yeas" and 46 "nays." And so the Bill was laid on the table. For good. Morton's petitioning and claims to Congress for compensation forever at an end. (Rice 1859, Woodward 1962) † Morton thus had to take another tack, for he desperately needed money. His creditors were circling and his dental practice was long gone. Congress had not been forthcoming with the justified reward for his selfless 25 Morton hoping that in this way it would be approved and compensation shared three ways. Horace Wells was by now dead. Frustrated in his claims for primacy, and having been incarcerated for bespattering harlots on Broadway with sulphuric acid, Wells had committed suicide, after inhaling chloroform, through severing his femoral artery in 1848. His family had taken up the cause in his name, as claimants, and hoped to be reimbursed for Horace's discovery of anesthesia.

70

3. William Morton

services to the country. In fact, adding insult to injury, and recognizing that his patent rights had been contravened, the House had directed him to maintain his right under the patent laws of the United States. He needed help from higher up. He needed to ask the President for help. Having arranged a Protest to the Secretary of the Navy and that this "Protest and Congressional Endorsement"26 be handed personally to President Franklin Pearce; it was probably now arrayed in front of the stern-faced President as he readied himself to face down Morton's well-rehearsed pitch. Morton sat erect in his chair but was a lot less confident now that the time of reckoning had come. Delivering his pitch, haltingly, in his irritatingly loud voice, his eyes flashing bright blue, reflecting the sunlight streaming into the President's office. The President paused (both Morton and Pierce likely remembering what Franklin had said in the same room over two years ago): "I want you to understand distinctly, that I consider the validity of the patent fully established, and because the government has used the discovery, consequently must pay for it in the end." The memory heartening Morton just a little. But instead the President was abrupt, dispelling all hope: "The Government wants a legal decision in your case against it before paying for the patent. Why have you not brought a suit against a surgeon using Letheon?" and added "Bring a suit against a surgeon, and when it is decided that the Government is violating your patent, the Government will pay!" The President stood up and Morton bade his farewells and slunk out, Barksdale in tow. The fight was over and the news of the Presidents failure to recognize the Protest and compensate Morton was bruited out that same night in the Evening Editions of all the major newspapers. Morton leaving the National Hotel that very night to travel to Philadelphia, then New York, and then Boston, where news of his defenestration preceded his arrival—an avalanche of creditors, smelling blood, descending to make their claims. In short order: 'attachments were at once served upon everything belonging to him, and keepers put in charge.' While three writs, one amounting to more than $10,000 were served in one day. The people of West Needham fingering their noses at his children, while his property was so rapidly attached and his credit and cash flow so low that: 'during one week in July the family were even in want of the simple articles of food' 26 Signed by 150 Congressmen and claiming that the right to Morton's Letheon patent be either purchased by the government or its use discontinued by its surgeons.

Leadership in Anaesthesia

71

compelling Morton to load up a cart with firewood and trundle it to the village square to sell: 'so he could buy a barrel of biscuit to feed his children.' 27 (Rice 1859) So low had the mighty Morton fallen—fortunately there were still friends to help. The Massachusetts General Hospital had gained world-wide acclaim as the American institution where the new era of anesthesia had dawned and so championed Dr. William Morton's discovery at every turn (Ether Day is celebrated in the Historical Ether Dome amphitheater on October 16 every year to this day). Wishing to support him in his hour of financial need, the Trustees of the great hospital started (in 1857) a National Testimonial Appeal: to the Patrons of Science and the Friends of Humanity—launched as a National Subscription Fund in Morton's favor. Instigated by Dr. Amos Lawrence and the Massachusetts General Hospital—the Hospital Trustees wished to promote the great discovery that had elevated the hospitals' standing considerably in the world, by kicking off the fund with a generous $1000.00 donation. Garnering at least five times that in donations, Morton put this and other monies from yet many further "Testimonial" and "Memorial" appeals, initiated on his behalf, to good use in defraying some of his costs; restarting his farm at West Needham; embarking on various land speculations; and generally busying himself with publicizing and furthering his seminal cause—publishing the: "Trials of a Public Benefactor" book in 1859 that he had coerced Dr. Nathan Rice to write.28 This book and copious further writings, promotions and campaigns were launched by Morton and the many others that had a stake in his successful prosecution of the claim for primacy in the discovery of practical anesthesia—until his untimely demise in 1868. 29 Morton spending the latter part of his life on his farm, conducting speculative land deals and obsessively (with increasing paranoia) tending to his benefit campaigns—launched by various groups and societies in seeking 27

The cart already in charge of the sheriff was still luckily available for his use. Nathan hated the title with a passion and didn't want his name associated with the book. When asked, who should be considered the discoverer of anesthesia, Dr Rice, who was of course intimate with every aspect of Morton's actual and prevaricated history, tellingly, responded that Dr Horace Wells should be credited. 29 Ultimately successful as he was accorded the honor of being added to the Hall of Fame for Great Americans in 1920, alongside William Penn, Abraham Lincoln and George Washington no less—the names of Charles Jackson, Horace Wells and Crawford Long notably absent. 28

72

3. William Morton

pecuniary rewards for his claims of primacy in the ether discovery—and touring around the country, giving lectures, and writing articles, incessantly, to promote his singular cause of making money out of the epoch-making discovery; becoming sick and spent and increasingly an object of ridicule for his tireless, some called it tiresome, persistence in the affair. Interpretation. Of course Morton wasn't the first. The first to discover ether. That wasn't necessary to his success. Although he thought it was. Morton's brilliance in leading the new medical era of practical anesthesia lay in his capacity for publicity and promotion; able to persuade senators, congressman, his fellowman and colleagues, if not presidents, to his cause. The first to provide practical anesthesia with ether was probably Dr. Crawford Long from Athens, Georgia. A retiring genial country doctor, he had prepared some sulphuric ether for inhalation for the ether frolic parties that he liked to hold for his friends. Noting that the bruising that occurred during such hilarity was not associated with pain; he contrived to try to perform painless surgery with it. Convincing one of his party-goers, James M. Venables, to inhale ether from a handkerchief, late one afternoon, he successfully resected a neck tumor—painlessly—on the historic date of March 30, 1842. 30 Never documenting or publicizing the handful of etherizations he subsequently performed—too busy taking care of his patients in his practice—he never had a hand in promoting his new findings (and probably did not recognize the potential impact) until he read of Morton's claims for primacy in the newspapers in 1849. That promotion was left up to others, like Morton and Dr. Charles Jackson, who thought they needed to claim primacy for the discovery to achieve their divergent goals. Morton to make money. Jackson to achieve fame as the scientific discoverer. To claim primacy for the discovery Morton retold the story, literally, through Dr. Nathan Rice's book: "Trials of a Public Benefactor" as if he was the scientific discoverer of etherization (not just the demonstrator of practical anesthesia). At a time when such scientific discoverers performed multiple experiments on animals (and themselves) before subjecting the unsuspecting public to such investigations, Morton embellished his unlikely story to include that he had experimented extensively on fish and his pet dog Nig, and—in tried and trusted selfexperimentation fashion—had sat himself down in a chair at Tremont Row 30 March 30 is celebrated each year as 'Doctor's Day' in the United States commemorating this seminal event.

Leadership in Anaesthesia

73

to inhale ether to oblivion; noting the time on his pocket watch before and after the event, in the easy chair. The much more likely truth is that Dr. Charles Jackson, who was a heavy-weight scientist, geologist, chemist and doctor, with an impeccable reputation and known around the world for his discoveries, told Morton what to do, exactly, on the fateful day of 30 September 1846—for the first time. Describing that he should use rectified sulphuric ether rather than the un-pure chloric ether that Morton thought he might use (it was a good local anesthetic when applied to paining teeth) and thus directing him on how to experiment in humans to demonstrate that the double-distilled ether could relieve pain from surgery. Dr. Charles Jackson was no longer practicing clinical medicine at the time and so was either unwilling, fearful, or incapable of attempting what he had directed Morton, a medical student, to do. Jackson's claims that he was the rightful discoverer are therefore correct in the scientific sense. This being the chief contention between the two claimants and the basis of the long-running rancorous battle between Morton and Jackson who—you will remember—was his erstwhile medical school tutor and gave him a roof over his young head for his first three months at Harvard Medical School, remarking at the time, that Morton: "could not write grammatically his own quack advertisements" and after having asked Elizabeth and William to leave his home, justifying this by stating: "both Morton & his wife being vulgar ignorant people." (Wolfe 1993) Morton only adding Jackson's name to the patent application for Letheon because he had been advised by his attorney that if he didn't, Jackson would likely sue him. And then later, Jackson re-assigning the patent solely to Morton (but retaining his place as a co-discoverer) to ensure he would not get the flack and opprobrium inevitable to a patent application at the time for a scientific discovery. The well-bred Jackson just could not let the uncouth trickster Morton get the better of him. Setting out to frustrate his claims for primacy at every turn; with prodigious science, undying enmity, an obsessive mindset, and vast legal resources at his disposal, which he used to uncover Willie's past transgressions and stymie his applications for remuneration till the bitter end—thwarting and provoking him at every turn. So too in an article headlined in the prestigious Atlantic Monthly; Boston's favorite monthly magazine. †

74

3. William Morton

Early Death—Everlasting Fame Ensconced in his favorite chair but uncomfortable nonetheless, Morton turned hurriedly to page 718 of the June 1868 issue of the Atlantic Monthly to read The Discovery of Etherization. Hopeful that it would credit him fully with the glorious historical event that he relived daily—despite the 22 intervening years—his hopes were soon dashed, and his blood pressure malignantly raised, when he saw the author J.H. Abbott's comments. (Abbott 1868) "The discovery was made by Charles T. Jackson"—Abbott adding in Morton's own comments of the time for good measure: "The discovery belongs to Dr. Jackson; Jackson shall have credit of it; I want to make the money out of it." Elevating the dentist's blood pressure even further was the contention expressed in this, the most respected monthly magazine in the country, that Morton's role was limited to verification of the discovery by administering ether at the Massachusetts General hospital to Gilbert Abbott, on that fateful day of 16 October 1846—so many long years ago. Leaving totally aside the extensive publicity and promotion that Morton had engineered in popularizing practical anesthesia to the world—that had consumed the better part of his life. No matter the motive for his doing so. Morton stood up and sat down again. He had not been feeling well for a long time now, but was infuriated and nonplussed, something needed to be done. His wife Elizabeth remarking that she had never seen him so agitated before. Morton was concerned that this very public announcement would compromise funding for a recently launched New York City Testimonial campaign established for his pecuniary benefit. He needed to travel to Manhattan post-haste to put things right. Perhaps he could publish a rebuttal in Harpers Weekly—boarding the train that evening, he took lodgings at the ostentatious Saint Nicholas Hotel on Broadway on July 7. Frustrated, running from pillar to post to get things done; this was an inhospitable summer to be in the City: a heat wave had struck New York. Over 250 people—that month alone—had died from the fearsome heat, which soared above 92 0F daily, cooling little at night but for a muggy mist. Morton telegraphed Lizzie to join him four days later to help him get over his paining leg and 'brain fever.' Finding Morton, a little better, tended to by Dr. Sayre, but the weather getting steadily worse—topping 100 0F on the 13th—she summoned Morton's doctors back again to the St Nicholas Hotel on July 15 as William had again become increasingly confused, rambling, and breathless. The

Leadership in Anaesthesia

75

doctors uniformly advising bedrest at the Hotel (despite the inferno heat) as there were no rooms in the hospitals available. Morton thought otherwise though. Hoping to escape the searing heat of the city, and wanting to book into a more northern, hopefully cooler Washington Heights hotel—he ordered a carriage urgently with Elizabeth in tow, headed up Broadway speedily, and entered Central Park at 59th street at around 8pm. Hastening the horses on ever faster, they careened up the carriage way, heading out to Harlem Gate at 110th street; the horse frothing at the mouth from the strain. Seeing the lake on their right, Morton pulled tightly on the reins, jumped out of the carriage and collapsed, lake-side, seeking to douse his confused head in the cooling waters, making ineffectual movements with his hands, he grunted and laid still. Quite still like one of his patients. Lizzie screamed for help. A policeman arrived and a double carriage was ordered—Morton loaded on and transported to nearby St Luke's Hospital; but unfortunately was pronounced dead on arrival—his three medals: from Norway, from Russia, and from France—earned in recognition for the ether discovery— still pinned flamboyantly to his foppish silk jacket. Standing bedside, recognition dawning on his inscrutable face, Dr. Charles F. Heywood, St Luke's Surgeon in Chief, formerly of Boston, who had witnessed the first ether anesthetic on 16 October 1846, asked of Elizabeth: "This is Dr. Morton?" "Yes." Then, straightening up and clearing his constricting throat, he turned to the gathered medical students at Morton's bedside and emotionally declared: "Young gentlemen you see lying before you a man who has done more for humanity and for the relief of suffering than any man who has ever lived." Elizabeth softly responding, somewhat bitterly, pointing to the glistening medals on Morton's now stilled chest: "Yes, and here is all the recompense he has ever received for it." (Woodward 1962, Wolf 2001, Fenster 2001) Interpretation. Morton was a sick man. Whether that was just mentally so or due to physical neurological disease remains highly debatable. He likely had sociopathic tendencies with strong strains of narcissism, but he was also intermittently, severely, potentially pathologically, depressed (and

76

3. William Morton

at times hypomanic 31), usually when he suffered extreme reverses in fortune; there being at least three episodes in his written biographies where he repaired to bed and home and did not return for weeks. x When he was expelled from school—Morton received an 'illjudged and outrageous punishment,' returning home where he was laid up for many months becoming 'a sufferer in health and unfit for action or thought.' (Rice 1859, Perley Poore 1856) x Summer to fall 1847: 'his legs shook, convulsive writhing pains seized his body causing Morton to scream, his nervous system shattered: a mild surprise or sudden noise set him off at a tangent, he was restless and couldn't stand long or sit in one position' and subsequently travelled to Saratoga Springs for recovery. (Rice 1859, Woodward 1962) x Early 1856: 'This sudden change in his prospects, with the ceaseless anxiety of his life for the past months, produced a second and alarming attack of illness, which confined him to his bed for weeks, and from which he with difficulty recovered.' (Rice 1859, Woodward 1962) From time to time Morton was either given the diagnosis of rheumatism by his doctors or alternatively rheumatic fever by his biographers—as an explanation for the sicknesses he suffered. But at that time (1868) rheumatic fever was not yet appropriately categorized as a disease entity. (Woodward 1962, Wolf 2001) What is likely, however, is that Morton had quite advanced arteriosclerosis affecting his brain function, worsened by undiagnosed hypertension. 32 Pointing to this diagnosis is that there are reports of Morton giving increasingly rambling, grandiloquent speeches—bordering on the bizarre—about his role in the Ether Discovery while on the lecture trail in 1866, and then 18 months later dying of a stroke. That final stroke probably brought on by a malignant hypertensive crisis, precipitated by Jackson's article, worsened by Morton's agitated response, and heightened further by the extreme heat-wave that plagued New York City that fateful night of his untimely, apoplectic, death. Dr. Henry Bigelow, Morton's indubitable champion, probably described it best: 31 Please see Chapter 2 for a thorough explanation of cyclothymia and personality disorders that can be found in leadership. 32 Blood pressure measurement was popularized much later by Dr Riva Rocci in 1896 in Pavia, Italy.

Leadership in Anaesthesia

77

"Morton fell with apoplexy, induced by the publication in behalf of Jackson, of a nature to prejudice a subscription then arranged in New York for his benefit." (Wolf 2001) William Morton wanted wealth, but instead achieved fame. Giving the world a grand new discovery; he ushered in a whole new era of possibility in medicine. Sir William Osler—considered by many in contemporary medical circles as one of its supreme pioneers—speaking to the British Medical Association in 1918, six decades after the event, summarized the situation conclusively: "Before October 16, 1846, surgical anesthesia did not exist; within a few months it became a world-wide procedure; and the full credit of its introduction must be given to William Thomas Greene Morton, who on the date mentioned, demonstrated at the Massachusetts General Hospital the simplicity and safety of ether anesthesia." Gathering voice, he went on: "In science the credit goes to the man who convinces the world, not to the man to whom the idea first occurs." and then: "Morton convinced the world: the credit is his." Fame is more valuable than wealth, for it lasts forever. (Wolf 2001, Osler 1917) †

Post Mortem Recounting the Seven Ages of Leadership presented in Chapter 2; Dr. William Morton provided his leadership during the Great Man Age stretching from 1840-1900. A leadership writer of the time, Thomas Carlyle, focusing more practically on studying the actual leader— eschewing the theoretical philosophical analysis of the past—in favor of studying the leader's origins, inventions, and accomplishments as well as the circumstances they faced. Believing that leaders created the circumstances that resulted in the progress for which they were recognized and had pioneered. (Clinton 1992) Although, arguably, Morton, was no 'Great Man' in the moral sense, he did champion a 'Great Discovery' and was instrumental in promoting practical anesthesia out to the world. †

78

3. William Morton

To compare the leadership profiles of the five pioneers of anesthesia that populate this book, a leadership competency rubric has been created—a skeleton—to allow a Post Mortem analysis of key characteristics of leadership. A motivation for the selection of these key 'body parts' chosen for this autopsy are presented in the previous chapter entitled: A Brisk History of Leadership. Many may quibble with such a pedestrian approach, being nonscientific and highly qualitative in nature, but I would argue that this is nevertheless useful in highlighting key concepts of leadership and how they manifest differently in different leaders. In the final chapter of this book, A Leadership Reckoning, we will use the derived skeletons to allow a comparison of the pioneers to elucidate these points. To develop a deeper understanding of leadership, in this and the forthcoming chapters, we will first examine the pioneer's leadership profile using the proposed 'Leadership Skeleton' and then go on to conclude with a series of key Leadership Insights that can be gleaned from the telling of their stories. The key 'body parts' of the Leadership Skeleton that will be used to examine Morton's and the other four pioneers leadership profiles is best captured using the rubric: Creative LEADER. Leadership Skeleton: Creative LEADER max score: +++, min score: 0.

William Morton

Creativity/Innovation/Imagination

+++

Legitimacy/Authenticity/Credibility

0

Emotional Competence/Psychological makeup/Personality Adaptability to Change

0

Determination/Passion

+++

Empathy

0

Resilience

+++

Total Leadership Score

12/21

+++

Leadership in Anaesthesia

79

Creativity (+++). Morton was creative but not in the conventional sense. More usually creative with the truth rather than in the scientific context. Morton's brilliance—perhaps born of his narcissism and nous for showmanship—was his talent in promoting and publicizing practical anesthesia (and himself) to the world; and in effectively setting up the first commercial Locum Tenens practice for anesthesia administration. The latter foundering, not because of a lack of creativity in developing the first ever Anesthesia Practice stretching across the North Eastern States, but chiefly because Morton's illadvised patent for Letheon was not honored by the government nor anyone else—the patent on a medical discovery flying in the face of the noncommercial medical tradition of the day. Legitimacy (0). Morton had none. Being a confidence trickster all his life and a half-trained dentist, with little to no medical education (despite going to Harvard Medical School classes a few times and admitted as an (honorary) doctor at the Washington University of Baltimore Medical School), Morton was seen for what he was: a villain and a fraudster and really had little to no legitimacy; until many years on, when he was finally credited with the discovery of practical anesthesia through his copious exertions in publicizing his role. Emotional Competence (0). Although Morton by all accounts had a stable relationship with his wife Elizabeth, he was unstable and erratic in his relationships with others. Given his tendency towards sociopathy, his abundant narcissism, and his cyclothymic personality, he appeared very able to connect with people to gain advantage from them, but not necessarily to build lasting relationships built on trust and reliability. Adaptability to Change (+++). Considering the multiple career changes that Morton underwent, his flexible approach to different opportunities that presented themselves— no matter how nefariously executed—and his ability to adapt strategies in seeking compensation from Congress and other sources; Morton showed himself eminently capable of adapting to changing circumstances. Determination (+++). Morton had this in abundance. Always with one goal in mind—to make money, which often led him astray. Probably stemming from his

80

3. William Morton

relatively poor background and his father's going bankrupt, Morton was determined to be rich; contriving time and time again, by any way or means, to achieve his goal. Empathy (0). Whether Morton evinced empathic leadership is not clear because those with sociopathic inclinations have learnt to fake this. Learning to act as if they are empathetic in-order to win another's confidence. As a confidence trickster, Morton must have had this down: convincing some, but not every-one, of his sincerity and good offices. Contrast the many Congressman he was able to convince (or bribe) with Dr. Charles Jackson, an erstwhile mentor in whose house he first stayed—becoming Morton's obturate foe, and eventually engineering his downfall. Resilience (+++). Resilience the inherent, but also developed ability, to bounce back from reverses of fortune, was a hallmark of Morton's competencies. Time and time again he stood up and returned to Congress to attempt yet another application for a monetary award—improvising approaches to achieve his goal. Seeming stronger each time he did. A hallmark of hypomanic personalities like Morton; resilience is strengthened by adversity. "It's not how many times you get knocked down that counts. It's how many times you get back up." 33 †

Leadership Insights A number of useful insights can be drawn from the telling of Morton's biography. x Let not the quest for money lead one astray. x Do not put all your eggs in one basket—keep your day job. x Develop trust and credibility at an early stage or court failure— implacable foes dogging future prospects. x Develop an awareness of sociopathy. x The highest trees catch the most wind—guard one's reputation assiduously.

33 Attributed to George Armstrong Custer (1839-1876) Cavalry Commander. US Army officer, American Civil War.

Leadership in Anaesthesia

81

† Let not the quest for money lead one astray. Morton was motivated by money and money only. Fortune not fame. As a simple dentist he had wanted to find a way to lessen the pain from teeth-pulling so that he could make more money from his burgeoning dental practice. Computed as netting over $10,000.00 a year, he was hijacked by Dr. Henry Bigelow (in turn impelled by his own professional advancement) with the lure of making even more money. Engaged to demonstrate ether anesthesia for surgical insensibility for a capital operation, Morton got in way over his uneducated, unsophisticated, head— into the high-brow, but brutally vicious, internecine battles of medicine, scholarship, and scientific discovery—in which he was neither capable, nor conversant, and for which he was totally unprepared and unsuited. Borrowing the scientific idea of using sulphuric ether for anesthesia from his tutor, the chemist, Dr. Jackson, and then patenting this idea for monetary gain; was not only considered unseemly and improper, but was going to be vigorously contested: the coin of the medical realm being fame (of discovery) and not fortune. Patenting a medical discovery that could be used to lessen pain and suffering from surgery was anathema—tantamount to unprofessional practice. Made much worse when proposed by a medical interloper, a raw, untrained dentist like Morton. No matter the fact that Dr. Henry Bigelow was Morton's undying champion; the medical and scientific world blew back with great opprobrium and vilification. Personified adroitly in Dr. Charles Jackson's reactions to Morton's plans. His former confidant becoming a sworn enemy and eventual medical and physical nemesis—Morton not finding the fortune he set out for; instead felled by getting in over his head—way over his head into the realms of science and medicine that he knew little about, nor cared for. x

Do not put all your eggs in one basket—keep your day job. Morton would have been much better off, in venturing carefully into the scientific realm he little understood, if he had kept his dental practice going to ensure a steady income, while he pursued this new opportunity. Instead he handed it off to Dr. G. Hayden and this source of income soon dried up as the practice fell apart to competitors. Although prioritizing and focus are key considerations in any new endeavor, it is crucial that new opportunities are approached with circumspection as it is estimated that around 50% of new business ventures fail. (Business 2018) x

82

3. William Morton

Develop trust and credibility at an early stage or court failure— implacable foes dogging future prospects. Morton's biggest problem was that he could not be trusted. From youth. He was obviously adept at gaining people's trust early in the relationship—having learnt to send the right physical and emotional signals to win their trust—but then could not sustain it; disreputable deeds shredding initial confidence in him asunder. Trust is built through consistency in word and deed. Talking the talk and walking the walk builds the necessary credibility to gain people's confidence for the long-term. In general, people are willing to give another the benefit of the doubt—having initially been convinced by their pitch. But once trust is broken, and the perpetrator's reputation for honesty and reliability has been sullied, they will be hard put to win it back. People feel cheated and diminished by their misplaced trust and will fight back hard to ensure that the person does not get away with it in the future. Especially if they have suffered losses as a result of the misdirected confidence. Witness, Mordicai D' Lange, bookkeeper for the firm of J.B. Sickles and Co. and, Dr. Charles Jackson—both of whom became implacable foe's; setting out to dredge Morton's sketchy past to bring him to justice. Mordicai accosting Morton back in 1840 threatening him with public exposure of his past transgressions, should he not leave St Louis and cease his fraudulence—Morton pleading and threatening suicide, but still not leaving the city as he had promised to; resulting in the publication of the BEWARE A VILLAIN article in the Daily Evening Gazette. And Dr. Charles Jackson, who amongst other approaches charged his attorney, J.L. Lord Esq., to take depositions tracing Morton's 'mercantile endeavors' in the distant past, discrediting him, making his claims for primacy in the Ether Controversy ever more unbelievable—probably tipping the balance against Morton; in his many applications to Congress for compensation; his reputation with the President of the United States in seeking redress; and with many others—his credibility shot through with holes from his early career as a swindler and trickster. x

Develop an awareness of sociopathy. Although Morton was not a psychopath, he nevertheless demonstrated sociopathic trends and behavior traits in his dealings with others—which has been characterized as famously difficult to spot in the present day work place where roughly one percent of true psychopaths rise rapidly to the top of organizations; their glib polish, charm, decisiveness, and cool-handed maneuverings regularly mistaken for leadership qualities. (Morse 2004) x

Leadership in Anaesthesia

83

Veritable chameleons—showing differing faces as the situation dictates—these individuals manipulate and ingratiate themselves; gaining peoples' confidence on their relentless quest to the top—remorselessly wreaking havoc in the process. Cunning and untrustworthy they manipulate and exploit every situation to their advantage, but are usually unmasked in the trenches. As they seek the top position in an organization, they are experts at camouflaging their psychopathy with the leaders at the top they seek to replace, but often let their guard down with subordinates or equals. Believing, amorally, that if they can take advantage of a fellow worker, their obvious superiority, justifies this; they will plant rumors, manipulate financial results, or make false allegations to turn co-workers against eachother, so seeking to destroy the competition and forge ahead in the hope of gaining favor with the chief. (Morse 2004) It is in the trenches of the work place where their perfidy can be revealed. Here they often let their guard down and based on the actions here witnessed the diagnosis can be made using a tool created by the Canadian Psychologist Robert Hare. Called the Psychopathy Checklist it comprises a review of 20 personality traits and an evaluation of past actions witnessed by colleagues to make the diagnosis—the Checklist having been used in the present day to aid courts in deciding on the type and length of prison sentences; and by doctors to decide on possible treatment of the condition. Unfortunately, there is no real treatment for psychopathy, so awareness is one's best defense against the "wolves in sheep's clothing" in our midst. The highest trees catch the most wind—guard one's reputation assiduously. In the Dutch language there is a well-known saying: De hoogste bomen treffen het meeste wind. The highest trees catch the most wind. It is inevitable that as a leader's stature and fame increase there will be those that will attempt to take them down—character assassination a handy means to do so. Drawing into question the leader's credibility and suitability to compete at the highest level, foes will make false (or true) allegations in an attempt to bring the high-flyer down. Morton obviously did not have a leg to stand on when Jackson and others started the process of questioning his credibility in attempts to undermine his legitimacy as a claimant for the primacy of the Ether Discovery. Nevertheless, William put up a mighty defense in attempts to salvage his reputation. Engaging Dr. Nathan Rice to write his self-edited biography; an extreme example of the lengths Morton would go to in rewriting his history. Fake news we would call it today. Nevertheless the x

84

3. William Morton

leadership insight is that on their way to the top, leaders should guard their reputation assiduously. It is the only one they've got. †

Concatenation Spurred by Dr. Henry Bigelow's 'Surgical Insensibility' report of Dr. William Morton's administration of practical anesthesia with sulphuric ether—surgical practice around the world exploded. Surgeons could now work meticulously—because there was less need for speed and the patients remained completely still—despite the surgical incision; not moving from pain and not having to be strapped or held down by six hefty men. Hence surgeons were given the time to experiment with different surgical approaches and so surgical techniques advanced in lock step with advances in anesthetic techniques. To step from the Art of practical anesthesia demonstrated by Morton in America, we spring to the science of anesthesia developed by Dr. John Snow in England—from the New to the Old world—as we track the pioneers who had a hand in developing the new medical practice of anesthesia born in 1846. †

4. JOHN SNOW

The Science “An anesthetic which might be inhaled with absolute safety, and which would destroy common sensation without destroying consciousness.” —John Snow

86

4. John Snow

The First Death

Doctor John Snow worked himself to death. The first physician scientist to dedicate his life to transforming the art of anesthesia into a science—he was far from the first to put his patient's health before his own—striving to find the perfectly safe anesthetic. Chloroform was not that drug. Even so, ever hopeful, Snow would back it—literally—to his dying day. † Hannah Greener was especially nervous about her second anesthetic because the first one—just three months ago—had made her terribly sick. A plump 15-year-old, she had suffered greatly from ingrowing toenails since childhood, requiring an excruciatingly painful surgical incision to drain her puss-filled left big toe. Admitted to the Newcastle upon Tyne Infirmary to perform that surgery, Dr. Potter had administered an ether anesthetic with reasonable effect: "she screamed during the operation but felt no pain." Nevertheless, she remained in hospital for nine weeks post-operatively: "fretting... but never complaining of ill-treatment." Hence, wanting to allay her anxiety about ether, Dr. Thomas Meggison had suggested a newer anesthetic for the next operation. Chloroform. Believing Hannah's right in-grown toe nail to be less serious than on the left—and so not needing hospital admission—Meggison and his assistant, Dr. Lloyd, planned the operation at her home for 28 January 1848—a historic date. "I seated her in a chair, and put a teaspoon of chloroform into a tablecloth, and held it to her nose. After she had drawn her breath twice, she pulled my hand down. I told her to draw her breath naturally, which she did, and in about half a minute, I observed the muscles of the arm to become rigid, and her breathing a little quickened, but not stertorous. I had my hand on her pulse, which was natural, until the muscles became rigid. I then told Mr. Lloyd, my assistant, to begin the operation, which he did, and took the nail off. When the semicircular incision was made, she gave a struggle or jerk, which I thought was from the chloroform not having taken sufficient effect. I did not apply any more. Her eyes were closed, and I opened them, and they remained open. Her mouth was open, and her lips and face blanched. When I opened her eyes, they were congested. I called for water when I saw her face blanched, and I dashed some of it in her face. It had no

Leadership in Anaesthesia

87

effect. I then gave her some brandy a little of which she swallowed with difficulty. I then laid her on the floor and attempted to bleed her in the arm and jugular vein, but only obtained about a spoonful. She was dead.... The time would not have been more than 3 min from her first inhaling the chloroform till her death." (Anonymous 1848) Despairing of this tragic death, Dr. Meggison immediately informed the police and called for an inquest— promptly held the next day in the New Inn pub at Winlaton. Having sworn a Jury, and upon completing a viewing of Hannah's dusky corpse, a hearing of testimony from all present at the operation was conducted—after-which the obligatory Post Mortem was performed by Sir John Fife and Dr. Robert Glover to determine the cause of this first recorded death under chloroform anesthesia. And, sadly, the next day, Sunday, Hannah was laid to rest in Winlaton church yard—the register of burials reading "Died from the effects of chloroform." But what are these effects? Was this an idiosyncratic effect of the drug peculiar only to Hannah? Was this an anesthetic overdose? Ineptitude of administration? Or a failure to understand the physiology and pharmacology of anesthesia and chloroform? Critical because at least 13 documented chloroform deaths would follow in the same year (1848); literally hundreds would occur during the rest of the 19th century; in 1910 more people were killed in England by chloroform than by manslaughter and in 1923: 42 people were killed in one hospital alone—the chloroform “holocaust” continuing unabated for years to come. (McNamara 1923) Hence, not soon after Hannah’s untimely death, Dr. John Snow set out to answer these questions—dedicating the lion’s share of his medical and scientific endeavors to the cause of finding the “perfect anesthetic.” In so doing becoming the recognized leader of anesthetic practice in England: anesthetist to one hundred London surgeons, seventy dentists, and Queen Victoria for the birth of Prince Leopold and Princess Beatrice, whilst authoring the first text book of Anaesthesia: "On the inhalation of the vapour of Ether" (1847) and, posthumously, publishing: "On Chloroform and Other Anaesthetics" (1858). Penning the final lines of the book before keeling over from a terminal stroke. (Snow 2009) †

88

4. John Snow

Ether and the Quest for Safe Anesthesia John Snow prepared himself well for his illustrious future although coming from humble beginnings. His father, William, a carter, and his mother, Fanny, the illegitimate daughter of a most important man—Charles Epsom (friend of Napoleon Bonaparte) who would feature prominently in supporting Snow's ambitious future agenda. (Vinten-Johansen et al. 2003, Shephard 1995, Snow 1858) Born in the walled city of York in 1813, which was bisected by the River Ouse, young John and his eight siblings were accustomed to unsanitary living conditions; inhabitants piped their night-soil directly into the river’s perennial flooding waters to avoid paying sewage rates—the probable source of Snow's later obsession with purity, temperance, and good sanitary practices. Completing private schooling at the Dodsworth School at Bishopshill, a Quaker based institution, the studiously serious 14-year old was determined to study medicine from an early age. There being three paths of entry into the medical profession in the first half of the nineteenth century in Great Britain. One route was to become apprenticed to a general practitioner apothecary and to achieve the Licentiate of the Society of Apothecaries (L.S.A.) and, together with a little knowledge of surgery and dentistry, setting one-self up in a well-paid country practice for life. Another; to study at a Medical School in London or Edinburgh, leading to the diploma of Membership in the Royal College of Surgeons (M.R.C.S) of England or Scotland, and a life-time of lucrative local practice as a doctor. No further examinations required. But no chance of advancement in the hierarchy of scientific medicine either. For that there was a third route. The route to becoming a Consultant Physician; highly prized because such a consulting practice came with patient beds in London’s teaching and private hospitals. Teaching beds allowing clinical studies, and private beds attracting high society patients: bringing both fame as a medical lecturer and fortune from the well-healed sickly. This ‘University’ route, however, usually took much money and social connections. Hence, only a few of the most intellectually rigorous, and persistent, who wanted to practice the best possible medicine—despite being impecunious and socially unconnected as Snow was—managed to attend Universities like that in London to complete the degree of Bachelor of Medicine and Bachelor of Surgery (M.B. B.S).

Leadership in Anaesthesia

89

The latter a necessary step for the achievement of the highest medical degree: The Doctorate in Medicine (M.D.), evidence of learning and scientific research beyond the average that allowed a physician to be a consultant in a teaching hospital, lecture, and conduct scientific research— the hall marks of academic medical practice. John Snow would follow all three routes—to the top.

Apprentice First adopting a utilitarian approach. Coming from a poor family, John took the pedestrian route of becoming a medical apprentice to the surgeon-apothecary, Dr. William Hardcastle—grateful for the introduction by his illustrious uncle, the dapper dresser, Charles Epsom. Hardcastle, a well-respected general practitioner of Newcastle upon Tyne (another walled city a full day’s coach ride north of York) owned a commodious practice—an apartment, surgery, shop, and stable, off the courtyard directly opposite St John’s Church; which was thus wellappointed to house Snow’s indenture for the next six years. The only apprentice to Dr. Hardcastle, John received medical and dental instruction, and in return was mandated to serve his master “faithfully:” follow all “lawful commandments;” avoid ale houses; steer clear of gambling, and remain a bachelor for the duration of his indenture. Probably setting Snow up for the abstemious life-style and the bachelorhood that would follow. On a typical day, John would rise early, attend to the daily drudgery of bottle cleaning, sweeping, getting the shop ready, and maintaining an inventory of drugs and compounds that could be used later to fill the prescriptions he would be commanded to deliver on foot to various patients houses—often at all hours of day and night. As he progressed in his apprenticeship, his days could be filled with setting fractures, lancing boils, performing post mortem dissections to determine the cause of death, pulling teeth, contending with measles epidemics and treating other childhood diseases punctuated, only occasionally, by formal training at the “Newcastle” medical school housed in a “large room over the entrance of Bell’s Court on Pilgrim Street.” Only recently established in 1832, John was one of eight enrolled students. Here Mr. H.G. Potter taught chemistry and Dr. George Fife: Materia Medica and Therapeutics. John completing his sixth and final year of apprentice training here; complemented further by “walking the wards” and clinical lectures at the Newcastle Infirmary and visiting Hardcastle’s

90

4. John Snow

patients at the nearby Lying-In-Hospital, to learn obstetrics as an accoucheur. Tellingly for Snow’s future career in epidemiologic research— cholera struck Killingsworth, a nearby collier’s town, in 1831. Considered Dr. William Hardcastle’s bailiwick, the general practitioner could not be in two places at once, so sent John instead: his, probably less than willing, unsupervised, assistant. Probably less than willing, because at this time medical science could do very little for patients afflicted by cholera and mortality from the deadly diarrheal disease was fifty/fifty in nearby Sunderland where the “Asiatic form” of the dreaded killer had been recently introduced on a ship that had arrived from the Continent on October 20, 1831 1 What probably saved Snow from certain death—if not 50% of his patients—was the fact that at the seminal age of seventeen he had read John Frank Newton’s Essay: “The Return of Nature: A Defence of the Vegetable Regimen." The book convincing him to conduct a life of purity: vegetarianism to avoid the consumption of unhealthy animal flesh; a fastidious attention to purifying water through distillation and drinking sparingly; 2 avoiding alcohol and taking regular exercise—all prescribed by Newton as healthful, that Snow eagerly adopted—becoming a man known for his culinary peculiarity and fastidious peccadilloes. Surviving this first experience with the killer cholera, Snow’s exit from Hardcastle’s practice in Newcastle and move to seek further experience in nearby Burnop Field in 1833, may have been hastened by the fact that John and a friend had been indicted for disturbing a Sunday prayer evening by exploding a firecracker on the Church porch. The punishment for this misdemeanor being £60.00 which was far more than an apprentice could afford—rendering Snow even more out of pocket than he already was—and in dire need of new employment and a fresh abode. Finding both in Dr. John Watson’s practice in county Durham where Snow was in for a rude shock. Watson being a “pre-1815 medical man” and so not fully trained in new techniques—having qualified before the Apothecaries’ Act became law—did not take well to the fastidious practices of his new charge: Snow, on his first day of work, upon seeing the 1

In all of England and Wales the Cholera Epidemic of 1831-32 would claim more than 22,000 lives. 2 At this time medical science was of the opinion that Cholera was spread by miasmas—bad airs—while it is actually caused by a waterborne bacterium: Vibrio Cholera which would be microscopically identified by F. Pacini in 1854 (unknown to Snow) but only fully scientifically characterized as a cellular structure by Robert Koch in 1883.

Leadership in Anaesthesia

91

general disorderliness and dishevelment of Watson’s spacious practice on Front Street; decided to take matters in his own hands and tidied up “getting everything as clean as a new pin;" disposing of the 'blisters' that had been packed for reuse in a bottom drawer, and tidying and relabeling the bottles, vials, and flasks that cluttered the cupboards and counters. To Watson’s eminent dissatisfaction. The good doctor, on seeing a subsequent patient with a swollen knee who would be well served by an application of a re-used blister 3—in the hopes of relieving the inflamed and painful knee, only to find, on reaching into the drawer where he had carefully kept the blisters for re-use, that Snow had discarded them all. Watson declaring: “Goodness! Where are all my blisters?” “I burnt them all; they were old ones.” “Nay, my good fellow, that is the most extravagant act I have heard of—such proceedings would ruin a parish doctor. You must never do such a thing again!” Not off to a very good start. Snow endured the relationship for one short year, and having little in common with Dr. Watson, justified his departure by stating he had to “work too hard for his money”—John moving again, this time to Patley Bridge in West Yorkshire, as an assistant apprentice to Joseph Warburton, a licensed apothecary; proud doctor for an extensive country practice. Here John busied himself with the usual medical practice of setting fractures, piercing boils and compounding his own prescriptions; and tempered and refined his J. F. Newton inspired thinking: transitioning from temperance to tee-totalism with respect to alcohol— resolute in the belief that distilled water was the ideal beverage, vegetarianism the ideal food sort, and that regular exercise was the third prescription for enduring health. Distilling the essence of his medical thinking (after nine years of medical apprenticeship) in his “teetotal address” at Patley Bridge in 1836— one of Snow’s first lectures in a celebrated career of speaking out on matters of public health—that would bring both fame and notoriety. Ostensibly to rail against the imbibement of alcohol as a public health hazard—inebriation caused overheating and overexcitement—Snow was a therapeutic skeptic like many other medical men of the time; believing that the healing power of nature rarely needed a helping hand— neither of alcohol nor any other substances. Telling his audience that “medicines are indeed a greater blessing” but that their use was the “substitution of a lesser evil for a greater” namely death. 3

A muslin patch impregnated with an ointment (canthrides) from the green blister beetle (to irritate the overlying skin, raise a pustule that could be lanced, and drain off the pustular fluid).

92

4. John Snow

Admonishing the use of spurious medicines in favor of a healthy lifestyle: veganism, pure water and plenty of exercise—Snow was obsessed with ensuring the purity of drinking water to avoid waterborne disease and showed an early interest in public health; undertaking to search for truly effective Materia Medica: chemical compounds that actually worked. Not knowing at the time, that it was he who would provide the scientific underpinnings to the very effective, yet serendipitously found, general anesthetics: ether and chloroform. Perversely, both intoxicants like alcohol which Snow was vociferously railing against, but would become a ceaseless protagonist for, after proper training as a doctor, scientist, and medical man at Medicine’s epicenter—one of the twenty-one medical schools in London, close to the polluted river Thames.

Medical Student Not one to shirk the opportunity to actively practice what he preached, Snow travelled from his home-town of York to London on foot. A four-hundred-mile journey, John travelled via Liverpool, through Wales, stopping off in Bath to pay his respects to his Uncle, Charles Empson, who in all likelihood financed the next two years of medical school; Snow struggling to keep his head above water at best. Settling on the Hunterian School of Medicine in Great Windmill Street for two good reasons. First, the fees at £34 in October 1836 were half that of the more eminent London University College Medical School and second, Dr. John Epps, one of the chief lecturers there, was similarly minded to Snow—a medical radical and temperance reformer. Consequently, John enrolled in the Hunterian School to become dually qualified: with the Royal College of Surgeons of London and the Worshipful Society of Apothecaries. The Royal College and the Apothecaries Hall, although having both common and differing requirements for lectures, courses, and lengths of clinical training (22-31 months), nevertheless allowed candidates to attend this schooling concurrently; in order to satisfy the prerequisites to sit the two examinations needed to become a Member of the Royal College of Surgeons and to receive a Licentiate of the Society of Apothecaries. Both conveniently fulfilled by attending one of London’s many medical schools like the Hunterian’s, lecture room and anatomy hall (dead-room), to receive instruction, tuition, and study dissection, and one of its Teaching Hospitals adjacent to the Houses of Parliament; to gain experience from observing and studying hospitalized patient case histories—medical students avidly recording these to inform their future practice. Subjecting these patient case findings to the newly hyped ‘clinical-pathological method’ of studying

Leadership in Anaesthesia

93

outcomes from patient remedies—success documented in a log book, or death catalogued in the Westminster Hospital’s Dead Room, where students like Snow could compare their clinical observations with the anatomical structures and pathological lesions found upon dissection at postmortem. Performing a postmortem however could prove a sickening experience. Especially when arsenic had been used as a preservative. Snow and five fellow medical students becoming severely ill one hot August day in 1837 whilst performing an autopsy—the newly qualified Doctor publishing his first scientific contribution on the subject in the Lancet in 1838 entitled: “Arsenic as a Preservative of Dead Bodies.” (Snow 1838). Using scientific laboratory methods newly learnt at the Hunterian School, Snow investigated the matter. At a time when cadaver preservation was at its infancy, the Hunterian School had embraced the practice of injecting a saturated solution of arsenite of potash intravenously in order to dissolve all venous congealed blood, allowing this to be replaced with an injection of a bright red dye that allowed easy identification of blood vessels and organs for subsequent anatomical dissection. Snow, noting that he and his fellow dissection mates often felt poorly: “one of the pupils suffered severely from pain in the stomach, and bowels vomiting and purging,” speculated that the arsenic they breathed in during close dissection was the probable cause—so he subjected the arsenic saturated tissues from one such a preserved cadaver to an experiment. First allowing the corpse’s tissue to decompose over three weeks under a bell-glass receiver—Snow gathered the effluent gases, added flammable hydrogen, and burned off the gaseous mixture; finding pure metal arsenic remnants proving his hypothesis. Happily, Snow’s investigation of arsenic poisoned cadavers overlapped with his participation in an important public health study launched by the Westminster Medical Society to investigate arsenic impregnated candles. Newly enrolled as a member, Snow’s probe into arsenical toxicology (demonstrating that sparrows were killed by the vapor from arsenical candles) served as his official introduction into the illustrious Medical Society on 28 October 1837. Dr. John Epps providing the introduction—knowing well Snow’s diligent investigative techniques; having previously taught John and eight fellow students the Hunterian Medical School’s course in Forensic Medicine. Snow’s foray into the forensic scientific method adding to the very public debate—newspapers, medical journals, societies—dealing with the use of arsenic in candles to make them burn much brighter than those manufactured from pure wax; the so called “Cheap Wax Lights” imported

94

4. John Snow

from, and now banished, in France. The Lancet picking up the public refrain against the use of “Arsenical Candles,” citing the Westminster Medical Societies’ studies as evidence against these “Poisoned Candles,” and chiding the Home Secretary for permitting the sale of candles that exposed the public to a five times greater quantity of arsenic than the prudent physician would administer to his patient internally. Burnishing step by step Snow’s scientific and public health credentials.

Doctor & Scientist

4

Qualifying as a surgeon-apothecary in October 1838, Snow moved from his tiny room in the Bateman Building just off Soho Square to set up a surgery and lodgings at 54 Frith Street nearby. Some thinking him crazy to attempt to set up a general and midwifery practice in central London; as there was a surfeit of doctors in the metropolis—four others having surgeries just steps away—but Snow must have determined that the advantages outweighed the risks: The Westminster Medical Society of which he was now a proud member offered a scientific community and comradeship; and although he did not have the highbrow connections and patronage to secure a hospital appointment in the City (and so attract high paying and high society patients), he could hope to become a lecturer in one of the medical schools and perhaps be enrolled at the University College of London, complete a Bachelor of Medicine and Bachelor of Surgery (M.B.B.S), and eventually achieve the pinnacle: the Doctorate in Medicine (M.D.) qualification, on the way to becoming a Consultant Physician—this route being newly developed for those who had not attended Oxford or Cambridge—in so doing John would shatter the glass ceiling that stopped medical men of his lowly background from the lofty goal of attending to patients from the upper classes. As it happened, his gamble and aspirations worked out quite well over the next eight years, starting haltingly at first. Although Dr. Snow was regarded as an outstanding clinician, had engaged four sick clubs, and worked in “Out-Patients” at the Charing Cross Hospital near Trafalgar Square, he did not attract a wealth of patients as he lacked the common touch, was regarded as diffident, peculiar, in fact odd in his interactions, and did not wish to pander to his working-class patients 4

William Whewell, founder member of the Cambridge University Philosophical Society and a Trinity College polymath, first coined the term "Scientist" to disentangle the natural philosophical thought processes of old from the more specialized thinking required for the new scholarship that the likes of Charles Darwin was presenting at the Societies meetings in 1835.

Leadership in Anaesthesia

95

requests; preferring instead to stress the importance of practicing sound and rational medicine rather than dispensing ineffective remedies from the pharmacopeia to win their favor. Snow being far more interested in the scientific study of medicine than building a thriving practice. So, to this end, he started climbing the academic ladder to achieve his goal; establishing a home-laboratory filled with a menagerie of animals and birds to investigate his area of great interest: respiration, chemistry and the physiology of gases and vapors—in order to author the necessary erudite publications, 5 pamphlets, and lectures—more usually presented at ‘Westminster Medical’—that would pave his way in London’s academic medical community of the day. And, in order to qualify for examination for the MBBS and MD degrees, he attended extra courses, (including learning Greek and Latin) ran scientific experiments, and undertook the respective grueling medical examinations which included not only the physical evaluation of sick patients, but discourses on the Philosophy of Locke and Hume, and a final oral examination—which Snow consummated successfully receiving both Degrees in 1844. 6 Placing him with the highest qualified physicians in the country, and, upon appointment as a lecturer in Forensic Medicine at the Aldersgate School of Medicine (1845), securing for Snow a position as a respected member of London’s Medical Society; well known for his ability as a researcher and recognized as an astute clinician and teacher.

Anesthetist Hence it was not altogether serendipitous that Dr. James Robinson, a well-known dentist from 7 Gower Street—just across the way from the University College of London—invited Dr. John Snow to attend one of the first demonstrations of ether for a dental operation on Monday 28 December 1846—having recently heard of the Boston Dentist, William Morton’s, successful ether demonstration just six weeks earlier from his friend and colleague, Dr. Francis Boot, who in turn had read the surgical insensibility article authored by Dr. Henry Bigelow, so recently transported across the Atlantic in the steamship Acadia. 5

Most scientific papers were published in the Lancet and The London Medical Gazette. 6 It is impossible to convey the exhilaration of pursuing, and then accomplishing, such a level of education: the author completed the M.B.CH.B, Fellow of the Faculty of Anesthetists of the Royal College of Surgeons of England, and Ph.D. qualifications around 150 years after Dr. John Snow.

96

4. John Snow

Dr Robinson describing the proceedings unfolding in his Gower Street Rooms. “In the presence of several medical men, I operated in my surgery.” (Robinson 1847b, a) Robinson, an eminent man in his own right, having serially invited the who’s who of London’s medical community to witness the use of ether administered using a glass apparatus—more usually used for making soda water—to en-numb three patients for dental surgery. The first, a young man of robust constitution, twenty years of age, was sat down on a solid chair, a padded copper molded mouthpiece thrust in his mouth, his nose compressed with a spring, and asked to inhale— vigorously. Drs. Snow, Liston and the othered gathered physicians watching closely as events unfolded. Noting the two glass flasks that constituted Nooth’s apparatus—both conical in shape—the top smaller one inverted into the bottom larger version, looking more like a Hookah than a medical device; two feet of plastic tubing connecting to the patient’s mouth piece— the doctors could see the cut pieces of triangular sponge in both glass containers impregnated with copious quantities of ether: increasingly suspicious that such a complex apparatus would never work; they observed the patient carefully, the glass surrounding the packed sponges blanching as ether vaporized and cooled, 7 causing water droplets to condense on the glistening surface with each deepened breath—brought on by the cold air of Robinson’s freezing consulting room. The gathered doctors amazed at the success: the patient after inhaling the vapor for about two minutes becoming insensible and the offending tooth extracted. On awakening and questioned on the experience, the patient recollecting only: “It was the queerest thing I ever knew in my life.” perfectly satisfied with the turn of events. 7

This is known as the latent heat needed for vaporization. As a liquid vaporizes it cools down, to provide the necessary energy to the liquid ether molecules to transform them into a vapor. And so the temperature of the ether drops as does the glass container: condensate forming on the glass container as surrounding air in turn cools, in so doing the air transforming to liquid droplets on the outside of the glass. At the same that liquid ether cools its vapor pressure also decreases, making less molecules available to provide anesthesia. This is a key concern in anesthetic apparatus “vaporizer” design because cooling causes a decrease in the delivered concentration of an anesthetic and so decreases its delivered potency. Hence temperature compensation devices are incorporated in all such apparatus, based on Snow’s scientific evaluation of the effects of temperature on the degree of vaporization (see next).

Leadership in Anaesthesia

97

The next patient however was not. “A youth between seventeen and eighteen years,” completely mistrustful of the goings-on—refused the proffered anesthetic because he had heard that “[Robinson] sent people to sleep and then took out the whole of their teeth.” “The third case was that of a female, between thirteen and fourteen years of age, of a weakly and delicate constitution. She took the vapour readily, in twenty respirations becoming perfectly narcotized, and the first molar of the lower jaw was removed.” But then. “She did not recover her faculties for four minutes and then had headache and oppression.” James Robinson going on to state: “I concluded that more vapour was given than necessary.” And here was the problem. The inconsistency of action of ether. Some patients over anesthetized to dangerous depths, and others only experiencing exhilaration—running screaming from the room never to return. Dr. Robinson and other’s believing that the solution to this problem was but a matter of empirically improving equipment design. While Snow, having experimented with ether back in 1843, as a ‘diapnetic,’ (an inhaled medicine stimulating respiration), realized that the mechanisms of its anesthetic action needed to be clinically and scientifically investigated to be properly understood. Propelling Snow to develop the science of inhalational anesthetics; devising laboratory, animal, self and patient experiments, to better understand the new medical discipline. Creating a body of work where none existed before. Transforming himself from a struggling Soho General Practitioner to the leader of the new field of Anesthesia. In short order—(in the next nine months): Generating and presenting: A Table for Calculating the Strength of Ether Vapour: suspended in the room for all to see at the Westminster Society Meeting of 16 January 1847. Designing his first temperature compensated Ether Inhaler—a coiled metal apparatus consisting of an enclosed circular tin, half-filled with water—added at the appropriate temperature—so that known anesthetic vapor strengths (read off from the Table) could be delivered: first demonstrated at the Westminster Society Meeting, (23 January 1847) and updated in design weekly over the next 3 weeks. Snow next conducts his first anesthetic (of close to 4500) on William Cowen at St George’s Hospital on 28 January 1847. A stout groom who had been thrown from his horse with great violence, the 23-year-old

98

4. John Snow

had developed putrefaction in his leg requiring amputation to save his life. Snow administering ether through his updated device to Cowen as he lay in his hospital bed, placing a mask over his face, pinching his nose, and encouraging him to breath—William rendered insensible in less than three minutes; willing hands hauling him to the foot of the bed (as he was too sick to move to the table) so that Mr. William Cutler could amputate. Cowan regaining consciousness as the last stages of the stump repair was completed, none the wiser and very well pleased: even smiling when addressed by the surgeons, and discharged from the hospital 10 weeks later in good health. (Snow 2006) Next, Snow speaks at the Saturday February 13 meeting of the Westminster Medical Society. (Snow 1847a) First providing: “Observations on the Vapour of Ether,” Snow relates that he administered eight anesthetics in the last week at St George’s Hospital for surgery as varied as fistula-inano and mastectomy for malignancy, and then goes on to describe the many animal experiments he had performed to dispel the notion that the mechanism of anesthesia was due to the accompanying asphyxia caused by the ether vapour displacing oxygen—demonstrating that adding in supplemental oxygen did not reverse the anesthetic state. Nevertheless cautioning that asphyxia too could result in insensibility, with fatal consequences, if not reversed rapidly, and so advised the enraptured Society members that respiration should be carefully monitored—not only to ensure that it had not stopped, but too determine the depth of the anesthetic state: “when completely insensible, the respiration was deep, slow and automatic, but [he cautioned] should never be stertorous—he had never seen it so.” Pointing to his tin-plated apparatus displayed on the table for everyone present to see, Snow explained that he set the water temperature at 780F, allowing the patient to first breathe merely air and then “turned on the etherized air, by degree, by means of a two-way tap, to prevent the irritation its sudden administration occasioned in some persons" and then, when the state of insensibility was fully formed, and the operation commenced, he "turned the tap to dilute the vapour more or less, to keep up the regular state of insensibility, without increasing the effects of ether beyond the necessary degree.” Using the well-honed scientific-investigative skills he had learnt in Medical School to observe clinical conditions and design experiments— Snow had grown his experimental work-space at Frith Street into a scientific laboratory where he devised equipment such as a new resuscitation apparatus (in 1841) to combat the common clinical problem of the stillborn,

Leadership in Anaesthesia

99

breathless, infant (that he came across regularly in his clinical obstetric practice) 8—and conducted animal experiments on an Ark of thrushes, rodents, frogs and fish, that he had collected for the purpose—losing no time in systemically subjecting his mini-zoo to etherization; determining that every sentient being was similarly susceptible to anesthesia (if you gave enough), and that the depressive effects of ether on respiration in humans lay somewhere between that of the bird and the rodent—concluding that ether’s fatal effects in man were thus also likely to be intermediate between avian and rat death. And that: There is a universal but variable susceptibility to anesthesia and that the rate of the effect of a fixed dose of ether was related to the efficiency of breathing and blood circulation—key principles still used today. Demonstrating these to disastrous effect: Invited to give a lecture-demonstration at the United Service Institution in May of 1847; Snow held forth on the subject of ether administration: placing a thrush in a jar filled with 30% ether vapor, while continuing to dispose on the need for careful monitoring. Turning back—the thrush was dead. Embarrassed, Snow exclaimed: “This accident shows the power of the agent” and remonstrated with the audience that ether administration required the doctor’s undivided attention: a dangerous medical practice that could not be left to dentists, druggists or dressers—unskilled as they were in the art and science necessary to its safe administration. June 1847. Snow presents his newest portable ether inhaler: championing the “thick octavo volume sized jappened-tin and plated-copper box”: half of which included a copper coil vaporizer for temperature controlled ether administration, while the other half allowed space for the plastic anesthetic tubing and the thin sheet-lead silk-clad face piece that could be stored therein—for convenient transport from bedside, to operating theatre, to dental office, for ether administration wherever that might prove useful. September 1847. At his own expense, Dr. John Snow publishes: “On the Inhalation of the Vapour of Ether in Surgical Operations: containing a description of the various stages of etherization. (Snow 1847b) Pulling together all the scientific and clinical wisdom he had gathered over the last nine months in one slender 78 page volume, Snow 8

The subject of his first public address; reading the paper “Asphyxia and on the Resuscitation of new-born Children” at the Westminster Medical Society on 16 October 1841.

100

4. John Snow

described his experience with 52 and 23 patients etherized respectively at both the St George’s and University College Hospitals in London, concluding with the assessment that in none of the six fatalities associated with the operations “can the event have been caused, or in any degree promoted, by the inhalation of ether, since there are very sufficient and wellrecognized causes to account for the result.” Attempting to deal conclusively with an abiding concern of the new practice of anesthesia: that it killed. Helpfully, Snow also provided a brief ‘Manual of Etherization’ in the book: a how to guide for practitioners in the field, describing the clinical signs that accompanied the Five Degrees of Narcotism that could be used as way points for determining the depth of ether anesthesia sufficient to avoid pain and awareness from surgery on the one hand, and death on the other, upon administration of 45% ether vapor in air. After 1 min: First Degree: Patients are conscious, co-operative, sometimes experiencing ringing in ears, sometimes exhilaration, and often excessively loquacious: feels pain. After 2 min: Second Degree: often slips through to next (3rd) degree, unless coughing occurs, when: patient performs voluntary functions in disorganized manner, pulling away the applied mask, gesticulating, and sobbing or screaming intervenes: patients can be exhorted to breathe to advance to the next degree. After 3-4 min: Third Degree: patients are unconscious, voluntary actions cease, may slide off chair, eyes stationery (no resistance to being opened), breath holding can occur and at surgical incision; groaning and flinching but no screaming. After 4-5 min: Fourth Degree: muscles limp, unconscious, regular automatic breathing (sometimes snoring) no reaction to pain: pulse full and fast. Snow advised never keeping the patient at this degree for longer than 5 min to avoid: Fifth Degree: (only described in Snow’s terminal animal experiments) Stertorous labored breathing progressing to apnea (cessation of breathing) followed by cardiac arrest. Snow commenting that if the ether was withdrawn from the animal before total apnea, the subject of the experiment would always recover. Interpretation. Clearly, Snow was initially ill equipped to become the leader of the new medical specialty of Anesthesia—given his humble beginnings, introvert nature, and awkward disposition. His adoption of this singular role as the foremost academic anesthetist in Great Britain,

Leadership in Anaesthesia

101

nonetheless, full testament to the fact that leadership can be learnt, and manifests differently in different personalities. Witness how one of his only close friends, Dr. Benjamin Ward Richardson characterized him in a memoir—written just 6 weeks after Snow’s untimely death, and so penned hastily as a preface for Snow's final book: “On Chloroform.” Snow, who was slight of frame and had close set eyes narrowly placed in a vulpine face, was considered of nervous disposition, but was always impeccably, yet modestly dressed. Richardson describing him as being kindly in companionship but reserved in company and with strangers. Lacking magnetism and charisma he was generally judged as somber, and: “laid no claim to eloquence nor had he that gift. A peculiar huskiness of voice, rendered first hearings from him painful” however on the “ear becoming accustomed to this peculiarity, the mind was quickly interested in the matter of his discourse, for he always spoke earnestly, clearly, and to the point.” Richardson going on to opine that Snow was: “Not particularly quick of apprehension, nor ready in invention, [but] he was always kept in the foreground by his indomitable perseverance and determination in following up whatever line of investigation was open to him.” Having determined early in life that he wished to become a renowned doctor, John as a schoolboy, then apprentice, then medical student; developed a talent for synthesizing, organizing and interpreting information as well as asking the right questions to help explain (eventually) one of the scientific riddles of medicine—how anesthetics work. Consider two examples of his investigative techniques: the first, the question of how to prevent apneic deaths of stillborn infants (Snow developed a resuscitation device) and the second, getting to the bottom of whether arsenic used to embalm cadavers or brighten candles could sicken humans; respectively subject matter for his first publication and first presentation at the Westminster Medical Society: both important entrée’s into academic medicine. John was a self-reliant, highly motivated loner, who was somewhat too hot-headed in his youth for his own good. Observe the fire-cracker incident and his first day as an apprentice with Dr. Watson, when he reorganized the practice and threw out the used blisters: The latter anecdote— often told by Snow with relish in later years—serving not only to demonstrate John’s energetic, impetuous nature, but also the organized, fastidious, and painstaking approach he brought to all his endeavors. Snow was highly principled in his approach, was not religious, but, “in his private relations, Dr Snow was a man of the strictest integrity and

102

4. John Snow

purest honor.” “The experiences of life, instead of entwining about him the vices of the world, had weaned him from the world.” Basing his early philosophy of life on John Frank Newton’s Essay: “The Return of Nature: A Defence of the Vegetable Regimen” Snow became a vocal protagonist for the concepts of totalitarianism, veganism, and exercise as the route to health, becoming an iconoclastic public health advocate—persuading through scientific reasoning. He largely eschewed human relationships, having few friends, little to no contact with next-of-kin, did not engage in romantic affairs— remaining a bachelor and leaving no correspondence—in short he was regarded as a serious, reserved, and somewhat discomfited man, who had no time for leisure pursuits (except exercise: he was a strong swimmer) finding all of his fulfilment in the pastime of clinical medicine, research, and teaching; like many a dedicated scientist before him—in pursuit of his ambition to reach the top; living a monkish life except for his professional interactions. 9 However, during the rare times that he did seek others' companionship, he was “full of humorous anecdotes which he told in a quiet, but irresistibly droll style, and when he laughed, his good-natured face, laughed in every feature.” Indicating that he could be empathetic when the situation required this. A self-reliant and highly motivated loner, John picked his way through the travails of medical training with some alacrity after he had secured funding for that purpose from his uncle, the redoubtable Charles Empson. Accumulating quickly the necessary licenses, certificates and degrees to be recognized as an academic—not so much through intellectual brilliance as through sober diligence—he made doubly sure to stay current with academic developments in the medical field and so was suitably primed to identify the major opportunity that the new phenomenon of etherization, in providing painless surgery, afforded. And because of previous studies on respiration, gases, chemical toxicity and resuscitation, recognized the unique pitfalls that the new ether administration might occasion. Having witnessed this for the first time at the invitation of dentist Robinson in the dying days of December, 1846—that seminal event

9

This charmless, drama-free approach, may explain Snow’s failure to kindle, in terms of human interest, the same renown that other equivalent 19th century medical personalities like, Sir Richard Bright, Robert Liston, James Young Simpson, in Great Britain, and, Louis Pasteur and Claude Bernard, in France, generated. Only his science spoke for him, not his public persona.

Leadership in Anaesthesia

103

launching and informing his life’s work and ultimate medical scientific goal, to find: “An anesthetic which might be inhaled with absolute safety, and which would destroy common sensation without destroying consciousness.” †

Chloroform, Cholera, Death, and Public Health There was a very British sentiment emerging against ether. The pungent vapour not only smelled, was nauseating, and explosive, but worst of all: came from America, and had been introduced by an upstart unwashed dentist—William Morton. Not to be out-done, Dr. James Young Simpson, a voluble Scottish Surgeon who had recently taken the Chair of Midwifery at the University of Edinburgh, sought to put matters right. First to administer sulphuric ether for the pain of childbirth—he set about trying to find alternatives, taking suggestions from local chemists. A robust man who liked to eat, Simpson favored dinner parties. Often concluded, much like a desert menu, with suggested chemical compounds inhaled around the table. As these dinner parties were held on Thursdays—often late into the night—a friend, Dr. James Miller, visited Fridays, at breakfast time, to see if all had survived. On 3 November 1847, chloroform was on the after-dinner menu. The guests around the table inhaling deeply from a tumbler. Early Friday, Miller arrived to find Simpson lying under the table surrounded by snoring friends—the next general anesthetic had been found. Wasting no time, Simpson ordered more chloroform be made immediately, and, upon administering over 50 anesthetics in the next few days found ‘chlory’ to be far more favorable than ether: it was quicker in action, non-flammable—in an era when naked candles provided artificial light—cheap, potent, did not give off a sickly lingering smell, nor cause as much vomiting as ether did. And, most importantly, chloroform had been discovered in the Old world rather than the New! Powered by his new discovery, Simpson, an opinionated fiery orator and crusader, promoted chloroform relentlessly—presenting his findings a week later at the first winter meeting of Edinburgh’s MedicoChirugical Society with a talk entitled: "A New Anaesthetic Agent, More Efficient than Sulphuric Ether." Championing the many advantages that perchloride of formyle had—little knowing at the time what a killer it would become. (Greene 1975, Simpson 1847, Mets 2018)

104

4. John Snow

Upon hearing of the new agent, and after trying it on himself and experimenting on a few choice animals from his laboratory, Snow made his way to St Georges’ hospital, portable ether inhaler under his arm, to administer his first chloroform anesthetic. Believing that Simpson’s method of pouring a teaspoonful of chloroform on to a handkerchief to induce anesthesia was unsafe—because unpredictable toxic concentrations might be administered—he had worked out the precise water temperature (55 0F) needed in the ether inhaler to ensure predictable chloroform anesthesia— which he successfully delivered: Dr. Tatum performing a total mastectomy on November 18, 1847. Thrilled with the convenience of chloroform, and feeling no more wretched after self-inhalation to unconsciousness with the new vapor than he had experienced after ether; Snow expounded on the virtues of the “new letheon agent” at the very next meeting of the Westminster Medical Society two days later. Putting the full weight of his now considerable reputation on matters of anesthesia behind chloroform, despite his recently published book: "On the Inhalation of the Vapour of Ether," 10 and going on to abandon etherization altogether in favor of chloroformism. Hence the news of the first death from chloroform—just ten weeks later—proved a public relations nightmare for Drs. Simpson and Snow; the anesthetic’s outspoken champions—more especially because Hannah Greener had died from chloroform after having received a previous anesthetic safely with the now vilified ether! Reacting defensively to this first reported death from chloroform, both Simpson and Snow did what they knew best—they provided scientific and academic opinions on the probable cause of death at scientific meetings, public gatherings, and through the weekly medical publications they both favored. The Lancet and the London Medical Gazette. Professor Simpson postulating—taking in to account the autopsy findings—that asphyxia was the cause of Hannah’s untimely demise (not chloroform) and Dr. Snow— that the method of chloroform administration by Dr. Meggison—using a hanky—led to an inadvertent overdose: the Fourth Degree of anesthesia progressing to the Fifth Degree—death. Both advising all that would listen that there needed to be a much better scientific and clinical understanding of chloroform anesthesia: its mechanisms of action and toxicity; safe ways of reliable and predictable administration through equipment design; and a fuller understanding of how and why patients were being killed by chloroform administration—in order to identify how they could be avoided. 10

Probably explaining why he only sold 126 copies.

Leadership in Anaesthesia

105

Snow endeavoring to study the matter thoroughly, look for possible alternative agents, and collect case histories of the anesthetics he delivered, while subjecting all the chloroform mortality reports he collected to a thorough analysis to ascertain the cause of death (Snow had collected 13 by the end of 1848 and would analyze 50 in total by 1857.) Embraced by the Editor of the London Medical Gazette for his erudition and concise writing, Snow was asked to provide a series of eighteen articles "On Narcotism by the Inhalation of Vapors" on the instalment plan. At a time when readership waited anxiously for the next installment of Charles Dicken's David Copperfield (in the newspaper or as a pamphlet), Snow’s approach of providing piecemeal reports describing his researches on chloroform and other putative chemicals that might produce anesthesia, was well accepted by the public and medical fraternity—hungry to learn of new developments in science and medicine. Snow going on to publish the eighteen articles on his clinical and research findings on the subject of anesthetics (with chloroform and other agents) over a period of three-and-one-half years starting in May 1848—not three months after Hannah Greener’s death. (Snow 1991) Informing his investigations and scholarly series of articles— Snow was quick to recognize that both ether and chloroform were likely part of a ‘family’ of similar chemical compounds that could be used to provide the medical miracle of anesthesia, and so embarked on a quest to find the ‘perfect’ anesthetic by looking for alternatives while continuing to study chloroform in his clinical practice and laboratory. Snow being fulsome in the knowledge that these drugs came from a series of potentially toxic compounds that might well be injurious to both him and his menagerie of precious animals; he proceeded with some caution but probably sickened himself when he tried benzene and bisulphuret-of-carbon self-inhalation: both causing convulsions and twitching in the mice and sparrows he studied—before inducing anesthesia to the fourth degree—slipping into the fifth—and concluding in the animal's death. Bromoform, Bromide-of-Ethyl and Dutch Liquid were toxic too: although providing animal anesthesia reliably; they killed with monotonous regularity—lung damage the problem identified at autopsy of a mouse subjected to the Dutch Liquid. (Snow had self-inhaled all of these agents too.) Chloroform also killed animals in Snow’s experimental laboratory. The mechanism of death closely studied in animals and humans for years to come following Hannah Greener’s untimely death: Snow collecting 50 patient case histories, for eventual publication in the book: "On Chloroform and Other Anaesthetics" cataloguing exhaustive details from autopsy

106

4. John Snow

findings, adding in his own interpretations of animal and laboratory experiments, and drawing on his rich patient case histories—all pulled together to explain the mechanism of chloroform’s lethality in man: starting with Hannah’s case in 1847, and concluding with Ann Stoner’s case in 1857: aged 17—she suffered from syphilitic warts requiring nitric acid fulguration under chloroform anesthesia, which would prove to be the death of her. Believing that the cause of death was invariably due to inadvertent overdose through inept, imprecise, chloroform administration (many doctors continuing to use sponges, lint, or handkerchiefs doused with liberal quantities of chloroform), Snow designed a new chloroform inhaler which—again—cleverly allowed for temperature regulation: the outer case surrounding the chloroform chamber filled with water heated to the desired temperature. The subsequent installment of: "On Narcotism by the Inhalation of Vapours (VIII)" describing “the conditions of the patient which influence the action of chloroform” Snow positing “that I know of no state of the patient, with respect to age, constitution, or disease, which positively contraindicates the use of it.” While further installments described planned anesthetic approaches for all manner of surgical operations: mastectomy, fistulectomy, amputation, as well as a description of postoperative sequelae: headache, hysteria, sickness; in short, an exhaustive evaluation of chloroform anesthesia and its propensity to kill. Comparing it with ether in several later installments, Snow was asked to opine on the two anesthetic agents relative safety at his favorite occasion: Saturday Night’s Westminster Royal Society Meeting. Which in his considered opinion was safer: Ether or Chloroform? “Ether” was the reply. And….. under the fire of cross examination, Snow was asked: “Well then why do you not use ether?” “I use chloroform, for the same reason you use phosphorous matches instead of the tinder box. An occasional risk never stands in the way of ready applicability.” (Richardson 1858) Interpretation. Snow’s complete turn-around from being a therapeutic skeptic—a doctor who thought that the body could cure itself needing no intervention—to a strong protagonist for, and purveyor of, potentially lethal anesthetic drugs to free patients from the agony of surgery, can be understood through the lens of efficacy. The practice of anesthesia being most seductive (and potentially lucrative) because it was effective:

Leadership in Anaesthesia

107

you administered chloroform, an operation was performed painlessly, and the patient recovered—usually. Contrast this with the empirical medical practice of the day. The patient more than often healing themselves (or not) as there were but few useful plant-derived drugs like digoxin (foxglove), morphine (poppy seed), salicylic acid (willow-bark), quinine (cinchona) and various heavy metals such as chalk, iron, mercury and arsenic available to the practicing doctor that might 11 be used to improve health. Unfortunate then that anesthetics, while effective, sometimes ended up killing the patient in the process. Ether was actually much safer than chloroform: it stimulated respiration and the heart, while chloroform depressed them. Chloroform was also much more potent—about ten times. Ether was administered at 4050% concentration; Chloroform at 4-5%. There were also comparatively few ether deaths when compared to the abundant chloroform deaths—usually from inadvertent overdose, commonly caused by inept, uncontrolled, administration—using less than satisfactory anesthetic techniques. But what killed Hannah Greener was not an overdose. She died from ventricular fibrillation under light anesthesia. Chloroform sensitizing Hannah’s heart to the overwhelming burst of adrenaline that flooded her blood stream when the very painful incision was made in her big toe: the anesthetic not yet deep enough to suppress this acute pain response. Neither Simpson nor Snow were to know this; Snow believing simply that chloroform paralyzed the heart, but not knowing the mechanism of its paralysis. 12 Nevertheless, the influential Simpson and the iconoclastic Snow failed to recognize the deadly chloroform for what it was—falling into the trap of many a scientist and medical man before, and after them, who had the ambition to make history—having attached their name to a new finding. Snow further persuaded by his own expertise—because in his proficient hands, chloroform was indeed perfectly safe: he had only one death in 4500 documented cases.

11

Mercury and arsenic were popular to treat syphilis but probably did more harm than good in an era when antibiotics had not yet been discovered. 12 Ventricular fibrillation is a condition where uncoordinated, disorganized, electrical discharges migrate across the heart muscle which fails to beat effectively and so paralyses the heart. This effect of chloroform, from excessive adrenalin release under light anesthesia, was first demonstrated in cat experiments, in 1911, by Dr. Alfred Goodman Levy: chloroform sensitizing the heart’s nervous conduction system.

108

4. John Snow

Nonetheless embarking on a quest to identify alternative agents (often through self-experimentation which proved injurious to his failing health) in order to better describe and explain anesthesia and its principles for safe administration to the medical fraternity ever hungry to be persuaded about the new science of anesthesia. It is now necessary to do a sidebar on Snow’s deteriorating health—aided and abetted by his self-imposed grueling work habits, his penchant for testing promising chemicals on himself, and his fearless investigation of infectious diseases like cholera. On arriving in London to become a Medical Student, his colleague, Joshua Parson had noted that John’s “constitutional powers” had been “impaired” attributing this to veganism; but on observing numerous episodes of feverish ague, and the fact that Snow was often “subject to great drowsiness” (despite being a teetotaler) which caused him to turn in at night much earlier than he would have liked (limiting the amount of time he had for writing and experimentation); Parson referred him to a doctor who diagnosed “pthisis pulmonalis”—tuberculosis of the lungs. Tuberculosis “the captain of death” of the time—for which there was no treatment except “rest and fresh air”—can spread beyond the lungs to other organs, grumble along insidiously, and was probably the indirect cause of Snow’s early death. Struggling along nonetheless, his work-load ever increasing, Snow became severely ill in the stifling summer of 1845, with “acute and alarming symptoms of renal disorder” for which he was referred to Dr. Richard Bright, an expert on the kidney. Bright persuading him to look after his health better by supplementing his veganism with a more robust meat diet, and the occasional glass of wine. Suggesting a vacation; Snow spent a week with the now Doctor, Joshua Parson, in Somerset; curtailing his only recorded holiday to return to his busy schedule back in London. †

Cholera There was another killer in Town. The second Cholera epidemic of 1849. Snow taking time away from his chloroform studies and London Medical Gazette installments to investigate the returned plague that he had first witnessed at Killingsworth in 1831, as an apprentice. Thought to be spread either by ‘Miasmic’ air—exhaled by dying patients or emanating from the rotting organic material rampant in London’s knackers or bone-boilers yards; or after contact with patients' fomites—

Leadership in Anaesthesia

109

diarrhea stained bedsheets, or clothes drenched by rice-water stools (the signature feature of the disease). Additional theories abounded: The ‘Contingent Contagion’ theory: cholera spreading by direct contact with the patient to individuals rendered susceptible by changes in weather, debilitating illness, or resident in ‘hovels’—at close quarters in crowded filthy unventilated conditions. And the ‘Infection’ theory: cholera transmitted through inhalation of volatilized ‘viruses’ (animalcules) emanating from diseased victims' bodies causing the terrible sickness when inhaled via the lungs. Waterborne spread, the actual mechanism of transmission, little talked about at the time, until dramatically demonstrated by Snow in the third cholera epidemic of 1854—to which we now jump to in order to demonstrate John’s leadership in the second field of scientific medicine that he founded: Epidemiology—in furtherance of improving Public Health. A nascent aspect of medicine that he had championed since his “teetotal address” at Patley Bridge in 1836; Snow was unwittingly (or perhaps wittingly), protected for his public health investigation into the causes of cholera, by his life-long resolve to drink only double-distilled pure water. And sparingly.

Death Sarah Lewis’s five-month old daughter was not doing well. Sickly from birth, Sarah had cleaned her little daughter’s bottom multiple times: the foul, reeking, rice-water like stools, soiling her bed sheets—which her mom had wrung out repeatedly; dumping the filthy water into the cesspool positioned at the back of the house at 40 Broad Street. A well-known address, because the Broad Street Pump that provisioned the neighborhood with water stood right next to the busy Public House, next door. 13 Sarah and her policeman husband, Thomas, often hearing the noisy clientele above them, at street level, as they sang songs in the pub or drew water from the pump supplied by the deep well adjacent to the wall of their underground apartment. Little knowing that their apartment cesspool drain had been “mis-constructed”—meant to drain into the under-street sewage system; instead, the cesspool and sewage backed up; leaching choleric excrement through the brick lining of the well which fed the Broad Street Pump. Dr. William Rogers, who had been attending multiple victims of the cholera epidemic in Soho, was especially worried about Sarah’s 13

The current sight of the John Snow Publican House. A great place to visit.

110

4. John Snow

daughter; visiting her daily as she deteriorated: listless, but vomiting intermittently, she died at 11 am: Saturday 2 September 1854, two days after her upstairs neighbor Mr. G, the tailor, had succumbed—fellow victims of the great outbreak of cholera around Golden Square, “the angel of death having spread his wings over the place” a yellow flag was hoisted to warn all—dead carts wheeling away bodies afflicted by the dread disease; killing 89 that week alone in Soho’s section of London. A year earlier, Snow, who had moved his residence from Soho to Piccadilly, and continued his busy anesthetic practice, had embarked on a series of exhaustive investigations into the origins of cholera—the killer that had inflicted such calamity throughout London—focusing especially on Southwark where four thousand had died—“being nearly eight to each thousands of inhabitants.” Snow, a pioneer of “disease mapping” pointing the finger at the polluted river Thames running through the center of London. Serving not only as the source of the great city’s water supply, but also as its sewage disposal system. Snow blamed Edwin Chadwick for the debacle. Barrister Chadwick, who was responsible for the Public Health Act of 1848, had been charged with sanitary reform on behalf of the poor and, hoping to clear the befouled streets of fecal matter and decomposing offal generated by the “Offensive Trades” of bone grinders, tanners and slaughterhouses, had directed that the capital’s excrement filled streets, byways, cesspools, stinking water closets, and piped sewage be discharged into the river: the Thames becoming both London’s sewer and water supply—often reeking to high heaven as a consequence, and known as the most polluted river in the world. To understand Snow’s crucial role in combatting the killer cholera in this third epidemic (1854), we must briefly return to England’s second. Where, in 1849, John slowed his investigations of chloroform, to hurriedly complete a published monograph on his public health findings entitled: "On the Mode of the Communication of Cholera,"—Snow centering his research in Horsley Down, Southwark, just south of the Thames, close to London Bridge, where the outbreak had started. Pointing to water as the likely source of transmission and John Harnold as the cause of the eruption. Newly arrived from cholera infested Hamburg on the ship Elbe, Harnold took lodgings at No 8. New Lane, Gainsford Street; dying from the disease a few days later.

Leadership in Anaesthesia

111

Dr. Russel attending to both Harnold and the next lodger: Mr.Blenkinsopp, noting that he subsequently contracted the fatal disease, having slept in the same bed and room where the fastidious doctor had treated both victims. Blenkinsopp dying eight days later after considerable vomiting and diarrhea—the vomitus and excrement, not soaked up by the bed-clothes, tipped into a slop bucket, bedside, and then emptied into the open sewer running outside. Snow noting how cholera then spread throughout Horsley Down from house to home—the next victims sickening three days later in homes “having no apparent connection with it, except that an open sewer, up which the tide flows, runs past both places, and the sewage from the houses in the first neighborhood is, when the tide rises, carried past those in the second.” (Snow 1849) Snow pointing out that cholera spread primarily through water and largely as a result of lack of hygiene. He exhorted people to wash their hands and that “everybody avoid drinking and using for culinary purposes water into which drains and sewer empty themselves” and that the “metropolis” needed a supply of water from “some source quite removed from the sewers”—referring to the fact that London’s water supply companies used as their source the polluted River Thames—lamenting that he did not have further time to investigate cholera as he was “preoccupied with another subject.” Chloroform! Going on to found the Epidemiological Society in 1850, 14 Snow continued his research on cholera (and chloroform), not too discouraged by the fact that this first monograph had not been well received; the necessary experiment crucis to prove cholera was waterborne was lacking—the monograph reviewers airing that this singular conclusive experiment still needed to be performed: to demonstrate that newly contaminated water from a source previously free of cholera, produced the disease in those consuming the water, while those who didn’t, escaped. Preparing to become the “Orator” of the London Medical Society 15 for 1853—a sure-fire path to the Presidency of 1855—Snow spent a year gathering his thoughts, writings, and epidemiological case studies for the Oration entitled: "Continuous Molecular Changes, More Particularly in Their Relation to the Epidemic Diseases." Delivered at the Thatched House Tavern on St James’s Street, on the occasion of the Society’s 80th Anniversary, John expostulated on the 14

and President in 1857. The Westminster Medical Society merged with the London Society of Medicine taking its name in 1850. 15

112

4. John Snow

nature of the transmission of contagious diseases of the time, witnessing agues like: yellow fever, small-pox, measles, syphilis and cholera, he wondered out loud on the nature of epidemics: diseases communicated from individual to individual, asking why they had variable prevalence and why they were held in check or not—spreading rapidly out of control? Contrasting syphilis with cholera for good measure. Syphilis, a disease well known for its route of transmission, “keeps a pretty even course in this metropolis, because there is a steady amount of vice for its support and a still greater amount of virtue to keep it in check.” (Snow 1853a) While cholera’s means of transmission was the subject of debate. The world having already been visited by two devastating epidemics, it was clear to Snow (if no-one else) that transmission was by the feco-oral route: “outbreaks were in many cases due to the mixture of the cholera-evacuations with the water used for drinking and preparing food.” Wishing not to take too extreme a position on cholera (he was politicking for the presidency—after all) he railed against the Miasma Theory of contagion, favoring waterborne transmission but, guardedly, admitted that dried excrement particles from infected victims could “waft a short distance through the air, like the seeds and spores of many plants.” This Oration serving Snow well. The extensive preparation required for such a major speech, priming Snow’s mind for the experimenta crucis that had been suggested back in 1849, while at the same time marking him as a heavy-weight contender on the subject of Contagious Diseases and elevating him to the upper ranks of London’s Medical hierarchy and Royal Circles: Snow summoned to Buckingham Palace to anesthetize Queen Victoria two weeks later. 16 Hence when the Third Cholera epidemic was visited on South London in the spring of 1854—Snow was ready. Readied by his new found thinking and the extensive knowledge built up during his previous investigations of the major water supply companies that had fed the outbreak in Southwark in 1849: The Lambeth Water Company and the Southwark & Vauxhall Water Company. Both drawing their water from the stinking Thames—Snow, furnished with government death-registration data, and upon conducting many personal interviews of inhabitants, painstakingly mapped the outbreak there: demonstrating beyond reasonable doubt that the mortality from cholera was far higher in the South Districts of London—numbering some four thousand—than the East Districts— numbering sixteen hundred: the latter district supplied by the East London 16

To be described later.

Leadership in Anaesthesia

113

Water Company which drew its water from the River Lea far beyond the tide of the polluting River Thames. Embarking on a new investigation in the South of London, armed with the knowledge that through an Act of Parliament, 17 the Lambeth Water Company had been forced to change the source of its water supply from the polluted Thames in London (near Hungerford bridge), to a section of the Thames that was twelve miles outside the city limits (at Ditton)—well beyond the tide, and so out of reach of the sewage of the metropolis. Garnering the support of Dr. William Farr the keeper of statistics at the General Registrar’s Office for his research efforts—this second study investigated whether the change in water supply could translate into improved choleretic mortality of the 300,000-populace supplied by the two companies. Determining the relative death-rates from each company was not an easy matter however; many inhabitants were not sure who supplied their water, and often the water pipes leading to their houses were connected at random to the different suppliers; residents none-the-wiser as to the water’s origin. Nevertheless, Farr and Snow could demonstrate that the districts of Southwark which were partly supplied by the Lambeth Water Company had a lower mortality from cholera than those supplied completely by the Southwark & Vauxhall Water Company, drawing its water from the sewage laden Thames; supporting Snow’s contention that cholera was likely waterborne and not Miasmic in transmission. Reporting their findings November 26, 1854. Realizing that this was not incontrovertible proof that cholera was waterborne, and, because he still required his experiment cruce—and upon hearing of Soho’s recent outbreak around Golden Square; Snow immediately theorized that the Broad Street Pump was the source— contriving once and for all to demonstrate cholera’s mode of transmission. Hastening to test the water drawn from the pump, he subjected it to a chemical and microscopic test. Confirming a large quantity of chloride, organic matter, and ‘animalcules,’—John became convinced of the source of the problem and then systematically went from house to house to investigate the matter. But Snow was not the only one to visit Broad Street to scrutinize the problem.

17 Informed by the Medical Officer of the General Board of Health to improve “Impure Water” provision.

114

4. John Snow

Sir Benjamin Hall 18 did too (important to Snow’s later public hearings). Newly appointed as the President of the General Board of Health replacing Edwin Chadwick in the role, ‘Big Ben’ was also a member of Parliament and so was touring the Northern London area to establish what “sanitary and preventive measures” had been taken to deal with the new site of the cholera epidemic north of the Thames River. Tallying the 89 cholera deaths claimed from the General Registrar's Office, Snow set out on a ‘shoe-leather epidemiologic’ quest to resolve the issue. This would be the experiment cruce he had hoped for. A chance to probe his theory that the cholera contaminated Broad Street Pump was the source of the high death rate. Furnished with a list of house addresses of each cholera victim, Snow returned to Broad Street, going from house to house to enquire where inhabitants got their drinking water. Ascertaining that fully seventy of the dead had drawn water from the Broad Street Pump; he announced that there “had been no particular outbreak or prevalence of Cholera in this part of London except among the persons who were in the habit of drinking the water” drawn from the pump's well. Citing too, and most importantly, the discriminating fact that the workers of the Lion Brewery—right across the street from the Public House—remained unaffected by cholera, because they drank solely ale on the job, which was made with water sourced from a different well altogether than that tapped from the Broad Street Pump, athwart the road. Asked to present his findings at an emergency meeting of the Board of Governors and Directors of the Poor for St James Parish (Soho)— Snow presented a summary of his investigation so far. The emergency committee recommending that the handle be removed from the Broad Street Pump—the order carried out the very next day; the tide of cholera deaths, already peaked and in remission, improving still further from the pump handle removal. And Snow had his experiment cruce: publishing a few months later the totality of his cholera findings in the comprehensively updated second edition of: "On the Mode of the Communication of Cholera" (1855). Interpretation. Cholera is a highly infectious disease caused by the bacteria vibrio cholera transmitted by the feco-oral route and only fully identified in 1883. Carried in contaminated water, excrement or vomitus, the bacteria attaches itself to the intestinal mucosa causing inflammation and extreme nausea, copious vomiting, and horrendous diarrhea—killing the patient through dehydration; called a ‘blue-death’ because of the patient's gaunt 18

Namesake of “Big Ben” the famous clock tower of the Houses of Parliament.

Leadership in Anaesthesia

115

look. 19 Effectively treated with intravenous fluids and antibiotic therapy today, the Asiatic form arrived in Europe from India in 1820, moving westwards, killing hundreds of thousands of people in its wake. Three epidemics occurred in Great Britain—1831,1849 and 1854—John Snow experiencing them as an apprentice and a highly trained consultant physician: doggedly using science and education to turn the tide of thinking from a miasma based, to the waterborne theory of transmission. His imprecations only starting to gain credence in 1854; and not fully accepted for many years beyond his death in 1858. One of the first to develop disease mapping as an epidemiologic tool to establish cholera’s mode of transmission, and render public health warnings based on his research—wash hands, purify water, decontaminate food—Snow is regarded as one of the founding fathers of epidemiology; in bringing to bear scientific principles to the study of the deadly disease. Cholera’s transmission an open question at the time. A void of knowledge filled with superstition, misinformation, misunderstanding, and an undercurrent amongst the poor; that the rich were visiting the dread disease on the poverty stricken, as a means of extermination. The scared populace summoning—the atmosphere, climate change, bad air in the form of miasmic effluents from Offensive Trades or putrid exhalations form patients, electricity, or, as cholera originated in India: the intemperate use of rank fish and bad rice—as the source of cholera transmission causing the dreadful, blue death. In this toxic mix, the quiet but persistent Snow made his mark. First as an untrained apprentice and then as a highly trained doctor and scientist, applying scientific methodology to resolve the important question: his own health never a consideration in the quest for a solution to the problem. “No one but those who knew him intimately can conceive how he labored, at what cost and at what risk. Wherever cholera was visitant, there was he in the midst.” (Richardson 1858)

Chloroform Snow was uncharacteristically tense about his patient. She was overweight, had what looked like a ‘difficult airway’—and was the Queen. Queen Victoria in labor with her eighth child. Summoned to Buckingham Palace by her husband, Prince Albert, who had taken a keen scientific interest in the practice of anesthesia, John 19

The author suffered cholera infantum as a one-year old child in Indonesia. Treated by his father, a doctor, he fortunately survived because of intravenous fluid therapy and a blood transfusion.

116

4. John Snow

was told to wait outside in an ante-room where he could hear Victoria groaning with the excruciating pain of labor. (Victoria thought pregnancy ‘wretched’ but her minders had cautioned against anesthesia because of Hannah Greener’s untimely death.) But now she had had enough and called for Snow. Who stood nervously outside. Uneased even further because yet another chloroform death had occurred—just a few days ago—at University College Hospital. But the opportunity to show-case anesthesia—despite the attendant risk, out-weighed all else. And, of course, he had been summoned—by the Queen! Called into the bedroom, with her personal physician Sir James Clark, Prince Albert, and Mrs. Lilly her midwife standing by; Snow calmly measured out one milliliter of pure chloroform on his coned handkerchief and pressed it lightly to the Royal Face. In her second stage of labor, her cervix fully dilated to allow the passage of a princely head, Victoria pushed and breathed in the “blessed chloroform” and bore down hard; quickly delivering Leopold into the world. Rapid expulsion of the placenta followed without too much bleeding, and “in a very few minutes… the Queen appeared very cheerful and well, expressing herself much gratified with the effect of the chloroform.” (Snow 1853b) Born after midnight on 7 April 1853, the Royal Birth was celebrated the same day—church bells ringing, newspapers announcing, and fireworks exploding over the River Thames—heralding the glad tidings to London; yet there was no mention of John Snow or chloroform. That seminal contribution took a few more days to unfold—a firestorm of polemic unleashed in the lay and medical press: the papers believing its use for labor pain to be anti-biblical; while the Lancet admonished Snow for his use of chloroform for Prince Leopold’s birth, as being far too risky to sanction. But fortunately in stark contrast, the Association Medical Journal came to Snow’s and the Royal Obstetrician’s rescue—arguing that insufficient chloroform was administered to risk the Royal Life—but just enough to still the pain of child birth. Queen Victoria having the final word. Writing in her diary 20 about her positive labor experience: I received that “Blessed chloroform, soothing, quieting and delightful beyond measure.” 20

April 22nd 1853.

Leadership in Anaesthesia

117

Sanctioning chloroform’s use for childbirth and providing a Royal Blessing. And after the Archbishop of Canterbury’s daughter had received Snow’s chloroform for her confinement that Autumn—the anesthetic agent received the Churches' Blessing as well; paving the way for the general acceptance of chloroform for pain relief from child-birth that James Young Simpson had controversially championed six years earlier. Popularized as ‘chloroform a la reign’—Queen Victoria’s Blessing added her Royal support to that of many other well-known figures of the time: Charles Darwin and Dickens’ wives—Emma and Kate—both having been beneficiaries of chloroform anesthesia to lessen birth pain for their, coincidentally, eighth childrens' births. A hattrick! Still. Despite the Queen, the Archbishop, and many other well-known figures being enamored of chloroform; not all were; Royal subjects and church goers alike fearing chloroform’s dark-side—afraid of its abuse to commit crimes—popularly known as Chlorophobia.

Chlorophobia Frederick Jewett, a solicitor of panicky disposition, proceeded haltingly along Whitechapel Road. Hoping to catch the 10 p.m. omnibus to his private residence, he could see the horse driven carriage dimly in the distance; the street lamps barely lighting the cobble-stoned road ahead. A woman touched him on his left side as he felt a handkerchief pressed over the lower part of his face. Then nothing. Margaret applying further chloroform while she helped Elizabeth drag their stumbling mark, forcibly, along the muddied road to their low lodging-house in Spitalfields. A matter of a few hundred yards, Higgins and Smith were determined to see this through. Two women of notorious character, they had learnt of chloroform’s power to overwhelm, because Higgin’s boyfriend had received the anesthetic for a recent operation; and managed to pilfer some for the planned robbery. Regaining consciousness the next day in the abandoned room on Thrale Street, Jewett was dismayed to find himself lying naked on a wretched bed, but for a rag cast carelessly across his loins; he was be-stolen of his greatcoat, hat, boots and precious jewelry—finding only his mudspattered trousers hanging over the back of a chair. Margaret Higgins and Elizabeth Smith meeting timely justice: soon after apprehended by the police, the two robbers “were subsequently

118

4. John Snow

tried, convicted, and sentenced to be transported [to Australia] for fifteen years.” The Annual Register reporting breezily on the crime: “Robberies by means of chloroform, or some other drug even more powerful, have become frequent of late.” (Office 1850) Chlorophobia, the fear of chloroform, enveloping the Victorian mind. Not only because of the much-publicized dread of death during anesthesia, but increasingly because of chloroform’s dark side: it’s addictive potential, and its use to commit crime through chloroform induced unconsciousness. Used to rape, rob, or capture; chloroform was used for worse still, to kill: to assassinate, or to commit suicide. Matters coming to a head, in 1851, when the newly appointed Lord Campbell—the chief justice of the Court of the Queen’s Bench—wanted to criminalize the use of chloroform when used for nefarious purposes; proposing an Act for the Better Prevention of Offences, that Snow would bitterly oppose—bringing to bear well-founded scientific arguments to the contrary, in his ongoing crusade as a public health advocate.

Public Health Advocate It is now time to pull together the threads of John Snow’s substantive foray into public health and the important polemics that he surfaced and promoted in the cause of improving London's communal wellbeing. Starting with his advocacy for teetotalism, Snow progressed to the great debate on anesthesia with chloroform; the hullabaloo around chlorophobia; the denunciations over cholera’s origins and its mode of transmission; and advanced to the invective around the Public Nuisance Trades. Much maligned by Miasmists and criticized by Chlorophobists, Snow courted and countered controversy at every turn; despite being of an exceedingly quiet and retiring nature.

Veganism and Teetotalism Having read John Frank Newton’s Essay “The Return of Nature: A Defence of the Vegetable Regimen” at the impressionable age of seventeen; Snow stepped on to the public soap-box early in his career— delivering his Patley Bridge address on Teetotalism to support his efforts at improving public health; he learned how to best advocate for the newly

Leadership in Anaesthesia

119

developing medical science that he would become one of the founding fathers of; becoming the President of the Epidemiological Society in 1857.

Anesthesia & Chloroform The adoption of anesthesia to relieve the pain from surgery, as accepted practice, was far from a done deal, when Snow and others took on the challenge of investigating and promoting the subject. Even Dr. Robert Liston who had first demonstrated ether’s use in England for Frederick Churchill’s very public amputation on 21 December 1846 had despaired of its use. His and other surgeons' interest flagging because the surgical anesthesia envisioned was increasingly being unreliably produced by unskilled practitioners who used unrefined techniques—lint, hanky, sponge—or rough and ready equipment— glassware, tubing, lead-sheeting—and so failed to provide adequate anesthesia for the planned surgery. Not only often resulting in failure, but sometimes death; caused by the variability and inexact concentrations of anesthetic delivered to render the patients unconscious. And then there was the furious debate—stretching across the Atlantic from Boston to London and Edinburgh—about anesthesia’s safety and utility. Was the outcome from surgery worsened or bettered by the application of anesthesia and should the pain from surgery or child-birth even be stilled? Or was pain just the natural order of things, and indeed, did that pain offer protection from the surgical insult visited on the body? And did interruption of this process, using anesthesia, kill the patient, instead? Morton, Snow and Simpson, advocating for the use of anesthesia while many others contrived against it. Snow’s special contribution to this advocacy was the wealth of scientific study he brought to the table; translated into a welter of books, lectures, case-books, peer-reviewed publications, pamphlets and public presentations to teach all who would read, or listen, the principles and practice of ether and chloroform anesthesia; striving to make these two drugs ever more reliable in their anesthetic effects, and safer to administer. Snow rising to become the President of the London Medical Society, in part, as a result of these efforts.

120

4. John Snow

Act for the Better Prevention of Offences Ever an advocate for chloroform (despite knowing that it was not as safe as ether) and desirous of calming nerves frayed by chlorophobia, Snow sought to combat the rank and file's misconceptions, by countering these with copious scientific writing and persuasive public advocacy using science to persuade and educate the populace. Responding in opposition to the newly planned Act on “Better Prevention of Offences” which sought to treat as a felony any crime committed with chloroform (punishable by seven years of deportation), Snow countered stubbornly in the scientific and lay press. Describing Solicitor Frederick Jewett’s robbery at the hands of the willful Higgins and Smith by applying chloroform to render him insensible as improbable, because the idea that a single whiff could fell a man (not already inebriated), was not borne out by his scientific evaluation of the subject—in animal and clinical investigations. Understanding well that the potency of chloroform used for anesthesia had propelled the urban myth that chloroform could be used for such crimes; he sought to allay such anxieties with the facts: Chloroform was extremely pungent and uniquely recognizable. Chloroform could only be given with the patient’s consent or by force (no animal could be anesthetized without restraining them). Chloroform did not work instantaneously: the idea of “one whiff” being untrue. Snow offering too, that it was likely that those who found themselves in compromising circumstances (he did not mention the Solicitor specifically) might use over-powering by chloroform as a convenient excuse for their desperate situation, having already been partially incapacitated by alcohol: prior inebriation enabled chloroform’s use to perpetrate a crime (when it was likely to have an immediate effect). (Snow 1850) So, seeking to inveigle against Lord Campbell’s Act, with a very public letter published in all the best papers, Snow might have been able to convince and calm many of Her Majesty’s Subjects on the subject of chlorophobia, but not the Lords of Parliament: The Act was retained and spelled out the consequences of conviction for a crime conducted with chloroform clearly: the perpetrator considered to “be guilty of a felony, and liable to be transported across the seas.” The Act going on to pass efficiently in Parliament; Lord Campbell hoping to crackdown on crime in advance of London’s Great Exhibition of 1851. (Vinten-Johansen et al. 2003)

Leadership in Anaesthesia

121

Nuisances Removal and Disease Prevention Act In 1854 Sir Benjamin Hall became president of the Board of Health of London. Put in charge of ‘Sanitary Reform,” Big Ben set out to regulate industries that polluted the metropolis—the so-called “Offensive Trades”— such as slaughter houses, tanneries and bone-boiling works, believed to be the source of odiferous miasma’s that visited contagious diseases on London’s long-suffering populace. Hoping to close them down and remove them from the city streets. The public believing that anything that stank must spread illness; miasmic effluvia emanating from the decomposing organic matter dumped in the streets that was the stock in trade of such industries—sickening many that inhaled too deeply and were subjected to the stench. Entreated by purveyors of the so-threatened Offensive Trades— tallow chandlers, gas-spinners, soap boilers—as an expert medical man to persuade a Select Committee on Public Health seated to adjudicate the “Nuisances Removal and Disease Prevention Act,” Snow was brought as a professional witness to testify at the Houses of Parliament on 5 March 1855. Fresh from delivering three successful anesthetics—dental extraction, bone extirpation, lithotripsy—in the morning; Snow was suitably energized for the afternoon debate with Sir Benjamin—the leading Miasmatist of the time—arguing (based on his extensive scientific evaluations of gas laws, air mixtures, cholera and anesthetics) that although the Offensive Trades might affront nasal sensibilities, the emanations could not cause illness in the general population if the carcass renderers themselves were not sickened. Positing that although he believed that epidemic diseases (like cholera) were propagated by special poisons which could be transmitted from one human to another; decomposing horse flesh, no matter the stink, was “not prejudicial to the health of the inhabitants around.” Snow going on to point out that given that Barrister Edwin Chadwick’s assertion that “all smell is disease,” was not based in scientific fact; he felt strongly that the Committee should not bring legal action against the Offensive Trades by calling them “pestiferous”—in so doing dragging in false science to prosecute their case. Instead the Committee should use ordinary law to declare them a nuisance (which indeed they were) in seeking their banishment from the center of the metropolis. Supporting his contention that only solid, and not bogus science should be brought into consideration—which would show that specific poisons caused specific diseases, while random foul-smelling Miasmic emanations did not.

122

4. John Snow

Unsurprisingly, much of the niceties of Snow’s close scientific arguments were quickly debunked by special interests; Snow drawn and quartered for his scientific disposition of the facts: the public and scientific press laying into him, upbraiding his efforts on behalf of the unsavory, profit seeking businessmen, the purveyors of the nuisance trades. The editors of the Lancet concluding that Snow’s arguments were scientifically specious in his singular focus on the transmission of cholera via the feco-oral route—and his denial that disease might be transmitted by other means: “The fact is, that the well whence Dr. Snow draws all sanitary truth is the main sewer. His den is a drain. In riding his hobby very hard, he has fallen down through a gully-hole and has never since been able to get out again.” The Select Committee moving quickly to other matters, negating Snow’s arguments in favor of Dr. William Farr's statistics—the mathematician noting that where he found an excess mortality beyond the usual prevalence, he had noted “noxious and removable causes in operation” 21 where the “resources of science [needed to be applied] to improvement of the health of the district.” (Editor 1855) †

Demise Snow burnt the candle at both ends. Not only had he become a leading authority in two new branches of medicine—that of Anesthesia and of Epidemiology; developing the science underpinning chloroform anesthesia and cholera transmission respectively—he also practiced as an anesthetist, was an impassioned public health crusader, and wrote avidly; working late into the night to complete the day’s work. So to 10 June 1858. Having come up in the world, leading to moderate financial success, Snow had moved from his apartment in Frith Street to a four-story house of his own at 18 Sackville Street, just south of fashionable Regents Street, convincing his former landlady’s servant, Jane Whetherburn, to move in with him as his house-keeper. Coming down to breakfast that fateful day, he reported some giddiness but then ate a hearty breakfast, before heading upstairs to start the day’s writing. 21

Like the Nuisance and Offensive Trades.

Leadership in Anaesthesia

123

Completing the last printed sentence of the book "On Chloroform," he got up from his chair, felt dizzy again, and keeled over, collapsing to the floor with a thud. Startled by the thump, Jane rushed upstairs to find Snow on the floor vainly trying to get up; paralyzed on the left side, unable to speak fully, his mouth drawn to the right by his stroke; he beckoned her to drag him onto the sofa to rest. Not wanting to be disturbed, he treated his chest pain with ether inhalations but got no rest, vomiting up copious amounts of blood, before allowing Jane to summon his physicians, who could do nothing for him; John dying five days later, calm, and at peace with the prospect of death. Post Mortem Report: (Male: 45 years), Brain: white softening, only detectable by the microscope, in the right corpus striatum. Both kidneys: severe contraction and engulfed by cysts. Lungs: Marked apical disease consistent with tuberculosis. Stomach: Gastritis with a chronic duodenal ulcer. Conclusion: Ample evidence of chronic polycystic kidney and lung disease that occasioned the hypertensive emergency and stroke that resulted in John Snow’s untimely death. Interpretation. To become the Royal Anaesthetist to Queen Victoria was no small matter. Nor was it beyond risk. Promising careers could be made or broken by such an appointment which was considered the apogee of a career, and hard won; it was Snow’s scientific standing and clinical reputation in London’s medical community that brought him to Prince Albert’s attention. The Prince inviting Snow to Buckingham Palace four weeks before the Queen’s eighth confinement to ascertain John’s competence and have him explain the scientific principles underpinning chloroform anesthesia—Snow convincing the Prince of its safety and utility. The rest is history. Chloroform anesthesia (and Snow’s practice) getting an enormous boost from the Royal Imprimatur. Repeated four years later with the difficult labor of the Queen’s ninth and last confinement; the Queen calling for more and more chloroform for the pains from obstructed labor; Beatrice’s head crowning; her shoulder stuck for many minutes—before the Princess was finally born. Boosting Snow’s practice to one hundred anesthetics that May of 1857, and upon receiving an invitation to the Royal Levee at St James Palace the next month; Snow knelt down gracefully in front of the fully recovered Queen, having waited long in a lengthy line of honoree's favored with a Royal Presentation at the grand event.

124

4. John Snow

Hard won too was Snow’s reputation as a Public Health advocate. Again based on his academic and clinical reputation, Snow was often brought in as an expert witness, and refused to be swayed by politically expedient, morally questionable, or crass economic considerations. Take for example his argument against the ‘Prevention of Offenses Bill’ submitted in the House of Lords by Lord Campbell which sought to criminalize the use of chloroform if it were used to commit an offense such as rape, pilfering or robbery. Snow vociferously opposing that chloroform was being criminalized in this manner as this might cause numerous frivolous and false charges against innocent people; he expressed that it was highly unlikely that the test case of robbery (of the Solicitor in ThraleStreet) could have been perpetrated by the use of chloroform. Not because he did not understand its usefulness in subduing crime victims, but because he thought the bill misguided, and unnecessary, and so he mustered all his clinical knowledge and acumen to criticize inconsistent fallacies that were reported around the crimes. Snow hoping to persuade through science; having a full understanding of the subject that, unfortunately, the House of Lords often could not appreciate and so rejected. In so doing hoping to protect the innocent from politically impelled bills such as that brought to bear against the Nuisance Trades, in a selfserving attempt to oust the harmless from the City center. †

Post Mortem Like Dr. William Morton, Dr. John Snow provided his leadership during the Great Man Age stretching from 1840-1900—presented in the Seven Ages of Leadership of Chapter 2. The leadership writer, Thomas Carlyle, believing that the leader and their origins, inventions, and accomplishments needed to be studied in the context of the circumstances that they faced. (Clinton 1992) Based on these considerations, Snow was undoubtedly a 'Great Man' and hence worthy of study for the two scientific fields of medicine he helped launch, the leadership he demonstrated in advocating for healthy practices for the public at large, and the stance he took against the 'special interests' foisted on the populace by governmental heavy handedness. In order to evaluate Snow's leadership profile we will again review the key 'body parts' of the Leadership Skeleton best captured using the rubric: Creative LEADER.

Leadership in Anaesthesia

125

Leadership Skeleton: Creative LEADER max score: +++, min score: 0.

John Snow

Creativity/Innovation/Imagination

+++

Legitimacy/Authenticity/Credibility

+++

Emotional Competence/Psychological makeup/Personality Adaptability to Change

+

Determination/Passion

+++

Empathy

+

Resilience

+++

Total Leadership Score

17/21

+++

Creativity (+++). "The best leaders are creative innovators who have big ideas." (Stoll 2019) Despite, or because of his eccentricity—bachelor, loner, teetotaler, friendlessness, dietary peccadilloes—Snow was a creative genius. His search for solitude fanning his creativity in solving the many scientific problems he encountered; investigating forensic, scientific and public health medicine, he documented this in voluminous abundance in books, case books, pamphlets, and other publications, for posterity. Legitimacy (+++). From humble beginnings as an apprentice (nine years), then medical student (three years), then surgeon apothecary in Soho—having obtained the requisite M.R.C.S. and L.S.A. qualifications (1838); the Bachelor of Medicine and Bachelor of Surgery degrees (1844); and the Doctor of Medicine (1844)—Snow built the necessary credibility to be invited to witness one of the first anesthetic demonstrations with ether in London (1846)—eventually becoming the first and foremost academic anaesthetist in Great Britain. While simultaneously ascending the academic ladder, conducting research—arsenic, respiratory physiology, chemistry— and publishing and lecturing at every opportunity, he established legitimacy in London's brutally competitive medical fraternity and became a respected—if controversial—member, and eventual president: of both London's Medical Society and newly founded Epidemiological Society.

126

4. John Snow

Emotional Competence (+). An eccentric genius who spent most of his life working; Snow had sufficient emotional competence to get ahead: making his way in London's professional circles with sufficient grace to win acclaim for his work—if not the support of many friends nor the consolations of marriage. Lacking some of the qualities like charm and refined interpersonal skills for which leaders are loved and followed, Snow was nevertheless sufficiently brave to doggedly pioneer not just one, but two branches of medicine: able to withstand and overcome the relentless public criticism that came with such leadership. Adaptability to Change (+++). Snow produced change. He envisaged a better, safer way of administering anesthetics and promulgated his approach widely. He remonstrated against the spread of infectious diseases like cholera—instigating the removal of the handle from the Broad Street Pump—proving his point, but unlocked great opprobrium for his actions: the populace complaining bitterly that they had to walk further from home, to another pump, to draw water. (At least they lived to tell the tale.) Determination (+++). Nothing would stop Snow from achieving his vision: to create a safer anesthetic. Not his deteriorating health, nor the indisputable fact that chloroform was more dangerous than ether—he kept trying to find better ways to administer it. From his humble youth to his vaunted status as the Queen's Anaesthetist, Snow was resolute in his determination to succeed. Empathy (+). The concept of empathy in leadership as an important attribute to success would be developed after 1910—a full fifty years after Snow's death. Snow was not an unsympathetic man, when dealing with his patients, but in the words of one of his biographers who knew him personally: "he was not the idol of the people in common practice"—Snow was too aloof, and scientific, and did not want to pander—just to make money—by handing out nostrums that wouldn't work; having been a therapeutic skeptic. He was however empathetic, in the larger sense, of the human misery produced by lack of sanitation and the spread of infectious disease; goading him ever on to find a solution for cholera.

Leadership in Anaesthesia

127

Resilience (+++). Leadership is an improvisational art. (Heifetz and Linsky 2002b) And resilient people are defined by their ability to improvise, their grip on reality, and their belief that life has meaning and purpose. (Coutu 2002) Snow could certainly improvise—inventing anesthetic apparatus and techniques, pioneering epidemiologic mapping charts, and, had a firm grip on reality: recognizing the plight of the common man, while also courting Royalty, and personified the fact that life had meaning and purpose: setting a vision/goal (of safe anesthesia) for himself, and working to achieve this to the very end.

Leadership Insights A number of useful insights can be drawn from the telling of Snow's biography. x x x x x

Set a vision for the future. Build legitimacy early to achieve ambitious goals. Seek excellence not just competence. Stand up for what you believe to be true (persuade through science). Don’t work yourself to death. †

Set a vision for the future. Snow's personal goal was to become a respected physician scientist in London. His unerring vision became to discover "An anaesthetic which might be inhaled with absolute safety, which would destroy common sensation without destroying consciousness." A "vision" or purposeful goal for one's life's work, often emerges in the fullness of time. So too for Snow. Having diligently prepared to achieve his personal goal, he was happily invited to witness one of the first ether demonstrations; adopting and refining the practice of anesthesia willingly and recognizing early the limitations and dangers inherent in producing unconsciousness to annul surgical pain. x

128

4. John Snow

Like Alexander Fleming in identifying penicillin, 22 "chance favors the prepared mind." 23 Snow—who had studied ether in the context of evaluating it as a respiratory stimulant previously—was quick to recognize both its potential as an anesthetic, but also its limitations, and so set out to investigate the matter: guided by his vision. The concept of a leader establishing a "vision" (or "Vision Statement") was not articulated in Snow's time, but today is considered a distinguishing feature between a mere 'manager' and a true 'leader' in that visualizing purposes inspires followers to achieve a common goal (Zaleznik 2004)—unlocking their creativity and engagement in transforming a system or organization for the better. (Heifetz and Linsky 2002a) Quite apart from this salutary effect on followers, a personal vision also inspires the individual to greater purpose, focusing his energy, serving as a motivating beacon of light; allowing the person to bear all manner of suffering in order to emerge from the darkness towards eventual success. So what is a 'vision'? And. How do I create one? A "vision" is an overarching meaning and purpose for a project, life's work, or organization. It is not something whimsical or mystical but a well-articulated goal: viz. John Snow's example. Vision's do not happen suddenly, or magically: they emerge from learning deeply, a thoughtful process of paying attention to one's experiences, immersing oneself totally in the work, integrating one's value system, and imagining the future as a better place than the past. The Reverend Martin Luther King, personifies the process well: 22

Sir Alexander Fleming who had a famously untidy laboratory, upon returning from a vacation, noticed that one of the stacked petri dishes which he had inoculated with staphylococci bacteria had become contaminated with a fungus—destroying the bacterial colonies immediately surrounding it. Declaring "that's funny" he established that the contaminating mold was from the genus: Penicillium; which upon further investigation revealed that the mold-juice released, killed all manner of bacteria: leading to the discovery of Penicillin in 1928. However, it took till 1943, and the efforts of Drs. Howard Florey and Ernst Boris Chain, to bring the first universally effective antibiotic into mass production to meet the needs of injured soldiers during World War II. The three scientists sharing the Nobel Prize in Physiology and Medicine in 1945 for the discovery. 23 Attributed to Louis Pasteur: "le hasard ne favorize que les esprits prepares" the famous French biologist.

Leadership in Anaesthesia

129

Standing on the steps of the Lincoln Memorial on a blazing hot August day in 1963 addressing 250,000 people: "I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin but by the content of their character." "I have a dream today." (Kouzes and Posner 2003) Build legitimacy early to achieve ambitious goals. Snow took no short cuts. He travelled the long road to fame and (limited) fortune. 24 Because he had worked in the trenches as an apprentice—facing cholera, practicing as an accoucheur, applying blisters, attending shop; had undergone the laborious studies necessary to become an Apothecary and Doctor; had taken the necessary examinations—M.R.C.S., L.S.A., D.M., to achieve the highest possible qualifications in medicine of the time, and had embarked on his own highly publicized scientific and epidemiologic research—Snow developed the necessary clinical, academic and scientific legitimacy, and with it the necessary recognition, to support the achievement of his goals. Contrast this with the one-time dentist William Morton. He forsook Harvard Medical School—too lazy; barely attended dental training with Horace Wells; and was considered an often-dangerous practitioner of anesthetics: his patients' asphyxiating from time to time. Whereas Snow had built his reputation as a competent clinician— recording only one death at his hand with Chloroform (of 4500 anesthetics) and became the recognized leader of anesthetic practice in England: serving over one hundred London surgeons, seventy dentists, and twice anesthetizing the Queen. x

Seek excellence not just competence. Snow struck out to become the 'Compleat' Physician. Excellent and not just competent to practice medicine according to the customs of the day; the run of the mill doctor of the time usually quite satisfied with just treating their patients and their ailments. Instead Snow was interested in using research before research had become a common component of medicine; to excel through a better understanding of the scientific principles that would improve his medical practice as a physician, anesthetist, and a public health specialist, at a time when such attempts were far and few between—and through his efforts x

24

He earned about 1000 pounds per year at the apex of his career.

4. John Snow

130

becoming the embodiment and creator of two new academic specialties of medicine: anesthesia and epidemiology. Driving excellence in clinical care, science and teaching, winning favor with the Queen and her populace, and becoming a renowned educator and prolific scientific writer. Snow's drive for excellence emblematic of the very idiosyncratic nature of its pursuit. Marcus Buckingham telling us that "effective leaders put their egos in the service of others" as Snow did, and adding that excellence can be cultivated, is unforced, is inextricably intertwined with each person's individuality, and an intelligent expression of whomsoever expresses it. The striving for excellence (which releases oxytocin in the brain) rewarding the individual with good feelings while neurologically areas in the brain that are already strongly developed are enhanced even further—sprouting ever more neurons and synaptic connections—perpetuating the virtuous cycle of building ability and proficiency in thought and action by the continual strive to be excellent. (Buckingham and Goodall 2019) Stand up for what you believe to be true (persuade through science). Snow was fond of controversy. Indeed he courted it, despite being retiring in nature. Always making doubly sure that he had an exact knowledge of the subject matter at hand: either through intensive investigations in his laboratory inside, or exhaustive 'foot-leather epidemiology' outside in the metropolis of London—hoping to persuade through science to the cause at hand. Witness the ether versus chloroform safety controversy; the crusade against arsenical candles; the cholera transmission polemic; arguments on behalf of Veganism and Totalitarianism, and Snow's voluble and voluminous exertions against the Prevention of Offenses Bill and the Nuisance Removal and Disease Prevention Act seeking to criminalize chloroform and ban "offensive trades" from the city center: Snow presenting often unwelcome scientific facts to support the cause celebre de jour. His leadership realized in that he championed often controversial issues, nary to the effect this might have on his reputation. One of his biographer's declaiming Snow's focus on such 'individual rights' well: “Dr. Snow’s amiable but firm nature led him often to this ultimatum. Freedom of expression was a right he always claimed; but for the same reason he extended the same privilege to others.” (Richardson 1858) x

Leadership in Anaesthesia

131

Don’t work yourself to death. In the quest to reach our goals in life we often forsake our health. Doctors like Snow are notorious in this regard. During the course of medical school we read and study all manner of dread diseases that we are convinced we will get, and will soon kill us. Then reality bites and we learn that this was just a false concern: the result of a heightened imagination and intimacy with the newly learnt disease process. So as psychological protection against the fear of death we fool ourselves into thinking that doctors are invincible, immunized against mortality, and in full control of life. After all we Doctors are the "Captains of Life and Death" controlling death and disease; not subject to it! This thinking was probably part and parcel of Snow's thoughts on the matter; believing himself to be invincible despite reality staring him in the face. He should have known better. There were warning signs that his health was deteriorating. Nevertheless, he paid them no heed: self-experimenting with highly toxic agents—benzene, Dutch liquid, bromoform 25—subjecting himself to exhausting shoe-leather epidemiology investigations into the source of the deadly contagious cholera, and burning the candle at both ends; working day and night to achieve his goals. His undying work ethic proving to be a self-fulfilling prophecy. x

†

Concatenation From the 1860's to the 1900's not very much progress was made in the advancement of anesthesia practice. Its science, equipment design, and techniques of administration, more or less sputtering along, as there were few champions for its development; anesthetics mostly administered by bystanders, dressers or medical students drafted in the operating room, or by nurses directed by surgeons. The surgeon in turn distracted by their need to focus on the operation at hand were forced to yell instructions: "more ether" "less chloroform" to the too often untrained tyro charged with administering the hazardous anesthetic. Unsurprisingly, outcomes were frequently poor and mortality high. Accordingly patients were categorized into three classes: those who 'took' the anesthetics well, those who 'took' them badly

25

"Believing that the personal trial was his duty and [holding] his own life of least consideration when the lives or well-being of others were under consideration."

132

4. John Snow

(and died) and those who would not, or did not, 'take' them at all— sometimes running screaming from the operating theater. Never to return. Sir Frederick Hewitt 26 bewailing the state of affairs and the lack of scientific progress since Snow's day, in an article entitled: "The Past, Present, and Future of Anaesthesia" published in 1896. Going on to recount that Anaesthesia was born a slave to the master Surgery he proceeded to champion "The Need for Specialism" pointing out "The administration of an anaesthetic for a modern surgical operation involves a risk to life which may be very considerably lessened by placing the administration in the hands of experienced and thoroughly competent hands." Adding that "every large hospital should have its anaesthetist just as it has its surgeon and its physician." Turning then to the future, Hewitt wrote: "It would, no doubt, be a great boon if an anaesthetic were to be discovered which would possess the simplicity, the agreeableness, and the potency which characterize the administration of chloroform, the safety which distinguishes ether, and the freedom from after-effects which is such an advantage of nitrous oxide." Concluding thus: "To say that the subject is worked out is but to confess a lamentable ignorance of it. Much is needed, and by patient observation and experiment much will be discovered." (Hewitt 1896) †

26 Dr. Hewitt, who had turned to anesthesia because his eyesight was failing and thought that the holding of a mask would not be too taxing, is credited with designing the first oral metal airway to treat anesthesia induced obstruction, and had a reputation for remaining exceedingly calm under pressure.

5. ARTHUR GUEDEL

The Practice "Maintain Flying Speed." —Arthur Guedel

134

5. Arthur Guedel

The Great War: 1918

All was not quiet on the Western Front! In fact it was bedlam. Casualties from the American Expeditionary Force stationed in France were in their thousands: the 26th division advancing up the Marne River pushing back the Germans that dreadful July of 1918. The machine gun bullets, exploding shrapnel, and toxic phosgene gas taking their heavy toll as the soldiers breached the trenches, ran across No Man's Land, and advanced towards Germany; moving the Firing Line and the western front—east. The severely injured blesses, left behind, extricated from this seven-mile 'Zone of Advance' by medics and orderlies to first aid dressing stations, tented field hospitals, and mobile surgical units where surgical anesthesia could only be provided in desperate circumstances and, far too often, with lamentable results. (Heddy 1918) Instead the stricken soldiers were bundled into horse-drawn or motorized ambulances, and trundled along the bomb shattered roads to the 'Intermediate Zone'—just beyond the reach of the Germans' big guns—to be treated in French evacuation hospitals or Allied and American Expeditionary Force Casualty Clearing Stations; where most initial surgery was perilously performed, with anesthesia when available. (Courington and Calverley 1986) Beyond this, again, was the 'Zone of the Interior'—lying some fifty miles behind the Firing Line—housing over two hundred Base Hospitals, competently supported by Allied and American Staff drafted from their hospitals back-home: the 'Lilly' 1 Indianapolis Base Hospital—#32 in Contrexeville, and the Mackey-Roosevelt Base Hospital—#15 in Chaumont; both featuring prominently in Dr. Arthur Guedel's story. Chaumont, in the province of Grand Est, serving as the Head Quarters of the American Expeditionary Force which had been established when the United States joined the war on 16 April 1917 and comprised over two million personnel, under the command of General John J. Pershing. † 1

Mr. JK Lilly, president of Eli Lilly & Co, had joined with the local Red Cross, to donate over $50,000.00 to support the necessary equipment and supplies, while around 180 staff were drawn from Indianapolis—the nurses trained in New York and New Jersey before travelling on the USS George Washington to staff the Unit. The Lilly base hospital was opened 18 March 1917 and closed 7 January 1919: two months after Armistice Day, when the war ended.

Leadership in Anaesthesia

135

Arthur Guedel's start with the AEF was inauspicious. In truth it would not have started at all if he had not been persistent—his service application was at first rejected because of his clawlike right hand; comprising just a thumb and an index finger—it looked like a lobster's pincer. Undeterred, knowing that he was one of only a handful of doctors that had specialized in anesthesia in America at the time, he successfully enlisted the support of a venerable colleague: Dr. Viktor Kiene, who paved the way for Guedel to enlist as a Casualty Officer in Anesthesia. Assigned to the Roosevelt Hospital AEF unit in New York City for initial training, Arthur resigned as Chief of Anesthesia at the Deaconess Hospital in Indianapolis, said good bye to his wife and two young daughters, and after a brief sojourn in the metropolis, disembarked for Southampton— arriving in England with the rest of the Roosevelt Unit on the first of August, 1917. Travelling to Chaumont, and the Army Barracks at Fort Lambert, Headquarters of the AEF in France; First Lieutenant Guedel was appointed Chief of Anesthesia for the region. Finding the work much to his liking he reported on his findings: "Many men who came over here with Base Hospital Units have at their own request been placed on 'surgical teams.' These teams consist of an operating surgeon, a surgical assistant, both medical officers, two surgical nurses, two surgical orderlies and an anesthetist, who may be either a medical officer or a nurse." Importantly he goes on: "This team is considered an itinerant unit and is sent from place to place wherever they may be needed to extract German souvenirs from the persons of our fighters who have been unable to get between the flying shell fragments and machine gun bullets of the enemy. That means that these teams travel around a lot." And. "Usually their work is in an evacuation hospital (casualty clearing station) during a rush period, with time for rest in the rear, between rushes." Recognizing very early on that there were far too few such surgical teams and far too few trained anesthetists, with the necessary expertise, to look after the war wounded. (Guedel 1918b) A sentiment echoed by Captain Dr. Geoffrey Marshal reporting from the Front: "Surgical operations performed at a Clearing Station are for the most part urgent. A correct choice of anesthetic is of the first importance: the patient's life will be as much imperiled by faulty judgement on

136

5. Arthur Guedel

the part of the anesthetist as by a wrong decision on the part of the surgeon." (Marshall 1918) And. "The bulk of preventable deaths at a casualty clearing station was due to improper anesthesia, 'giving the wrong anesthetic, or giving the right anesthetic wrongly.'" (Courington and Calverley 1986) Not at all surprising to Arthur Guedel because on his travels around the area—riding a commandeered motorcycle—inspecting base hospitals, casualty clearing stations, and field hospitals, he had found the same: anesthesia was usually provided, not by trained nurse anesthetists, or medical officers, but by untrained nurses, orderlies, a few secretaries, and even a Chaplain; dragooned into service to provide the anesthetics—none the wiser as to how they should administer these lethal drugs. And if this were not enough, the untrained anesthetist would often be attending to three patients at the same time: the anesthetist at a casualty clearing station centered at the head of three operating tables radiating out from him: one patient being prepared, one recovered, and one maintained under anesthesia to accommodate the heavy surgical volume at hand. On one exceptional day, a trained specialist anesthetist having to manage 34 patients in one sitting. On another, the afore mentioned Chaplain unhappily recounted unfolding events: "I remember one case, ....a man of tremendous size, a colonel.... I couldn't get the man under. Then to my horror, the fellow ceased breathing.... Just when I thought I would have to give up, he took one gasp and began to breathe... but as soon as the operation began he started to sink and he died on the table." (Courington and Calverley 1986) Here, exactly, was the problem that Guedel would find a solution for: the untrained tyro anesthetist did not know how much anesthetic was sufficient for the surgery and so overdosed the patient stopping their breathing—having not been trained to identify properly the stages of anesthesia, and the correct management of the inevitable respiratory depression. Guedel set to work; he started an anesthesia training school at the Head Quarter Barracks in Chaumont. And, using his honed ability to simplify complexity, he built on Dr. John Snow's description of the stages of anesthesia from 1847—to define the exact way point clinical signs, and danger signals, that would identify these stages: much like a road map, or guide, for a motorist. (He probably refined his thinking for this chart on his long motorcycle rides through the French countryside.) (Waters 1952)

Leadership in Anaesthesia

137

He reproduced this 'road map' as an Anesthesia Pocket Chart, on cardboard, that each anesthetist could have at the ready—to identify the stage of anesthesia their patient should be at, and so; allow the surgery to occur without deepening it too far to cause respiratory paralysis and death. All they had to do was administer the ether and look at their patient's respiratory pattern, note their eyeball movement, and watch for involuntary swallowing. When the latter two ceased, the patient was deep enough, and the anesthesia should be lightened—lest further anesthetic would cause respiratory arrest. (The driving notion behind his Anesthesia Pocket Chart, Guedel would recount much later: "It wasn't the idea to teach these technicians all of the anesthesia they could learn. It was to teach them to pour ether safely, with the use of the fewest possible signs.") (Guedel 1923) There were also many other problems to address. Dr. Guedel bringing these out very publicly in the American Journal of Surgery: broadcasting the state of affairs in France at Base Hospital #15: "As far as Anesthesia in the American Army this should be given some general attention by the United States authorities. As it is the methods are slipshod and careless to a degree that causes an enormous wastage of anesthetic material and occasional accidents which are costly to the government, to say nothing of the occasional life of an American soldier." (Guedel 1918a) Going on to complain, with some vitriol, that he found the French ether rotten: filled with impurities causing patients to cough (especially those who had been subjected to phosgene gas) and in so doing delayed the speed of anesthetic induction even further. To address these anesthetic problems and bring down the speed of induction with ether from between eight to fourteen minutes to closer to two minutes, he designed an anesthetic technique using a mixture of ethyl chloride (that the French had in abundance), chloroform (that the English had brought), and ether for induction: utilizing a rubber hood that was placed over the patient's face— recounting that over 2000 anesthetics had been performed in this fashion. Confident in the knowledge that this rapid induction technique had been readily adopted by neophytes to anesthesia (twelve nurses and three orderlies inexperienced except for what they had learnt in the AEF anesthetic course that he had developed), Guedel motivated to the Commander-in-Chief that this approach should be implemented throughout the AEF; his rapid induction technique cut the need for anesthetic agents in half, sped turnaround time enhancing efficiency, and could be used easily and rapidly for the agonizingly painful daily wound-dressing-changes that some soldiers required. Occasionally 20 days in a row.

138

5. Arthur Guedel

The Commander-in-Chief handing the recommendation down the line; the Commanding Officer of the Vittell-Contrexville Hospital Center— where Guedel would be transferred to in the future as Captain—ordering Arthur to train the anesthetists in the surrounding 25 Hospital units in the Vognes area in the technique; and more than 40,000 soldiers subjected to the rapid anesthetic induction using the new rubber hood. Meanwhile, in November of 1917, Lt. Guedel was transferred to Paris to the newly opened Red Cross Base Hospital #3, situated on Rue de Chevreuse. The problem was, there was nothing to do. The hospital had no equipment, furniture, nor staff; but one commanding officer who was AWOL, and a corpsman who idled about—Guedel slumped into a nostalgic depression that would plague him intermittently throughout his life. (Guedel 1952a) This time, however, there was some relief; he became friendly with a French school teacher who became a good drinking companion on the one occasion when he got "potted." Having purchased five pounds of sugar from the American Commissary; Guedel offered the scarce staple for a trade in kind. The teacher knowing exactly what to do; he sought out the proprietor of a 'hard or soft beverage emporium'—a tiny hole in the wall dugout—"where we three sat .. fairly well into the night .. drinking .. not too fast—from his store of not too soft beverages;" translating sugar into a pleasant evening of bonhomie. Guedel going on to relate: "That was by far my least sad day of my stay in Paris until I was sent to the Hospital Center at Vittel and Contrexeville; where I did anesthesia and was less unhappy." Here, Captain Guedel was appointed as the Consultant Anesthetist for the Hospital Center comprising four base hospitals: two in Vittel (#23 and #36) and two in Contrexeville: Base Hospital #31, and the LillyIndianapolis Base Hospital # 32, that Arthur had asked to be transferred to. The latter Base hospital comprising two converted hotels: the 900 bed Cosmopolitan Palace Hotel (for all surgical cases) lying right next to the Chalindrey a Mirecourt railway line, and the much smaller 275 bed, Hotel de Paris, which lay conveniently across from The Colonnade Public Baths along the Rue de Belfort and served as Base #32's headquarters. The two not much more than a half a mile apart. In addition, as one of only three American specialist anesthetists in the AEF at the time, the young Captain was also charged with arranging the education and overseeing anesthesia services provided within the region's many other evacuation hospitals and casualty clearing stations. Totaling a

Leadership in Anaesthesia

139

score of sites; newly trained anesthetists were pressed into service and instructed in the use of Guedel's Anesthesia Pocket Chart and visited almost daily by motorcycle; Arthur motoring from site to site to monitor anesthesia practice had built his reputation as the "motorcycle anesthetist." (Kovac 2016) Often stopping overnight to bivouac in the officer's mess, Guedel, an accomplished pianist, never failed to start his repertoire with the Indiana Hoosier's favorite: "Along the Banks of the Wabash, Far Away," many better singers chiming in to support his thready voice. His piano playing earning him his second nickname: "wab," for playing the home-sick soldier's beloved song, far, far away from home, in the Vosges hilly foothills. (Helen 19—) Here too he was an unremitting champion of the American doughboy: the widely popular nickname for the American Infantry man that was the backbone of the AEF. Publicly praising them at every turn: "The biggest man I seen is the American doughboy. I saw hundreds of them in the operating rooms, many at the gates of eternity—but there was never a whimper from any of them. They were of the highest type I ever worked with, unselfish, brave and the gamest sports in the world." Endearing Arthur to many in providing anesthetic care to the deserving combatants wounded in the service of their country in the Vosges region of France. (Scrapbook 1956) "Maintain flying speed." Is how Guedel put it throughout his life. Less you lose altitude and crash. Guedel did, he roared around the Vosges on his motorcycle from place to place to monitor anesthesia's safety. In March of 1918, Dr. Leslie Burwell from New York reported for duty as a specialist anesthetist at Base Hospital #23: the AEF Medical Headquarters in Vittel. Upon his request that he be assigned as an anesthetist, the medical officer in command rejoined: "You will have to see Guedel. He runs the anaesthesia in this region. He blows in here every day or two, like a wild Indian, on a motorcycle. Wait for him." Sure enough, the next afternoon, with a roar and a put-put the motorcycle arrived in a cloud of dust. (Waters 1952) Captain Guedel well pleased to welcome Dr. Burwell to provide specialist assistance in enhancing anesthesia services in the area; he likely assigned him to help supervise the Vittel region while he prepared the Contrexeville district. Well aware that General Pershing was marshalling the AEF for a major campaign against the Germans'—10,000 new doughboys

140

5. Arthur Guedel

were being deployed daily in June, and the Allied 'rifle-strength' on the Western Front would surpass that of the Germans by over 100,000 troops in late July. 2 Hence, when the Second Battle of the Marne, the Franco-American counterattack, was launched and all hell broke loose on the Western Front in late July, they were ready; but not ready for the massive assault of casualties that they had to look after: on 22 July a trainload of 513 patients from the 26th Division, northwest of Chateau Thierry, arrived in Contrexeville: the next day another 249: totaling 1000 patients in four days—many of the patients coming directly from field hospitals and bypassing casualty service stations altogether, so that Base Hospital 32 became all three combined. Guedel together with three other physicians and a dentist, supervising forty concurrent operating tables and working three days nonstop: patients recovering in emergency cots and mattresses in every available corner—the patients nevertheless still overflowing the converted hotel building. Dr. Guedel, although tired, was nonetheless well pleased with the preparations he had brought to bear to provide competent anesthesia services in the hospital and its environs—reported on enhancements in glowing terms: "No other hospital in France made as great progress in practical anesthesia as Base Hospital 32 and the Vittel Hospital Center." (Guedel 1922) The Surgeon in Chief for Base Hospital 32, Lieutenant-Colonel Edmund D. Clarke, providing the confirmatory statistics for the year: Of 5719 surgical patients, there were 58 deaths—1.14% mortality: ten already moribund when they were removed from the ambulances. And. Upon the signing of the Armistice on 11 November 1918, the long war at last over—the Lilly-Base Hospital Unit 3 and Dr. Guedel with it, were transferred to the coastal town of St Nazaire in January 1919, and on February 28, he returned to the United States; honorably discharged from the army, to return to civilian practice as a doctor in Indianapolis. †

2

August 1, 1918: 1,672,000 Rifle Strength. Hospital Base Unit #3, Contrexeville, Vognes, France, officially closed its doors Saturday May 10th, 1919.

3

Leadership in Anaesthesia

141

The Hoosier According to his mother, Mary Lemmes, ever since the age of four Arthur wanted to be a doctor. Perhaps a slight disappointment, because she had hoped that her fourth son would be a farmer and hunter like her forebears. Being partly of Native American descent; Mary's grand-mother 'a full-blooded Indian squaw' who had married into the Lemmes family in Harrisburg Pennsylvania—Mary had been born in 1843, and had grown up on the family farm in Milton, Indiana, where the whole family had moved to live—travelling by covered wagon from the Pennsylvanian capital to get there. (Judy 1950) Born in the same year in Switzerland, Arthur's father, John Guedel, came from a well-to-do Swiss family. The proud owners of a large distillery, a beautiful home—resplendent with servants and magnificent gardens; the family fell on hard times, propelling John to seek his fortune in the United States in 1863. A bright, inventive man, he gathered his few possessions and his prized accordion, took the sea passage to the new world, and found his first work at the Salzman Hotel in Parkersburg, West Virginia. Finding this not altogether to his satisfaction he odd-jobbed Cincinnati, looking for permanent work, and then eventually settled in Indiana at a large farm east of Milton, to work for Mr. Canover, a respected farmer. Opportunely meeting Mary there—when she sought work to sustain her three children; having recently been widowed: her husband keeling over and dying quite suddenly after seven years of marriage. Mary and John were married a little over two years later, and would have a further seven boys together—all but one surviving in to old age. Fearing the bad luck that Friday the 13th might bring, Mary had hoped to hold out past midnight with the fourth child: Arthur Ernest Guedel—to no avail. Going into labor for what would now be her seventh child, Mary was all too aware of the tell-tale signs, and the pain that the delivery would bring. Consequently, their 10-year-old, Charlie, ran out to summon Dr. Mouch, the coal oil lamps were lit, clean linen prepared, and more wood added to the kitchen range to boil hot water for the house doctor's use: Arthur delivered just before the clock struck twelve—that hot June night of 1883. A chubby little fellow, "Art"—all of two years old—toddled after his brothers at their Carlena Hill home in Cambridge City where his father had moved to better himself by working in a car shop. Known as "the little rascal"—by the age of five—all who would listen had been told that he wished to be a doctor; and the family physician, Dr. Houck, had agreed that

142

5. Arthur Guedel

Art could ride along on his house calls as long as he would stay outside and watch the horse and buggy while the diligent doctor went in. Hoping to improve their financial situation, which was imperiled by the large family he had to sustain, John Guedel moved the family to Indianapolis in 1889. Here he had found a job in the world-famous E.C., Atkins Saw Company, and a house conveniently close to the saw mill. Employed as a general worker, John brought his inventive mind to work in designing experimental devices that would aid the saw mill to enhance their efficiency: tinkering and inventing an ingenious method for setting the teeth on saws that he eventually patented and received royalties for: John would continue to work at the plant for the rest of his working life, despite the tragedy that would be visited on his son. Meanwhile Arthur took to grade school with a vengeance; developing a reputation for being mischievous but getting good grades; he looked for every opportunity to make some money so that he could eventually pay for medical school. Keenly aware of the straitened circumstances of the family’s' finances he acquired a paper route in first grade; saving his money in his china piggy bank. If poor, home-life was nevertheless good. Arthur fondly remembering the evenings that the family would gather around the kitchen table to sing along with his father playing on the accordion—which likely stoked his second great ambition beyond medicine: to become a musician. So, at the age of thirteen, having put aside a good amount of savings for medical school from his daily paper route, Arthur decided to disburse some for his first piano lesson. Finding this greatly to his satisfaction and anticipating with eagerness his next lesson, he hoped to make some extra money by volunteering as an apprentice at his father's sawmill. E.C. Atkins paying good fees for apprentice help, put him to work immediately: dusting the jagged circular saws whirring noisily at the sawyers' work benches without much proper training for the perilous job. Hoping to ingratiate himself; Arthur worked during the lunch break. Using his dust rag deftly, despite the fast-rotating saws. But not deftly enough. His dust rag got caught and his three fingers separated to the wrist, lost in a flash, the serrated saw crippling him for life; blood pouring out, till his whimpers for help brought his father to his side and he was carted off to the hospital: the damage nevertheless done. The severed fingers could not be re-attached, he had suffered marked blood loss, and developed a chronic infection and chronic pain; stating later that this was the reason he chose anesthesia as his specialty.

Leadership in Anaesthesia

143

But that was a long way off. It took him three years to recover from the injury. A once carefree boy had turned into a troubled teenager. Handicapped and of ill-health, no one would employ him and his family could not pay for the necessary high school for him to qualify for medical school, nor were there high hopes for his aspirations as a musician: "you can't play piano" the judgement of one of his teachers when he raised his clawed right hand. Fortunately there were a few who were more encouraging: Mr. West, an employee of E.C. Atkins, who was also the physical director of the Indianapolis Y.M.C.A., helped Arthur to join to learn swimming and wrestling: Guedel becoming the "Best Y.M.C.A. Wrestler" in 1901. Art considered a "Confirmed Weakling Two Years Ago" by a local newspaper, had bulked up from 103 to 150 lbs., to beat his opponent effortlessly. The Atkins sawmill also helped: in lieu of going to High School that he could ill afford, they gave him a day time job. (Fortunately he did not lose any other digits working there.) And, a local high school teacher befriended him; helping Art to borrow school text books from the library and follow an outline of high school studies by teaching himself. And despite his hand injury precluding formal piano lessons—he practiced for hours on end by himself; eventually reaching concert level performance and recording his own compositions. Nevertheless, he was no closer to achieving his dream of going to medical school to become a doctor, as he did not have the qualifying highschool diploma that was vital to his acceptance. Turning once again to a family physician for help; Arthur approached Dr. Brocking who had long admired the boy's tremendous struggle to overcome the poor hand he had been dealt in life—Dr. Brocking pleaded Guedel's case with the Dean of the Medical College of Indiana University. It worked. He created an exception: if Art could pass the entrance examination, he was in. Passing the examination with flying colors to the Medical School Faculty and Dean's evident surprise; Art was registered as a freshman in the fall of 1903. Here the aspiring doctor made good: "His infectious smile and good-humored flexibility soon won him many friends." (Helen 19—) His routine was however brutal: he woke up at 3 a.m. to deliver his newspapers, studied his medical school text books till 7.30am, and then

144

5. Arthur Guedel

rushed to his first class at 8.00am, completing his innumerable medical student responsibilities during the rest of the day. Held up by his medical school professors as a model student with average grades of 94.6 and 96.00 for his freshman and sophomore years; Guedel was nevertheless unduly self-critical and unhappy with himself. Determining that his unhappiness rested with his lack of acquaintance with the humanities and classics: he dropped out of medical school for a year and enrolled into the Arts College of Indiana University at Bloomington in the fall of 1905. Deeply out of pocket—with just $9.50 to his name—he persuaded the registrar to permit tuition payment at the end of the year; earning his way by waiting tables, working in kitchens, firing furnaces—nothing being too dirty, menial, or hard for him to do to pay his way through college. And, as there was still time left-over, Arthur tried out for football: making the Varsity team but failing to play; his already injured knee was damaged further in the thick of a practice session's scrimmage—another injury that would plague him for the rest of his life. His thirst for the Arts soon quested; Art re-enrolled for the final two years of medical school in 1906—finding new ways to support his medical school fees; he enrolled as a football coach for Butler University in nearby Irvington and, always interested in helping others with handicaps, Guedel was appointed as the Physical Education Director for the Blind Institute of Indianapolis. By 1907, now in his final year of medical school, Guedel was serving as an extern at the Indianapolis Hospital. Recently injured again in football; he hobbled around from ward to ward with crutches—his right leg encased in a weighty Plaster of Paris cast. Rushing wonkily around a corridor corner to see his next patient, Arthur crashed into his future wife: Florence Dorothy Fulton, a probationary nurse—who slipped and fell, dropping a bed-pan clashing to the marbled floor. Both flustered by embarrassment: Arthur apologized profusely as he attempted to pull her up from the floor—his crutches unsteadily under his arms preventing him from being much use—she got up, picked up the bedpan, and ran tearfully down the hall, not looking back, not once. Collecting himself unsteadily—smitten in more ways than one by the encounter—Arthur hobbled over to the nursing supervisor's desk and asked: "Who was that pretty nurse, the one who is so dumpy?" Hearing that she was known as "Dottie" he endeavored to bump into her as often as possible, calling her "Dumpy Dottie with the Wadley Walk." Graduating from medical school in May of 1908, Arthur took up a six-month internship at the Indianapolis City Hospital to learn clinical

Leadership in Anaesthesia

145

practice, likely with two additional goals in mind: to be as close to "Dottie" as possible, and to teach himself the practice of anesthesia with ether and chloroform so that he could open a private practice—recounting later that: "I was flying by the seat of my pants" adding "The first anesthetic I ever saw given was one I performed myself." The latter goal eminently realized, but the first not: Dottie had returned home to Columbus, Ohio; her probationary period at an end at the City Hospital—Arthur never summoning up the courage to ask her for a first date. Wistful about that lost opportunity, he struck immediately upon Dottie's return to Indianapolis to live with her aunt: visiting her the first evening of her return with the excuse that he wanted her to review a paper he planned to present at the Marion County Medical Association: he had more than one thing in mind. He proposed and gave Florence a record entitled "Dear Little Girl" that he had composed, when she agreed. Married in Columbus early in 1909, Florence recognized later that Arthur was twice married: once to her, but also to another she called: "a gal named Anesthesia." Adding: "but I soon learned to respect her realizing that she was going to play a very important part in my life." (Guedel 1956) Opening a less than busy general practice at the corner of Prospect and Smith Cast Street, right next to the John A. Hook Drug Store, Arthur would practice medicine in the afternoons and anesthesia in the mornings: serving as the Superintendent at the Deaconess Hospital where he would entreat the surgeon's for work. Indianapolis being an extremely competitive city to practice medicine in, Arthur marketed his practice avidly. Not having sufficient patients to fill his waiting room, he would invite some friends to come and read their newspapers there; demonstrating to all that he had a thriving practice. To win surgical patients for his anesthetic practice, he started investigating new techniques and developed anesthetic equipment. A facile gadgeteer and tinkerer, despite his mal-formed hand, Arthur explored new approaches to anesthesia by day, and crafted apparatus by night—often incurring controversy for his experimentations. One area in particular attracting his interest for personal reasons: the inordinate pain that women suffered during child birth. Noting that ether, chloroform, and the 'twilight sleep' induced by morphine and scopolamine unduly suppressed the mother and baby; he experimented with laughing gas instead. Fashioning the first of many anesthesia machines he would design so that the laboring mother could self-administer nitrous oxide, but would: "seldom [be] rendered entirely insensible, sight and

146

5. Arthur Guedel

hearing being retained, and while there is no suffering, she appreciates all that is taking place about her." The revolutionary new technique although working very well, unlocked a fire storm of controversy in medical circles and the local press; boosting sales nevertheless. (Reporter 1911) Steadily starting to gain an income from his growing practice— Arthurs's prospects were much enriched: Florence was pregnant, they moved to a larger house in South Union Street, and his means of transportation improved—after first walking to work from his home close to Prospect Street, he purchased a horse and buggy in the fall of 1910, and a year later a Penn 30. His uncle despairing of the many breakdowns that the 30-horse power motorcar had endured, sold the auto to Art for a song 4— the mechanically minded Arthur much better able to keep it in good running order. Just as well that he now possessed a speedier, if perhaps not as reliable form of transportation, because Art now needed to travel to his new office in the Hume Manse Building, had devoted all his professional time to the practice of anesthesia, and so needed to motor around the city to different hospitals. So too on a spring day of 1911, when Arthur attempted to hurriedly complete an anesthetic on Mrs. Browning at the Deaconess Hospital. He knew full well that Florence had gone into labor early that morning but thought he might be able to complete the planned anesthetic before her delivery. But couldn't. He could not leave his patient under anesthesia and attend to his wife in the obstetrics unit at the same time; and so became greatly perturbed when he heard that Florence had been admitted to the hospital with severe labor pain, and had called for his new anesthesia machine invention. Worried particularly, because although he had already supervised its use in a few patients—standing by just in case—no one had yet self-administered the nitrous oxide anesthetic alone; and he was fearful that Flo and the baby might asphyxiate. Florence was however not so troubled; she had helped Art to design the machine. Confidently inhaling the anesthetic through the rubber mask as labor progressed: Marian was delivered before Art could rush to her side. His wife demonstrating elegantly that the new anesthetic machine was safe. But not safe from controversy. Upon presentation of the new approach in Cincinnati a few weeks later at an anesthesia meeting under the title "Nitrous oxide-air, SelfAdministration for Obstetrics," a conflagration erupted: on returning to Indianapolis, its Medical Society hauled Dr. Guedel in front of the Ethics Committee—threatening expulsion for false claims of primacy for an invention. 4

$ 90.00: one tenth of its 'new' price of $1000.00.

Leadership in Anaesthesia

147

Cooler heads fortunately prevailing when his colleagues testified that he had already used the technique routinely on many patients (including his wife), had been straight forward in his presentations, and had never claimed primacy for the invention—but as a reliable method for relieving obstetric pain. The controversy settled, Arthur was not reprimanded, but the polemic did help his anesthetic practice; the Medical Society and surgeons started to recognize his contributions to the anesthetic field, and his practice and reputation took flight. Arthur learning another important lesson from the experience: not to be absent for his next baby's birth. Gretchen was born in December of 1914. The contrite doctor standing by Flo's bedside for the delivery. His second daughter born in Indianapolis, just after the First Battle of the Marne in France became the Western Front stalemate that would interrupt Guedel's anesthetic career in America, from 1917 to 1919, when he volunteered to serve the American Expeditionary Force abroad. †

Creative Dualism Arthur sought a definitive demonstration. A showpiece spectacle that would convincingly demonstrate the utility of his newly designed airway device—a cuffed intratracheal catheter—that could solve a pressing anesthetic problem. Now, back in his basement in Indianapolis (he had returned intact after the Great War and established an Anesthesia Practice in the City), Guedel had established a laboratory to design anesthesia apparatus. Here he had decapitated a condom sheath and glued an inch and a half of the remnants to the end of a finger-breadth rubber tube: making sure that the sheath was about a fingers-breath clear of its tip. To allow intermittent syringe inflation of this 'cuff' with around seven cc's of air, Guedel had cemented a fine-bore rubber tube into the condom and run it the length of the catheter so that this could be operated conveniently: well out of the patient's mouth. The pressing anesthetic problem Art was trying to solve was how to limit the loss of precious anesthetic gases leaking past the intratracheal catheter connected to the anesthesia bag to-and-fro system that his colleague and fast friend, Dr. Ralph Waters, had designed. The most commonly used anesthesia system of the time consisting of a four-liter black rubber bag attached to a "Waters" cannister: a foot-long silvered torpedo shaped device

148

5. Arthur Guedel

filled with soda lime (to absorb exhaled CO2), that was in turn, either connected to the patient's mask, or, very rarely, to an endotracheal tube— endotracheal intubation, a practice that Guedel hoped to encourage by means of a spectacular demonstration. 5 The issue at stake for Guedel was an economic one. If he could restrict the use of gas—oxygen, air, nitrous oxide—to that contained in the anesthesia bag and cannister system, and not let it escape around the patient's mask by sealing off the airway using a cuffed endotracheal tube instead—anesthetists would not incur the expense and inconvenience of having to constantly replenish the tiny portable gas cylinders of the day; carried from place to place to provide anesthesia services. Guedel had practiced the endotracheal intubation technique already in a patient or two: writing excitedly to Dr. Ralph Waters of its success in sealing the airway: "You should have been here today. Handed a woman closed intratracheal ethylene with ether... filled her mouth and nose full of nice clear water and left it there for fifteen minutes." Eagerly continuing: "Inspiration would lower the level of water in her mouth about a quarter of an inch. But you should have seen her there— carrying her water brim full and without a gargle."(Guedel 1928a) Another letter pointing out to Waters that the technique could be problematic: "I filled another one up on Thursday. Easy stuff. If you try it, be sure to have aspirated out all the water before you remove the catheter. I left it to the intern and he didn't. Result, annoying laryngospasm due to the water, probably immediately the catheter was removed." Guedel had practiced in a few dogs too: One breathless letter to Ralph Waters predicting his planned demonstration: "Dog anesthetized—ethylene—closed intratracheal—and then the whole thing, apparatus, dog and all, thrown into a glass tank of nice warm water and kept there for two or three hours." Continuing. "I don't know anything of a dog's larynx but if it is anything like ours, I can promise success of the show." (Guedel 1928b) But a second dog, anesthetized in a similar fashion for 3-4 hours, did not fare so well. And died of pneumonitis a few days after the experimental intervention. Despite such setbacks Guedel pressed on. Determined as always to maintain flying speed—he prepared diligently for the demonstration: planning to perform the experiment in the laboratory of the Indiana University School of Medicine in mid-April 1928 5

The whole contraption looking much like a large fish with a silver body and a rubber bag for a tail.

Leadership in Anaesthesia

149

and, confident of his success, he selected his favorite pet dog: a pure-bred beagle with silky ears, dubbing him 'Airway' for the spectacle. (Guedel and Waters 1928, Guedel 1952b, Calmes 2002, Waters 1952) And had invited a suitable audience for the event: Dr. Ralph Waters, who had recently become the first Academic Chair of Anesthesia in the country, travelling down from Madison, Wisconsin, and two other prominent specialists, Dr. Trusler and Dr. Thomas, from Indianapolis. In addition two senior medical students: Messers. Meredith and Davidson, and a group of juniors collected around the anesthetizing table; packed in tight with anticipation for the planned events—most a little puzzled as to what was going to happen next as they spied a glass aquarium, half-filled with water, standing to the side. Guedel spoke softly to Airway—a little skittish from the intramuscular injection of morphin—as he eased a mask over his pet's snout. The dog licking its lips as the ethylene took hold. Its eyes closing and, as its tail stopped wagging, Arthur turned the dog on to its back and using a laryngoscope, deftly placed the intra-tracheal catheter down its windpipe and inflated the condom cuff with 8 cc of air: so hoping to seal Airway's airway. Then he carefully tied the rubber tube in place by securing this firmly with a bandage rapped around the dog's snout, and attached the torpedo shaped canister with the protruding four-liter anesthesia bag, filled with oxygen and ethylene anesthetic, to keep the dog asleep for the duration of the experiment. Well satisfied with progress, and having noted the dog's pulse— 140—and breathing rate—20—he picked up the ten-kilogram animal and gently submerged it in the tank: the water level rising and almost overflowing the tank—just the black breathing bag visible above the glassy water: gently inflating/deflating with the dog's steady respirations. But the whole inverted dog in plain sight—underwater—visible through the aquarium's glass walls: just a few remnant bubbles escaping from Airway's mouth, but none further. Not for the whole hour of submersion from 2.15 to 3.15p.m.: the beagle's heart and respiratory rate almost returning to base line at the end of the 'dunked-dog' demonstration, when Guedel emptied the breathing bag and refilled it with pure oxygen to allow the animal to recover from the anesthetic. Repeating this two minutes later, all gathered, were startled when Airway sat up in the tank. Hurriedly, Guedel moved to extricate Airway from the aquarium, but in the confusion, on lifting the animal up, the intra-tracheal catheter remained behind, the cuff still fully inflated, as he placed his pet on the floor.

150

5. Arthur Guedel

Airway stood up, looked around, shook off the water clinging to his coat, and lay down for a short nap. Then got up and trotted out. None the worse for wear—to loud applause by the gathered audience. All gathered visibly impressed that the demonstration was a success, and that endotracheal intubation with a cuffed tube could not only seal the airway from above—and so protect against aspiration into the lungs—but would also allow the use of minimal anesthetic gases to provide insensibility. That night, Ralph Waters and Arthur Guedel celebrated. Having met at anesthesia meetings around the country since 1923 they had become firm friends; corresponding almost weekly on matters of anesthesia technique and equipment design. And, as Ralph and his wife were staying at the Guedel's home; the two investigators went down to Arthurs' basement laboratory to discuss shop. Waters, while watching Guedel painstakingly attach a condom to a rubber tube, sampled his favored drink, took a tug on his pipe, and then suggested that Arthur use a doubled Penrose drain instead: an idea that was immediately adopted. Guedel ruling Waters a collaborator in the cuff development from that time on: all that remained to be decided was upon whom the primacy of authorship should be conferred—a matter that was settled by coin-toss: the Guedel-Waters Cuffed Endotracheal Tube so named in perpetuity. A good few drinks later, Waters’ made another suggestion. That they repeat the demonstration at the forthcoming Meeting of Anesthetists in the Miscellaneous Topics session of the American Medical Association to be held in June at the University of Wisconsin. Guedel and Waters together performing the demonstration with a different dog, a terrier, to loud acclaim. Airway having retired to the Waters’ household, no longer a dunked dog, but again a pet. (Waters and Guedel 2019) (Correspondence 2019) † Much earlier. In fact nine years earlier, returning from the Western Front, 1 April 1919, honorably discharged as a Captain from the Army, Guedel returned home to Indianapolis. The war concluded, Guedel's fight was far from over. In fact only beginning. Penniless, he rejoined Florence and their two girls: Marian and Gretchen and started the struggle that would consume the rest of his life on three fronts: work, wealth and—probably because he was a heavy smoker—

Leadership in Anaesthesia

151

health. Haltingly finding work, but inexorably struggling with the latter two, for the rest of his life—his vacated Deaconess Hospital job taken by another; he started work as a free-lance anesthetist, fitfully picking up cases round town. Guedel also realizing that, while he had a knack for the making of anesthesia equipment which might bring in much needed remuneration; he also needed to understand the science behind anesthesia better. Consequently, he established basement, garage, or home laboratories, in each of the houses he lived in over the rest of his career—to forge new anesthetic equipment that he hoped to bring to commercial use; anesthesia equipment companies like Foregger and Heidbrink becoming the major beneficiaries of his work. Nevertheless often provoking much controversy in its wake: The previously controversial "Guedel Gas Apparatus" that Florence had tested with Marian's birth, now commercially produced by A.C. Clark & Co being a case in point. Although commercially available from 1917, in 1922, a storm of controversy erupted when Arthur presented his findings for the use of "laughing gas" in obstetrics, at the National Anesthesia Research Society meeting in Columbus, Ohio. Contending that he had perfected painless child-birth using nitrous oxide he invited any willing patient for a demonstration, the local newspaper emblazoning the invitation, fanning the polemic: Guedel Discovers Way to Make Birth Painless Seeking Woman to Demonstrate Efficiency of Guedel Treatment "A storm of debate in medical circles has been aroused." Responded another. Yet another quoted a well-known Grant Hospital obstetrician, Dr. Goodman as saying: "This is nothing new, but extremely dangerous." Adding, in response to Guedel's assertion that babies born after nitrous oxide administration were pink at birth: "next we will have a noon-day snooze which will make babies red, white and blue." By the end of the meeting where Dr. Guedel had received the National Anesthesia Research Society Silver Cup for his efforts on behalf of laboring patient, a reporter still lamented that: "As the convention drew to a close no woman had been found who would submit to a test of the new gas."

152

5. Arthur Guedel

Interpretation. These were difficult times for anesthetists. There were still far too few of them that were well-trained; surgeons remained skeptical of their efforts; and anesthesia was far, far from safe. In fact often deadly: the anesthetic agents of the time: ether, chloroform, ethylene, and ethyl-chloride, killing patients through mechanisms that were little understood—or through respiratory depression and airway obstruction that was patently obvious, but inexpertly managed and so commonly fatal. Hence research, by those few who were willing to undertake it—considering that it brought in no money and was often expensive—was directed at finding ways of more safely administering the anesthetics as well as investigating measures to combat respiratory obstruction; spurring the developments of airway devices and anesthetic techniques that could assist with this problem. Private researchers like Guedel, creating their own home laboratories (and hoping to profit from their inventions), while the occasional university professor like Dr. Ralph Waters as the first Academic Chair of Anesthesiology in the country, had access to a University Laboratory at Madison in Wisconsin. As further background: at the beginning of the twentieth century in the United States, where both Drs. Guedel and Dr. Waters’ story starts, anesthesia practice was rudimentary; there were no exclusive practitioners, permanent departments, or residency training programs. In fact it was an altogether ad hoc affair. Nurses, surgeons, medical students and as I noted: orderlies, secretaries and chaplains serving in the AEF, were often pressed into administering anesthetics when the need arose. The demands of the American WW1 war effort accelerating the pace of anesthetic development to keep up with the terrifying wounds that the new shrapnel laden bombs and machine guns inflicted; the surgeons performing ever more complex surgeries to save their patients, requiring ever more facile anesthetic techniques. As a result surgery and anesthesia advanced hand in glove. One other driver was the universal fear of pain. The pain of surgery and that of childbirth. Particularly influential in motivating for relief from obstetric pain in the United States was the feminist movement which had its inception in 1848, and sought not only the universal suffrage achieved in 1920, but also strove to improve the medical care of women and children: maternal mortality rates having changed little since 1853 when Dr. John Snow administered the blessed chloroform to Queen Victoria for the birth of her 8th child. (Caton 1997)

Leadership in Anaesthesia

153

But the use of chloroform and ether had been largely abandoned in obstetrics as the majority of experts had concluded that the risks of anesthesia outweighed its benefits. Hence, Dr. Guedel's brave foray into treating this problem by applying a nitrous oxide gas machine met with such initial opprobrium in 1911 (despite Florence self-testing the device for Marian's birth), to be eventually acclaimed in 1922—the previously championed Twilight Sleep, induced by a shot of morphine and scopolamine and applied to provide obstetric analgesia, falling into disfavor. Because: firstly, the idea originated in Germany, and, secondly, one of the major protagonists of the national Twilight Sleep campaign, Mrs. Francis Carmody of Brooklyn, had died during child birth herself in 1915, having received the intramuscular cocktail during labor. Dr. Arthur Guedel going on to take up the life-long challenge of improving the safety of anesthesia by collaborating with various colleagues: Dr. Richard von Foregger, an equipment manufacturer, and Dr. John Lundy, Dr. Paul Wood, Dr. Wesley Bourne and many others, but most especially with Dr. Ralph Waters; bouncing ideas off of each other; creating novel anesthetic equipment and approaches that would stand the test of time. Creative dualism at its best. Reaching its apogee in the Guedel-Waters collaborations, as they refined together, not only the endotracheal tube described in the dunkeddog experiments, but also the Guedel Airway and, in their very first of literally hundreds upon hundreds of discussions: talked of Arthur's wish to add a further physical sign—increasing intercostal paralysis—from ether anesthesia, to the Anesthesia Pocket Chart that Guedel had first developed on the back roads of the Western Front, and would eventually become the basis of Arthur's text book: "Inhalational Anesthesia" published in 1937. One of the first anesthesia text books to follow and build on Dr. John Snow's concepts developed in turn, in his own first text: "On the Inhalation of the Vapour of Ether" (1847), Guedel defined the stages of anesthetic depth that could be monitored by physical signs in the patient; identifying danger signals: which if surpassed could put the patient in peril of respiratory depression or death. Guedel in writing the preface to "Inhalational Anesthesia," which he termed "A Fundamental Guide" described the book aptly in motoring terms: "The road guide for the motorist is intended to get him to his destination. It points out the landmarks necessary to that end, but avoids unnecessary detail."

154

5. Arthur Guedel

Probably remembering the many rutted roads of the shattered Western Front, he continues: "Neither does it describe all the obstructions in the road nor the temporary changes of varying conditions. A rut or boulder may be here today and elsewhere tomorrow." Then referring usefully to "Inhalational Anesthesia:" "Like the road map for the motorist, this outline is intended to guide the anesthetist up to and through his first few general anesthesias. It is not complete in detail save where detail is necessary." Guedel reserving that for his detailed description of the 'Signs of Anesthesia' section of the book. Predictably, Dr. Ralph Waters wrote the foreword to the book: "Due to the deplorable lack of knowledge of anesthesia in the medical corps of the American Army during World War 1, the author of this little book found himself in the embarrassing position of providing pain relief for our wounded soldiers in several base hospitals in the war zone." Going on: "The necessity was obvious for a simple and rapid means of teaching physical signs and danger signals which could be readily grasped by the uninitiated." (Guedel 1937) Waters commenting, much later, on his collaborator's masterful skill set—that of being able to tell the perfect story, embellished just right to illustrate a point, and his remarkable "tendency towards practical simplification rather than towards more complication of methods and concepts."(Waters 1952) A refined leadership ability indeed: to master simplicity from complexity. † These were undeniably difficult times for anesthetists; even for those as well trained and capable as Arthur Guedel. In the winter of 1920, his free-lance anesthesia practice not providing sufficiently for his family, Arthur accepted the position of Chief of Anesthesiology at the Swedish Hospital in down town Minneapolis. Packing up his family and pets, they motored the 600 miles west across the country to start the well-remunerated position; only to find that he was expected to start a Nurse Anesthesia School as part of his responsibilities. This posed a problem.

Leadership in Anaesthesia

155

During the Great War, when there was a paucity of any kind of anesthetists, Guedel had extended training to all; using his Anesthesia Pocket Chart and building the Chaumont Headquarters into a training center. Indeed there were American nurse anesthetists: Margaret Henke, Sarah Greenhalgh and Hazel Alkire, seconded to Base Hospital 32, under his command as Captain. But, back in the States—Arthur believed that Anesthesiology should be the practice of medicine and run by doctors only. (Guedel's thinking may well have been influenced by the fact that such was the case in Belgium, England, France and Germany: whose country-men he had encountered during his time in the AEF.) So he refused the job. Resigning because he felt that he should not train nurse anesthetists to become the equivalent of Anesthesiologists as they were not doctors to begin with. So, having just moved his whole family and already struggling to make ends meet, he needed work and found a little by joining the Minneapolis General Hospital: providing some private practice anesthetics in the city, writing a monthly column—'Anesthesia Notes'—for the Lancet, and giving a daily lecture to medical students and interns at the School of Anesthesia at the General Hospital—all while conducting personal research at home. Serendipitously, he met Dr. Jay Heidbrink, a local dentist, who had financed a small postgraduate school of anesthesia at the General Hospital and founded a company to manufacture anesthesia gas equipment: collaborating and likely developing a prototype for a new "midget" anesthesia machine that would eventually be marketed by Dr. Richard von Foregger's Company, and further refined by the Waters - Guedel duo. Still not busy enough to support his families' needs by April; Guedel reapplied to Mr. Wills—superintendent of the Swedish Hospital— for the position that he had so recently resigned from. Requesting a position as a "Professional Director of Anesthesia" with a minimal monthly salary of $250, payment of $1.00 for each patient anesthetized by the department, and permission to do private work, should that be asked of him. Undertaking to instruct anesthesia technicians and medicals students in better anesthesia—through lectures, clinics and supervision of their work. Partially motivating this reapplication was the fact that Guedel— as part of his responsibilities at the General Hospital—had been required to teach a mixed group of clinicians at Heidbrink's post graduate school of anesthesia comprising: twelve physicians, four dentists and three nurses. Complicating the matter of this 'mixed' education of different practitioners,

156

5. Arthur Guedel

more especially because there were nurses in the mix, was the fact that Arthur had received a respectful, but forthright letter from Dr. Frances Hoffer McMechan admonishing against training nurses anesthesia. 6 McMechan, one of the foremost anesthesiologists of the time, had been crippled by rheumatoid arthritis, confined to a wheelchair, and no longer practiced anesthesia, but instead had dedicated himself to professionalizing its practice (to distinguish it from nurse anesthesia practice) and had also launched the International Anesthesia Research Society—serving as the Editor in Chief of its journal: "Current Researches in Anesthesia and Analgesia" —fast becoming the pre-eminent journal for anesthesiologists, that Dr. Guedel sought to publish his work in. His quest for work was however, rudely interrupted by the sudden death of his Swiss father, John Guedel, back in Indianapolis. Arthur returning there hurriedly to bury the 78-year-old and upon seeing a local advertisement, immediately availed himself of the opportunity to apply for the Chief of Anesthesiology position at St Vincent's Hospital there. Upon returning to his family, who could not travel to the funeral for lack of funds; Guedel was greatly relieved to receive a telegram offering him the position. Promptly resigning—when the school year finished in June—to drive Marian, Gretchen and Florence back the 600 miles east to Indianapolis: they moved into their newly purchased home on Carrollton Avenue. Arthur now feeling much richer—secure in the knowledge of a whopping $5000.00 per year that the Hospital had promised him to take on the job—added a basement animal laboratory to his new home and kitted it out with necessary tools to study anesthetics, perform experiments, build apparatus, fashion equipment, and generally tinker around designing contraptions that might improve the safety of anesthesia. Ill-pleased with the tendency for anesthetics to cause the lifethreatening airway obstruction that he had encountered in his many patients on the Western Front—Guedel sharpened his endeavor to find solutions to the airway problem. Florence aiding and abetting him in his endeavors. Ever-helpful in matters of anesthesia, she purchased sheep's larynxes and trachea's from the local butcher for close study of the utility of his devices in static conditions. But seeking to contrive the real-life situation, Guedel also performed live 6

Dr. Ralph Waters echoed this sentiment against training nurse anesthetists, in a personal letter to Dr. Guedel (Dec 2, 1927), this being the prevailing opinion amongst physicians attempting to advance the nascent specialty of anesthesiology in America.

Leadership in Anaesthesia

157

experiments anesthetizing dogs in his basement. These were more expensive to study though: costing four dollars if they died or just one dollar if returned to the pet-shop in good nick. But Arthur did not just perform practical animal experiments and craft equipment—he also attended to clinical questions: addressing lucidly, the theoretical and practical aspects of anesthesia; performing clinical evaluations of anesthesia's effect, in studying the efficacy of ethylene, divinyl-chloride and cyclopropane; and researched the reasons behind the tendency for anesthetics to cause explosions in the operating room. Writing a series of eloquent articles and a guidebook on the use of nitrous oxide—he outlined the clinical signs of the deepening planes of ether anesthesia in: "Third Stage Ether Anesthesia: Signs and Stages"—and was also intensely interested in the effects of anesthetics on metabolic rate: debating such matter's in copious correspondence with Dr. Ralph Waters; both extending their discussions on equipment design to include Dr. Richard von Foregger. Dr. Foregger, an Austrian with a Ph.D. in chemistry from the University of Bern, had first worked for the General Electric Company in New York before becoming interested in the science of oxygen generation, which in turn led to an interest in anesthesia equipment for which he had set up a workshop in a barn at Roslyn, Long Island, in 1914. Foregger's modus operandi was to team up with specialist anesthesiologists to develop anesthesia equipment, and, in Guedel's case, Dick would become an important source of income in royalty payments on the Guedel Airway, when Arthur became terminally unemployed and his income dwindled. (Foregger 1996) Interpretation. With respect to the development of the Guedel Airway the following: Although Sir Frederick Hewitt had fashioned a short straight tubed 'airway' back in 1908 to keep the mouth open, and the need to counter upper airway collapse had been documented as far back as 1880, very little effort had been expended in designing a device that could maintain patency of the air passageway to the lungs—until Dr. Ralph Waters modified Hewitt's design. Engaging Foregger's steel smiths to help; they flattened Hewitt's circular tube; curved it to better adjust to the oropharynx—its inlet hovering over, but not entering, the glottic opening—and Waters had the smiths add an attachment for gas insufflation to a side port at the tube's mouth. A flange around the tube's opening had also been created to limit the device's entry into the mouth—contained by the patient's lips—but there was still a major drawback: much damage to teeth was incurred—when the patient clamped

158

5. Arthur Guedel

their mouths tightly around the steel device: clenching of teeth, a common phenomenon as patients recovered from anesthetics—their surgeon's most unhappy by the shattered teeth that resulted. Guedel wanted to find a solution to this conundrum in his laboratory, believing that an airway needed to be in place when patients recovered from anesthesia, to avoid the obstruction that the inevitable pharyngeal spasm incurred, maintaining, rightly, that this could not be adequately managed without one—he suggested an approach to resolve the life-threatening problem: "By holding the gas mask tightly to the face [so that] a small amount of oxygen may be forced past the obstruction. " And so he fashioned a similarly shaped device to that contrived by Waters, but completely made out of rubber, with a short square metal 'mouthpiece' insert embedded in the opening of the device at the mouth, so that when the patient clamped their teeth down around it, the airway would remain patent and their canines intact. Guedel and Waters again bandying about design modifications— in their personal interactions and correspondence—to create an airway device that is still in use to the present day: manufactured by Foreggers Company Inc. and eventually sub-licensed to the Heidbrink Company. (Mani 2016, Baskett 2004) Similarly, before the Guedel-Waters advocacy for the use of an "upper" airway device to combat respiratory obstruction described above, in the 1920's, and before their vivid 'dunked dog' demonstrations to promote the use of endotracheal intubation, the use of a metal or rubber tube to 'intubate' a patient's trachea was not the order of the day. In fact far from it. Usually anesthesia was administered via a mask of some sort. The 'mask' could be of wire mesh covered with a cloth material upon which was dripped ether, chloroform, or ethyl-chloride in sufficient quantities to anesthetize the patient—or instead the 'mask' could be made of rubber or be a lead-clad-leather device that fitted more snugly to a patient's face, to which anesthesia tubing or anesthesia gas apparatus was attached—so that the anesthetist could deliver the anesthetic to the airway: the naso-oropharyngeal space leading to the windpipe and lungs. The patient inhaling and exhaling the anesthetic without any external assistance (ventilation) being applied by the anesthetist. In other words: the anesthetist relied solely on the powers of the patient's breathing and patency of the airway to deepen or lighten the anesthetic—the patient

Leadership in Anaesthesia

159

in turn inhaling the additional anesthetic provided, or if the anesthetic agent was withheld: exhaling anesthetic from their body to recover. And while ether was the sole anesthetic that stimulated the patient's respiration, enhancing their inhalations and exhalations: all others suppressed breathing immediately—ether also doing so at higher dosages. And therein lay one of the greatest dangers of anesthetic administration. Respiratory paralysis and predictable death. (Occasionally, if respiratory arrest (apnea) occurred, some anesthetists from John Snow's day on had been taught to provide artificial respiration—turn the patient over and knead their chest, while snow-angelling their arms to expand their ribcage—with variable results at best; but this technique was far from the norm, and hugely ineffective in resuscitating the patient.) Common practice therefore was reliance on an "open" natural airway and spontaneous breathing efforts by the patient to maintain the anesthetic and their life. It is not to say that intubation of the trachea had not been previously described; it had, and as far back as 1791, when James Curry used the method: the various tubes described made of either steel, rubber, or leather. It was just not common practice in America. Although in England, the Great War had propelled the use of the Magill rubber tube, placed through the nose, so that British surgeons could work to repair the destroyed faces of allied soldiers. These first endotracheal tubes were selected to be sufficiently sized to fill the vocal slit of the trachea leading to the lungs, and, to avoid any leakage past the tube, the pharynx would be packed with gauze. Hence the Magill tube did not have the added benefit that the Guedel-Waters inflatable cuff conferred: namely, protection from aspiration of stomach contents and the ability to fully control ventilation7 and so minimize the need for supplemental anesthetic gases if the Waters’ carbon dioxide absorbing canister was attached in the anesthetic apparatus; just added oxygen could be given, as the average patient only needs around 250 milliliters of oxygen gas to survive—expelling this as carbon dioxide which was in turn removed by the calcium carbonate granules in the Waters' canister. (Waters, Rovenstine, and Guedel 1933) What was in common practice by the 1912's; was insufflation anesthesia. After anesthesia had been induced using a mask, a narrow catheter would be fed down into the patient's trachea blindly and high flow ether and 7

Through intermittent inflation of the lungs by squeezing the rubber anesthesia bag inflated with gas.

160

5. Arthur Guedel

oxygen supplied through the slight catheter to continuously anesthetize the patient—critically positioned so that sufficient space existed "between the outer wall of the catheter and the vocal chords, for the escape of the insufflated air." The technique however was slowly falling into disfavor because the high flow gases applied in the conduct of insufflation anesthesia, not only cooled and dried the patient's airway, but also expelled the carbon dioxide necessary to the patient's respiratory drive, and, if the blindly placed catheter impinged into a patient's tissue, would create a "wind tumor," a cause of much anesthetic embarrassment. Hence anesthesia conducted with the Guedel-Waters cuffed endotracheal tube would eventually supplant insufflation anesthesia; but required some expertise to apply. First the anesthetist needed to learn how to provide sufficient anesthesia to obtund airway reflexes that would be provoked by placing a rubber tube into the trachea, and, secondly, a device, a laryngoscope, was needed, that would allow the anesthetist to visualize the tracheal opening to place the endotracheal tube. The Foregger Company, Inc. Anesthesia and Respiration Appliance - Catalog soon advertising the Guedel Laryngoscope: an, L-shaped, steel device, comprising a two-battery filled silver handle, and three different sized blades—small, medium, large—each with a light at its tip, that could be screwed onto the handle as needed: for pediatric, teenage or adult patients: "Designed for the anesthetist to facilitate rapid endotracheal intubation." And priced, reasonably, at $47.00 for a complete set. And in order to make anesthesia administration an altogether more organized affair, Guedel designed the first 'Sleep Machine.' Hoping to consolidate most of the accouterments now needed to administer anesthesia: the oxygen, nitrous oxide, carbon-dioxide and cyclopropane cylinders; the water depression flow meters used to guestimate the amounts of ether administered; the foot pump used to insufflate oxygen; and the needed gas delivery tubing, anesthesia bags, and Waters’ cannister into a convenient system—Guedel put this all together on a cabinet-trolley on wheels. Reaching about hip height and topped by a nice horizonal working surface under which were stacked three vertical drawers, hovering over a trestle where the foot pump was handily placed; the whole contraption could be wheeled around the hospital to the operating room, radiology suite, or wherever the anesthetic needed to be provided. The "Old Gray Mare" becoming the standard structural design upon which future anesthesia machines would be based.

Leadership in Anaesthesia

161

But it was not quite suitable for what Waters and Guedel next had in mind—they needed something more portable that could be carried from place to place and deposited into the back of one's car to do so. A small sleep machine. A Midget. Guedel and Waters again working with Dr. Richard von Foregger during the course of 1924-1927 to fashion such an apparatus. Held together by a central handle it incorporated a clutch of small "A" gas cylinders attached to either: four yokes (Waters’ design) or, five yokes (Guedel design), and eventually comprised six yokes, with two flow meters incorporated: one for oxygen and one for the explosive cyclopropane—all conveniently packed in a sturdy-strapped-leather carrying case, that you could sling right across your shoulder. Designed specifically with portable, low-gas-flow anesthesia in mind—that the Waters’ to-and-fro canister, and the Guedel and Waters’ cuffed endotracheal tube allowed—the Midget would soon be put to good use in private practice anesthesia in California, and in the future, see service during the World War II, where it reprised as the "Fox Hole Midget" anesthesia machine. (Ball 2013) † Meanwhile, things went along swimmingly in Indianapolis. Until they didn't. Art waking up one morning with a grumbling stomach pain; Flo thought it was just his insomnia acting up, and the after-effect of lack of sleep, that was such a common problem for him. But no—the grumbling ache became a growl, and turned into acute cholecystitis requiring urgent operation. Art, as usual, worried much more about the competence of the anesthetist than that of the surgeon assigned to take care of him emergently—fussed about it endlessly; Flo calming him nevertheless. Four days later things went from bad to worse. Arthur's abdominal wound ruptured: bowel spilling out onto his bed sheets when he coughed, probably from smoking a cigarette in bed— wound disruption often proving a fatal event in the late 1920's; especially in a 212-pound giant. Six weeks of stormy convalescence followed, the inevitable infection overcome, and Arthur recovered; a shrunken and wasted man— only a shadow of the gymnast and wrestler that he had been. His doctors predicting that he had only five years to live; his brother Walt—who had been summoned to Art's deathbed from Los Angeles, California—

162

5. Arthur Guedel

suggesting that the two Guedel brothers should go into the burgeoning briquet business together: the citizens of the Sunshine State barbecuing with charcoal all year round, and the weather in the west much more conducive to Arthur's recovery. Accordingly, while convalescing, Guedel contemplated whether to abandon clinical anesthesia altogether—he found it a great stressor—in favor of becoming a business man to make some hard-needed money instead; Art took up his brother's offer and travelled to California in May of 1927 to start the joint venture. It came to naught. Three months later they gave up the idea. Enough time however for two surgeons: Dr. Hutchinson and Dr. Seymour to convince Art that there were too few anesthesiologists in Los Angeles and that they needed someone full-time to take care of their work. Art returning home to Indianapolis—recommitted to the practice of anesthesia and his research—but nevertheless contemplated a move to California a year later, should Flo and the girls agree.

The Great Depression of 1929 On July 15, 1928: their Ford packed full, the Guedel family left for Los Angeles. (Not having any room in the car, Airway had been dispatched by express mail to Ralph Waters’ house in Madison, Wisconsin, and their remaining dog—to Beverley Hills, where Guedel had rented a house.) Arthur, on arriving in California became ever more doubtful of his ability to "make a go of it in LA" but was much bolstered by Ralph Waters encouragement of the business in canine vernacular: "Stick your tail in the air and go to it." Both loving to tell pet-dog stories in their exchanges. Maintaining flying speed, the family was soon ensconced in their rental on Linden Drive; Marian and Gretchen enrolled in high school; Florence explored the Beverly Hills Woman's Club; and Arthur had calling cards printed and started looking for work. His first case at St Vincent's Hospital calamitous. Nervous as hell, Arthur had put together his Midget, filled the cylinders to capacity, and checked all his equipment meticulously. It was a set-up: the first time he had worked with the surgeon— one of the kingmakers of the hospital. The patient: a young mother of a nine-year-old boy coming for a hysterectomy:

Leadership in Anaesthesia

163

Her husband—the best X-Ray man in the Hospital—standing by in the Operating Room. In the confusion, Mrs. S had not received the usual premedication of morphin and scopolamine and so too was nervous: her adrenalin running high. Arthur sought to calm her, placing the mask over her face with his hooked right hand; he dialed in the Nitrous Oxide with his left—turning up the N2O control valve to its maximum—100%: Six liters a minute; he bled in some ethylene anesthetic: "Some cyanosis" she turned blue. "I felt the pulse to be indefinite. Seemed feeble but still passable." "As cyanosis increased I inflated with Oxygen." "No Pink"—indicating that the oxygen was having no effect. Instead: "More oxygen." "No Pink." "No pulses." "I put a catheter [endotracheal tube] into her larynx and conducted artificial respiration by inhaling my own lungs full of oxygen and blowing it into her lungs through the catheter." To no avail, despite these desperate attempts—Mrs. S.: "died within three minutes after the anesthesia was started, and before the operation was begun." Her husband witnessing it all. And Arthur extremely depressed about his first case at St Vincent's Hospital: "We sometimes feel the futility of our efforts. There is so damned much we do not know." And...... a few days later in October of 1928, as Guedel dragged himself from clinic to hospital and back again: picking up dribs and drabs of anesthetic work—he was practicing insufflation anesthesia at the Free Clinic at Sawtelle: "The jinks tried to stay on. Had an emphysema in a five-year old child." Otherwise known as a 'wind tumor' the insufflation tube feeding in high pressure oxygen into the child undergoing a tonsillectomy under general anesthesia got stuck in his pharyngeal tissue and: "Plump" "-up goes the left side of his neck and face." These complications, and the slow process of getting established in a totally new environment took its toll on Guedel's mental state—he complained to Ralph Waters in the Spring of 1929, that he had "just finished a rotten month mentally" and had developed an intention tremor making it

164

5. Arthur Guedel

very difficult for him to practice clinically; he had tried to cut down cigarettes and coffee drinking—so hoping to minimize his increasing performance anxiety. He kept applying for jobs in central Los Angeles, but his reputation as a "trick anesthetist" hurt him. Known as a trick anesthetist because of his penchant to use the Guedel-Waters cuffed tube to intubate his patients; many of surgeons feared that this practice would "destroy" their patient's larynx post-operatively; had mixed feelings about this new Anesthesiologist from the east; and so followed their patient's post-operative process assiduously looking for any signs that this complication might develop. Guedel noting that indeed some patients did get sore throats if the cuffed balloon was inflated too vigorously: he was most particularly wary of causing laryngeal damage in patients who sang as a vocation and eschewed use of the new endotracheal tube in singers. Always short of money—despite the "Roaring Twenties" economy of Los Angeles—Arthur followed the local advice: he borrowed $9500 from his brother, Martin, and bought a nice plot of land on North Bedford Drive— hoping to build a house and sell this at a profit. Doubly sure that this would be the case as the plot was in tony neighborhood; close to Wiltshire Boulevard and the Los Angeles Country Club. (Waters and Guedel 2019) Consequently, by September 1929, one month before Black Tuesday's Stock Market crash would launch the Great Depression, things were looking up for Guedel and his family. He was averaging two and one-half cases a day, but wanted more. The girls were reasonably happy and the family had moved to their newly built home. Hoping to improve the situation further he had applied to be Head of Service at the Good Samaritan Hospital and there was talk of a new Jewish hospital that would likely be completed the following year. He noted however, somewhat surprised at the fact, that he and the other physician anesthesiologists were often pitted against nurse anesthetists— supervised by surgeons—in providing anesthetic care. This despite last year's California Board of Medical Examiners ruling that anesthesia was the practice of medicine. And. Although many nurse anesthetists had lost their jobs over this, many hospitals, including St Vincent's where he had practiced, had ignored the statement, often flaunting their practices of nurse anesthetists, whose numbers were vastly greater than anything he had encountered in Indianapolis. Putting him on a collision course as the Great Depression deepened. (Van Nest 2006a) One month later, in October, things were no longer so rosy: Guedel was in "a rotten mental state," he missed Indiana greatly, was living well

Leadership in Anaesthesia

165

beyond his means now that the Depression was biting, and, needed to cut costs to make ends meet. He had put up the house for sale, hoping to profit from the endeavor, if he could get the $45,000 asking price. He would be sorry to sell though; having again fashioned a nice animal laboratory in his Beverly Hill's home garage. And things got steadily worse: The Cedars Lebanon Hospital—a two hundred bedded hospital—did open as planned, but Guedel was not appointed as the Chief of either of the two hospitals he had applied for— although he was allowed to practice there. But not at St Vincent's Hospital. After Mrs. S.'s death, the hospital board had proscribed the use of any ethylene and any gas administered through ether via an anesthesia gas machine—Guedel's modus operandi. Things were however looking up academically. The Anesthesia Travel Club had been established by Dr. John Lundy from the Mayo Clinic. Launched so that the leading young anesthetists of the USA and Canada could gather together annually to discuss and present laboratory and clinical techniques at the host's home institution, both Arthur Guedel and Ralph Waters were invited as two of the select fifteen anesthesiologist's who travelled to Rochester, Minnesota, to attend its inaugural meeting in December of 1929. There was also steady progress in the adoption of the GuedelWaters cuffed endotracheal tube and the Guedel airway, and further developments on a new front—occasioned by the need to assure optimum ventilation of the patient's lungs during thoracic surgery. A necessary development as surgery of the lung at the time was attempted only with much trepidation, because breaching of the thoracic cavity by the trauma surgeon's knife often resulted in lung collapse, and eventual death, if ventilation was inadequately managed. Waters had serendipitously found a solution—that the duo would refine together—when he mistakenly intubated the right bronchus, instead of the trachea, with a cuffed tube. Noting that this provided one-lung ventilation to the right lung (and allowed the left lung to collapse for the planned surgery) without the patient decompensating—Guedel and Waters collaborated on the double-cuffed endobronchial tubes: which became the standard approach for thoracic surgery. In addition, Arthur Guedel had set up a relationship with Dr. Chauncey Leake and Dr. Peter Knoefel. Travelling from Los Angeles to San Francisco to perform dog-lab experiments at the University of California San Francisco Laboratories on Parnassus Avenue, investigating divinyl ether, mechanisms of death from anesthesia, and, eventually, cyclopropane anesthesia—that would form the basis of many erudite publications and

166

5. Arthur Guedel

serve to expand Arthur's reputation as one of the foremost academic anesthesiologists of his time. It didn't bring in any money though. In fact he often had to pay for the privilege. So he had to continue practicing anesthesia (often very reluctantly) to make ends meet. Finding that he often had to decline cases because they were all booked at the same time of day (8am) at different locations, he took on a willing partner, Dr. Ike Wineland who had been trained by Dr. Waters in the residency program at Madison, and was willing to move west to start his career. Strategizing endlessly together on how best to bring together a group of anesthetists to create a Department of Anesthesia, as Ralph had been able to do at the University of Wisconsin, (and Dr. John Lundy at the Mayo Clinic) they commiserated about the difficulty of providing decent anesthesia services to patients without having a single anesthesiologist in charge—a chief anesthetist who was accountable to the hospital for all the service delivery. No matter that this chief might delegate this service to other physicians who might actually be more competent than the head of department: what was far more important was that there be one mind that was responsible for the science, instruction, clinical co-ordination, efficiency, and safety of the Hospital's Anesthesia Service. Guedel and Waters were also of one mind on another matter: that they should rather train anesthesia physicians and even technicians to bring them up to the necessary standard, but not train nurse anesthetists, because they strongly believed that Anesthesia should be the practice of medicine, and they were intent on developing the professionalism of anesthesiology practice. Interpretation. Nurse administered anesthesia was likely the most common practice of anesthetics in the United States at the time: developing over several decades after William Morton first demonstrated the use of ether in Boston, in 1846. This was based on the surgeon-nurse anesthesia model that took hold in America. (Koch 2015) American surgeons recruiting nurses to serve in the civil war, and beyond—directing them on how to give anesthetics from across the drapes. In contrast this was not the case in England, and many European countries, where news of the American discovery had soon spread. Within a month in fact. Why the discipline of anesthesia developed so differently on the two continents is open to conjecture, but likely rests with the pharmacology (and relative safety) of ether versus chloroform; the controversy surrounding

Leadership in Anaesthesia

167

ethers' discovery; and the professional image of their respective champions: Dr. William Morton and Dr. John Snow. (Greene 1975, Snow 2009) Firstly, ether which predominated in America, was a much safer agent to administer. Bar the fact that it was explosive, it stimulated respiration and blood pressure, and so could be administered more easily by less trained practitioners as demonstrated by Dr. Guedel with his Anesthesia Pocket Chart for ether administration on the Western Front. In stark contrast, chloroform, which predominated in England and Europe, killed: unpredictably, and was considered far too dangerous to administer by non-physicians. 8 Some, countries like Germany, legislating specifically that anesthesia could only be administered by physicians in person. Although chloroform was non-explosive, this anesthetic was much more potent than ether: depressing respiration, the heart, and circulation, and could result in malignant irregularity of the heart beat that was inevitably fatal. Hence it was considered to require much more training to administer. Secondly, the professional image of the two major champions of ether and chloroform impacted the way physicians regarded the emerging discipline of anesthesia. William Morton, a half-trained dentist, and the disputed discoverer of ether, had neither the respect nor professional reputation in Boston that Dr. John Snow had in London. In fact the opposite. His claims for the ether discovery—echoing for the next forty years or so—and his sullied reputation, would bring the practice of anesthesia into disrepute; consequently surgeons relegated the conduct of anesthesia to those lowest on the totem pole—medical students or interns, and if those were not available, dressers, orderlies or even a member of the family, was put to the task. Hence, no self-respecting doctor of the time saw anesthesiology as of sufficient professional or scientific challenge to pursue. Contrast this with the situation in Great Britain. Here, Sir James Young Simpson, a noted surgeon, and a powerful crusader, had identified chloroform. While Dr. John Snow, the renowned physician scientist, had become its major protagonist; conducting extensive research and writing two books on the subject. Hence in Great Britain, anesthesia was solely practiced by physicians from its outset in 1847. However, on both sides of the Atlantic Ocean during the rest of the 19th Century, anesthetics as an academic professional discipline had been 8

The practice of chloroform anesthesia was little adopted in America, largely because Boston Surgeons of the time (1847) feared the lawsuits that would inevitably be brought for wrongful death by patients' families.

168

5. Arthur Guedel

left at the starting post when compared with, say, medicine and surgery. Such progress in other disciplines often stemming from the University Professors who had advanced the profession through scientific inquiry, scholarly writing, and structured education programs—until at the start of the 20th Century, the likes of Sir Frederick Hewitt and Sir Robert Macintosh in England, and Dr. Arthur Guedel and Dr. Ralph Waters in America, set out to improve the situation. Meanwhile in the interregnum in the United States, during the closing of the 20th century, nurse anesthesia had developed apace to help fill the breach in competent anesthesia practice that American patients deserved. The usual model being that the surgeon directed a nurse who committed to anesthesia practice—the first formal nurse anesthesia training program developed at the Mayo Clinic in Minnesota in 1889. (Koch 2015) Here, Dr. William Mayo undertook to instruct Miss Edith Graham, a practicing nurse, on how best to administer anesthesia. As she went on to marry his brother, Charles, in 1893, and so left nursing practice, she was replaced by Alice Magaw who would become justly famous—perpetuating the training of nurse anesthetists, which, although not fully formalized at that early stage, resulted in the concept spreading to surgeons in other states such as Philadelphia, New York, and Rhode Island—many so qualified nurse anesthetists moving across the country to find work elsewhere. So too, Nurse Anesthetist Dagmar Nelson, who had trained at the Mayo Clinic in Rochester Minnesota with Dr. Verne Hunt, a newly appointed surgeon, recently recruited to start work at the St Vincent's Hospital in Los Angeles. An impetuous man, Dr. Hunt had returned to the eight-floor hospital because he had completed his internship there, but had recently developed a terrible reputation for temper tantrums—throwing scalpels in anger: not just onto the floor as was the custom of the time, but out of the seventh-floor operating room windows to fall into the garden below. Having experienced the death of a patient after induction of anesthesia in 1932, and despairing of the Hospital's anesthesia services, Hunt had called the Mayo Clinic and asked Dagmar to join him to be his sole anesthetist at the St. Vincent's Hospital. This was highly unusual as the customary anesthetic practice was a physician based one; the Hospital sanctioning the appointment, despite this being in contravention of the 1928 California Board of Medical Examiners ruling that anesthesia was the practice of medicine, to appease the volatile surgeon. (Van Nest 2006a) †

Leadership in Anaesthesia

169

Depression was closing in on many fronts. Ralph enquiring of Arthur whether he was not feeling "Top hole?" Guedel complained of his paining teeth that were putting him back: his "head now out of the cyclone cellar" he still needed some tooth pulling and oral carpentry to set them right—he eventually became edentulous: shot of all his teeth. And the Great Depression was making it impossible to sell his house; he had to cut his partner Ike's salary; and his brother, who had given him the loan necessary to build the house was now flat broke: Walter was out of work completely and subsisting on only the $900.00 annual interest that Arthur repaid him on the loan. Art became increasingly desperate to find a way to support his own family and so in order to 'maintain flying speed' he started practice as a locum anesthetist, flying to Phoenix Arizona to render anesthesia care there and bring in hard needed cash. Finding that travelling by plane was not just four times quicker but also much cheaper than by train—he became a keen aviation enthusiast. † By 1934, Dr. Arthur Guedel was under enormous pressure. An academic anesthetist in private practice, in Los Angeles, he detested the politicking and politics required of him to make ends meet; to earn sufficiently to look after his family and do the research and writing that would advance the specialty of anesthesia that he so dearly loved. Beset by problems both personal, practice related, and political. On the personal front, his Cadillac had finally given out so he had traded it in for a red Chevy on loan repayment, and both Marian and Gretchen were still in college getting university degrees requiring his support. And. Having sold his speculative home in Beverley Hill's at a loss, and moved to a rental home at 1800 Angelo Drive; the family now had to move again because the place was too unwieldy, and expensive, and Flo was insistent that they cut unnecessary costs. On top of this, Arthur was probably also cyclo-thymic: elated at times and depressed at others, and suffered terribly from insomnia: he would stay up all-night writing to pass the time, and muss up the bed in the morning so that Flo would be none the wiser as to the problem. He would occasionally take barbiturates to get some sleep and then a benzedrine tablet to wake himself up again the next day. He smoked excessively, worrying

170

5. Arthur Guedel

when his health deteriorated further, that he should have started with (filtered) Woodbines 15 years earlier to protect his health. On the practice front things were far from better: "We are full of discontent here. The profession in anesthesia here is becoming crowded." Guedel having let his partner, Dr. Ike Wineland go, but had recruited a new one: Dr. Dave Treweek who was already much better respected, but needed more anesthetic work so that Arthur could adequately pay him. So much so that: "We have to resort to politics to get business. For example we are having a bunch of doctors and wives in for dinner tomorrow night. That is almost unheard of with us." He wrote of his troubles to Ralph Waters. But these problems were all small potatoes compared to Art's expected political role: as the plaintiff's expert anesthesia witness in the Los Angeles Superior Court case against nurse anesthetist Dagmar Nelson's practice of medicine without a license—brought by Dr. Chalmers-Francis and others, that would determine the future of anesthesia practice in California—and perhaps, the whole of the United States. Previously, Dagmar Nelson, a nurse anesthetist trained at the Mayo Clinic had been invited by Dr. Verne Hunt to become his personal anesthetist at the St Vincent's Hospital in Los Angeles. However the appointment of a nurse anesthetist by the disputatious Dr. Hunt at a prominent hospital, and the threat that this posed to other physician anesthesia practices around the County, did not sit well with the Chief of Anesthesia, Dr. William Chalmers-Francis, at a competing hospital in the district. Adding insult to injury—there being bad-blood between Hunt and Chalmers-Francis from previous altercations—Dr. Chalmers-Francis led the charge working in concert with the Anesthesia Section of the Los Angeles County Medical Association, to seek an injunction against the St. Vincent's Hospital and so bar Dagmar Nelson from practicing anesthesia there. On 24 March 1934. Judge Roth of the Superior Court denied the request for an injunction and on July 12th the case finally went to trial. 12 JULY 1934. JUDGE ALLEN B CAMPBELL PRESIDING NO JURY (it was a bench trial only).

Leadership in Anaesthesia

171

There had been a break in the heat-wave that had lambasted Los Angeles that summer—the thermometer peaking at 850F—nevertheless temperatures ran high in the heated exchanges that were unlocked as witness after witness paraded through the court room to give their testimony. The stakes were very high for the practice of anesthesia in America. The key issue at stake for the prosecution was that the state issued license to practice medicine was a property right of the licensee which was usurped by those practicing illegally without a license, and, hence, harmed the incomes of those holding the license legally i.e. the physician anesthetists. (Van Nest 2006b) The key issue that the defense wished to demonstrate was that the nurses were supervised and controlled by the surgeon who monitored both their practice and the patient while performing the surgery as well, and so the nurses were not acting illegally. 9 One of the reasons why Dr. Arthur Guedel was brought in as an expert witness, was to tap his expertise on the signs of the planes of anesthesia that needed to be monitored to assure the safe practice of anesthesia. Testifying against Dagmar Nelson and the St. Vincent's Hospital where he had recently been effectively disbarred—Guedel highlighted the fact that the patient's eye signs were absolutely critical to monitoring the anesthetic state and that this could never be monitored by a surgeon, while performing surgery, because he was not at the head of the bed to perform this function. Going on to add that he was in the process of writing a book on the subject that would explain these eye signs, signifying anesthetic depth, for all practitioners to be aware of. Dagmar Nelson took to the stand. Testifying that she did not use eye signs to gauge depth of anesthesia, but instead monitored the patient's breathing pattern to ascertain the depth of anesthesia resulting from her administration of the anesthetic. 10 The defense surgeons noting that they could monitor respiration, the patients' pulse, and see their faces from the surgical field while they supervised drug administration—not ever yelling out exact dosages 9

Despite the fact that many of the surgeons had received only two weeks of training in anesthesia or none at all. 10 The alert reader will note, that it was Guedel's description of the eye signs in his chart that would signal earlier to the anesthetist the danger signals of impending respiratory depression and so was a much better monitoring method of the depth of anesthesia. Respiratory depression leading to respiratory arrest and certain death, if not countered.

172

5. Arthur Guedel

(required for nurses to practice legally) but on an as needed, a prn basis, to maintain anesthesia. The defense arguing, that although nurse anesthetists were competent to manage anesthesia, they were not making a case that they should be allowed to do so alone; merely that the surgeon be the captain of the ship, and that the nurses practice legally under their supervision. Interpretation. Dr. Arthur Guedel had been much troubled by the court case. There had been so much riding on it. Not just in securing immediate remuneration for physician anesthetic practice. But the much larger issue was establishing the profession of specialist anesthesiologists. If nurses could practice semi-independently, how could the nascent physician specialty of anesthesia grow and attract the best and the brightest physicians to its ranks, and so advance the much-needed science of its medical practice? He was also keenly aware of the plans of two leaders of the field at that time: Dr. Elmar McKesson and Dr. Francis McMechan, in response to the Anesthesia Travel Club, to establish the American College of Anesthetists to improve the professional standing of physician anesthesia, and, was likely aware that the American Association of Nurse Anesthetists had already been established in 1931 11—so the stakes were high in seeking advancement for the profession. But, Florence was so distressed about Arthur's state of mind at the time, that she wrote a personal letter to Ralph Waters asking him to write an "encouraging letter as to the future" to her husband, recognizing full well the "perilous state of the anesthesia situation" and mentioning the upcoming "Trial of the nurse anesthetists before the grand jury." She continued that: "If we are successful anesthesia will come to its own." But worryingly. "Art is discouraged about the entire situation." And. "He has been very nervous and tired and seemingly uninterested in his work."

11 The American College of Anesthetists would become the American College of Anaesthesiologists of the American Society of Anesthesiologists which in turn developed when the New York Society of Anesthetists— formed in 1911—changed its name to the American Society of Anesthetists in 1936, and then to the American Society of Anesthesiologists in 1945. Doctor Guedel was a founding member of the ASA board of trustees and helped to formalize the credentialing process necessary to becoming a 'board certified' anesthesiologist in the United States. A very important process to help standardize and set practice standards for anesthesia practice.

Leadership in Anaesthesia

173

Adding further salt to the wound, just before the date of the court case, someone crashed into the side of Guedel’s brand new, bright red, Chevrolet. An ominous sign which would prove to be spot on: On 31 July 1934, Judge Alan B Campbell ruling that Dagmar Nelson and the St. Vincent's Hospital were not acting in violation of the California Medical Practice Act, because the nurse anesthetists never acted independently; having been under direct supervision by the surgeon of record at all times. Guedel writing on the matter to Waters: "You ask about the trial. The details are many. We all believe that the decision in the lower court was settled before the trial, because of politics. We are now getting money and medical society help to carry the case to the supreme court, where we are assured by the attorney general of the state, and other officials of a favorable decision." That hopeful letter was not to come to pass however. Dr. Chalmers-Francis first filing for a mistrial and when this failed, he launched an appeal to the California Supreme Court which was denied in 1936, and would have taken this to the U.S. Supreme court but ran out of funds to do so. And what happened to the stormy surgeon, Dr. Verne Hunt, who launched the whole fracas by hiring Dagmar Nelson to the St. Vincent's Hospital in the first place? He met an unfortunate and untimely end in 1943: a mentally disturbed patient walked into his office and shot him—dead. † By 1937 things were looking up, before they turned down. Arthur and Florence had made their last move to a new house. Situated on 1633 Wellington Road—its back-garden garage converted to a workshop—the new home would become famous for the weekly 'Wednesday Seminars,' Guedel would conduct there after his clinical retirement. Arthur was now an associate clinical professor of anesthesia at the University of Southern California, which was in the process of developing a fledgling anesthesia residency training program; so he limited his clinical practice to the Methodist Hospital where most of the training took place. Marian, the elder daughter, had finished school, practiced as a kindergarten teacher, and would soon be engaged to marry Dr. John Hart: they would bear a fine grandson in the future.

174

5. Arthur Guedel

Gretchen, now twenty-three, would also marry a budding doctor that year: Bill Shuman, who would become an anesthesia resident at the Methodist and a future attending anesthesiologist with Dr. John Lundy at the Mayo Clinic. They too would have a son; but Gretchen would forever break his heart. † It was partly broken already. 1937 started off well enough. Dr. Guedel, as the Host for the Anesthesia Travel Club that was visiting Los Angeles that January, had planned assiduously for the event. The weather was fine, the hotel appealing, and Arthur had prepared innumerable practical laboratory and clinical demonstrations to inform and entertain his hosts. (Dr. Lundy would be presenting the new intravenous anesthetic, thiopentone.) 12 When Guedel took a turn for the worst on the second day of the five-day event; he collapsed and found himself in a hospital bed suffering from a possible heart attack and was forced to conduct the rest of the meeting in a sedentary position—the Travel Club participants concluding their busy days over scotch whiskeys, congregating around his infirmary bed to wish him well, his pet dog by his side: small comfort for the ignominious turn of events. Guedel recovering well enough; he was considerably cheered by the publication of the first edition of "Inhalational Anesthesia, A Fundamental Guide," later in the year. It sold briskly—topping 900 copies in the first two months—which Art thought most gratifying given the years of work he had invested in the concepts he described—many formulated on the back roads of the Western Front. †

12 Dr. John Lundy pioneered the use of the first intravenously administered short acting barbiturate anesthetic. Before the advent of this quick acting agent, all anesthetics were administered by the inhalational route. Because intravenous anesthetic agents injected through a vein could speed the induction of anesthesia, this new drug, commercially sold as Pentothal or Thiopental, would become widely adopted around the world.

Leadership in Anaesthesia

175

1939-1940: things go from bad to worse. Although professionally Arthur was doing very well: his book sales exceeding 2200 copies, and the Guedel airway and intubation techniques he had championed already well accepted—Art and his family's state of health deteriorated markedly. He suffered from increasing angina, was winded easily climbing a flight of stairs with his Midget machine, and often had to sit up in bed to relieve breathlessness at night. His increasing frailty forcing him to give up practicing 'spinal' anesthesia; fearful that his worsening tremor might result in him injuring a patient with the sharp needle used to deposit the local anesthetic in his patient's back. Having recently heard that one of his colleagues, Dr. Hank Raab, had departed "via the coronary route" he wrote to Ralph Waters late one December night: "May St. Peter's accept him. I am going to bed. And I am scared." Arthur had a heart attack the next day. A bad one—he was only allowed out of bed for two hours at a time after 8 January—when the biggest blow that his heart could ever take—hit. Gretchen, who he had lovingly called 'Tommie' all her life, and who had only six months ago given him and Flo such incredible joy with the birth of their first grandson—John William—suffered a ruptured brain aneurysm, and died. 13 Their lives a roller-coast of emotions: the next month, Marian, gave birth to their second grandson: Ralph, providing some relief from the great loss, but not much. So, in an effort to heal their torn family, Arthur and Florence, gathered the two grandchildren, two sons'-in-law, and remaining daughter into their Wellington Road home to try to put things together again. In stark contrast to this emotional roller coaster, academically— 1940—was a hell of a year: Art had written a series of four articles as "Teaching Outlines" embedding the key concepts of his book: Inhalational Anesthesia, which had done very well, and also published his extensive work on "Cyclopropane Anesthesia," a new inhalational anesthetic agent which he had experimented with, for the inaugural issue of the brand-new anesthesia journal: Anesthesiology, first published by the American Society of Anesthetists, in July of 1940. 13

Dissecting aneurysm of the circle of Willis.

176

5. Arthur Guedel

Interpretation. Although professionally at his peak as one of the first and foremost leaders of anesthesia in America, Dr. Guedel was mentally and physically at an all-time low: Stating, after his December heart attack and before Gretchen's untimely death: "I am through." "Aside from the inelastic pump, I would certainly be afraid to give another anesthetic alone." And, because Dr. Bill Shuman, the son-in-law married to Gretchen, had become Guedel's assistant at the Methodist Hospital practicing anesthesia: "I would be in a Heck of a shape if it were not for my apprentice— Young Bill—who is now bringing in my living." "Just now he is a life saver." With that said: Dr. Arthur Guedel's brilliant clinical career was over and done; he would never again administer another anesthetic to a surgical patient. And, after Gretchen's precipitate death from a bleeding cerebral aneurysm: "As for our Tommie, she had the easiest way out. There could be no happier ending to her condition and although we miss her we should be happy for her." "My plans for the immediate future are a sojourn in a cabin in the woods for a couple of months. I am looking forward to sitting on the bank of a brook and communing with fish, flowers, chipmunks and blue jays." And on reflecting on the past year's events in a Christmas Eve letter to his friend Ralph Waters: "It has been the turmoil of these family changes and the memories stirred by the Holiday Season that have set me a bit topsy-turvy and have deepened some lines in Florence's face." "Physically we are both as good as we were two years ago." "Mentally we are a couple of casualties, but with good prognosis." Anticipating the question that Ralph would surely ask—Guedel responded before the asking. "Me? That's Easy. O.K. as long as I don't try a hundred-yard dash and keep eating Seconal. 14" "Recently I have found that a bit of Benzedrine, probably by keeping my B.P. up within reason, helps." 15 Adding, only a bit defensively: 14 15

A barbiturate which is addictive and depresses blood pressure. An amphetamine which is addictive and wakes you up and elevates blood pressure.

Leadership in Anaesthesia

177

"I suppose that you would condemn such medication on account that it produces an artificial state of affairs and serves only as a crutch." "I see it differently." "I would rather move about on crutches than not move about." (Waters and Guedel 2019) Notwithstanding his now failing health—Guedel was long ready to retire from practical anesthesia: he found it enormously stressful at times when patients or surgeons turned sour, and at other times, boring: he grumbled a lot about having to practice clinical anesthesia if it did not pose a new problem to resolve: "Then it is fun." Having regularly commented to Waters about the $200-250 per month insurance that he could get if he were disabled—often writing longingly on the subject—he was probably not unhappy with the fact of his clinical retirement. But was really quite impaired, and that bothered him. He had severe emphysema—made worse by his continued smoking; chronic pain of his back in the rhomboid muscle; walked with a cane from his football injury; had severe crippling ischemic heart disease; and was addicted to barbiturates—at a time when there were really no good medications or therapeutic interventions that could combat his illnesses. On top of this—and this was his greatest complaint—he had peripheral vascular disease causing his two typing fingers—his index fingers—to become painful from lack of oxygen supply: becoming scaled and keratotic. Finding that this limited his ability to type, and so write and correspond—he devised two solutions to continue smoking while typing. He used two thimbles to cover his index fingers and devised a new oxygen hood—which Dr. Richard von Foregger then produced—that he wore to better supply the tips of his index fingers with oxygenated blood: in so doing staving off the terrible ischemic pain of his finger-tips; allowing him to type and smoke all-night long, if he couldn't get to sleep from his chronic insomnia. Considered the first addicted anesthesiologist in the United States, Arthur, managed to overcome the addiction and set things right by talking publicly about the problem, and giving lectures on barbiturates and amphetamines in order to help inform anesthesiologists of the predicament. Anesthetists being at particular risk of developing addiction as they have ready access to addictive medications in the course of their daily work. (Calmes 2016) †

178

5. Arthur Guedel

Homebody What Dr. Arthur Guedel liked to do most, was be at home with Flo. Tinkering in his workshop creating new anesthesia gadgets, or typing in his study writing letters, articles, pamphlets or books about anesthesia and its developments; often corresponding with others to set the historical record straight in his later years. In addition, he made himself and his study available for personal consultations and conducted a weekly tutorial in his den that all were welcome to attend. Widely recognized, the 'Wednesday Seminars' would become an institution—people travelling from far and wide to be present. Callers often welcomed by his piano playing—able to gauge Art's varied moods from the music played—his own stormy compositions, or love songs played with brio, or his beloved mellifluous Brahms played majestically, resounding in the large house—Arthur finding much peace in the music he played in the family home that had been the scene of such traumatic emotions. Being such a homebody and suffering ever greater incapacity—he had active angina, chronic back pain, was increasing breathless, and walked with a cane—Arthur avoided or turned down many invitations, to speak, present research, or to serve in a leadership capacity that came with his elevated status, from all over the country; never again travelling abroad after serving in France, during the Great War. Not even to receive one of the world's most outstanding Anesthesia Awards: The Royal Society of Medicine of London's, Henry Hill Hickman Award, never heretofore given to an American, 'for original work of outstanding merit in anesthesia.'

Awards Suitably bow-tied, but nonetheless discomfited, Guedel sat back, having just partaken of a splendid dinner in his honor at the Los Angeles County Medical Association, as His British Majesty's Vice Consul, Mr. Gilbert Holliday, rose from the table seat next to him, cleared his throat, waited a few moments for affect, and then placing his hands firmly on the back of the chair in front of him—delivered the presentation address on behalf of the Royal Society of Medicine of London, honoring Dr. Arthur Guedel with the feted award. Awarded in the name of Dr. Henry Hill Hickman, who too had experimented with his pet dogs to render them anesthetic—with carbon dioxide, in 1824—Mr. Holiday explained the significance of the award: it was presented every three years to the man or

Leadership in Anaesthesia

179

woman who had performed outstanding research work in anesthesia, in the intervening period. 16 Dr. Guedel rising to receive the Award to loud applause, the dining lounge filled with friends and admirers who had gathered together, in spite of one of southern California's rainy nights. 17 Dr. Thomas Chalmers Myers, the current President of the Association, closing the proceedings by stating: "This has been the most impressive meeting ever held by the Los Angeles County Medical Association." All rising that October 1941 evening, to render their loud applause of approval. That same year, Dr. Guedel was nominated to become the next President of the American Society of Anesthesiologists by its Board of Directors. The then Secretary of the organization, Dr. Paul Wood, writing a letter of invitation to him. Dr. Guedel gracefully declining: "I am not able to do the job as it should be done, either physically or mentally." "It's not the work that kills but the worry of work." And despite many separate entreaties from American Society of Anesthesiologists board members, Arthur steadfastly declined—despite being suitably honored to be offered the Presidency of the respected society. The Hickman Award was not the only award that Dr. Guedel would receive, but arguably it was the most prestigious: he had already received the Silver Cup from the National Anesthesia Society in 1921 and, would be board certified by the American Board of Anesthesiology in 1943, and go on to be awarded the American Society of Anesthesiologists Distinguished Service Award, in 1951. Attending his first ASA meeting in fourteen years at the Shamrock Hotel in Colorado, to receive the Distinguished Service Award—Arthur recounted his humble beginnings; describing his first medical office in back of a corner drug store operated by John Hook in Indianapolis. "We talked about how I could cut a window from my consultation room to his prescription room for fast service, but neither of us had enough business at 16

Dr. Henry Hill Hickman presented his research work on 'suspended animation' at the Royal Society of Medicine in London, but it was rejected as bogus. Disappointed, he would eventually commit suicide at the tender age of 30. Dr. Ralph Waters would receive the same award in 1934, three years after Guedel. 17 Dr. Guedel would comment later in a letter to Dr. Paul Wood: "It was a dandy meeting, but I don't remember when I have had a more uncomfortable meeting." Dr. Guedel certainly looked mightily discomfited on the press photograph of the event, despite his neat bow-tie.

180

5. Arthur Guedel

the time to really do it." Although Arthur did borrow John Hook's telephone to cut costs. Dr. Guedel, would also receive honorary scrolls from the International Anesthesia Research Society in 1949, and the Cuban Society in 1953, but would never leave the US to receive them; preferring instead to stay closer to home.

The Cost of Life Dr. Arthur Guedel was always short of money. For various reasons. Anesthesia did not pay, he didn't practice much clinical medicine, he spent a lot of money on research and gadget making, and needed to support his family, while his revenue streams from his book and many of his inventions provided little to nothing in extra money: "Royalties are a Bunk." Save one, the royalty payments on the Guedel Airway he had designed, and which had been produced and marketed by Dr. Richard von Foregger. Sold at $2.50 a piece, and distributed in their hundreds of thousands around the country; this afforded a reasonable income to Guedel initially, but by 1942, as America's involvement deepened in the Second World War after the Pearl Harbor attack, there were reports of many other anesthesia equipment manufacturing companies selling the Guedel Airways under their own labels and so undercutting Dr. Guedel's royalty revenue stream. (Foregger 1996) This financial setback occurring when he could least afford it; having retired from clinical practice and now focusing on equipment design with Richard, as a means of supporting himself. Dr. Foregger, in turn, reporting back on such developments to Arthur to keep him abreast of the multiple problems of equipment design, and marketing, by writing copious letters sent from his New York offices held at 55 West 42nd Street, in Manhattan. The Foregger Company Inc. having grown into a substantial enterprise since 1914, as Manufacturers and Designers of Anesthesia and Oxygen Appliances. The two inventors deciding to take out a patent on the Guedel Airway to counter the Ohio Chemical; R. A. Hawk, and Heidbrink Companies from eating their lunch. The mounting problems however coming to a head much later in their longstanding relationship when Dr. Foregger went slowly mad. 18 (Foregger 1996) 18

In 1958, at the age of 85, Dr. Richard von Foregger was diagnosed with paranoid psychosis and declared incompetent to practice by a jury of twelve peers in 1959.

Leadership in Anaesthesia

181

Mad with paranoia, refusing to honor the later year royalty payments to Guedel because he thought that Arthur was working with a competitor against the Foregger Company, unlocking a blister of scorching correspondence between the two to set things right. Which were satisfactorily resolved by 1956, but only unfortunately, in the year of Arthur's death—spurring Guedel to feel hopeful about his future: 19 "Dear Foregger, Thank you for the two checks. They were needed." "Matter of fact they were belonging to the trades people before they arrived." Adding, in reference to the recent contentious dialogue and obvious paranoia that Richard had been exhibiting: "Your letter is the best we have received from you for many months. More like the Foregger we have known for years." Guedel going on to note, hopeful of a prolonged life: "I have not made a new airway but may have to do it any time as a matter of self-defense. I have lived too long; have lived up most of my few holdings, cashing in on it for living expenses, and the difficulty is that I seem to be improving physically all the time." Continuing regretfully: "I should have gone along with the woodbine twelve or fifteen years ago." And then, ever hopeful: "But now it looks like there are ten or twelve years ahead." (Correspondence 2019) † Two months later: On a Sunday afternoon at home—Arthur Ernest Guedel died of a heart attack. Last Rites were performed in the Chapel of Bresee Bros & Gillette on Washington Boulevard on the afternoon of June 14, 1956. A large crowd had gathered to wish him well. After the service, knowing full well how much Arthur had loved his music, Florence played: "Dear Little Girl," the record platter that Arthur had Dr. Foregger died in 1960. The autopsy showed: severe cerebral arteriosclerosis and cystic degeneration of the brain. 19 In fact he had started accepting invitations to attend meetings again to give presentations.

182

5. Arthur Guedel

composed and dedicated to her for their engagement—48 years earlier—in celebration of their long-married life together. Florence recognizing early as a bride that she was twice married: to Arthur and to Anesthesia—she was at first: "very jealous of a gal named Anesthesia, but I learned to respect her realizing that she was going to play a very important part in my life." Going on perceptively: "I found out at the time too that she was almost a child." "I watched her grow, develop and finally gain a maturity which made Anesthesia one of the most sought-after specialties of medicine, and I am happy I can say I knew her when." Florence Fulton Guedel, rendering a fitting tribute to her husband after his death: one of Anesthesia's outstanding leaders of the time. † Interpretation. Dr. Arthur Guedel retired from clinical practice at the relatively young age of 56, a very sick man. Despite this he lived to be 72 years old. He had bad emphysema, but never stopped smoking, needing supplemental oxygen therapy to get by—which he used as well to still the pain of his degenerating two index fingers; vital to execute the enormous volume of typing that he undertook over the years of his retirement. (He did at times have a stenographer, but she was far too expensive for routine use. And remember, he only had a hook of a right hand: an index finger and a thumb.) Before dying of the inevitable heart attack, brought on by the ischemic heart disease he had long suffered from—Arthur lived more or less as a cardiac cripple would: he did not drive, and hobbled around with a walking stick because he suffered from arthritis of his right knee caused by a football injury. It was thus less than surprising that he minimized travel as much as possible, preferring to stay at home to conduct his business of writing scholarly work, endless correspondence, and tinkering: designing as well as refining anesthesia equipment in his backyard work shop, which he would then seek to be produced and marketed by Foregger Company Inc, amongst others. Guedel was not an altogether happy man in his later years. Becoming by his own admission increasingly irritable, often argumentative and sometimes controversial—he was said to be obsessed with defining his legacy and corresponded with many to set the record straight: fearful that

Leadership in Anaesthesia

183

his legacy would be forgotten or not afforded the historical credit it deserved. (Larson 2006) A telling example of this was his detailed, but very respectful, letter written in 1955 to Major Thomas Keys author of the highly esteemed: "The History of Surgical Anesthesia" (1945) pointing out historical errors in the book pertaining to subject matter that Guedel had either written about or been involved in. Another, the never published document entitled: "Some Errors in Anesthesia History"—unfinished and running to 42 pages—in which Arthur hoped to set the record straight for posterity. (Guedel 1952b) Still another was his unfortunate, 'falling out' with Ralph Waters— some contentions as to primacy surfacing—as Dr. Ralph Waters' star continued to rise while Guedel's was slowly waning: their correspondence slowing to a trickle, where it had previously been a flood—nevertheless a well spring of emotional support for the both of them over years past. (Waters 1952) (Waters and Guedel 2019, Correspondence 2019) Another area where the developing science of anesthesia inquiry was passing Guedel by, was in his advocacy for the method of producing Ether Apnea: a method of deep anesthesia where Arthur hyperventilated the patient via the Guedel-Waters cuffed tube, robbing them of carbon-dioxide and so the drive to breathe; stopping diaphragmatic movement in its tracks, and with ever greater anesthetic depth, causing abdominal musculature relaxation equivalent to that which spinal anesthesia could produce. (Guedel and Treweek 1934) In so doing allowing the surgeon to operate in the abdomen more easily—bowel didn't extrude, retractors were easily placed—an anesthetic technique, which if it did ever take off, was now being definitively replaced by the recent description by Dr. Harold Griffiths about the use of the muscle paralytic, kurare. An extract from Ecuadorian Liahna plants that had been used by South American Indians to tip their poisoned arrows, kurare had been commercialized as Icosotron and had been administered intravenously to good effect; providing abdominal muscle relaxation—rendering a patient's musculature as "soft as dough." (Griffith and Johnson 1942) First adopted in 1942, Arthur was very supportive of the new muscle relaxant approach, writing to Dr. Griffith: "Curare is going to be a big help to us in maintaining the higher standard." "I shudder when I think of how I used to force the surgeons to work through the board like belly wall of N2O."

184

5. Arthur Guedel

Recalling in an earlier letter (1942)—Guedel having observed the surgeon struggle to operate in the abdomen in a patient administered only nitrous oxide for anesthesia: "It was then, back in 1914 or thereabouts, that good old David Ross, 20 after such a struggle with me, made the remark that it would be nice if we could just apply something like curare..." Encouraging Griffith further: "It is your work that recalled that incident." Dr. Arthur Guedel—to the end—ever the champion of progress in anesthesia. † Finally, in recognition of his work. The Arthur E. Guedel Memorial Anesthesia Center was created in 1963. Funded by private donations and the California Society of Anesthesiologists, its purpose was to serve as a library and museum to keep the history of the specialty of anesthesiology alive. Housed initially in the Health Science Library at the California Pacific Health Center on Sacramento Street, it was closed in 2015 and the lion share of its contents pertaining to Dr. Guedel's life, transferred to the Kalamanovitz Library of the University of California San Francisco to be curated in the Archives and Special Collections Section of the Medical Library—as the Guedel Museum Archives Collection. †

Post Mortem With respect to the historical stage within which Dr. Arthur Guedel provided his leadership, it is apposite to realize that his activities straddled the Domination Age of 1900-1920 where leadership was recognized as "the ability to impress the will of the leader on those led, and induce obedience, respect, loyalty, and cooperation." As well as the Trait Age of 1920-1950. Here leadership was considered the ability to influence the situation rather than dominate it, and there was a gathering appreciation that leaders could be made: once leadership traits had been identified they could then be developed in leaders through training.

20

Surgeon from Indiana University

Leadership in Anaesthesia

185

Dr Guedel also straddled the Group Goals Age of 1950-60, during which research workers studied a leader's ability to build up relationships with their followers, in order to persuade rather than coerce them to the cause at hand. (Northouse 2018, Clinton 1992) Based on our knowledge of Dr Guedel, it is abundantly clear that his leadership rested with being able to favorably influence the development of the specialty of anesthesiology, and more particularly, its growing knowledgebase wrested in science: through careful clinical observation and description; scientific evaluation of different anesthetic drugs; persuasive argument and presentation of his researches, and through the development of anesthetic apparatus and equipment. And, so; through his great industry: Guedel considerably enhanced the growing specialty knowledge base of anesthesiology—that would lead to more efficient and safer anesthesia administration in the future. We will again review key 'body parts' of the Leadership Skeleton to examine Dr. Arthur Guedel's leadership profile, best captured using the rubric: Creative LEADER. Leadership Skeleton: Creative LEADER max score: +++, min score: 0.

Arthur Guedel

Creativity/Innovation/Imagination

+++

Legitimacy/Authenticity/Credibility

+++

Emotional Competence/Psychological makeup/Personality Adaptability to Change

+

Determination/Passion

+++

Empathy

++

Resilience

+++

Total Leadership Score

16/21

+

186

5. Arthur Guedel

Creativity (+++). Although physically impaired by the saw-mill injury that ruined his right hand, leaving only a thumb and finger to work with, Arthur was a recognized expert gadgeteer, fashioning all manner of new apparatus from various media like rubber, plastic, and the diverse metals that he incorporated into his design of innovative anesthesia equipment. In creating such ideas he liked to discuss them, or rather bounce them of others, as he did most especially in his conversations and correspondence with Dr. Ralph Waters in a creative duet. However Arthur's creative dualism was not limited only to the physical. Far from it. Together with Ralph (and others) he found solutions to the many vexing problems that presented themselves, more especially the problem of explosions in the operating room and the ventricular fibrillation that would eventual kill the use of the anesthetic cyclopropane—that they both investigated so avidly. Ralph capturing Arthur's creativity better than ever: "How rarely do we find in the same individual such command of execution combined with originality, imagination, and critical thought." (Waters 1952) Legitimacy (+++). Arthur grew up poor. Nevertheless he had one goal in mind from an early age. To become a doctor; and so found the means to do so. Tagging along with the family doctor, Dr. Houck from the age of five, he earned sufficiently to support his medical school education, and decided after his internship—having experienced relentless pain from his saw-mill injury— to dedicate his life to anesthesia. From there on he was one of the first to dedicate his clinical practice solely to the nascent field of anesthesia, knowing that for it to advance, beyond the surgeon-nurse dyad, common to American practice, the medical science associated with its practice needed to be understood. So he became one of the first to investigate its scientific basis; establishing animal laboratories in his homes to do so. Partnering with many of the foremost anesthetists of the time in the Anesthesia Travel Club to share their scientific findings, Dr. Guedel was regarded as one of the foremost anesthesiologists of his day. Emotional Competence (+). A genius and probably occasionally mildly cyclothymic, Arthur was a nervous loner. Often irascible, he frequently quarreled with someone first, before making up later, and developing a long-term relationship. He fell in and out of relationships, sometimes because of his business troubles, or, at other times, because he felt that he was not getting sufficient credit for his contributions. He was absolutely dedicated to Flo, his partner for life,

Leadership in Anaesthesia

187

who returned the dedication in spades. He had obvious performance anxiety, which made him doubt his ability and affected his willingness to perform spinal anesthesia, thought to be a risky undertaking at the time. He could be quite direct in his comments and because he suffered from insomnia he became addicted to barbiturates. The only useful 'sleep aid' of the time. Recognizing this he made amends by curing himself of the problem and spoke about addiction in order to forewarn young colleagues of the problem for anesthetists. Adaptability to Change (+). Although Arthur became a leader of the field of anesthesia, he was a leader of men only in his younger years: Captain and Consultant Anesthetist for the Hospital Center in Vittel and Contrexeville on the Western Front, and Chief of Anesthesia at St Vincent's Hospital in Indianapolis, 21 before he sickened and transferred to Los Angeles where he did not again become a Chief—although he applied for a number of leadership positions. It is quite possible that this indicated that Arthur could not adapt well to the changing clinical circumstances that he found himself in, as he aged. Determination (+++). Guedel was determined with a capitol D. Setting out to become a doctor and musician despite not having the means to do so, and becoming crippled at the age of 13. He let neither impecunity nor incapacity stand in his way to get through medical school, or advance the science and scholarly work necessary to champion anesthesia till his last days. When he could not type anymore because the arterial spasm in his typing fingers was causing the skin of fingers to break down, he donned thimbles and an oxygen mask to continue to do so, despite the pain. Empathy (++). The concept of empathy as an important attribute of leadership would find shape in the early 1920's and was well exemplified by Arthur— both on the Western Front, and subsequently, in California. First the Western Front. On an inspection tour to assess the American Expeditionary Force preparedness for the planned Allied counter-attack, General John J Pershing's motorcade crept slowly through Contrexeville. The whole town 21

It is not clear whether he was replaced from this position. Guedel referring obliquely to the fact that he was no longer needed at St Vincent's Hospital in a letter to Ralph Waters; others wanting him out.

188

5. Arthur Guedel

had gathered along the Rue de Pont Rouge to see the Commander in Chief's cavalcade as it passed through the town and on past the railway station. Craning to see the parade; a press of bodies around the Post Office suddenly released a young girl who ran out and under the oncoming car. Her distraught parents crying out as the procession juddered to a halt, Guedel ran to help; administering first-aid on the spot. Observing that she had only minor injuries, General Pershing nevertheless alighted from his vehicle, consoled the parents, paid his respects to the young Captain, and then headed off past the Casino and along the Rue de la Gare to exit the town. The parents stayed. Beside themselves with happiness at the good outcome of the near miss, they kissed Guedel profusely and gave him a sprig of Lily of the Valley flowers in gratitude. Soon, home-sick, he sent the sprigs of the flowering plant to Flo in Indianapolis, and, subsequently, replanted the sprays in their home in Los Angeles. The tear-drop shaped flower's becoming his favorites: memorializing the spring event. Further evidence of Guedel's empathy was its reciprocation by 'his' men on the Western Front. He was welcomed on his motorcycle tours of the region—especially when he stayed overnight in the officers' messes playing the piano: justly earning the nickname "wab" for his regular playing of the Hoosier's favorite song: Along the Banks of the Wabash, Far Away. And in turn, when Guedel hosted the highly regarded Wednesday Seminars that he held at home in Los Angeles for many years—it became an institution attended by locals and international luminaries alike: Sir Robert Macintosh from Oxford University putting it thus: "I look back at the wonderful conditions I encountered in California." Referring to his stay at the Guedel home fondly—where Art, during the World War II years and beyond, welcomed everyone who came to visit—often showing off his favorite flowers, and playing the piano as part of the evening's entertainment. Resilience (+++). Resilience is like a muscle. The more you exercise it the greater it strengthens. From the first injury and suffering that Arthur endured; he built a mindset that he would overcome any obstacles, including incapacity, to achieve his goals. If a setback is framed in positive terms then resilience strengthens. Recovering from the injury to his hand, Arthur new that no piano teacher could teach him to play the piano. After all he only had a thumb and index finger on the right hand. So he taught himself, practicing over and over again, becoming a concert level pianist as a result of it. †

Leadership in Anaesthesia

189

Leadership Insights A number of useful insights can be drawn from the telling and analysis of Guedel's biography. x x x x x

Simplicity from complexity. Professionalism in practice. Develop functioning teams. Creative dualism at work. Adversity can make you stronger.

Simplicity from complexity While some argue that complexity has many advantages in building an organization's resilience and adaptability to everchanging situations—this comes at a cost. There is a decrease in the endeavor's efficiency (through built-in redundancy) as well as understandability and hence manageability: a leader often losing control of a simple problem because of the complex environment. Witness the Three Mile Island nearnuclear disaster of 1979. The crew at the nuclear plant losing control of the situation—becoming bewildered by the complex alarm system—when all that was at fault was the simple fact that a coolant-draining valve had got stuck. (Martin et al. 2020) Hence the leader's need to create simplicity from complexity. Dr. Arthur Guedel did just that. Reducing the complexity of Anesthesia to a number of simple stages—correlating these with physical signs in the patient that the anesthetist could observe. First, for an Anesthesia Pocket Chart to be used on the Western Front and then, eventually, for a text book—the 'road map' to anesthesia practice—A Fundamental Guide on Inhalational Anesthesia. Professor Robert Macintosh, the first Academic Chair of Anaesthetics at Oxford University in England, complimenting Arthur on the fact; he underscored the key steps Guedel must have performed to achieve this simplicity, in referring to the book: "Yours is the modern "John Snow" of anaesthetics and will for all time remain a classic because of its simple exposition of the facts. It must have taken a great deal of pruning to eliminate irrelevant details and to make it so easy to read." Dr. Ralph Waters complimenting Guedel's ability for "practical simplification rather than towards more complication of methods and concepts." x

5. Arthur Guedel

190

Pointing to another aspect of Art's leadership that is crucial to success: his ability to tell a good story to illustrate an issue: "One of his strongest assets, in writing, in lecturing, and in conversation, was his use of the pertinent story—of the perfectly illustrative case." Professor J.P. Kotter of the Harvard Business school further underscored the important leadership skill that Dr Guedel had developed in abundance; pointing out that most great leaders of the 20th century had developed the skill to persuade by communicating in simple and clear ways—often through story-telling—engaging people and finding the best way for individuals to grasp the issue or cause; in so doing impelling the task at hand—ever forwards. (Kehoe 2010) Professionalism in practice. One of the most important causes at hand for Dr. Arthur Guedel, was to professionalize anesthesia practice. He championed that its practice should be based in the discipline of medicine (rather than nursing), so that medical scientific experimentation and discovery could be brought to bear to enhance its safety. He believed strongly that only through creating a separate specialty of Anesthesiology with doctors dedicated to its practice, that the discipline could take its rightful place amongst the growing medical specialization that was taking place in America (and the United Kingdom) at the time. To ensure this, he believed that structured residency training programs needed to be developed like the first Academic Residency Program that had been started by Dr. Ralph Waters in Madison, Wisconsin. And he was prepared to put his 'money where his mouth is' for this belief. Forgoing the well remunerated Chair of Anesthesia position at the Swedish Hospital in Minneapolis, where he had moved from Indianapolis in 1919, because he would have to start a Nurse Anesthesia School there. In other words—train the competition; and in so doing help to maintain the status quo: the predominant practice model of the surgeon-nurse supervisory dyad prevalent in the United States at the time. To combat this status quo, he acted as the expert witness for the prosecution in the "Nurse Anesthesia Case" held in the Los Angeles Superior Court that hot July of 1934. Hoping to legislate against the surgeon-nurse dyad of anesthesia practice in favor of an anesthesia specialist-based practice of Anesthesiology. After all, if nurses could continue to practice semi-independently, how could the nascent physician specialty of anesthesia grow and attract the best and the brightest physicians to its ranks, and so advance the muchneeded science and the professionalism of Anesthesiology? x

Leadership in Anaesthesia

191

Ultimately, the case was lost in the Superior Court and the appeal to the Californian Supreme Court did not prevail—nevertheless Guedel remained undaunted and persevered: for the rest of his career he championed the professional development of anesthesia; conducting scientific experiments, writing scholarly papers, conducting Wednesday Seminars, teaching in a residency training program at the Methodist Hospital in Los Angeles, and mentoring future leaders like Dr. Virginia Apgar; all the while shepherding anesthesia to the present-day specialtybased practice of anesthesiology for the rest of his life. Develop functioning teams. First, as the Chief of Anesthesia for the Chaumont region, and subsequently, as the Consultant Anesthetist for the Hospital Center in Vittel and Contrexeville, not to mention the score of evacuation hospitals and clearing stations in the immediate environs that fell under his jurisdiction— Guedel had his work cut out for him. To meet the challenge, Guedel helped create functioning teams: building 'surgical teams' to enhance efficiency and the safety of care. Partnering in the effort with the surgeons, surgical nurses, and orderlies; he added an anesthetist to the team—trained using his Anesthesia Pocket Chart. Then monitored their good functioning (checking how they had used the chart) by motorcycling from place to place—the teams often itinerant units themselves: moving to where-ever they were most needed on the Western Front. Well satisfied with the care that was so provided, having monitored the situation—Guedel opined that the team formation also sat well with the participants: "many men... have at their own request been placed on 'surgical teams.'" x

Creative dualism. Like Wilbur and Oliver Wright before them, Dr. Arthur Guedel and Dr. Ralph Waters would become famous for their creative collaboration. The Wright brothers' launching the Kitty Hawk revolutionized flight, while the anesthetist duo revolutionized anesthetic practice by being the first to develop the cuffed endotracheal tube. Arthur and Ralph becoming firm friends and kindred spirits in their passion for anesthesia, they constantly bounced ideas of each other, and in so doing created a welter of anesthetic equipment, and innovations, while also advancing the science of the anesthetic state and its often-dangerous consequences in the body. But this is not all that this creative dualism provided for. Probably more importantly, it provided these pioneers with the mutual emotional x

192

5. Arthur Guedel

support that such leadership of a new field requires. In so doing helping overcome the misgivings and failures that inevitably occur. Two examples of Guedel's and Water's mutual support of each other should suffice. When Ralph, who was the first Academic Chair for an Anesthesia Department in USA, was particularly down in the dumps about departmental matters, Guedel wrote to him to buoy him up: "No job can be a success if you let it ride you. RIDE IT." And after Ralph had complained to Guedel that at times he was just down right LAZY. "You and your job! You have made it the biggest job in anesthesia in the world by effort and ability and you have enough left to finish the job." "Of course you are lazy." "You have a right to be so." Continuing. "General Mitchell—at one time chief of aviation of the U.S. army—had three rules of flying." "1. Keep flying speed." "2. Keep flying speed." "3. Keep flying speed." "Your laziness causes you to land at intervals while you still have flying speed." "If you lose flying speed you crash." In turn, riding on the train back from a business meeting, Ralph Waters wrote to Arthur and Florence upon hearing of the sudden death of their daughter Gretchen: "You both have my sincerest admiration for the way you meet 'situations' and life in general with a poise that would be a credit to the very finest people on earth—which you both are." (Waters and Guedel 2019, Waters 1952) x Adversity can make you stronger. Probably one of the most shocking events that can happen to an aspirant pianist and doctor, happened to Arthur in his first teenage year. At thirteen he severed half of his right hand in a saw mill—leaving him with a painful claw to fend for the future. Converting a happy-go-lucky boy to a distressed teenager. Arthur, with help from a teacher, turned it around. The injury serving as an inoculation for forthcoming adverse events, making him more capable of coping with adversity in the future; he became a prize-winning

Leadership in Anaesthesia

193

wrestler, a swimmer, a pianist, and passed the high school examinations despite the set-back. Penury and poor health would go on to dog him for the rest of his life. Arthur, usually positive when not depressed, bouncing back to overcome the endless trials and tribulations of life—keeping up flying speed to the end. †

Concatenation Anesthesia was well on its way to maturing as the specialty of Anesthesiology when Dr Arthur Guedel exited in the West of the United States. To learn of further contributions that helped to realize this trajectory, we now turn to the East—to Dr. Virginia Apgar in New York City. †

6. VIRGINIA APGAR

Outcomes “Birth is the most hazardous time of life.” —Virginia Apgar

6. Virginia Apgar

196

The Apgar Score

Babies were dying. At the Sloane Hospital for women, it was the first minute after birth that was most treacherous. It was then that the newborn was worst. Swaddled in a blanket and abandoned in a crib in the back of the delivery room; all attention was focused on the mother. The mother's belly massaged, the afterbirth delivered, fluids administered, and as the labor pains subsided—the inevitable question asked: "Is my baby alright?" Usually no-one confirming that it was so. Too busy with the new mother to look at the second patient in the room. The baby, left to its own devices sometimes faltering—a few weak breaths and then nothing. No one any the wiser until the crib was moved to the post-natal room, and she was found dead in bed. So too at this obstetric unit of the College of Physicians and Surgeons of Columbia University in 1949—The Sloane Hospital for women situated alongside the Presbyterian Hospital at Manhattan's 168th Street. Here Dr. Virginia Apgar had just been promoted to Professor of Anesthesiology, and, as the first female to hold a professorial position, had decided to dedicate herself to obstetric anesthesia and the care of the newborn. Sitting together with a group of medical students in the hospital cafeteria early one morning after a particularly harrowing night on call; Virginia was asked a seminal question: "Dr. Apgar, how would you evaluate a newborn?" "That's easy you do it like this." Virginia replied reaching over to grab a 'Do Not Bus Your Trays' sign left on a trolley alongside the table they were sitting at, and jotted it down. "Five points—heart rate, respiratory effort, muscle tone, reflex response and color—are observed and given zero, one or two points. The points are then totaled to arrive at the baby's score." A total of nine or ten was optimal. Then she rushed off to try it for herself, her white coat flapping behind as she made her way upstairs to the obstetric unit. (Mets 2018) †

Leadership in Anaesthesia

197

A Woman's Struggle Virginia excelled early in life. Her father, Charles Emory Apgar, teaching his only daughter to read by the age of three, using some of the theories then being developed by Dr. Maria Montessori. Descended from the Apfelgards of Germany, via Johannes Peter Apgard who had arrived in Philadelphia in 1732, Charles married Helen Clark, the daughter of a Methodist Minister in 1894. Together creating a happy, lively, home—'that never sat still'—filled with learning, music, creativity and science; for Charles was enthusiastic about many things. Apart from being an auto salesman by day, he was a professionally published astronomer, a radio-ham who helped crack a German submarine code, an outstanding musician, and an inventor and gadgeteer; designing the beautiful house built on a corner plot in Westfield, New Jersey, that Virginia was born to—in 1909—and grew up in; until going to university at the allfemale Mount Holyoke College in South Hadley, Massachusetts. (Mets 2020) Virginia was preceded by two brothers. One, Charles, dying of tuberculosis at the age of three before she was born, and the other, Lawrence, two years her elder, suffered from chronic eczema requiring many doctor's visits, but would also become a talented musician like his sister. Before attending the elite college, however, Virginia shone at school: stamp collecting, studying music, and Greek, (she could later read passable French and German), mathematics, and science; she had boundless energy and enthusiasm. Tall and sylph slim, she loved tennis, basketball, and track, was a fierce debater, and a keen member of the school orchestra; having learnt to play the violin at six years of age. Her high school year book reflecting on her industry: "Frankly how does she do it." No surprise then that Virginia sought out an unconventional route. Choosing not to get married like most of her friends after high school; instead she was determined to become a doctor and applied to colleges as the first step. No one in the family was really quite sure why she had set her sights on this vocation (as the usual route would have been to become a nurse)—Virginia might have been influenced by the talk surrounding the premature death of her brother; the multiple visits to the family doctor that Lawrence's chronic medical condition required; the scientific bent of her father; or the caring and nurturing nature of her mother. In any event it was an expensive, if unorthodox proposition—the family budget not being equal to the high fees of Mount Holyoke; Virginia

198

6. Virginia Apgar

made her way through gaining a scholarship and by earning extra money odd-jobbing on the side. First reports back to her mother from Mount Holyoke were glowing: "I'm very well and happy but I haven't one minute to breathe." Virginia well-pleased with her college choice, and they in turn well-pleased with her: she majored in zoology, minored in chemistry, took extra jobs to make ends meet: catching cats for the laboratory that would be dissected later, serving as library assistant; while playing tennis, horse riding, swimming, rowing, angling and playing basket-ball, and still found time to play in the orchestra—violin, cello—debate, and perform drama; winning the class prize for Zoology. Her friends calling her 'Jimmy'—the girl who did it all—from the first day on, and Dr. Chrissie Smith, her Zoology tutor, elated with Virginia's performance, waxed lyrical: "It is seldom that one finds a student so thoroughly immersed in her subject and with such a wide knowledge of it." (Smith 1974) Finishing, at Mount Holyoke in the Class of '29, at the age of twenty, Virginia applied to only one medical school. Columbia University. She had been dating one of the Columbia Medical Schools Professors' sons (who attended Harvard) and upon presenting herself at the College of Physicians and Surgeons for an interview, the Professor took her straight down to the Dean's office and told him to take her. He did. And when applying for a scholarship to part pay her way, Virginia was relieved to find that: "the scholarship fellow asked me entirely about extra-curricular activities, nothing about academics at all." (Houston 1974) But the scholarship only provided $250 per year and was far from sufficient to pay for the tuition, board, books, equipment and other living expenses that rolled into the costs of attending medical school. So her father part supported her and two Uncles, Malcolm and Leigh, provided long-term loans. A good thing as the Great Depression had just started as Virginia embarked on her first year of medical school, October 1, 1929. Horrified, that she only received a score of 91% for her first chemistry exam, Virginia was somewhat mollified when the medical school secretary explained that this was actually the top mark in the class. Jimmy explaining this away with characteristic candor: "I was fortunate, maybe, in going from one of the best classes that Holyoke had ever had to... P & S, it happened to be one of the less brilliant classes I got into, in fact one of the stupidest ones they ever had, so it was very easy coming from Holyoke, from the class of '29. It was very easy: I

Leadership in Anaesthesia

199

worked in hospitals during the summers and learnt a lot of things we didn't have in our Ivory Tower—no syphilis, no gonorrhea no nothing." (Houston 1974) One of nine women in a graduating class of ninety medical students in 1933, Virginia strove to distinguish herself; hell-bent on getting into a coveted position as a surgical intern to become a surgeon; she volunteered for extra duties: "I lived in the emergency room... when they needed a second assistant, there I was, ready to hold hooks." But there had been only four female surgeons before her at Columbia since 1916, so a surgical position was far from secure. Graduating fourth highest in the class. And on having been noticed for her efficiency by the Professor and Chair of Surgery, Dr. Allen Whipple, her future prospects brightened and a two-year surgical internship was duly secured. Here Virginia availed herself of every opportunity to advance, completing over two hundred surgeries together with her consultant colleagues in the Auchinchloss firm; she was pulled aside one day to meet with Dr. Allen Whipple in his imposing office atop of the Presbyterian Hospital. "So Dr. Apgar, I hear you wish to pursue a career in surgery." "Yes Dr. Whipple." "Well. I am not sure that this is a good idea. I have trained four female surgeons in the last years and they cannot get sufficient work in New York City. Not even females want to go to female surgeon, they prefer males." "Yes Dr. Whipple." "However, I do need an efficiently run proper Division of Anesthesia. Why do you not find a way of being trained in anesthesia and then we can talk again about a permanent position in the Department of Surgery." Interpretation. These were trying times for both surgery and anesthesia and more particularly for female doctors in the work-place. For surgery—the discipline was hampered in what it could accomplish; extensive radical operations like thoracotomies were hobbled by the lack of advancement of anesthetic techniques, drug, and clinical care delivery—limited by the status quo: adhoc anesthesia services chiefly managed through the surgeon-nurse anesthesia dyad—falling far short of the science-based progress needed to develop a physician led specialty. This was hurting surgery as bright graduating physicians were eschewing surgery for more exciting specialties. Surgery could not advance unless anesthesia improved.

200

6. Virginia Apgar

For anesthesia—the nascent physician led specialty was just beginning; there were insufficient national training programs—fifteen in the USA and four in Canada—only two actually paying residents to attend; the specialty was poorly remunerated, organized, and respected—anesthesia practice considered just "nurses work" that the less trained could do. For female doctors in the workplace it was an unremitting struggle. Although Virginia had got a position at Columbia, seemingly quite easily, this was far from the situation elsewhere in the United States: Harvard Medical School was closed to females till 1945, and other Eastern Medical School Deans admitted that they allowed for only limited quotas of females in their classes, one stating tellingly: "We do keep women out, when we can. We don't want them here....". A committee at Harvard only, eventually, recommending that the available 'mediocre men' be replaced by 'very superior women' who had proved their worth by scoring considerably higher on the medical school application aptitude tests. (Hudson 1996) While the first female doctor, Elizabeth Blackwell, 1 earned her degree in 1849, and started the New York Infirmary for Women and Children—launching the first American hospital staffed completely by women; the percentage of female doctors in the United States peaked around 1910 at about 6%, but then declined following the Flexner Report's vilification of American Medical Education: many of the seventeen women's medical schools created closing—unable to afford the newly scientific medical education suggested by the Report. (Calmes 2015) Consequently as Virginia Apgar was ending her first year of medical school (1930), there were only 5825 women physicians in the US workforce (just 4.4% of the physician population), while over the period 1920-1948 women comprised a slightly larger proportion (11-13%) of the ranks of the professional anesthesia organizations in the country. (Calmes 1992) Surgeon Whipple's suggestion to Virginia was therefore a good one on at least three fronts. 1

Dr. Apgar would receive the Elizabeth Blackwell Award in 1966 from the American Medical Women's Association. Dr. Blackwell was admitted to the Geneva Medical College in 1847, (after her application to 29 other medical schools had been rejected), upon the all-male medical students voting acceptance of her application. Hailing from Bristol England, she would become the first woman to register with the General Medical Council in London, practice and teach medicine in both America and England, and become a role model for female physicians. Like Dr. Apgar she never married and was commemorated with a U.S. postage stamp (18 cents:1974).

Leadership in Anaesthesia

201

Surgeons were well disposed to females providing anesthesia as they believed their inherent feminine characteristics—multitasking, pliability, empathy—were useful in managing the anesthesia of the time; after all it was chiefly administered by nurses who were almost without exception female. Unmarried women had limited options for work. Typically, this was either clerical work, nursing, or teaching; all low paid professions—the jobs inevitably terminated when women married and their future husbands could support them. And, given the paucity of females that were (economically) successful in surgery—going into anesthesia, a relatively new specialty, might well be to Virginia's professional advantage. † Dr. Virginia Apgar certainly seemed to think so. In 1934, while very busy as a Surgical Intern; a Senior Resident, Dr. Crunbar approached her. Had Virginia thought of anesthesia? No she hadn't, but: "Maybe this wasn't such a bad idea. To be a bigger fish in a smaller puddle, because it would take three or four more years in surgery and [so] it was purely financial that I changed to anesthesia, which is not a bit dramatic, it's the truth." (Houston 1974) Virginia, pursuing the idea immediately, wrote to Dr. Frank McMechan in his capacity as Secretary of the Association of Anesthetists in August of 1934, to enquire about possible residency positions in the United States and Canada. She was somewhat encouraged to note that there were four programs in Canada and fifteen in the United States that could be approached; four of the departments already headed by women, including Dr. Mary Botsford of San Francisco, who was the first female to devote her practice completely to anesthesia back in 1897. Importantly, two other names appeared on the list that Dr. McMechan had sent: Dr. Arthur Guedel, of Beverley Hills, California, and Dr. Ralph Waters of Madison, Wisconsin. And the letter added that residencies of between six months to one year; fellowships of between one to three years; and post graduate courses of any length desired, could be applied for by writing to the individuals listed. Virginia followed suit. To all of them.

202

6. Virginia Apgar

Becoming bitterly disappointed as there were no suitable positions to be had, despite her intensive networking—letter writing, going to meetings, telephone calls—for a slot in the oversubscribed residency training programs of the time. Interpretation. It really wasn't easy to find a suitable residency training program (for anyone), because many heads of anesthesia departments were struggling to convince the hospital authorities of the need to replace surgeon-nurse anesthetic practice with the physician-anesthetic model of practice. Dr. Mary Botsford responding to Dr. Apgar's letter explained the issue cogently in August of 1934. Dear Dr. Apgar: In a couple of months the status of physician anaesthetists will be settled, following a verdict from the Supreme Court as to whether nurses may legally administer anaesthetics and if decided in our favor, there will be opportunities in either the University of California or Stanford Medical School for training and ultimately positions. Dr. Arthur Guedel, who was serving as an expert witness for the prosecution in testifying against Nurse Anesthetist Dagmar Nelson at the time (referred to in the above letter), wrote less hopefully: Dear Doctor, Beverly Hills, and Los Angeles at the present time offers little or no opportunity for instruction in anaesthesia. We hope in the future to establish post graduate training in the subject at our General Hospital here, but although there is such instruction now by name, it is not sufficiently well developed to be attractive. And Dr. Ralph Waters, Dear Doctor Apgar, I liked your letter of August 10th....The appointments, however, are full at the present time, and so far as I can see are likely to be full for a long time to come in that I have four men....and we hope that they will stay at least three years.

Leadership in Anaesthesia

203

In truth though, at a time when masculinity was unabashed, there was still strong sentiment by men against employing women in the workforce. In correspondence between Guedel and Waters: Guedel declared: "I don't believe in women doctors" and "Women are bunk." Waters corroborating this. Not because they both believed that women were less competent than men, but because women tended to get married; removing them from the workplace. (Waters and Guedel 2019) And then there was the prevalent thinking that if a woman took a man's position she would be robbing a family of a breadwinner. Depriving the father of the opportunity to support his wife and kids. (Mets 2020) † Not one to dwell on the situation too long without a plan, Virginia tried another tack to gain anesthetic training experience. In November of 1935, having completed two years of surgical internship, she was offered an Assistant in Surgery position 2 and while doing research in the animal laboratories, trained in anesthesia with the Presbyterian Hospital's nurse anesthetists. More specifically with Miss Anne Penland who was the head of the nurse anesthesia service and would become a life-long friend, living to be 95 years of age. 3 Upon being appointed as a Resident in Anesthesia at the Presbyterian Hospital in July of 1936, Virginia was now officially in training, but knew full well that she needed much more experience than could be had through the nurse anesthesia program there, so she again pursued a position with Dr. Ralph Waters in the preeminent, and first, physician led residency training program in the country. Dr. Waters responding to her telegram and letter that he strongly supported Dr. Whipple's efforts to improve anesthesia at Columbia University's Presbyterian Hospital, and given that she could not spend a full three years in residency training—there were no positions—he recommended that she consider being a visitor and observer at the Madison program for at least seven months starting January 1937 and extending to August 1—in order to avail herself of the clinical practical experience that resident vacations and sickness leave would inevitably provide.

2

At $1000.00 a year. Miss Penland was a highly experienced nurse anesthetist who had practiced anesthesia with the Presbyterian Hospital surgical unit in France during World War 1.

3

204

6. Virginia Apgar

However, according to Virginia, Dr. Ralph Waters had been twice burnt in the past with women anesthetists in Wisconsin: "one got married and one went crazy, and I had to tell him I wasn't going to do either." And there was another problem that Ralph brought up: uncertain accommodation prospects for women residents. The chief of the hospital, Dr. B. Buerki was willing and able to provide board but no lodging. There were only rooms set aside for male residents in the hospital, but Dr. Waters wrote, relatively cheap quarters were available nearby or Virginia might find a 'hole in the wall', and if all else failed; he had it on good authority that she could be roomed at one of the two undergraduate women's dormitories: either Ann Emery or Langdon Hall. (Mets 2020) †

Residency Training: Madison, Wisconsin, and New York City Although cold, snow had not yet fallen on New York City on New Year's Day of 1937, when Virginia gathered her belongings, took a taxi to Penn Station, and boarded the train for Madison. Encountering freezing rain in Illinois, and snow in Wisconsin, she arrived the next day to find that although "Waters had tried hard" he had had "no luck finding a room" so they gave up and she went to bed at 4 p.m. in Waters' office—having not slept at all on the long train ride. By Monday the 4th, Virginia had got her bearings, gone on patient rounds, and administered her first anesthetic: "Not Bad. But wouldn't wake up." And by the next day; received her uniform, found a room, and gave another anesthetic: "Another strange recovery" and attended case conferences in the afternoon and evenings; setting up a regular pattern of training as the only female in the all-male training program of 16 residents. Noting in her diary, the daily highs -, and lows /, of her experience and progress with penciled in emoticons; similar to those she had used since her high school days in her letters home. Virginia gave brief voice to the significant clinical, professional, social and sporting happenings of her life: she had to move at least three times in the seven months as a female anesthesia resident to find suitable sleeping arrangements (including spending around two weeks bedding down in Dr. Waters' Office). She gained experience—both good and bad pointed out with emoticons—with multiple complex cases and scenarios: learning how to give spinal anesthetics, provide thoracic anesthesia and become adept at the

Leadership in Anaesthesia

205

new intra-tracheal intubation techniques that Waters and Guedel were just beginning to champion. She took up tennis lessons at the university tennis courts, shooting at the Police Academy Rifle Range, bowling at the local alley, and fishing, sailing, and swimming in Lake Mendota as the weather turned better. She tried her first hand at golf: "Terrible." She bought and paid off her first car—of many—which she then drove furiously around Madison and on road trips to Chicago and Rochester, Minnesota, to attend anesthesia meetings and gain expertise from the likes of Dr. John Lundy; champion of the new groundbreaking intravenous anesthesia with thiopentone. And then on 25 July, Virginia packed up her new car, said goodbye to Dr. Waters and his family, and sped on her way to New York City to start five months of further residency training at the Bellevue Hospital with Dr. Emory Rovenstein, a former graduate of Dr. Waters' Wisconsin program. Here, again, she was faced with the professional women's problem; lack of suitable female accommodation for a doctor seeking residency training who needed to be 'in-house' to perform their duties properly. There was no room available for her on arrival, so she stayed with a friend, and then on 5 August moved into a nearby deserted building to find shelter; which proved downright unsatisfactory, if not unsafe, so she was forced to move to the maid's quarter in the clinic building. No emoticon could do this justice, so she simply wrote: "MAD" in her diary. The residency training was however greatly to Virginia's satisfaction. Crowned by the request from Dr. Allen Whipple to meet with her at the College of Physicians and Surgeons on 168th Street—Virginia took the "A Train" uptown by subway to attend the November appointment— where he asked her to draw up an outline for the first Division of Medical Anesthesia within the Department of Surgery at Columbia University; with Dr. Apgar as the Director.

Director: Division of Medical Anesthesia, Columbia University On 16 January 1938, newly energized by a two-week fishing vacation, Dr. Virginia Apgar launched a new era as the Director of a Medical Anesthesia Department at the College of Physicians and Surgeons at Columbia University. While in the past surgical anesthesia had been provided by employing 14 nurse anesthetists, led by Miss Anne Penland, using the surgeon-nurse model; the new Division in the Department of Surgery was

206

6. Virginia Apgar

now to be run by a specialist anesthesiologist director—responsible not just for surgical anesthesia in the operating room, but also for instigating novel clinical programs, assuring that the necessary education and research was performed, and that the division's finances and administration were managed adroitly: all to create a new service to meet the Presbyterian Hospital's expanding needs for safe clinical anesthesia care. Part and parcel of Dr. Allen Whipple's long-term plan to improve anesthesia delivery to progress the department of surgeries capabilities in provide cutting edge surgery—Virginia's November outline for the organization and functions of the Division of Anesthesia had been largely accepted: The Division was to be headed by Dr. Apgar (with an Assistant Director joining later) who would recruit ten residents—each providing 1-3 years of service—to replace vacated nurse anesthesia positions: with the ultimate goal of creating a fully-fledged physician-only anesthesia program—modelled on Dr. Ralph Waters' program in Wisconsin. In addition Virginia had a list of priorities to work on: (1) To have interns and medical students rotate through the operating rooms to learn to administer the simplest anesthesia: open drop ether, safely. (2) To replace the part-timers, Dr. Buchanan and Dr. Wood with more active anesthesia consultants. (3) To keep Miss Penland's and another nurse anesthetist, Miss Justus's, positions for them as long as they wished to fill them. And. (4) To hold-off on actively developing the research work in the department till 'after the teaching program is under way.' Again following Dr. Ralph Water's advice on the matter. (Reports 1938) To this end, the clinical and educational programs grew in fits and starts—driven by the developing science of anesthesia in problem solving solutions to deadly problems, and as a consequence, enhancing its increasingly important role as a specialty both in and outside the operating room. In the operating room a major clinical problem needed to be urgently addressed. The tendency for anesthetic drugs like ether and cyclopropane to explode. Ignited by either the discharge of built-up static electricity on anesthesia equipment or personnel; or from electrical equipment used in the operating room—alternative techniques needed to be

Leadership in Anaesthesia

207

found—the problem coming to a head with a fatal explosion from cyclopropane on 15 April 1940. 4 Cyclopropane was immediately abandoned, ether only used when electrical equipment was out of the question, and the department investigated ways that anesthesia could be provided by alternative means: the use of non-explosive anesthetic agents like nitrous oxide increased markedly, intravenous anesthesia with thiopentone took off, and spinal anesthesia 5 became a compelling alternative. Dr. Apgar investigating the use of 'fractionated' or 'continuous' spinal anesthesia to perform the most complex intra-abdominal operations of the day; again to meet the needs of the surgical department. Dr. Allen Whipple being famous for the pancreatic cancer resecting surgical procedure that carries his name: The Whipple Procedure. (Apgar 1942) Outside the operating room the Anesthesia department also expanded by leaps and bounds in providing a consulting service 'on par' with that of the departments of Radiology and Pathology—via preoperative and post-operative visits on all surgical patients; via honoring requests for procedures to treat intractable pain, and; by providing diagnostic and therapeutic blocks, dealing with difficult sedative problems, and providing resuscitation of sickly patients on the wards. While the Hospital's obstetric service had asked that the department take over all the anesthesia required to manage laboring patients. In addition, in order to enhance the national reputation of the department, and in so doing attract the best possible residents into anesthesia, Virginia started off her directorship by showcasing the institution through hosting high-level national anesthesia conferences: accommodating the American Society of Anesthesia Meeting at the Presbyterian Hospital in October of 1938, and the Anesthesia Travel Club in October 1939. Manpower to staff the operating room was Virginia's continual headache. Requiring to-and-fro negotiations with respect to salary and housing conditions with Dr. Whipple—Dr. Apgar adopted the clever tactic that she put all agreements in writing, and if Allen would not meet with her (on one occasion, not showing up four times for a planned meeting) she would put this to him in a forthright letter instead, and often noted their agreements, pointedly, in her Annual Anesthesia Division Reports.

4

The homicide squad investigated the incident till 6.30 p.m. that day. The deposit of a local anesthetic mixture into the spinal fluid—to deaden the pain from surgery—via a lumbar back puncture using a sharp needle, so avoiding the need for a full general anesthetic with an explosive anesthetic agent.

5

208

6. Virginia Apgar

Accordingly, the first two residents, Dr. Robert Gladstone and Dr. Charles Stein—both male, the way she wanted it—were only hired at the end of her first year. And, only three years later, in 1941, the first Attending Consultant: Dr. Ellen Foote was appointed as the Assistant Director; finally realizing the outlined plan of November 1937—it being exceedingly difficult to recruit into anesthesiology: there being very few resident graduates and remuneration far better in private than academic practice. Although the staffing situation seemed to be improving, things became more difficult again in 1942 as the American World War II effort resulted in doctors volunteering abroad. To address the problem, Virginia devised a novel manpower plan. To increase the residency size: she hired dentists to serve as residents to replace the nurse anesthetists. And to increase the Attending staff: on finding the dentist-residents to be more than equal to the task, hired the willing to become consultant anesthesiologists. (BZ. 1974) Encountering yet another problem she had confronted before; lack of suitable housing for four of her residents at the Presbyterian Hospital, she paid for some of their accommodations out of her own pocket to grow the program. Having found innumerable creative ways to expand, not surprisingly, by the time her decade at the helm was over, the department had become quite substantial, and comprised: one assistant director, ten instructors, 22 residents, four nurse anesthetists (including Miss Penland and Miss Justus) and two secretaries to manage its affairs. To attempt to build departmental research over the years, Virginia had motivated for the hiring of a director for research—offering to take off a year to learn research herself as an alternative—but the former had never been realized, nor the latter approved; sowing the seeds of destruction for her chances to be named the Professor and Chair of a separate Department of Anesthesiology (as will be demonstrated later), should that ever be endorsed by Columbia University. In the interim however, the Anesthesia Division's reputation, and so the ability to recruit to its ranks, was considerably boosted by Virginia's inimitable teaching style, caring leadership, legendary interpersonal skills, and skillful administration. Virginia could do nothing slowly, least of all teach. She talked with the rapidity of a machine gun: rattling of facts pell-mell in the operating room, lecture halls and on the wards. In fact the only time she stopped talking was when a patient was in trouble. With an accent that crossed New York and New Jersey like the George Washington Bridge she traversed each

Leadership in Anaesthesia

209

day to work: Virginia held forth loudly, rapidly, and non-stop. "Nobody fell asleep in Virginia Apgar's class; everybody was on their best." (Morishima 1996) And she liked to shock and surprise. A spicy speaker she would say outrageous things: listeners hanging on every word to catch the next one: to expectant mothers on establishing that the drug demerol administered during childbirth passes through the placenta rather than held back by it: "Your placenta is a dammed sieve." To a national audience on television, her favorite joke: "How do you tell the sex of a chromosome? You pull down it's genes." And an outrageous rhetorical question and answer: "Do you know what the difference is between heredity and environment? .... If a child looks like his father, that is heredity. If he looks like the man next door that's environment." (Beck 1974) In fact at one international presentation, the translators found the rapidity of her speech impossible to keep up with, yet the audience loved it and were enraptured: It was not what she said but how she said it. (James 1975) And in the operating room, for a practical instruction she would offer her own crooked coccyx for palpation by the medical students and residents to demonstrate how to place a spinal anesthetic. Or disconnect the oxygen supply to an anesthesia machine surreptitiously to keep a resident on his toes and assess how quickly he came alive and responded to the decreased oxygenation of his patient. Or she inhaled helium to demonstrate its lighter than air property, transforming her voice to a mere squeak; demonstrating its practical use for obstructed airways. In short, she taught non-stop, and everywhere: in the air, in hotel dining rooms, in church, at a furious pace, often using props to illustrate her teaching; in later years carrying around an 8-week-old fetus "Billy" floating in a glass bottle for demonstration purposes. Once stopping all in-flight service when she showed it to an air-stewardess on a coast to coast airplane flight. Her interpersonal leadership skills were also legendary. "People found her irresistible. She could establish an instant rapport, and her victim was immediately captivated. Her thoughtfulness and attention to little details were unforgettable." And as a result, people loved to work for and with her. "She personified idealism, and firmly believed that once idealism was lost everything else would die on the vine." (James 1975)

210

6. Virginia Apgar

She was infectiously hypomanic: always of good cheer, with a glowing effervescence to her personality—she had a cheery word for everyone: the many policemen that handed out speeding fines to her, the shop assistant, or the colleagues she worked with. (Eaton-Enochs 1994, Beck 1974, Hunt 2002) And, although she never dawdled, she was much too busy for that, she always paused, just long enough for a cheerful greeting, and then quickly moved on: a whirlwind of a white coat flying through the corridor. She had the uncanny ability to get the best out of people without in any way antagonizing anyone exhorting all to: "Do what is right and do it now." She would assist at every turn, whether out on the streets, the highway or in church, she was ready to help; her purse holding a laryngoscope, penknife, tracheal tube and band aids so that she could manage any emergency; reputedly using her equipment sixteen times in critical situations over the years. Avowing: "Nobody, but nobody is going to stop breathing on me." Completely honest and humble herself, she could point out people's mistakes without causing umbrage and quite disarmingly would sit down with pupils or colleagues and with a warm smile say "Tell Momma all about it." And then really listen to the response, providing calm and considered support, a reassuring hug, or whatever was needed to smooth the way forward. There were things Virginia really disliked. They were scheming, subterfuge, red tape and administration, and thus she was plain spoken, open, and forthright in her actions as a Division Director—never shirking the responsibilities to her people, who she cared for deeply, but not particularly relishing the burdens that administration put on her time to be more creative. (James 1975) On the national level, Dr. Apgar's leadership and skillful administration was also recognized. On completing her American Board of Anesthesia examination in 1939 she became the first woman and 50th specialist anesthesiologist to be certified by the A.B.A., started as the Treasurer and Officer on the Board of the American Society of Anesthesiologists, was included in the Anesthesia Travel Club (the who's who of anesthesia of the time), and yearly, attended the Aqua Alumni Society meetings—held in honor of Dr. Ralph Waters for all graduates of

Leadership in Anaesthesia

211

the program he started in Madison, Wisconsin; serving as its president in due course. 6 So too in April of 1947. Virginia communicating two important facts; at its business meeting, and in a subsequent letter to Dr. Clayton Christensen, the Aqua Alumni Secretary and Treasurer. Facts that would have far reaching effects on Dr. Apgar's life: That the plans submitted ten years ago for a separate Department of Anesthesiology had finally been approved by Columbia University; and that Virginia had sickened and been admitted to the Presbyterian Hospital that April with severe jaundice producing infectious hepatitis; which she jokingly called "Conroy's Disease." A fellow alumnus, Dr. Alan Conroy, having suffered with the same problem. Interpretation. Dr. Apgar was a role model and trail blazer for women in medicine and anesthesia. At a time when there was much sentiment against, and many barriers in the way of the 'weaker sex' doing the 'man's job' of medicine—in becoming a doctor rather than the expected nurse; Virginia would have none of it. Believing that gender had nothing to do with it. Upon being taught to play tennis like a man: aggressively and without restraint—she played well. Once receiving the backhanded compliment: "Quite good for a girl." She barked back: "What do you mean?—If you're good you're good!" On completing High School in New Jersey she was in no doubt as to what she wanted to do; she would become a doctor. And nothing would stand in her way. You will recall her singular application to Columbia Medical School; convincing the Dean to take her on the spot. And Dr. Allen Whipple's foresight in steering her towards anesthesia (and away from surgery), assured that she could set up a successful division to meet the needs of escalating surgical complexity. Virginia motivating thus: "For the unmarried woman physician, I see no reason why she should not be as expert and as successful in anesthesiology, both financially and professionally, as her male counterpart." (Apgar 1964) For the married woman, she thought it more complicated but not impossible. Pointing out in 1964, fully aware of the practical implications, "Once she accepts a residency, however, in fairness to the hospital chosen,

6

Like Dr. Arthur Guedel (1950) before her, Dr. Virginia Apgar would receive the American Society of Anesthesiologists' Distinguished Service Award in 1961: the first of only three women to be honored with the accolade.

212

6. Virginia Apgar

it is expected that she will postpone further pregnancies until residency is completed." (Virginia never married herself stating that she never found a man who could keep up with her, or cook.) 7 Articulating forcefully that one should: "Never underestimate the power of a women." She nevertheless eschewed the 'Feminist Movement' believing that: "Women are liberated from the womb the day they were born." Typical of women at the time, she did not complain publicly about the restrictions put on her as she forged her career, although privately she was maddened by many of them: writing 'MAD' in her diary when she was not welcomed at a 'Stag' cocktail party or dinner reserved only for men after work: and deeply frustrated again and again—when for the umpteenth time there was no suitable female accommodation provided for doctors in training. And speaking to Dr. Hisayo Morishima—a young female protege—just before her untimely death: "It's a shame that women have to be so much better at things than men do to be recognized by society. No doubt in your daughter's time this sort of prejudice will start to disappear, but when I was on the way up, and for people like you who are now on the front line, the society of today— especially the medical profession—is very tough. Avoid looking back and you will achieve much." (Morishima 1996) For young women, she was a torch shining the way forward: canvassing to girls at Mount Holyoke College, her alma mater, where she was an Alumni Trustee and would receive an Honorary Doctor of Science degree—to consider medicine as a career and convincing many a young female doctor to make anesthesia their specialty of choice; possibly reflected in the fact that towards the end of her life, while 6% of doctor's were women; 11% constituted the proportion of female anesthesiologists. 8,9 (Baird et al. 2015) She asserted later in life that women could achieve irrespective of their gender and should never use this as an excuse for failure; reckoning 7

Apgar hated to cook. Burnt offerings her specialty; most friends believed she liked burned food and pots. 8 In the United States today, just over 50% of medical students are women, and in 2013: 25% of anesthesiologists were female, but this proportion was 40% in those who were under 36 years of age, signifying an upward trend. 9 Dr. Elizabeth Frost, who played with Dr. Apgar in a quartet in New Jersey, credits Virginia with convincing her to take up a career in anesthesiology (personal communication).

Leadership in Anaesthesia

213

that women had to do a better job to be considered equal with men in societies eyes stating: "I've been lucky all my life. I can hardly believe it. So often I have been asked by interviewers, 'What obstacles did you meet as a woman, as you became a physician?' Their faces uniformly fall when I tell them that there were no obstacles at all in my career, such as it is. True, I did not achieve everything for which I aimed, but these failures constitute probably less than 10% of the opportunities presented." (James 1975) Considered by many a pioneer feminist, promoting the advancement of women in society, she would undoubtedly have agreed with Dr. Edna Blackwell: "It's not easy to be a pioneer—but oh, it is fascinating." (Morishima 1996, Calmes 2015, Smith 1974) But she did not like administration. (Morishima 1996, James 1975) But nevertheless had to contend with it. And never more than when addressing a seemingly never-ending problem. Parity in pay. And in anesthesia this was not only a gender issue but also a problem for the nascent specialty in relation to the established practice of surgery. Namely, that while surgeons charged their patients for surgical care. Anesthesiologist did not, and the hospitals and surgical chairs discouraged this. Despite many patients expecting to pay for the specialist anesthesia services rendered. And so there was no means of developing a budget for a department of anesthesia based on the billing of professional fees that could support the salaries of its Director, Consultants, and Staff. Consequently, in order to address this problem, for both herself (parity in pay to a male division director in another department) as well as to develop a professional budget for the department of anesthesiology, Virginia sent multiple letters to Dr. Whipple requesting that this be set straight. Including one—for good measure—that stated that she had been offered a much better paid job in Chicago. Receiving no satisfactory response in reply, Virginia resigned from her Clinical Responsibilities as head of the division in 1940. A resignation that was apparently never accepted but responded to positively, and ultimately resolved, by the end of 1941—Dr. Apgar noting in The Fourth Annual Report of the Division of Anesthesia: "After much consideration, and with the help of especially Dr. Whipple, a salary budget was provided, and a source of income established, in an attempt to make the anesthesia department self-supporting." Adding in—tellingly. "The salary of the Director was adjusted satisfactorily...." (Reports 1938)

214

6. Virginia Apgar

Setting both the Director and the Department on a course for success, on the financial front at least. If not on the research front. † Perhaps Columbia University was not yet ready for a woman as the first Departmental Chair in 1949. Despite Virginia having motivated to the new Surgical Chairman, Dr. George Humphry, for an independent Department of Anesthesiology the year before. And. Dr. Apgar presuming that she would head this independent Department, with the newly requested director of research reporting to her—that was not to be. (Calmes 2015) Instead, Dr. Emanuel Papper, who had been a junior colleague of Apgar's at the Bellevue Hospital, but had a far better research resume, was appointed as Professor and Chair of the Division of Anesthesiology—full Departmental status only followed in 1952. While this turn of events was a definite disappointment, indeed the failure to become a chair a pivotal point in Virginia's career—Dr. Apgar was pleased to relinquish the accompanying administrative responsibilities, advanced to be the first female full professor in the medical school, visited a number of European Departments on sabbatical, and re-oriented herself to focus primarily on obstetric anesthesia at the Sloane Hospital for Women— building an obstetric anesthesia unit that would be regarded as the foremost in the country, if not the world. †

A Mother's Mother Virginia uttered the words clearly concisely and fast: "Time is of utmost importance. Delay is damaging to the infant. Act promptly, accurately and gently." Turning to the medical students and residents gathered around the resuscitated newborn baby settled in his crib, she went on at pitch: "If an infant is not crying well within a minute after birth, he probably needs assistance with ventilation for respiratory acidosis that leads quickly to metabolic acidosis from which recovery takes hours." (Morishima 1996) Clear guidance, learned from implementing the Newborn Scoring System, and studying the neonate's oxygenation and acid base balance in

Leadership in Anaesthesia

215

the laboratory adjacent to the birthing rooms, that Virginia had established with the help of Dr. Duncan Holaday, an anesthesiologist with training in biochemistry, and Dr. Stanley James, a New Zealand pediatrician. Called the APGAR Score only 12 years later, Virginia considered the Newborn Scoring System, which she had first written down on the cafeteria's Do Not Bus Your Trays sign, key to focusing attention on the newborn immediately after birth to assure that the baby was alright. And if not. To institute resuscitative measures straightaway to forestall later complications. The epigram—APGAR—standing for Appearance-Pulse-GrimaceActivity-Respiration, serving as a handy aide-de-memoir to assessing: Appearance: color; Pulse: heart rate; Grimace: reflex response to a slap on the feet; Activity: muscle tone: limp or active motion; and Respiration: absent, irregular, or best of all, active crying—that could be, and was, displayed prominently in the birthing suite for all to see and use. (Literally around the world). Introduced as an Epigram only in 1961 by Dr. James Butterfield; a great deal of research needed to be performed to validate its use before the approach was accepted worldwide. (Butterfield and Covey 1961) Virginia, already a full professor at the age of forty, launching the effort in 1949, as she refined her focus on obstetric anesthesia and the welfare of the newborn child. A Mother's Mother, she sought to enhance the safety of childbirth through research for both the mother and her newborn child: a largely neglected field at the time. Using the APGAR Score: ten being the highest score possible— determined one minute after complete delivery of the baby, and measured with the second hand of her golden watch 10—as an interim measure of the baby’s 'outcome' after birth, Virginia reported: "A Proposal for a New Method of Evaluation of the Newborn Infant," at a national meeting in 1952, and in a paper a year later; using her findings in obstetric anesthesia as a practical application of her newly developed scoring method, to demonstrate a baby's outcome from delivery. Establishing clearly that general anesthesia with cyclopropane administered for a cesarean delivery was detrimental to the newborn when compared with spinal anesthesia: the average score being 5.0 vs 8.0 respectively; Virginia noted a most important fact: "the condition of infants 10

The golden watch—which had an engraved smiley face on its back in recognition of the emoticons that Virginia used in her letter writing—was given to Dr. Apgar when she relinquished her role as head of the division of anesthesia to Dr. Emanuel Papper. They worked very well together afterwards.

216

6. Virginia Apgar

after spinal anesthesia was definitely better than after general anesthesia." A fact that was somewhat surprising; as the mothers had experienced a much lower blood pressure when receiving spinal anesthesia. (Apgar 1953) But the Newborn Scoring System was by no means spectacularly received at first: "Not differently from any other paper. Just another paper." recalled Apgar when telling the story of her now legendary first presentation at the International Anesthesia Research Society; there were however suggestions given for areas of investigation: In obstetric anesthesia: what caused the detrimental effects of general anesthesia: was it the depressive effects of the drugs used or some other factor. In the study of newborn: how did the Score correlate with the actual state of asphyxiation of the newborn, and could it predict long term outcomes from the effects of hypoxia occasioned by the process of delivery. (Houston 1974) Interpretation. With respect to the newborn. Upon birth, a baby transitions from a relatively low oxygenated state—provided via the placenta and umbilical cord in the uterus—to a higher state as soon as the lungs are expanded with air, and her blood circulation is directed through the lungs. The consequence of a series of connections—the foramen ovale in the heart, and the ductus arteriosus between the pulmonary artery and aorta—closing off at birth; allowing the newborn to transition from a fetal circulation to a neonatal one. The problem that Dr. Apgar wanted to address, and the scientific question to answer—both posed by a not uncommon clinical scenario that all too often played out like this: A newborn, having not fully expanded her lungs with a lusty cry, if left to its own devices can falter—a few weak breathes and then nothing. No one checking to see if she is alright—her blood flow might transition back to the fetal circulation, but the umbilical cord life-line has been severed, and there is no going back—the child becoming steadily more hypoxic and acidotic and then dies. Could this situation be saved by early lung expansion through artificial respiration, and was the acidotic state that terminal newborns suffered from the norm, or a consequence, of respiratory inadequacy? With respect to the mother.

Leadership in Anaesthesia

217

Maternal mortality in the United States was amongst the worst in the world and New York City was at the heart of efforts to improve this. And obstetric anesthesia was both rudimentary and perilous: relying on open mask cyclopropane gas, or spinal anesthesia, for cesarean delivery, and caudal and spinal anesthesia for vaginal deliveries. Although Curtis Mendelson had publicized his concerns for aspiration of gastric contents in pregnant patients by 1946; most anesthesiologists thought the airway could be managed without the need for intubation till about 1956 when Dr. Apgar adopted this much safer practice. (Calmes 1997) In essence obstetric anesthesia practice, listed as the third highest cause for maternal mortality at the time, had been neglected and had not received the attention required to meet the Baby Boom: a birth rate increase from 20.4 million in 1946 to 25 million in 1953. At the same time statistics had shown that newborn mortality peaked in the first 24 hours of life, so there was great advantage to be had from studying obstetric anesthesia to improve maternal and perinatal mortality. (Census 1975, Apgar 1955) With respect to the APGAR Score. The 1950's would herald a watershed into research directed at improving the well-being of mothers and their babies; an endeavor supported by the National Institute of Health entitled the Collaborative Perinatal Project. (Hardy 2003) Central to this endeavor throughout the country would be the adoption of the APGAR Score that each newborn would be assessed with at the time of birth. Low Scores predicting not only immediate outcomes—a very low sustained score often associated with the demise of the child—but also foretelling long-term decrements in neurological outcome; babies with low APGARs often demonstrating neurological impairment later in life. (Drage et al. 1966) But the score would come to be found to be especially useful in helping to prevent poor outcomes by indicating clearly when resuscitative measures—assisting breathing, applying extra oxygen—were needed. (Apgar et al. 1958) The APGAR Score paving the way for better perinatal care of the newborn and the new pediatric subspecialty of perinatology. Having established the priority areas for her research as being obstetric anesthesia, neonatal resuscitation and newborn welfare, Virginia became one of the first to champion both obstetric anesthesia and the new discipline of perinatology—the study and treatment of the factors that led to good baby outcomes after pregnancy. Recognizing the obvious, but at the

218

6. Virginia Apgar

time little appreciated fact, that there was a second patient in need of care in the delivery room, beyond the mother: she set about putting together the research and patient care infrastructure to address the identified problems. In so doing Virginia worked in two fields at the cutting edge of progress—contributing the APGAR Score to both. First she recruited two outstanding collaborators—Dr. Stanley James and then later Dr. Duncan Holaday—created a laboratory adjacent to the obstetric unit, added the necessary equipment, 11 and set to work to establish the mechanisms behind low APGAR Scores: determining that babies were born hypoxic—bereft of oxygen in varying measure; causing asphyxia and anaerobic metabolism. This resulted in the baby's blood becoming more and more acidotic; depressing the heart, breathing, and other vital functions. An ever-spiraling downward loop to death, if breathing was not started: and quickly, with a face mask gently applied to squeeze in oxygen and expand the newborn's still collapsed lungs—the depressed child not having the energy to respire by herself. (Calmes 1984) Then, with these insights in hand, Dr. Apgar and her colleagues started teaching infant resuscitation techniques, while dispelling the myth prevalent in 1955, that all that was required to treat the asphyxiated newborn was to provide the baby with intragastric oxygen through a catheter—which they showed scientifically, was worse than useless. They made representations to special committees: On Infant Mortality and to the American Medical Association and others. They created Monographs on infant resuscitation for wide national distribution. They created a movie on newborn resuscitation with a drug company: Travenol—again for national distribution. They created workshops, teaching hundreds of physicians how to use a laryngoscope to intubate and the mechanics of resuscitation; smuggling in recently dead babies to do so (at a time when there were no alternatives; no plastic mannequins). (Calmes 2015) In short, Dr. Apgar and her team investigated and taught the science underpinning the resuscitation of the depressed newborn: a low APGAR Score at one minute after birth providing the alarm—something needed to be done—while the subsequently added five-minute APGAR Score, could be used to measure not only the 'outcome' of the delivery, but also the effectiveness of the resuscitation management of both the mother and her newborn child. 11

The Astrup pH Electrode from Copenhagen—becoming available in 1955—the lab purchased one immediately (See next Chapter).

Leadership in Anaesthesia

219

(Apgar, Dr. J.S. Drage, and others would of course publish extensively on the utility of the APGAR Score: as a guide to the need for resuscitation; as a measure of morbidity (short and long term); and as a gauge of mortality outcomes. (Apgar et al. 1958) ) Apgar, after studying 15,348 newborns, predictably noting that the one-minute time point for the APGAR Score measurement was especially useful in judging the need for resuscitative measures, such as respiratory assistance: as, after-all, she had picked out this time in the first place for the assessment, because she had found that the babies were at their worst at 60 seconds after delivery. And. Dr. J.S. Drage, reporting that the five-minute APGAR Score better predicted long-term morbidity—neurological abnormality, motor retardation etc. (Drage et al. 1966) † By, 1956, notwithstanding outward appearances to the contrary, Virginia was not "all work and no play"—quoting a brief diary entry quip that she had made as an anesthesia resident, twenty years earlier. In fact there was a lot of 'play': Virginia hated cooking, loved socializing, and so met for dinner and cocktails in great abundance, rarely, it seems, eating alone. There was another 'play'. She loved to play music. Especially the viola. Knowing this fact, and that Virginia would always visit her patients on the ward the night before the next day's surgery, a Columbia Surgeon suggested to Mrs. Carleen Hutchins (an up and coming violin maker and acoustics expert) that she bring an instrument to the Harkness Pavilion, connected to the Presbyterian Hospital, the day before her planned surgery there: so that Mrs. Hutchins could show the violin to Dr. Apgar— who would no doubt love to play it. They hit it off immediately. After the pre-op visit, Virginia remained to play the violin with gusto in Carleen's room, to everyone's evident delight. And, upon Carleen mentioning to Apgar that when making telephone calls to her husband using the payphone booth situated in the entranceway of the Harkness Pavilion, and had impatiently drummed her fingers on a maple shelf waiting for the dimes to drop, she had noted a particular resonance that would be just perfect for the back of a viola she planned to make, Carleen went on to declare that she must have it. What could Virginia do?

220

6. Virginia Apgar

The operation over and Carleen now recovering in the Harkness Pavilion ward, Virginia hatched a plan. She first approached the hospital authorities, but they would not let her replace the shelf. So an alternative must be arranged. A late-night replacement heist. Virginia stained a piece of plywood with the exact same varnish used previously for the telephone booth, having found this in the local hardware store. Then, when the evening 'patient-visiting-hour' was over, Carleen and Virginia snuck downstairs; shelf, crowbar, and a hacksaw in hand to make the switch, but encountered problems. Night watchmen and nurses walking through the entrance way; Virginia stood guard outside the booth, while Carleen attempted the shelf swap—a tap on the booth signaling that more dimes needed to be inserted and a telephone call feigned. Prying away the prize maple wood shelf, they found that its replacement was too large, by a quarter inch, needing immediate adjustment to fit, to hide their theft. Carleen took the replacement into the adjacent "Ladies Room" to fix it—sounds of sawing emanating through its closed swing door. Virginia discouraged a passing nurse wondering at the noise: "It's the only time repairmen can work in there." The nurse probably impressed by the well-known physician dressed in her white scrubs and hat, left it at that. Accordingly the shelf was rapidly replaced, photographs of the event taken, and the maple wood shelf incorporated into the first viola that Virginia would learn to make, with Carleen's expert help. The purloined maple wood from the Harkness Pavilion, now the back of her first viola, travelling with Virginia, and used in pickup performances of the Amateur Chamber Music Player's, around the world. And no-one the wiser as to the heist, until a year later, when Virginia showed pictures of the caper at a medical staff picnic. † Until 1957, when she finally relinquished her responsibilities for patient care as head of Obstetric Anesthesia, Dr. Apgar did much, much more to promote patient, and especially mothers and babies, welfare— applying her considerable talents both clinically and scientifically. Beyond working on the APGAR Score and studying resuscitation science, clinically, Virginia was reputed to have taken care of over 20,000 anesthetics, trained 250 residents, and had overseen 17,000 births, launched a residency and medical student training program in anesthesia for obstetrics, provided 24-hour anesthesia coverage of the service in the Sloane Hospital—

Leadership in Anaesthesia

221

insisting that every patient should be seen pre and postoperatively—and ensured that laboring patients had appropriate pain control. And scientifically, Virginia went on to study the effects of anesthetic and other drugs administered in labor on the newborn. In effect studying maternal-fetal placental transmission. Initially, a chance finding shining a light on the problem. During a cesarean delivery under cyclopropane anesthesia, the mother unconscious; the baby was delivered screaming, and upon receiving placental blood—stopped. The probable cause? Cyclopropane gas in the mother's blood transmitted to the newborn. So the researchers performed cyclopropane, ethylene and nitrous oxide placental transmission studies providing Dr. Apgar with incontrovertible data to her distinct dismay. After looking at the data for cyclopropane, showing that the babies of mothers anesthetized with her favorite agent were significantly more suppressed, Virginia declared at that day's lunch in the cafeteria: "There goes my favorite gas." And that was it, the death knell for cyclopropane gas in obstetric anesthesia. And also the demise of general anesthesia in obstetrics as the favored approach—as spinal anesthesia had been clearly demonstrated to be safer for both mother and child. The APGAR Score showing the difference for the newborn incontrovertibly. (Apgar et al. 1957) And, eventually, the APGAR Score that Virginia had birthed, and so assiduously studied, would gain such worldwide acceptance, that by 1968: – In twenty-nine provinces in China a hospital administrator boasted that: "97 per cent of our babies will this year be born with APGAR Scores;" – The New York State Department of Health had mandated the recording of the one-minute APGAR Score on every babies Certificate of Birth (Item 39); – Dorland's Illustrated Medical Dictionary had included its definition in its pages, and – In some hospitals overhead paging for—"Dr. Apgar. Calling Dr. Apgar."—would send any available doctor scurrying to the hospital's delivery room to assist with a pediatric emergency. (Greengold 1968, Apgar 1966) Virginia Apgar, a Mother's Mother whose name saves newborns. (Debendette 2018) †

222

6. Virginia Apgar

March of Dimes & Fame The National Foundation for Infantile Paralysis 12 was founded by President Franklin Delano Roosevelt in 1938. Paralyzed from the waist down by polio himself—since the age of thirty-nine—the President had issued a proclamation to create a national program to combat the disease, engaging the comedian Eddie Cantor and other promoters to help develop a donation strategy for the President's Annual Birthday Balls to fund the program. 13 Cantor, thinking of a popular newsreel, 'The March of Time' suggested that a national radio pitch for dimes donated directly to the White House; a "March of Dimes," would find popular appeal: "The March of Dimes will enable all persons, even the children, to show our President that they are with him in the battle against this disease. Nearly everyone, can send in a dime, or several dimes. It only takes ten dimes to make a dollar and if a million people send only one dime, the total will be $100,000." The national campaign worked. The President received an avalanche of dime donations, often sent in envelopes for the purpose, totaling $280,000 for the first Birthday Ball of 1938. Having successfully developed a national program to eradicate the scourge of polio, the National Foundation's long-standing president, Basil O'Connor, announced a new mission on 22 July 1958 for the "New March of Dimes." Birth defects prevention. A totally new public health endeavor, but nevertheless continuing the organizations focus on disorders and disabilities appearing in children. The National Foundation was very soon funding genetics research, developing strategies to identify and prevent birth defects (the haunting nightmare of every pregnant woman) and establishing birth defects treatment centers in hospitals across the country in an attempt to remedy the situation. †

12 The National Foundation for Infantile Paralysis would change its name to the National Foundation (1958), and then to the National Foundation-March of Dimes, and then March of Dimes-Birth Defects Foundation (1979), and finally to just the March of Dimes, in 1988. Colloquially the 'March of Dimes' and 'National Foundation' had been used interchangeably for a long time before that and so will be used interchangeably in this narrative. 13 There will be a great deal more written about poliomyelitis in the next chapter.

Leadership in Anaesthesia

223

In 1958, in order to be better able to understand the complex mathematics and statistics that her research into neonatal outcomes was presenting her with, Virginia took a year's sabbatical leave and enrolled for a Master's in Public Health degree at Johns Hopkins University in Baltimore. She had cast the net widely and determined that this was the best school available, and was enormously excited about the prospects in public health. She also claimed later that "it was the toughest year of my life." It would, however, forever change her planned career. Having finished a three-hour epidemiology examination one morning in January, and on her way back to New York City via Towson to get her hair done for a Dinner and Movie date, she had an eureka moment under a hair-dryer: deciding to "go into epidemiology [for the] next 25 years -." Immediately writing off for a catalogue for the Columbia School of Public Health: "- Whoopee!!"—she started making plans for her future back in New York City. Then, on having multiple conversation with Dr. Thomas Rivers, a virologist who was teaching at Hopkins, and also directed the March of Dimes research program, Virginia became interested in the organization's new focus on improving outcomes from pregnancy through preventing birth defects—thought on the matter deeply, met with Dr. Papper, the Chair of the Department of Anesthesiology at Columbia University in April of 1959, got his blessing on her plans and was free; having spent 30 years at the institution since starting medical school there. Next, Dr. Apgar attended the John's Hopkins University Graduation ceremony on the day she turned 50, and after three weeks of vacation—fishing, violin making, playing music, and rearranging her affairs—on July 1, she backed her bright red convertible out of her Tenafly apartment garage, put the top down—it was going to be a hot, exciting day—gunned down the I-95, shot through the Lincoln Tunnel, and steered over to Manhattan's Eastside to arrive on time at the National Foundation offices on Park Avenue: the Art Deco building between 32nd and 33rd street. 14 Starting at 8.15 sharp, Dr. Apgar was welcomed to her new job as the Director of the Division of Congenital Malformations, and started work, but not before a celebratory lunch was held at the Cloud Club, on the 67th Floor of the Chrysler Building nearby. 14

The National Foundation-March of Dimes would move its offices to White Plains, New York, February 15, 1971. Dr. Apgar was then the Vice President of Medical Affairs.

224

6. Virginia Apgar

Ten people packed tightly around the table of the well-known allmale club to welcome her; Virginia tucked behind a door—but excited nevertheless: "-." She had expanded her mission in life from helping mothers to deliver healthy babies, to preventing birth defects. A problem that stalked every expectant mother, but that had been largely ignored and proved an irresistible challenge for Virginia's pioneering mind. Interpretation. Birth defects 15 were considered to be the greatest unmet problem in child care of the day. Afflicting a quarter of a million children annually at the time that Dr. Apgar joined the National Foundation as Director of Congenital Malformations, she set out to research the causes and consequences of birth defects and was charged with increasing public awareness and funding for the problem, seeking preventative solutions, and developing mitigation strategies to avoid stigmatization of the afflicted children so that they could be managed at home, and by avoiding institutionalization, be kept with their families as effective members of society. (Apgar 1968) While the National Foundation had been very effective in eradicating polio through sponsoring Dr. Jonas Salk and Dr. Albert Sabin's vaccination research (in Pittsburgh); a nationwide trial of millions of children demonstrating a decline of polio by 1955, there was little that was definitively known about what caused birth defects, nor how they could be prevented: propelling a strategic shift for the well-funded national organization to help manage a new problem for America's children. There had been encouraging clues as to birth defects origins from research done since the 1920's in various fields, and connections were being made from insect and animal research as to what caused teratogenesis: the effects of infectious diseases like rubella (German Measles), pesticides, radiation, and alcohol, on the developing fetus gathering apace. But little that could be definitively translated to the pregnant human. Meanwhile the accelerating advance of molecular biology— following DNA's description by Watson and Crick in 1953—promised progress in the genetic coding of inherited diseases, potentially opening up avenues for genetic counselling and intervention. The wind at Dr. Apgar and the National Foundation's back— impelling the new initiative forward—because of the publicity surrounding 15 The National Foundation-March of Dimes definition: "A structural or metabolic disorder present at birth, whether genetically determined or a result of environmental interference during embryonic or fetal life." Birth injuries are not included in this definition.

Leadership in Anaesthesia

225

the thalidomide disaster. A sedative anti-emetic drug introduced in Europe that was causing dreadful birth defects known as phocomelia: babies born without limbs or with only seal-flipper like appendages, instead. The disaster only narrowly avoided in the USA because of the actions of a newly appointed physician at the Food and Drug Administration—Dr. Frances O. Kelsey—emblazoned on the front page of the Washington Post, July 15, 1962: 'HEROINE' OF THE FDA KEEPS BAD DRUG OFF OF MARKET. Dr. Kelsey had stubbornly put her foot down, insisting that more research needed to be supplied to justify the drug's approval beyond the rat research that had been performed to date, the national newspaper aired its approval: "A Government physician prevented what could have been an appalling American tragedy, the birth of hundreds or indeed thousands of armless and legless children." The prominent article unlocking wide-ranging discussion around birth defects, propelled the meticulous testing of drugs in humans before they were declared safe for administration during pregnancy. There being a growing recognition that the placenta was not a barrier to the transmission of drugs from the mother to the fetus after all, but rather a "damned sieve" as Virginia had declared—having studied this for demerol; showing that it was transmitted and depressed the newborn. Other objective data further justified the March of Dimes birth defect program—perinatal statistics between 1955-1960 failing to show an expected improvement in infant mortality; explained by an increased incidence of premature births. The death of John and Jacqueline Kennedy's infant son, in August of 1963, catapulting the problem of prematurity to national attention. And thrusting Dr. Apgar from the bed-side as an anesthesiologist, to travel around the country and the world; her many speeches, public appearances, writings, and conversations bringing the issue of birth defects—often considered a private tragedy—to very public attention, as a national, indeed international, public health problem. Virginia declaring excitedly: "After all those years under an anesthetist's sheet, I'm really seeing the world for the first time."

226

6. Virginia Apgar

Dr. Apgar going on to traverse the country and world exhaustively; clocking into the hundreds of thousands of air miles 16—and thousands of car miles—to conduct her appearances, evaluate research proposals, and seek funding for the March of Dimes, presenting herself with candor, energy, and grace in the interests of the public. (Hunt 2002) † The temperature climbing to just under 950F outside; the Subcommittee on Health, gratefully took their seats in the coolness of Room 4232 of the New Senate Office Building, adjacent to Capitol Hill, that stifling last day in June of 1969. Senator Ted Kennedy providing the opening statement in support of: S.2264 To Amend the Public Health Service Act to Provide Authorization for Grants for Communicable Disease Control S.1622 Vaccination Assistance Act of 1969 "Today the Senate Subcommittee on Health opens hearings .... of major importance to eradicate infectious diseases in America. In February 1962, when President Kennedy first proposed the Vaccination Assistance Act in his special message to Congress on national health he said: 'There is no longer any reason why American children should suffer from polio, diphtheria, whooping cough, or tetanus—diseases, which can be prevented, but which still prevail in too many cases.'" Senator Kennedy continuing: "When the Vaccination Assistance Act was signed into law in October 1962......the act has brought immense protection to millions of American children....[but] ..In spite of the progress we have made, it is clear that we have not yet accomplished our goals... I am hopeful that these hearings will illuminate the areas where special new efforts must be made." Then adding, that although in his prepared statement he had concentrated primarily on measles to highlight the long-range need for the extension of the Vaccination Assistance Act, he hoped the House would 16 Before they existed in their current form provided by the airlines in the 1990's, Virginia needed to calculate the mileage herself.

Leadership in Anaesthesia

227

recognize that there are numerous other areas where the provision of the Act could be vital. Going on to highlight that the National Foundation had been working on Rh hemolytic disease; he noted that despite a 100% effective antibody having been developed by researchers, fully 25% of pregnant women remained at risk. He then turned, importantly, to the case for rubella, pointing to the predictions of a severe epidemic in 1970 or 1971: "Today in the United States, 50 million children and child-bearing mothers are unprotected." Going on to propose: "Indeed, the imminence of the approaching rubella epidemic offers what I believe may be the strongest immediate argument for extending the act." The stenographer seated at the front of Room 4232 quietly clacking on her machine to record the Senate Hearing for posterity. (Senate 1969) Dr. Virginia Apgar, newly the Vice President for Medical Affairs of the National Foundation-March of Dimes was then called to the stand to provide testimony. Senator Harold E. Hughes who was presiding over the session announcing loudly: "Dr. Apgar you may proceed." "Thank you Sir. .....Mr. Chairman, the National FoundationMarch of Dimes, is pleased to have been invited to present its views on proposals to the Senate for control on communicable disease." Apgar then going on to relate, that since its inception in 1938, when government support of health research and development was minimal, the National Foundation was the principal resource for funding major advances in virology research, leading to the licensure of the Salk vaccine in 1955, and the eradication of polio. Turning to the present, and the threat of rubella, Virginia added: "The last major epidemic, in 1964, caused an estimated 50,000 abnormal pregnancies, resulting in some 20,000 live-born babies with birth defects and about 30,000 fetal deaths before birth." Relating further that many of the victims were now still being cared for in the 107 March of Dimes birth defect centers, spread around the country, where they required ongoing intensive medical and educational services.

228

6. Virginia Apgar

Adding: "With widespread immunization of children with the new rubella vaccine, this tragedy may not be repeated." Stating further that in her view there were two formidable obstacles to success: One educational, the other fiscal. "On the educational side, the idea of vaccinating children against rubella to protect unborn babies from birth defects will not be easy to get across to the public." Accordingly, Dr. Apgar recounted that 145,000 copies of a review article on rubella by Dr. Louis Cooper had been mailed to physicians around the Nation. Cautioning that: "As for the fiscal obstacles, however we are less optimistic." There being 56 million children aged one to fourteen in the Country, and if the target for the immunization program were to be a 75% vaccination rate: "Some 42 million doses would be required initially." Going on to make her case cogently also for the prevention of Rh incompatibility disease. 17 And completing her testimony with a strong motivation: "In view of the cyclical nature of rubella epidemics and the consequent need to achieve rapid vaccine coverage, neither of the legislative proposals appears to be entirely adequate to meet this challenge. The appropriations authorized in S. 2264, however, more nearly approach the requirements." Senator Hughes: "Thank you very much, Dr. Apgar. How high a funding authorization do you think would be necessary in S.2264 to do the task as outlined in here?" Dr. Apgar: "Well, I believe, omitting the Rh problem, it is something around $54 million, depending on the cost of the vaccine." Senator Hughes: 17 Through the administration of an immunoglobulin (Rhogam) to Rhesus-negative mothers should they birth Rhesus-positive children, thus preventing maternal immunization against the rhesus positive blood type of their newborn baby to ensure that a subsequent child does not suffer from the potential killer: Erythroblastosis Fetalis (hemolytic anemia of the newborn) brought on by the transmission of maternal induced antibodies to the subsequent fetus.

Leadership in Anaesthesia

229

"I take it then, from your statement that you are supporting, basically, S.2264." Dr. Apgar: "Yes, sir." Senator Hughes: "And you feel it still falls short of doing the job?" Dr. Apgar: "It is a good start toward it." Senator Hughes: "You would be pleased with it, I would imagine." Dr. Apgar: "Yes, sir." And, Dr. Apgar was. And so it came to pass; not immediately, but quite soon afterwards—a national immunization campaign supported by Congress and launched by the Center for Disease Control in Atlanta to vaccinate children against rubella; the predicted epidemic avoided—by the end of 1975: 69 million doses of rubella vaccine had been administered throughout the country, and 65% of children under 12 years had been vaccinated. (Hayden 1977) † Another strength that Virginia's advocacy brought to the March of Dimes was her ability to attract funding for the organization, as she ascended from Vice President to Senior Vice President of Medical Affairs in 1973; tripling the annual funding from $19 million to $46 million over the 15 years—she launched one of the most successful programs to date: the annual March of Babies in 1970. Previously known as the Walk America fundraiser of the year, this has since grown enormously: over 900 communities and a million people a year contributing over $1.8 billion to the March of Dimes, since 1970. Under the slogan: "Be Good to your Baby Before it is Born," Dr. Apgar broadened the March of Dimes reach even further, in improving birth outcomes, through emphasizing the need for a comprehensive approach to perinatal health by including both prematurity and low birth weight babies into the equation; advocating for the establishment of a birth defect registry, and most importantly, that both a genetic and pregnancy history be made a routine part of medical record-keeping for all pregnant woman; going on to

230

6. Virginia Apgar

convene the March of Dimes Committee on Perinatal Health that published "Toward Improving the Outcome of Pregnancy," which became a model for the reorganization of perinatal health care around the country. Never far from her academic roots, but missing medical students and a good library, Dr. Apgar became a Professor and Lecturer in Teratology at the Department of Pediatrics at Cornell Medical College in 1965, gave six lectures to the third year students annually, and attended babies in a Birth Defects Clinic weekly: the results of her industry, very well recognized, as she was subsequently awarded three Honorary Doctoral Degrees for her ongoing academic and lay publications—receiving these from the Women's Medical College of Pennsylvania, the New Jersey College of Medicine and Dentistry and her alma mater, Mount Holyoke College—while her other alma mater, the Columbia University College of Physicians and Surgeons, conferred the Alumni Gold Medal for Distinguished Achievement. Virginia was becoming famous. A very popular speaker, her staccato speech and wry turn of phrase notwithstanding, Dr. Apgar's often reassuring message about a hugely important topic found great favor with the public. Hence it was not surprising that she became a much sought-after public figure; appearing on innumerable radio talk-shows, and a multitude of television programs—she became a celebrity. Her Radio and TV Interview Schedule for the second week of January in both 1964, and 1965, offering a good example of how busy she was: Virginia appeared on the Martha Dean Show and Metropolitan Memo as well as You and Your Health in 1964; and the Vincent Tracy Show, the Mimi Benzel Show, and You and Your Health, again in the same week, in 1965. The pace only increasing with the years as her popularity grew. The publication of her book: Is my Baby Alright? in 1972, further increasing Virginia's publicist's demand (and her diary), for book tour appearances with her co-author and good friend Joan Beck. The work load from TV appearances such as The Killers, 18 the Johnny Carson Show and the Phil Donahue Show, became sometimes unbearable—Virginia commenting on the "devastating" number of letters that she received after the Phil Donahue Show—all painstakingly and kindly answered (around one hundred letters over three months). Her maxim to live by: "Work hard, give of yourself and practice TLC 19 -." Virginia worked excessively hard all her life. But was feted for it—receiving an invitation to the White House to meet with the First Ladies: 18 19

On genetic defects. TLC is an acronym for 'Tender Loving Care.'

Leadership in Anaesthesia

231

Mrs. Lyndon Johnson and Mrs. Hubert Humphries to honor "Leading Woman" in the country in 1968; and chosen to be the Woman of the Year in Science and Research by the Ladies Home Magazine in 1973. And in 1995, 'Ginny' to her adult friends, and 'Jimmy' to her school girl friends back then, was inducted into National Women's Hall of Fame in Seneca Falls, New York. †

Paraphernalia: Cars-Planes-Music-Stamps-Fishing: A Zest for Life Cars & Planes Virginia could be a scatterbrain. She was always in a hurry and rushing around, but would occasionally miss planes and often lose things: all her keys to her new car, her briefcase in a taxi, her precious camera, which she never went without on her yearly air travels—catalogued in exact detail in miles flown in her January "Ginny Grams." The sobriquet 'Ginny Grams' having been suggested by her favorite lawyer, Andrew Knowlton, to entitle Virginia's annual summary letters that she avidly typed out and circulated to her hundreds of friends, to summarize much of the past year's activity: always including her travelogue for good measure—28 business trips in 1961; 35 trips and 75,900 miles in 1964, 32 trips and 86,700 miles in 1965; 42 trips and 97,600 miles in 1966. Adding in the 1966 Ginny Gram that this mileage was "not including the Westside and East River Drive when in town." Car mileage which she would drive at a furious pace from her apartment home in Tenafly, New Jersey—over the George Washington Bridge—and on into New York City to the Presbyterian Hospital at 168th Street, or via the Westside Highway, to Park Avenue where the March of Dimes had its offices. Driving from there as needed. Her friends fearing to drive with her because of the speed she drove: "driving her automobile as if it was an airplane." Ginny claiming that she didn't need to change the tires because they rarely touched the ground. Well this was a joke if ever there was one, as a series of diary entries cataloguing mishaps, punctures, car changes, and speeding tickets indicate: 1958: March 21: Beautiful New Pontiac

232

6. Virginia Apgar

April: Friday 4th: Long ride—ending in accident at United Nations. April: Friday 11th: Ordered new car. (she had an Allstate Insurance car in the interim.) June: Friday 27th: Lost camera July: Sun 6th: To Bergenfield to exchange car—Power steering stinks. July: Wed 9th: To Bergenfield to get car back—ok—FLAT TIRE—3rd since Bot. August: Thursday 21: Flat Tire August: Thursday 28: "Almost forgot to get on plane at Idlewild." September: Saturday 27: "Traffic fine on way, $11.45." November: Sunday 5th: " Back via Hutch—85 mph—NICE policeman. 'Don't take that MD license too far!'" In her annual Ginny Gram of 1969, having lost count of the yearly air-mile totals, Virginia recounted: "have given up calculating the miles but it's in the second million." And, upon the fact dawning on her that she was often a single passenger in a small plane—Virginia wanted to be able to control the situation in case of an emergency—decided that she might as well take up flying lesson's so that she could fly, and land, the plane should the single pilot succumb: she enrolled in flying lessons at the age of 60. Goal setting a customary practice for her, she set as a goal that she wished to fly a plane under the George Washington Bridge that she drove over every day to work, and reported on progress in 1971's Ginny Gram: "My newest hobby, flying, is up to 12 hours instruction, 25 landings and take-offs (any idiot can do that!). 20 Lamenting to a colleague: "I seem to have the bad habit of wanting to see where the wheels are going to touch down, which means a direct nose dive onto the runway!! I'm working to overcome that deficiency!" Fearless as ever; having personally witnessed an air-plane crash back in 1962. Taking off from New York City's Idlewild in a dual prop plane for Albany, New York—it was a beautifully clear, cold, sunny day. Virginia, sitting in the aisle seat next to her friend Carleen Hutchins at the window, as far up-front as possible to better enjoy the view, the pilot gunned the plane down the runway and whirred into the air. 20

The author, a Professor of Anesthesiology, who served as the Residency Director in the Department of Anesthesiology at Columbia University from 1993-2002, has had a similar amount of flying experience as Dr. Apgar recounts: and found it great fun too!

Leadership in Anaesthesia

233

Virginia describes the horrible event beautifully: "Today I saw 95 people die, all at once. In my profession, I have seen many more than 95 people die, one at a time, usually as a welcome relief from pain and suffering. Today was different. All of a sudden, we both fastened our gaze on an unbelievable sight. A stunning silver jet was descending vertically, very fast, directly in our line of vision. The plane never wavered from its downward course. The water almost seemed to part to receive it. The plane went straight down into the deep mud and disappeared. All this took less than five seconds." Then. "Our pilot circled twice over the area, to pin-point the site for the observation tower. A little more debris came to the surface as we watched, but there was no smoke nor fire. A big flock of white sea gulls flew in and settled on the debris to look it over." And then. The pilot came over the intercom and said: "Some of you have just seen a most distasteful sight. A 'dead' airplane dove in the water. It was a jet. There is no hope for any survivors. We are sorry for the delay." The plane renewing its ascent, continuing onwards to Albany, Virginia remarking: "It took hours for the enormity of the accident to creep upon our nervous systems." Continuing: "As John Glenn said the next day, that in our strides of progress in space, there will be inevitable losses. Such a loss is this, to interrupt the wonderful record of American Airlines flights, and of jets everywhere." Virginia concluded optimistically: "I'll take an American jet to the west coast, the next time I have a chance." 21 (Apgar 1962) †

Music Ever since she started playing the violin at the age of six, Virginia was an active musician; playing in quartets, mini-orchestras and music ensembles at home and abroad. Usually carrying her viola with her on trips, she loved to play with other musicians and was a most active member of the 21

Dr. Apgar, never managed to fly under the George Washington Bridge as she had hoped.

234

6. Virginia Apgar

Amateur Chambers Music Players that had around 6000 members distributed across 62 countries: fertile opportunity for her playing efforts. And since the telephone booth caper—with her now close friend Carleen Hutchins—she had learnt to make her own musical instruments: the first a viola, backed by the remnants of the Harkness Pavilion telephone booth, and the second, a violin completed in 1961. In order to learn more about stringed instrument making, she had become a member (and treasurer) for the Catgut Acoustical Society, another international society, this time devoted to the research, development, and improvement of stringed instruments worldwide, and had embarked on making her own cello, completing this four years later. She was particularly excited about taking her first lesson on the new instrument as she embarked on her fourth, a mezzo violin. 22 †

Stamps Virginia loved to collect stamps. From a child's past-time it became an adult passion. A member of the American Philatelic Society; as a to-do on her extensive travels abroad, she would jot down a stamp wish-list in her travel diary. Often bringing back hundreds of stamps from her trips, she added to the collection of foreign stamps those that she would inevitably receive in the mail from her newly made international friends. Virginia engaging her mother, Helen, living nearby in the same apartment complex, to help wash off the stamps and sort them—amassing a collection of 48 albums and over 50,000 stamps. Never knowing that one day it would be her kind face that would grace a stamp: Dr. Apgar's stamp, the fourth 20-cent stamp in the US Postal Service's Great American Series, was released posthumously on October 24, 1994, at the American Academy of Pediatrics in Dallas, Texas. To celebrate the event, a quartet of pediatric doctors played a selection of Virginia's favorite chamber music using the violin, viola, cello and mezzo-cello she had crafted in the 1960's—the Apgar Memorial String Quartet celebrating the pioneer perinatologist's exuberant life. (Skolnick 1996) † 22

All four instruments: The 'Apgar Quartet' consisting of a viola, violin, cello and mezzo-violin, are now held in the Health Science Library of the Columbia University College of Physicians and Surgeons.

Leadership in Anaesthesia

235

Fishing From a very young age, Virginia loved to fish. Fishing everywhere she could: in the Hudson River alongside the Presbyterian Hospital, in Lake Mendota in Madison, in the St Lawrence River more than 25 times, in Scotland and in Norway, in Alaska and at the Great Barrier reef off of Mackay, Queensland—where after trying three days of casting to no avail, in 1952, she recounts: "Finally Caught a fish—a striped bass—blue + aqua + yellow to match my shirt! Lovely Day." She was looking forward to her favorite spot on the St Lawrence River, having readied a new rod for a summers fishing in July of 1974. †

We are remembered by the way our work is continued Virginia bravely faced her deadly illness. Cirrhosis. She had planned to live to 95, like her mother. But that was not to be; the severe hepatitis she jokingly called "Conroy's Disease" in the Spring of 1947, was no joke: her liver relentlessly failing—incapable of sustaining her unstoppable spirit. Over the last three years she became increasingly sick. She had required multiple admissions to Presbyterian Hospital and the Harkness Pavilion before; but this now accelerated. Not one to tolerate her own incapacity, she had communicated to colleagues before undergoing major surgery in 1971 that she did not want extraordinary measures to keep her alive. (And certainly didn't want people to see her sick). (James 1975) Fortunately they weren't needed and she recovered fine; the world knowing little of her struggles as she went on the, Is your Baby Alright? book tour with her co-author and friend Joan Beck. But in 1974, things got steadily worse: fluid accumulating in her lungs, requiring painful drainage and posing a diagnostic dilemma. Was it cancer or cirrhosis or both? She was scheduled for exploratory surgery on August 7, 1974, in the hospital she had served in as a medical student, doctor, resident, and consultant: stretching back forty years. Dr. Hisayo Morishima, a close friend, visiting her on the ward the day before tells of her spirit: "Her unbounded enthusiasm did not stop until the very last day of her life. Even when she was scheduled to undergo exploratory surgery, she slipped out of her hospital room to visit the Babies

236

6. Virginia Apgar

Hospital Perinatal Unit, which had just been built and which she had not yet seen." That night, Dr. Virginia Apgar died in her hospital bed. "She left this world 30 years too soon." (Morishima 1996) † Two memorial services were held. One in New Jersey and one across the Hudson River in New York. In New Jersey on 8 September, a "Memorial Service of Worship" was held at the Tenafly United Methodist Church: the church Virginia had attended religiously each Sunday with her mother. Her elder brother, Lawrence, serving as the organist for the service; many in the large local congregation standing up spontaneously to share testimony; bearing witness to Virginia's many acts of thoughtfulness and kindness. In New York a week later, "A Service of Gratitude for the Life of Virginia Apgar" was held at the Riverside Church. Thousands attended. The public, her colleagues, students, and even her local shopkeepers and policemen who she did so much business with. At both Services her favorite hymn: "Take my life, and let it be consecrated to Thee" was shared and the violin played—Bach and Brahms—to celebrate her life. At the last, Dr. Stanley James, her close friend and collaborator provided a fitting eulogy: "She was one of the most remarkable people I have ever known. With her life was exciting: her youthful enthusiasm and energy were boundless. She was warm and compassionate, and at the same time had a great sense of humor, sometimes earthy. Integrity was her hall mark: she was utterly sincere and honest and could not tolerate any form of deception. Her approach was forthright, direct, realistic and practical. She was loyal and generous, always dependable, and ready to help those in crisis. And despite her many talents she had great humility. All these qualities, and many more, together, with her magnetism and charm, contributed to her greatness... We are remembered by the way our work is continued." In delivery rooms all over the world, thanks to her scoring system, Virginia Apgar is remembered every day. (Hunt 2002) †

Leadership in Anaesthesia

237

Post Mortem With respect to the historical stage within which Dr. Virginia Apgar provided her leadership, she spanned the Trait Age of 1920-1950, the Group-Goal Age of 1950-1960, and the Behavior Age of 1960-80. In the Trait Age leadership was considered the ability to influence the situation rather than dominate it and surfaced the wish to understand the leaders themselves in order to learn from them and so develop those traits in others: the idea that indeed leadership could be learnt. Further, the Group-Goal and Behavior Ages drove the study of the leadership behavior necessary to building relationships—in order to persuade rather than coerce followers—focusing a lens on leading improvements in organizational behavior as organizations became ever more complex to run. Witnessed very well by Dr. Apgar's ascendant leadership role, culminating in becoming the Senior Vice President for Health Affairs at the March of Dimes a large corporation with national scope. We will again review key 'body parts' of the Leadership Skeleton to examine Dr. Virginia Apgar's leadership profile, best captured using the rubric: Creative LEADER. Leadership Skeleton: Creative LEADER max score: +++, min score: 0.

Virginia Apgar

Creativity/Innovation/Imagination

+++

Legitimacy/Authenticity/Credibility

+++

Emotional Competence/Psychological makeup/Personality Adaptability to Change

+++

Determination/Passion

+++

Empathy

+++

Resilience

+++

Total Leadership Score

21/21

+++

238

6. Virginia Apgar

Creativity (+++). Virginia's creativity often lay in her ability to create simplicity from complexity. In creating the simple APGAR Score that would be implemented around the world—it is unlikely that this came to her in a flash in the Cafeteria; jotting it down presciently on the Do Not Bus Your Trays sign. 23 The truth was more likely that she had been thinking on the matter for some time after she had taken over obstetric anesthesia. Here she had become appalled by the prevalent neglect of the newborns that at birth, when apneic, listless, and often malformed or premature, were classified as 'stillborn' and left to die without any attempts at resuscitation. So in order to force people to observe the child, she collected signs in the newborn that indicated the need for immediate action: "I put down all the signs that you could look at without equipment and we had some 15 or so and we got it down to five." (Houston 1974, Finster and Wood 2005) Another creative master-stroke was the simple expedient of an annual newsletter: the Ginny Gram. As Virginia travelled around the world she used this as a means of bringing people together. Running to two or three pages, brimming with information, Ginny told of her friends and their children's success stories, provided department updates, and related her own progress and travels with the intent of keeping people connected as her network expanded. Legitimacy (+++). Virginia was present at the birth of two new fields of medicine. Obstetric anesthesia and perinatology. Championing and studying both, she had the social and academic credibility to match; becoming famous for the work she undertook to improve the health of mothers and children around the world. Emotional Competence (+++). Most of the time, Virginia was mildly hypomanic: thinking, speaking and walking and talking fast. She was gregarious, sociable, everfriendly and always upbeat—and able to come to another's emotional rescue, even when in a dire state herself: The day before her death, upon telling Dr. Hisayo Morishima that she likely had cancer: "She stuck her tongue out at me and made a face like a naughty child. I was unable to conceal my surprise; to be thus consoled by her was 23 Dr. Apgar often used these signs to jot down things; either to teach or to remind her about something later.

Leadership in Anaesthesia

239

quite painful, and I could not help but feel a great sadness." (Eaton-Enochs 1994) Adaptability to Change (+++). A humble girl from a modest family in New Jersey, Virginia embraced international stardom. Always willing to help, she adapted herself to the situation at hand. When a job as a surgeon was an unlikely prospect. She set her sights on anesthesia. When she couldn't find a training position in anesthesia, in one of the 15 residency programs in the country: she created one for herself; joining the nurse-anesthetists at Presbyterian Hospital. Going on to head the first Division of Anesthesia at Columbia, based on a blueprint she had crafted. And, when not named its Chair; she created a new position in obstetric anesthesia. Finding there that children were being neglected; she focused on the second patient in the delivery room, and became a perinatologist. And, hoping to enhance her research statistical skills, she took a degree in public health, and finding epidemiology to be to her liking: she changed tack completely, left clinical medicine, and dedicated her career to one of public health through the March of Dimes. One of the first women in the many fields of endeavor she adopted, Dr. Apgar enfolded change, reveling in the new things she had to learn to do so. Determination (+++). If the above does not speak sufficiently to Dr. Apgar's determination, then the Telephone Booth Caper certainly does. Frustrated by the hospital authorities from getting the resonant maple telephone booth shelf from the Harkness Pavilion for the back of her planned viola, Virginia was resolved to achieve her goal by illegal means. (Which was really quite out of character for Dr. Apgar: being exceedingly honest and forthright about all other matters.) Determined to get her way—one night after visiting hour, she replaced the shelf with a plywood one with the help of Carleen Hutchins; having snuck the necessary tools into the hospital in a suitcase. Empathy (+++) Virginia was very good at empathic leadership as women often are; given the feminine characteristics that this entails.

240

6. Virginia Apgar

Females usually having a holistic approach to leading: sensitive to their senses, with an emphasis on relationships and how parts interconnect; the process considered just as important as the results. Whereas the male approach to leading is often quite different; rational and emotionally detached, they are vested in separating and categorizing to uncover the hidden order of things, and prize a focus on reasoning to get results. (Green 2018) Celebrating group successes rather than the individual success often celebrated by males, puts females at an advantage as leaders because their empathic nature brings people together better, ready for the next leadership challenge. Dr. Apgar's Ginny Grams were a good example of this: she would celebrate the groups successes as well as other's successes far more than her own. But if there was one of her own, she would always put in a suitable disclaimer: in 1962: "I was given the Distinguished Service Award of the A.S.A. I was dumbfounded!! And of course very pleased. Thank you one and all, for these honors which I most certainly do not deserve." Closing one Ginny Gram, with the following advice: "Work hard, give of yourself and practice TLC -." Resilience (+++). Resilience is more prevalent in hypomanic personalities and works like a vaccination. It is not simply a human characteristic, but one that can grow depending upon how the reversal that the individual suffers is interpreted: in a positive or a negative light. If a positive light is shone on the incident or issue the individual becomes psychologically more resilient to stress in the future. Virginia did that by exercising a wry sense of humor. As previously related: Dr. Apgar suffered from liver cirrhosis, a terminal illness. Requiring multiple major operations, that the world new little of. She mentioned this in a Ginny Gram: "I've slowed down quite a bit. - Two hospitalizations this fall clipped my wings. This past year, I've logged only 55,500 miles." †

Leadership in Anaesthesia

241

Leadership Insights There are a number of leadership insights that evolve from Dr Apgar's life story. x x x x

A woman's trailblazer. Curiosity and lifelong learning. Work hard, give of yourself and practice TLC. Grave situations can be managed with a light spirit.

A woman's trailblazer. Despite women in America having been given the right to vote through passage of the 19th Amendment to the U.S. Constitution in 1920— one of the goals of the movement for women's rights launched at Seneca Falls in 1846—opportunities for women in the workplace in the nontraditional fields of teaching, typing, and nursing were far and few between when Virginia entered Columbia University Medical School as one of nine females in a class of ninety in 1929. Aged just twenty, Virginia had applied to the second oldest medical school in America 24 and upon interview immediately got in. Speaking volumes to her persona and ability. Another telling comment of the times she lived in, was provided by another pioneer in this book: Dr. Arthur Guedel. On Virginia visiting their home in Los Angeles, and upon meeting his wife Flo, Arthur wrote to Virginia: "After you had bounced out with all of your enthusiasm, my wife said, 'There. I'll bet that girl does something.'—to which I replied, tongue in cheek, Yeah; if they'll let her." 25 And "they" let her! But it was an uphill struggle for Virginia as a woman. Not only because of active sentiment against a woman 'robbing' a man of a job (that would support his family), but because the hospitals were not set up to accommodate female residents. Even though residency training programs required their doctors to be resident in-house; there were no provisions to lodge female physicians in the 'married quarters' in the hospitals of the time. 26 x

24 The oldest medical school is the one at the University of Pennsylvania, in Philadelphia. 25 September 27, 1941. 26 There was, however, onsite housing for Columbia University Medical Students, be they female or male.

6. Virginia Apgar

242

Virginia expertly, if at times unhappily, navigated the billeting issue, and the lack of opportunity for a female in surgery, by going into the new field of anesthesia at the request of the Chair of Surgery, Dr. Whipple— having pre-arranged that she would head the first Division of Anesthesia at Columbia, upon completion of her training. Facing off many a derisory remark from surgeons who were used to ordering around the nurse anesthetists—with equanimity and a joke or two—Virginia new well that she needed to be much better than the males that surrounded her, and worked doubly hard to achieve that goal. Finally recruiting as the first Assistant Attending to the department, Dr. Ellen Foote—trailblazing the path for females into medicine and anesthesia. She would do much more as a role model for women. Imposing, articulate and fair, she had only one prejudice: Mount Holyoke girls. Hoping to advance the girls from her Alma Mater whenever and wherever possible; she would actively seek them out on innumerable visits to South Hadley to council them on their careers, keeping a log of their achievements. Virginia also notched numerous female firsts. First female BoardCertified Anesthetist. First female Professor at Columbia College of Physicians and Surgeons, First female Distinguished Service Award recipient from the American Society of Anesthesia, and its first female Treasurer. Curiosity and lifelong learning. "Virginia was a student until the day she died. Learning was the focal point in her life. Her curiosity was insatiable, and new knowledge held a continuing fascination for her." (James 1975) Having completed her Master's in Public Health at the age of 50, at the age of 60, she took up flying lessons and at 64, enrolled in a degree in Genetics and Teratology at John's Hopkins University. Never fully satisfied with her abilities, and despite being an excellent (and abundant) scientific and lay writer viz. above: ("Today I saw 95 people die, all at once.") she applied to the Famous Writers School to become even better in 1971. x

Work hard, give of yourself and practice TLC. Dr. Apgar corresponded in hundreds upon hundreds of letters; responding with kindness, warmth and compassion. Never more so than after a television or radio broadcast provoked mothers to question her about birth defects. One letter coming all the way from Singapore. x

Leadership in Anaesthesia

243

Asking for forgiveness for writing because there was little information available in her country, Mrs. O. related that she had just delivered her first baby with a myelomeningocele; the doctors telling her that the baby had only two weeks to live, because the spinal defect was too large, and the overlying skin too thin, to operate. Her physicians also suggesting that she have a new baby soon; Mrs. O. wrote to enquire as to the likelihood of 'a risk of repetition,' given that she had had to take iron tablets at five months into the pregnancy— resulting in terrible diarrhea—although there was no history of any such problems on both sides of her family. Virginia replying by return of mail: "Of course we answer overseas letters, especially such a beautifully written one like yours." Adding that this must have been a terrific shock, but unlikely to have been due to the iron tablets, and, though there was no absolute guarantee that another child would be entirely normal: "the chances are excellent he/she will be." Mrs. O wrote back regularly and three months later informed Virginia that the baby's head had now started swelling and x-rays had shown numerous holes in S.'s brain: adding "Poor little baby,—why have things turned out such a mess for her?" Going on to relate that she was pregnant again but was keeping it quiet: "If the next one is alright then it will be a nice surprise, and if by chance it is not, then it will be easier for us because we kept it quiet." And then two years later: "I want you to know that S. passed away last Wednesday night." And continuing. "Poor little girl, I hope she is happier now wherever she is." Brightening, she wrote further: "I know, one day, I should love another sister or brother to keep this fat, healthy & very naughty little son of ours company." "But I keep thinking, if I wait a few more years we may know the reason for S.'s tragic little life. I couldn't bear to watch another suffer like she did." Mrs. O. concluding the correspondence: "I'll make this do for now, hoping we will still hear news of your good work." (Mets 2020) x

Grave situations can be managed with a light spirit.

Dr. Apgar was a great anesthesiologist. Trusted by surgeons and patients alike.

244

6. Virginia Apgar

Dr. Allen Whipple, her boss, and Nurse Elsie Blunt, head nurse for the Babies Hospital, deserve special mention. (Eaton-Enochs 1994) Dr. Whipple, often becoming agitated in the operating room if the patient under anesthesia appeared restless or started moving, would demand of Virginia that more ether anesthesia be given; at a time when she was administering her favorite agent: cyclopropane. Unfazed, Dr. Apgar would deepen the anesthetic with cyclopropane, pour some ether on to a sponge and tuck it under the surgical drapes; the smell of the pungent vapor soothing the agitated surgeon. And..... Dr. Whipple, none the wiser—but much, much calmer. Dr. Apgar was also often asked to look after colleagues like Elsie Blunt as patients. Fearful that her newborn might have a birth defect, the first words she heard Virginia say after the delivery under general anesthesia was: "Wake up, Elsie, I've put a tube down her and a tube up her and they meet." reassuring her mightily that the baby was normal. APGAR Score: 8 out of 10. †

Concatenation Having tracked anesthesia from its crude beginnings in Boston, in 1846, with William Morton's 'discovery' of the art of surgical insensibility that ether could produce, we crossed the Atlantic to London, where John Snow progressed its science, and then to the Western Front, Indianapolis and Los Angeles, where Arthur Guedel honed its practice—proceeding on to New York City for Virginia Apgar to demonstrate the outcomes in newborns from the application of different anesthetic and resuscitation techniques using the APGAR Score. To take the final leap of the historical transformation of Anesthesia to Anesthesiology we continue with Bjørn Ibsen in Copenhagen who will take its practice beyond the operating theater (using the hard-won anesthetic skills there developed) to save moribund patients—and go on to establish the first intensive care unit in the world. †

7. BJØRN IBSEN

Anaesthesia ĺ Anaesthesiology: Beyond the Operating Theater "I knew I could." “At the beginning of intensive therapy it was a problem to keep the patient alive— today it has become a problem to let him die.” —Bjørn Ibsen

246

7. Bjørn Ibsen

Poliomyelitis

Doctor Bjørn Ibsen had been given one chance to prove himself. (Berthelsen and Viby-Mogensen 2007) One chance to demonstrate that anesthetic techniques used inside the operating theater could be used outside. One chance to save a life! Much like the time he found his breathless daughter—turned blue on the family couch, her airway plugged by oatmeal, five years earlier—this time Ibsen had been asked to intervene on Vivi Ebert paralyzed and suffocating from bulbo-spinal poliomyelitis; a victim of the polio epidemic sweeping through Denmark. The paralyzing polio epidemic, centered in Copenhagen, reaching a crescendo in August of 1952, creating a crisis of almost biblical proportions—Dr. Henry Cai Alexander Lassen, an epidemiologist, and Physician in Chief of the Blegdams communicable diseases hospital, sketching the predicament well. Noting that the 500 bedded 'fever' hospital which served a population of well over a million had received close to 4,000 polio patients that year—fully one third of whom suffered from paralysis requiring close to 400 victims to be admitted for respiratory care; the hospital being pitifully resourced to deal with the crisis—resulting in 27 of the 31 patients admitted with respiratory failure dying in spite of the heroic efforts of the hospital staff. A 90% mortality. (Lassen 1953) The under-resourced Blegdamshospital in imminent danger of being completely overwhelmed—Copenhagen threatened by an unprecedented polio attack rate of 238/100,000 citizens when compared to previous epidemics visited on other cities around the world: some believing that it was less than coincidental that the Second International Polio Convention had been held in Denmark's capital just a year earlier. (Wackers 1994) And a catastrophe in the making, as the epidemic appeared to be increasing—hence a Blegdamshospital Crisis Committee had been convened: Dr. Mogens Bjørneboe; senior registrar to the all-powerful hospital chief recommending that Dr. Lassen invite Dr. Ibsen—a free-lance anaesthetist who he had recently witnessed managing a newborn paralyzed by tetanus—to rescue the situation. Accordingly, a demonstration was hastily planned for 27 August 1952, the patient: Vivi Ebert, 12 years old, dying from bulbo-spinal polio despite the 'Iron Lung' respirator that encased her. (Andersen and Ibsen) (Zorab 2003)

Leadership in Anaesthesia

247

Interpretation. Poliomyelitis struck the fear of the living god into a person. Especially if you were a parent. Known as infantile paralysis and regarded as "every parent's greatest dread," the polio virus was transmitted via the feco-oral route—through close human contact; spreading easily and insidiously throughout communities. Insidiously, because in 95% of polio infected patients it is unremarkable; having no clinical symptoms. While in 4% it is 'abortive'— demonstrating only minor symptoms of fever, malaise, vomiting, and headache in the children the virus attacks, and so indistinguishable from the common cold or flu. It is in the remaining one percent, when the virus penetrates the central nervous system, that the problem lies. Known as either non-paralytic polio (where recovery is complete), or, paralytic polio, having a mortality of 6%—which can increase to an alarming 20% should 'bulbar' polio occur—caused by the impaired breathing and swallowing that ensues. Central to the danger of polio is the virus's destruction of the anterior horn cells which run the length of the spinal cord. From just beneath the brain to the tip. Usually protected from trauma in a vertebral canal stretching from the base of the skull to the tail bone, the spinal cord is in essence a bundle of interconnected neurons and axons which serve as a telephonic cable transmitting messages from the brain to the muscles telling them whether to contract or relax. The upper motor neurons for a particular muscular function (pinching your thumb to index finger) originating in the brain—where each generates a nervous impulse that travels down its long nerve body (axon) to a 'synapse' connecting the tail of this first axon with the next spinal cord lower motor neuron lying in its anterior horn cells. This in turn propels the nervous current through this second axon ending in a terminal embedded in the muscle (in the hand), spelling out its action. It is this junction in the anterior horn cells—between the two connecting neurons—that is the focus of the polio virus's attack: invasion and destruction of the cell body of the neuron causing the whole cellular apparatus, from the spinal cord to the muscle, to die back—permanently. And it is the virulence of the particular polio strain that shapes the extent and intensity of the paralysis afflicting the patient. Most feared is when the virus destroys anterior horn cells in the brain stem causing paralysis of the cranial nerves responsible for functioning of the pharyngeal and laryngeal muscles important to the clearing of secretions, proper speech, and swallowing. Known as bulbar polio; the patient drowns in their own saliva as they cannot cough properly. Instead inhaling the pooled secretions causing pneumonia and other respiratory problems.

248

7. Bjørn Ibsen

'Spinal' polio occurs when sections of the spinal cord are infected causing 'myelitis'—the segments affected determining where the paralysis settles: the legs, arms, or the intercostal muscles and diaphragm—further impairing the ability to breathe adequately. Another problem for the poliomyelitis victim is that the virus can attack the autonomic nervous system causing added respiratory as well as circulatory embarrassment (hypertension, hypotension)—however the most common terminal event is respiratory failure. Copenhagen's poliomyelitis epidemic was especially vicious— unleashed by a particularly virulent strain—attacking not just children, but also adults with a much higher incidence of respiratory and bulbar paralysis than had occurred in the past or in the present day. 1 Striking at a time when there was not yet vaccination to combat the virus, nor a full understanding of how polio killed the afflicted, and so how best to manage them; the received wisdom being that the virus saturated the brain stem, causing paralysis of the respiratory control centers, and swamped the brain—the patient slipping into a coma from a toxic overload of polio in the central nervous system. Still to be established, (and Ibsen would demonstrate this nicely) was the fact that the terminal coma was not wrought by a polio viral overload but, instead, the result of un-expelled carbon dioxide building up in the body: brought on by the respiratory insufficiency that the paralytic virus caused—through respiratory center and muscular paralysis, aspirated secretions, lung congestion, and pneumonia. Respiratory insufficiency triggering two major consequences from poor ventilation, both lethal: hypoxia from lack of oxygen exchange, and carbon dioxide retention. Carbon dioxide, not removed through ventilation, reaching critical blood levels that causes a patient to become unconscious; commonly known today as carbon dioxide narcosis. But unrecognized at Blegdamshospital as the probable cause of the very high death rate—of 90%—that had occurred over the last three weeks in August of 1952. The attendant physicians of the Hospital fatalistic about their patients' survival chances—throwing up their hands in despair at the polio virus overload killing their patients.

1

Fortunately in the present-day paralytic polio affects only 1 in 1000 infected patients.

Leadership in Anaesthesia

249

This fatalism, known in medical circles as therapeutic nihilism, became a self-fulfilling prophecy: death from bulbo-spinal polio becoming all but certain—a problem that Bjørn Ibsen was determined to overcome. † Bjørn Ibsen nearly died at birth. His mother, Betty, struggling to be free of him; laboring for two long days. His father, Carl, despairing that he would die with a single name; added a middle name in desperation: Bjørn Aage Ibsen wouldn't breathe—coaxed back to life on 30 August 1915 at the Frederiksberg Hospital in Copenhagen. Consequently an only child, he was baptized at the family's wash-stand with evident gratitude. The wash-stand featuring prominently in Bjørn's memory; as its only other use was for Dr. Linholm the family doctor to wash his hands after a home visit to examine the young boy's throat or lungs. (And probably one of the reasons Bjørn chose medicine as a career.) Growing up in their simple family home, Bjørn attended the local Ordrup prep school located on Hyldergardsvey; showing his rebellious nature at an early stage. At the tender age of seven, having been accompanied to school by his mother for a full year to make sure he safely traversed the pedestrian crossing over the high-speed railway track—he was allowed to go it alone. Making full use of the opportunity, he stood waiting for the oncoming train travelling at full speed between Chalottenlund and Klampenborg, jumping in front of the locomotive at the last moment to "get as close as possible" and leap away just in time: reveling at the sight of the half-maddened engine driver leaning out of the train "with a piece of coal in his hand to scare the stupid kid away." (Ibsen 1990) Having studied Robinson Crusoe during his third-grade year; selfsufficiency had been hammered into young Ibsen from an early age— cleverly winning a Boy Scout award; he was the only one to have the foresight to bring soap, a towel, and water, to a fire kindling and dough baking competition—his baked bread the one offering that was pure white. Going on to the Oregard Gymnasium, Ibsen graduated from high school in 1933. 2 Sadly, one month earlier, his father died of pneumonia at the Gentofte County Hospital. Bjørn remembering well how his dad simply suffocated from the secretions before the days of penicillin—noting the helplessness of the doctors in coming to his father's rescue; all they could do was stand by his bedside, look worried, and prescribe morphine—he determined to become a doctor to see what he could do. 2

The same year that Dr. Virginia Apgar graduated from Columbia Medical School.

250

7. Bjørn Ibsen

But first he would try it on for size. A friend, Erling Ratjen, and he contriving to attend a clinical presentation at the Rigshospital on Blegdamsvej held in the hospital's surgical auditorium. Both being wellsatisfied with the presentation, they signed up at the University of Copenhagen Medical School; starting that year in 1933. Left impecunious by his father's passing, his mother Betty, sickened by asthma, moved in with her brother to make ends meet; Bjørn having to fend for himself—earning his way through medical school by taking a plethora of different jobs: fetching books in the Gentofte and Ordrup public libraries, tutoring students, and in the brief Copenhagen summers, manning the bicycle shed at the Bellevue Beach Baths just north from home. 1933 was a difficult time in Copenhagen; Denmark was coming out of a recession, but Adolf Hitler had just come to power in an ascendant Germany. Undaunted, Bjørn rapidly advanced through medical school. A good-looking tall man with brown 'velvet' eyes, a slightly receding but full crop of brown hair, and a winning smile, he was all the rage with the ladies, and took full advantage of the situation—dating frequently; he met Doris Shluntz studying to be a physiotherapist. Married in 1939, Birgitte their first girl was born subsequently; followed closely by the Nazi invasion of Denmark. Not a particularly avid student, but strategic nevertheless, Bjørn had picked up the tip of using Lis Jacobsen's Danish Dictionary—mining this for quotes to embellish his essays—hoping to give the impression of being a great cultural and literary talent. A tip learnt from his grandfather, Frantz Thorval Bjørn, the strategy did not help much in completing medical school with a high ranking in 1940; he just pulled through—placed 60 out of 65. This poor placement had important consequences as it cost Bjørn five years practicing as a doctor in the periphery, in the Jutland Peninsula— far from Copenhagen where he wanted to train as a surgeon. First to Viborg, where his second daughter Annette was born (causing Bjørn to question his insurance agent whether he needed to insure against further female children); then Braedstrup, and then Hjorring for 1942 and 1943, as a registrar in the X-ray department. Here Bjørn parlayed his musical talent. A passable pianist, Ibsen created a Musical Association; bringing the Aarhus City orchestra to Hjorring, and delivered lectures on Toscanini’s Technique of Conducting. All the time contriving to perform scientific research in addition to his doctor's duties to win favor with the professors back in Copenhagen.

Leadership in Anaesthesia

251

Readily winning the Aarhus University Prize for Biochemistry in 1944 for his work on 65 rabbits investigating the relation between liver injury and jaundice—he received an Accessitt: an honorable mention; bringing Ibsen to the attention of Professor Dahl-Iversen and winning him a permanent surgical position back at the University of Copenhagen's Rigshospital—having left the institution five years previously upon graduating from medical school. Taking up residence in a second-floor apartment on the Solvgade—just a short walk across the Fredensbrø bridge spanning the Sortedams lake from the Rigshospital—where Doris and Bjørn's third daughter, Crystal, was born in 1945. The war now over; Ibsen pursued his career ambitiously and strategically. Appointed to the surgical department headed by the famed thoracic surgeon; Professor Erik Husfeldt, he was seconded as a surgical assistant to the Chief Registrar, Dr. Ib Andersen. A match not made in heaven: Dr. Anderson had hoped for another companion surgeon, and was exceedingly critical and discomfited by Ibsen. Operating together one day, the criticism intolerable, Bjørn stood back from the surgery, put down his arms and remarked with a wry smile: 'Do you know what Dr. Andersen?' 'What?' 'Every day when I come home and sit round the dinner table, my two daughters sit with big eyes and look excitedly at me and say: What did Dr. Ib Andersen say to you today dad?' Ibsen remarking in his autobiography: 'It helped. From that day we were good friends.' (Ibsen 1990) Standing them both in good stead for their careers: Ibsen collecting the surgical case histories necessary to his Doctoral Thesis, and Andersen becoming a highly respected thoracic surgeon at Copenhagen's Gentofte County Hospital—collaboration being much better than antagonism—in furthering their respective careers and executing successful surgical operations. Completing one such an operation together one afternoon at the Rigshospital in 1948, Ibsen received an urgent call to come home immediately: his two-year-old daughter, Crystal, was dying. Donning his white coat, its pockets brimming with medical equipment, Ibsen jumped into the front of a waiting Falck ambulance, urged the driver to rush, directing him to the apartment, as it progressed rapidly across the Fredensbrø bridge, sirens wailing, blue lights flashing, and made its way as fast as possible to manage the emergency. Shuddering to a halt, Ibsen looked

252

7. Bjørn Ibsen

up at the balcony on the second floor where Annette stood crying and sobbing: "too late, you're too late." Leaping up the stairs, and seriously out of breath, he rushed to find Crystal, quite blue, lying on the couch: Doris explaining that their youngest daughter had vomited up oatmeal and aspirated and stopped breathing. Rummaging in his coat pocket, quite by chance, Ibsen pulled out: 'one of the suckers used by mid-wives for newborns—a rubber tube with a small glass flask and mouth-piece.' 'I managed to get it down the trachea and soak up mucus and oatmeal and then spit it out again.' Then he started artificial respiration, and after much effort, Crystal started breathing again, but remained unconscious—for 24 anxious hours—suffering no long-term sequelae beyond three months of nightmares: she wanted to make sure the security chain was on the door so no-one could come in. Obviously extremely talented at resuscitation in life and death situations, Ibsen next made a strategic decision about his career. Having joined a Young Doctors Committee, that had assessed the odds of a younger doctor's chance for a successful career in surgery—at 2%—he decided to alter course from becoming a surgeon to an anesthetist instead. 3 Not a particularly salubrious choice, because, as a result, Copenhagen's surgeons looked down on anesthetists; considering them second class citizens and 'also rans' who had opted out of surgery. (But especially necessary because the surgical chief, Dr. Erik Husfeldt, was crying out for competent anesthetists; his previous general anesthetics performed by Ole Lippmann, who was not a doctor, but an importer of medical equipment made in the United States.) (Reisner-Selenar 2009) However Ibsen was no stranger to anesthetics; he had observed Dr. Ernst Trier Morch—considered the first Danish anesthesiologist—when he provided anesthesia for the thoracic patients that Dr. Erik Husfeldt meticulously operated on; Ernst telling Ibsen that he had benefitted enormously from a year's training at the Massachusetts General Hospital in Boston—there being no anesthetic residency training programs in Denmark at the time. And, had gained experience as a medical student at the Holbaek Hospital on the Jutland Peninsula in 1939; Bjørn had been dragooned into anesthetic service replacing the surgeon's secretary in the job. Furnished with just a Wanscher's rubber bag, that he filled with 100ml of ether, a Young's tongue forceps, and a Heister's mouth opener, Ibsen provided the majority of anesthetics for the six-month surgical rotation—lamenting: 'there were no oxygen cylinders, no tubes, no laryngoscopes, no absorbers, 3

Not unlike Dr. Virginia Apgar's calculations on the matter.

Leadership in Anaesthesia

253

no suction devices'—remarking on only one advantage of the crude situation: 'the surgeons had to be quick.' (Ibsen 1975) Hence, without much further ado, and with funding from the Danish Foundation, Dr. Ibsen packed up his family—Doris and the three sisters—to start a one-year job on the first of February, 1949, as an assistant resident in the Department of Anesthetics of the Harvard Medical School at the Massachusetts General Hospital, headed by Professor Henry K. Beecher. Here, Ibsen was amazed at the differences in practice in Boston. Not only was there one collaborative surgical department—rather than the hypercompetitive divisions of surgery back home—but the different departments were not organized in as hierarchical a way as the oldfashioned Prussian system present in the Danish Hospitals; with the Chief the commanding general at the top of the pyramid—whose word was absolute law. And, at conferences, the young American doctors spoke freely with a certain dignity, uncharacteristic of the Danes, and seemed much more self-assured than Ibsen was used to. All the more impressive, Bjørn thought, was that post-operative complications were freely discussed and not swept under the carpet. Less impressive, however, was the fact that Dr. Henry Beecher prohibited the use of the new muscle relaxant curare (having established that this was associated with a higher anesthetic mortality in a study he was conducting at the time. (Beecher and Todd 1954)) and insisted that thiopental be only given in incremental doses of 25mg (because of the high death rate associated with its use anesthetizing injured soldiers at Pearl Harbor). In so doing guaranteeing that all anesthesia trainees became experts in managing excitement in their patients from a far too small anesthetic dose of the sulphurously yellow induction agent introduced by Dr Lundy of Rochester, Minnesota, almost a decade earlier. † Returning on a Danish ship bound for Copenhagen, January 1950, his family preceding him by a month; Doris Ibsen fell into conversation with Dr. Mogens Bjørneboe, a fellow Dane working at the Rigshospital which Bjørn had planned to return to. In multiple conversations, Doris told him of her husband's year of training in anesthesia at the Harvard Medical School which Mogens diligently noted down for future reference—trained anesthetists being in short supply in Copenhagen—as he was entertaining the possibility of becoming the Senior Registrar at the Blegdamshospital— lying adjacent to the Rigshospital, separated only by a small park;

254

7. Bjørn Ibsen

historically to avoid infection spreading between the two hospitals fronting on Blegdamsvej. Dubbed one of the first specialist anesthetists in Denmark, upon completion of his resident training in America in 1950, Dr. Ibsen first established his Copenhagen practice as a "free-lance" anesthetist. Travelling around the city, he provided anesthesia at various hospitals: the magnificent Kommunehospital on Oster Farimagsgade facing the beautiful Botanical Gardens, and the Rigshospital; conveniently just a short five-minute bicycle ride apart. That same year, Prof. Erik Husfeldt had championed the need for expanded anesthesia services within Denmark and through the good offices of the World Health Organization had established the Anaesthesiology Center of Copenhagen together with Dr. E. Wainøe Andersen who had preceded Ibsen as a resident trainee in Boston. This Anaesthesiology Training Center initially drew mainly on leading anesthetists from the U.S.A. and Great Britain as instructors, but eventually would tap Dr. Bjørn Ibsen and other European based leaders—proceeding to train over 650 anesthetists from 65 countries across the world over the 23 years of its existence; becoming a great source of inspiration for Dr. Ibsen, and spurring the development of anesthesia within Denmark and beyond. Recognizing early, that in order for the newly created specialty of anesthesia to advance required not only separation from the surgeons, but separate departments of anesthesia, Ibsen set his sights on becoming the first Chair of Anesthesia for the Rigshospital—should that position be created in the future. Knowing full well that to be competitive for such a position, he would not only need his just completed Doctorate 4 but also considerable clinical research, he teamed up with Dr. H. C. Engell, a Danish thoracic surgeon freshly back from a course on respiratory physiology, held in the Netherlands, conducted by Prof. R. Brinkman, who had developed an apparatus (the Brinkman Carbovisor) that could measure carbon dioxide in expired air continuously. Brinkman promising Engel that he could take a prototype back to Copenhagen to study CO2 levels, in real-time, in anesthetized patients undergoing thoracic surgery at the Rigshospital. Ibsen first anesthetizing the thoracic patients with ether or cyclopropane and after intubation with a Guedel-Waters cuffed rubber endotracheal tube, then placed a urinary catheter down into the lungs to measure the levels of CO2 exhaled; displayed vividly on a grey boxed galvanometer, its needle quivering under the circular-glass-screen, pointing exactly to the measured carbon dioxide value. Studying 50 patients, Ibsen 4

"Necrosis capitis femoris post fracturam colli femoris veri et fracturam pertrochantericam" A 'Surgical' not an 'Anesthetic' Dissertation.

Leadership in Anaesthesia

255

could demonstrate that when the patient's breathing slowed or was stemmed by surgery on the lung, the CO2 would rise, inexorably, eventually arresting all spontaneous inspiration attempts. Coinciding with this carbon dioxide rise he noted that the patient's skin became clammy and that their blood pressure and heart rate would rise alarmingly, until he corrected the situation by intermittent positive pressure ventilation: gently squeezing the oxygen and nitrous oxide filled rubber anesthesia bag attached to the endotracheal tube—bringing the galvanometer's deflection down and the alarming clinical symptoms back into the living range; the patient regaining the 'respiratory drive' to inhale spontaneously once physiological levels of carbon dioxide had returned. Demonstrating vividly the physiological effects of toxic levels of carbon dioxide (CO2 narcosis) on patient physiology. 5 (Engell and Ibsen 1952) Seeking to burnish his academic credentials even further, Ibsen joined the University of Copenhagen's Library as a Consultant affording him ready access to the emerging academic literature. Scouring the recent literature he came across a paper that had fascinated him so much that he had written to the author, Dr. A.G. Bower, in the United States, requesting a reprint. (Bower et al. 1950b) (Bower et al. 1950a) Published in November 1950, it dealt with the subject of his great interest, namely, the effects of positive pressure ventilation on alleviating toxic carbon dioxide retention, that Bower had studied in the recent polio epidemic in Los Angeles—reporting therein his management of such patients at the L.A. County Hospital between 1946 and 1949. Running to more than 30 pages of dense data, it contained a number of important points that informed Ibsen's current research with Dr. Engell and, unbeknownst to him—for he could not know that he would be faced with a polio epidemic in the near future—would support his heroic future endeavors. Hence, upon receiving the requested reprint from Dr Bower, he read with mounting excitement: —that the Iron Lung respirators used to treat polio patients often resulted in inadequate ventilation below respiratory requirement; —that this resulted in low arterial oxygen and high carbon dioxide levels accompanied by acidotic blood; —and that this was not reversed by simple oxygen therapy but needed intermittent positive pressure ventilation to improve,

5

To be clear: at low levels: CO2 stimulates a patient to breathe: at higher levels it suppresses all breathing and produces unconsciousness i.e. coma, just like anesthetic agents do, and hence is termed 'CO2 narcosis.'

256

7. Bjørn Ibsen

—and that this technique of intermittent positive pressure ventilation had a salutary effect on the mortality from bulbar polio: decreasing this from 90 to 20% in four years. (Bower et al. 1950b) † As early as 1950, as part of his free-lance anesthesia practice, Dr. Ibsen had started work as a consultant to a mental institution, 50 miles outside Copenhagen. Here he would provide anesthesia to protect patients from the consequences of Electro Convulsive Therapy administered for all manner of psychiatric conditions, but chiefly severe depression. This psychiatric therapy involves the administration of a jolt of electricity administered using electric calipers placed at the temples to provoke a convulsion that 'resets' the brain in the interests of psychological improvement. However, when administered in the absence of anesthesia the convulsion often causes long bone and vertebral fractures and always, extreme hypoxia—the patient becoming deeply blue before recovering. Consequently the anesthesiologist combats these effects by anesthetizing the patient to avoid any pain from the electric shock; paralyzes the patient with a muscle relaxant to avoid overt convulsive injury, and provides masked oxygen with intermittent positive pressure ventilation to combat hypoxia. So too, Dr. Ibsen. Using this opportunity to learn how to use the first therapeutic muscle-relaxant curare, given that its use had been prohibited by Dr. Beecher back in Boston. In so doing rendering the patient temporarily paralyzed from curare administration, a technique that would be put to good use to counter the life-threatening spasms caused by another infectious disease: tetanus—posing a dire problem for the doctors practicing at Blegdamshospital in 1952. In January of that year—Dr. Mogens Bjørnboe (who had met Doris Ibsen on the ship back from Boston in 1949) accompanied one of his relatives to a Copenhagen psychiatry clinic for electroconvulsive therapy treatment; standing by her bedside during the therapy. Noticing that the anesthetist had administered curare to induce paralysis in his relative—in so doing avoiding the convulsion induced injury as well as making her easy to ventilate through the mask applied to her face—he wondered whether this technique might be used to allay the tetanic spasms that were preventing adequate breathing in his patients—killing them from respiratory embarrassment in the wards he was now managing at the Blegdamshospital; he had recently transferred there to work for Dr. Lassen its Chief Epidemiologist, as the Senior Registrar.

Leadership in Anaesthesia

257

Finding an occasion to test his theory, five months later, when faced with a newborn succumbing to tetanus; he contacted Ibsen (the only anesthetist he knew by name having jotted down his details on the ship returning to Copenhagen) to ask for help to save the child's life. Ibsen agonized over the consultation for help. (All five of the previously tracheotomized patients with tetanus at Blegdamshospital had died.) His children watched him pacing around the dining room table as he pondered what to do. Would long-term paralysis with the curare drug render the recently tracheotomized neonate permanently paralyzed? Would there be another untoward effect like hypotension that Beecher had warned against? Then—putting into practice a tried and trusted approach: he took out his favorite Schubert record, wrote the date and time on the cover, put it on the record player, lay back on the carpet fully-stretched out, and made his decision. The next day, June, 1952, the Ear Nose and Throat surgeon tracheotomized the baby and Ibsen administered curare which completely paralyzed the child, stopping the terrifying spasms, and allowed adequate respiration, but required manual ventilation round the clock—six hourly shifts at a time. The boy receiving curare for ten days straight after which it was stopped. Even so, despite a full recovery from the paralyzing agent— demonstrating its efficacy in tetanus therapy for the first time— unfortunately, the child could not be kept alive. And died. (Bjorneboe, Ibsen, and Johnsen 1954, Ibsen 1975) Interpretation. Faced by the escalating polio epidemic, Dr. Henry Lassen's back was up against the wall. As the Physician in Chief of the Blegdams communicable diseases hospital, he had a crisis in the offing. In late August of 1952—40 to 50 patients with paralytic polio were being admitted per day, and he had not the means, nor equipment—just seven ineffective negative pressure respirators—to manage the situation. Respirators that were problematic at best. There were two types of respirators: the tank ventilator and the cuirass ventilator. The tank ventilator, better known as the 'Iron Lung,' completely encased the patient in a metal vacuum tube—that they could be rolled in and out of on a bed—with only their heads sticking out; their necks cinched tight with a rubber collar, an electric vacuum pump providing intermittent negative pressure within the tube—in attempts to expand their chest and

258

7. Bjørn Ibsen

lungs; the polio-stricken patients drawing in life-saving air through their mouths and noses outside the tank. Problematic, because, not only did the Iron Lung need an air-tight fit around the neck to work, but access to the patient's bodies had to be gained by a set of glass portholes so that nursing care could be provided. Hence these respirators were completely unsuitable for ventilation of patients in the operating theater where Ibsen and others were using simpler, more effective, techniques in paralyzed patients. Adding insult to injury, these 'Drinker' respirators 6 were not particularly effective—especially when patients developed lung disease like pneumonia or atelectasis (partial collapse of the lungs) as the negative pressure generated was insufficient to re-expand lungs so compromised. The 'cuirass' ventilators were no better. 7 Consisting of a clam-shell like device placed over the patient's chest, it generated negative pressure through an attached vacuum pump. Named after body armor protecting the chest in medieval times, it too resulted in inadequate ventilation of the paralyzed patient—demonstrated clearly as the flaccid patient sickened further—via femoral arterial blood sampling: the physicians at Blegdamshospital mis-interpreting the elevating "total carbon dioxide content" of the blood sample as being a metabolic problem, rather than the carbon dioxide retention that was actually killing the patients. Often administering oxygen in response, which, although it treated the cyanosis— the patient pinking up nicely—did not solve the problem: carbon dioxide levels continuing to rise. Hence, those who presented with respiratory paralysis—died: a mortality of 90%. Consequently Dr. Lassen's hospital staff felt they were in a state of war—empty handed. (Lassen 1953) And he was the boss: The Physician in Chief's expertise undisputed, and his orders obeyed without question—Lassen had to swallow considerable professional pride in soliciting outside help. First he consulted with experts who he thought might make a worthwhile contribution; requesting the opinion of the well-known physiologist, Dr. Einar Lundsgaard—who offered none. Then, he consulted his Senior Registrar, Dr. Mogens Bjørnboe. Happily, Bjørnboe had joined Lassen's Staff, and, knowing of Ibsen's facility in managing the tetanus baby using a tracheostomy— 6 So named after one of its inventors: Philip Drinker (1894-1972) who first developed them in 1928 at the Harvard School of Public Health. 7 Invented by Aubrey Burstall (1902 - 1984), Professor of Engineering at the University of Melbourne in 1938.

Leadership in Anaesthesia

259

administering curare for paralysis to quieten the neonate's muscular spasms—he had wondered whether the same anesthesia technique of round the clock ventilation might be used in the polio patients. Recognizing that in contrast to the tetanus patients who had muscle spasm, polio patients were in effect already paralyzed (and probably easy to ventilate), he urged Lassen to consult with Dr. Ibsen—the only specialist anesthetist he knew. Lassen was extremely reluctant. What could a mere anesthetist do, from a new-fangled specialty that had only become official in Denmark that very year? (Wackers 1994) Nevertheless relenting: a Blegdamshospital crisis committee was convened on August 25th, and decided to ask Ibsen for advice. Attended by Drs. Neukirch, Lassen and Bjørnboe, the head of the clinical laboratories, Dr. Poul Astrup, was also crucially in attendance. As always, Dr. Ibsen arrived early, impeccably dressed, and, fully equipped for the meeting; he brought Brower's polio paper to make his case. Suggesting that the patients should be tracheostomized to provide a clear airway and then be ventilated using intermittent positive pressure bag ventilation as performed in the operating theaters—his suggestion was at first roundly rejected. Lassen objected strenuously. Having experienced many deaths from the tracheostomy procedure; he remained resolutely unconvinced by the experience in the Los Angeles epidemic documented in Brower's paper—stating that the Los Angeles patients were much healthier than those subjected to the virulent polio strain now visited on Copenhagen. Fortunately Lassen relented. On hearing that an especially sick patient—Vivi Ebert, just 12 years old, and already quadriplegic from polio who had been admitted that day—had sickened further, despite being placed in the only tank ventilator (an Emerson) that the Blegdamshospital possessed—Mogens Bjørnboe was able to convince Lassen that Ibsen be given this one chance to perform a demonstration of the proposed technique. What did they have to lose? Ibsen, not quite sure however that he wanted to take on the reputational risk; but feeling that something needed to be done—beyond throwing up one's hand in despair—said he would examine the records and post mortem reports of the four polio patients admitted to the mortuary that day; and spent the next day making up his mind whether he wanted to take the case and proceed. Noting that one of the dead, a boy of 12 years, had died in a respirator, with both a high blood pressure and elevated blood bicarbonate level—and with lungs not so atelectatic to make adequate ventilation impossible—he became convinced that the Blegdamshospital physicians

260

7. Bjørn Ibsen

were misinterpreting the situation; the eminent doctors believing that the young boy was overwhelmed by the polio virus rather than the true state of affairs—carbon dioxide narcosis—which Ibsen was convinced was eminently amenable to intermittent positive pressure ventilation. He nonetheless struggled over the decision whether or not to take the case. Discussing the situation at the dinner table that night, his daughters listening attentively as always, as he told Doris about the problem. Then, thanking her for dinner, he went to his study and paced around. He knew he could do it, but needed the courage to proceed. If he failed his idea would die with the patient. If he succeeded he would be able to save many lives; using simple anesthetic techniques learned in theater—beyond the operating room. He must have thought back to another time, another time when: "I knew I could." 8 One Sunday morning, back in Rockport in 1950 while still in the United States, Ibsen was watching his neighbor and seven-year-old son playing soccer across the street—the boy had kicked the ball high into a tree where it was now stuck between the branches; they were struggling to find a way to release the ball from the trees grip. Tired of looking at their vain efforts. Bjørn grabbed a tennis ball, aimed, and threw it at the soccer ball— hitting it square in the middle—ejecting it from its perch. His chest swelling with pride in his supreme ability: "I knew I could."—offering to help should it happen again. "Just call me." (Ibsen 1990) He decided to take the case.

Vivi Ebert Quadriplegic, breathless, feverish, clammy and distressed, Vivi Ebert, her hair severely combed back, frightened eyes wide open, let Dr. Mogens Bjørnboe place his stethoscope to listen for breath sounds. Hearing a rattle: a chest X-ray had confirmed the inciting problem—left lung atelectasis complicating pneumonia; her condition deteriorating rapidly after her admission to the hospital two days earlier, despite the intensive therapy she had experienced inside the Iron Lung. Now, rolled out on its padded bed, her blood pressure and temperature were high, her morale low: she was cyanotic and sweating as the E.N.T. surgeon got out the local anesthetic and readied the knife to cut into her neck to place the tracheotomy that would rob her of speech but hopefully save her life. (Reisner-Selenar 2006a) 8

Which Dr. Ibsen has related helped him in many difficult clinical situations.

Leadership in Anaesthesia

261

Ibsen was well prepared as always. He spoke softly to Vivi hoping to calm her and improve her spirits while meticulously planning the intensive therapy he had in mind. The Blegdamshospital nurses helping him to arrange the space around Vivi's bed to look more like the inside of an operating theater than a ward. Behind him towered a massive compressed gas cylinder from which a pressure regulator with a gas flow meter protruded: connected through a bubble humidifier, the 50% oxygen in nitrogen gas was filtered through a water trap, to be fed through a long rubber tube to a stainless-steel-L-shaped connector topped by an adjustable "gas escape" valve. The one side of the L, the patient side, could be connected to a mask or endotracheal tube supplying the patient. The other end was firmly attached to a silver—torpedo shaped, to-and-fro—'Waters' cannister; about a foot long and filled with soda lime (to absorb exhaled CO2), its opposing end connected to a rubber anesthesia bag. (The whole contraption looking much like a large fish with a silver body and a rubber bag for a tail.) This four-liter bag would be filled with gas when the flow meter was cranked open—to provide oxygen enriched gas to the patient attached to the other limb of the L connector if they were breathing adequately, or if not, be squeezed to assist respiration through intermittent positive pressure ventilation should that be needed instead. (Andersen and Ibsen 1954) Toward the other side, not too far from Vivi, Ibsen had placed a modified trolley packed on its left with the Brinkman Carbovisor that he had used to study exhaled carbon dioxide levels with Dr. Engel: an attached urethral catheter readied to place through the planned tracheostomy to demonstrate real-time changes in carbon dioxide levels brought on by ventilation. While on the right side of the trolley Ibsen had positioned the monitoring apparatus for the Milikan oxygen analyzer—clipping a clamplike device to Vivi's earlobe so that her blood oxygenation levels could be read off, as they (hopefully) improved, with the therapy he was planning to provide. In addition, a catheter had been placed into her femoral artery to sample blood allowing Dr. Poul Astrup to measure the 'total CO2 content of plasma' in the hospital laboratory—the only means used to date to (erroneously) analyze respiratory therapy. The stage so set, and the ward prepared for the demonstration to begin; the who’s who of the hospital had gathered to witness events, crowding round, marveling at all the equipment gathered in readiness; Dr. Ibsen signaling to the E.N.T. surgeon that he and Vivi were ready. That's when things went south, not at first, but later:

262

7. Bjørn Ibsen

The surgeon slashing high into the trachea, just below her 'Adams apple,' a cut was made and a tracheotomy tube inserted: through which a red rubber tube was attached to the readied to-and-fro breathing system, the gas flow upped to five liters per minute, the rubber bag distending— squeezed intermittently by Ibsen to allow steady ventilation. The Milikan oxygen analyzer showing 100% saturation: couldn't be better. Lassen, Bjørnboe, Astrup and Neukirch, suitably impressed, gathered closer as Ibsen disengaged the tube and thrust the urethral catheter down the tracheostomy to measure CO2 using the attached Carbovisor prominently displayed on the trolley—first sucking out copious secretions that had gathered over the last minutes in an attempt to improve ventilation. Then the struggle started: Vivi becoming unconscious, went into unrelenting bronchospasm—copious secretions plugging up the endotracheal tube—she kicked and sweated, and the oxygen saturation dived: 80% to 70% while the CO2 level—indicated by the twitching galvanometer needle—rose: 6% to 7.5%. Ibsen struggling to get any gas into her lungs called to a nurse to switch the cylinder to 100% oxygen in desperation, as the group who had assembled to witness this triumph, slowly ebbed away from the scene, having other urgent duties to perform: "They didn't want to see another futile death from polio: they had seen too many already." Leaving Ibsen to struggle on his own. Then. The master-stroke—Bjørn administered thiopental rapidly: not in the half-baked Beecher dose, but four times the amount—100mg—breaking the bronchospasm, anesthetizing Vivi, stopping the struggle to ventilate, and so bringing down the monitored CO2, and upping the oxygen saturation, while settling the heart rate: Vivi lying peacefully as if being anesthetized in the operating room for an operation. "I knew I could."—Ibsen sighed with relief, a confident smile breaking out, he continued ventilating Vivi, his hand gently squeezing the bag and asked the nurse to call back the departed onlookers so he could continue the demonstration. With all important people returned; Ibsen continued. First he demonstrated that if he squeezed the anesthesia bag less frequently and less deeply, causing underventilation of the lungs: the Carbovisor CO2 reading would go up, and co-incidentally, Vivi's blood pressure and heart rate would rise and she would become pink and clammy from the associated carbon dioxide retention, releasing torrents of adrenaline into her blood stream (an arterial blood sample showing a high total CO2 content of plasma in the laboratory). Then, if he reversed the

Leadership in Anaesthesia

263

situation through hyperventilation, squeezing the bag rapidly and deeply, Vivi collapsed in a state of shock, needing intravenous fluid and blood administration—the low blood carbon dioxide stemming the high adrenaline levels that had previously sustained her. The assembled physicians, no doubt suitably impressed by this physiological demonstration of the effects of inadequate ventilation, Ibsen true to the showman he was, next delivered the coups de grâce: he disconnected the to-and-fro breathing system from Vivi's endotracheal tube, rolled her back on her padded bed into the Iron Lung, took care to tighten the rubber collar around her neck below the tracheostomy so that she could draw oxygen enriched air freely, and then switched on the negative pressure ventilator vacuum pump—setting this to minus 15 bar, and the respiratory rate to 24 breaths a minute. Demonstrating once and for all the failure of the Emerson Tank Respirator to adequately ventilate the complicated respiratory patient: over the next hour Vivi's oxygen saturation plummeted, her carbon dioxide level rose; the slight child becoming agitated and restless, started sweating, developed an irregular heart rhythm, and fell out of synch with the respirator: requiring another dose of thiopental and reversion to the to-andfro bag system and positive pressure ventilation to rescue the situation. And. Finally. Irrevocably convinced that Ibsen had effectively demonstrated a way of managing the polio crises—by tracheotomy, intubation, and manual ventilation using a technique commonly employed in the operating theater—Lassen, as the Physician in Chief of the storied Blegdamshospital, sprang into action immediately: his reputation at stake. Commissioning three floors, 35 beds a piece, to look after all polio patients showing any signs of respiratory embarrassment in the "G block" of the vast Hospital—Lassen was later to admit how relieved he was that using this simple approach: "we were now in the position to treat every single patient requiring respiratory aid. In this way we avoided being placed in the dreadful situation of having to choose." (Lassen 1954) The logistics however were daunting. In the days after Ibsen's successful demonstration; 40 to 50 polio patients were admitted daily of which up to twelve were admitted to the G block multidisciplinary polio unit to receive intensive therapy. A team comprising an E.N.T. surgeon, an anesthesiologist and an epidemiologist, supported ably by the laboratory and radiology service, led the patient care and held daily medical conferences to consult with other specialists like cardiologists, physiologists and neurologists who were invited to contribute.

264

7. Bjørn Ibsen

Considering that at the height of the crisis 70 patients required intermittent positive pressure ventilation simultaneously—using the to-andfro system round the clock—the University of Copenhagen Medical Student Organization had been approached for help: 200 medical students being deputized daily to provide respiratory support in 8-hour shifts. Although the pay was quite handsome at 30 schillings a shift, the job was emotionally taxing on the medical students as they sought to provide both respiratory and emotional support—many reading to their patients to pass the long hours and buoy their spirits; some patients nevertheless, literally, dying in the assigned medical student's hands—from overwhelming pneumonia or kidney failure. All in all, to successfully break the polio crisis—which was declared over in May 1953—more than 1,500 volunteer medical and dental students 9 provided more that 165,000 hours of ventilatory support, while 600 trained nurses and hundreds of auxiliary personnel helped in the endeavor—the mortality for ventilated patients decreasing fourfold (90% to 25%), and Dr. Lassen estimating that at least one hundred lives were saved by Ibsen's intervention. (Trubuhovich 2003, 2004, Lassen 1953) So too Vivi's life. She struggled but survived; requiring round the clock ventilation for four months. Permanently crippled for life with quadriplegia, she was nevertheless discharged home, and married, becoming Vivi Andersen, but died young: at 31 years of age. But not before saying thank you to Dr. Ibsen—she attended the Rotary Club Jubilee Presentation in a wheelchair in 1969: "Thank you for saving my life." (Ibsen 1975) Interpretation. The concept of positive pressure ventilation through a hole in the wind-pipe (tracheostomy) was not new—in fact as far back as 1543 the great physician anatomist Andreas Vesalius noted: "But that life may be restored to the animal, an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again and take air." (Vesalius 1543) But adapting an anesthetic technique of intubation and positive pressure ventilation using the simple to-and-fro—fish-like—breathing device described, outside of the operating theater; unheard of. Hence provoking much skepticism, if not downright hostility for the upstart, Ibsen, a brand-new anesthesiologist, from Dr. Lassen, an epidemiologist of world-wide renown, and Physician in Chief of one of the 9

None of the nurses, doctors or medical students contracted polio as a result of their helping: most having passive immunity from the previous 1934 and 1944 epidemics.

Leadership in Anaesthesia

265

celebrated 'fever' hospitals in the world; established in 1880 following a cholera epidemic visited on Copenhagen. (Berthelsen 2014) Ibsen, calculating, that if he were successful, and it was a big if (he might have killed Vivi from the dose of pentothal and the tracheostomy placement)—not only would he help save lives and combat the crisis enveloping his city, but, never far from his calculations, it would also help him in his quest for future advancement. Should he fail, however, he would have much to lose; his reputation would have suffered a possibly fatal blow, and his idea to advance anesthesia care beyond the operating room would have died with Vivi. Ibsen's masterstroke, was not just that he succeeded, but it was also in his scientific presentation of Vivi's case—using monitoring devices measuring exhaled carbon dioxide, and oxygen saturation, backed up by arterial 'blood-gas' laboratory derived data; not only to convince the skeptics, but also to combat convincingly—once and for all—the mistaken impression that polio killed the patient by overwhelming the brain; when in many instances it was the inadequately managed carbon dioxide narcosis that was killing the victim. In so doing not only helping to manage the deadly polio epidemic but also demonstrating the key components required of the "first intensive care unit" that he would create in the future: managing respiratory failure (using intermittent positive pressure ventilation), the need for monitoring the patient intensively in real-time, round the clock—the patient's intensive care further supported by adequate laboratory and radiological services. (Wackers 1994) Dr. Paul Astrup, Head of Blegdamshospital's Laboratory Services, going on to further develop (with the Radiometer A/S Company) the technique of 'blood-gas' measurement. An arterial blood sample used in the future to evaluate a patient's plasma acid-base status, which would prove crucial in monitoring the effectiveness of intermittent positive pressure ventilation—allowing the individual adjustment of ventilation parameters 10 to that required for a specific patient—having demonstrated that, in fact, most of the Medical Students over ventilated their polio patients. (Severinghaus, Astrup, and Murray 1998, Astrup, Gotzhe, and Neukirch 1954) Ibsen's leap beyond the operating theater—bringing anesthesia techniques to bear to provide intermittent positive pressure ventilation to patients on the wards—did not go unnoticed around the world: many physicians from all over Europe visiting Blegdamshospital, impressed by 10

Adjustment of depth and rate of ventilation.

266

7. Bjørn Ibsen

what they saw. Most recognizing too that this was a major breakthrough on another front: convincing many that anesthesiologists were not just technicians but 'proper' doctors—like any other that took care of patients on the wards of the hospital; helping to elevate respect for the foundling specialty of anesthesiology. (Berthelsen and Cronqvist 2003) All concurring however that there was a need to develop "Mechanical Medical Students"—reliable mechanical ventilators that could be used to manage respiratory failure. 11 Launching a welter of ventilator design initiatives around Europe; the Engstrom Company of Sweden superseding the Bang and Olufsen Company of Denmark which had created the Claus Bang ventilators—fourteen bought for the Blegdamshospital— with a superior design that would be rapidly incorporated throughout the Scandinavian countries. Consequently, when the inevitable, equally ferocious, polio epidemic was visited on Sweden the next summer; the country was ready. All the polio patients with respiratory failure could be adequately managed with purpose built Engstrom ventilators; so much so, that no medical students were needed to combat the epidemic in Sweden and they could spend their time studying for their final examinations instead. (Sund Kristensen and Lunding 1978) Ibsen stating in an interview, in the last year of his own life: "That I could save the patient's life with such a simple method, was one of the incredible moments of my life." (Reisner-Selenar 2006b) †

Intensive Care Dr. Erik Husfeldt (1901-1984) an internationally famous Professor of Thoracic Surgery and progenitor of the World Health Organization Anaesthesiology Center of Copenhagen, had been a vociferous champion for developing the nascent anesthesia services within Denmark. Having convinced the Danish National Health Service, the University of Copenhagen, and the Geneva based World Health Organization, that the fledgling specialty needed significant help, it was not surprising that he sought to insert his favored candidate, Dr. Ole Secher (1918-1996), to serve as the inaugural Chair of Anesthesia for the first separate Department of Anesthesia in Denmark—planned at his home institution: the Rigshospital in 1953. (Secher 1978) 11

Dr. Lassen was of the opinion that medical students were just fine at the job.

Leadership in Anaesthesia

267

It is not that he didn't have a high regard for the more experienced Dr. Bjørn Ibsen; who was both eminently qualified and had set his sights on the job many years ago. It was something else: he owed Ole. A much younger Dr. Husfeldt having served in the Danish Resistance—code named 'Architect Jorgenson'—he had actively participated as an editor of an illegal newsletter, and amongst many other underground resistance activities: in the rescue of Danish Jews (from extermination) in October of 1943; Ole, then a medical student, had been assigned to Husfeldt as his bodyguard and, it was rumored, saved his life on one desperate occasion. Thus Husfeldt owed Ole Secher. Big Time. Dr. Lassen was no help in Ibsen's quest for the Rigshospital Chair position either. When Bjørn approached Lassen for support to be named the first Chair of Anesthesia at the Rigshospital instead of Dr. Ole Secher; Lassen dismissed him outright, saying: 'It's always the generals who win battles not the foot soldiers, you should know that. If you had not worked for me, you would not have come up with these solutions and treatments'—refusing to acknowledge Ibsen's seminal contributions in the polio epidemic publicly. 12 (Lewis 2007, Reisner-Selenar 2009) Hence, it was not altogether surprising that although the official position of the Chair of Anesthesia had long been approved by the Rigshospital Doctor's Council, and the Medical Faculty of the University of Copenhagen; the coveted job was only finally advertised upon the completion of Dr. Secher's Doctorate (on Ether Anesthesia); this being a necessary pre-condition to apply for the position of the first Chairman of Anesthesia in the country. And the banal official reason given for this relatively junior anesthetist's appointment—over the head of the more senior, Dr. Ibsen— later provided by the University: Dr. Secher's doctoral thesis was on the subject of anesthesia, while Dr. Ibsen's was not—it dealt with surgery; was met with some controversy. (Ibsen 1975) Ibsen was bitterly disappointed by the turn of events; bitterness that resounded in the many interviews and statements that he made 12

In fact in the seminal Lancet article reporting on the 1952 polio epidemic, Dr. H Lassen had not mentioned Dr. B Ibsen's name until the Editor of the Lancet insisted that he do so. Admitting in the final version of the article: 'at that point we consulted our anaesthetist colleague, Dr. B Ibsen, and on Aug 27th the first patient was treated.'

268

7. Bjørn Ibsen

subsequently—for he did not know whether there was going to be another Chairman opportunity in another (second) separate department of anesthesia. Admitting much later, however, that this decision point ultimately turned out to be a boon not a bane—allowing him to set up the first intensive care unit at the Kommunehospital where he would eventually become the Chair. † As it happened, at the time of establishing the first separate anesthesia department at the Rigshospital on 1 April 1953, newly chaired by Dr. Ole Secher; the Danish National Health Service was actively debating whether to proceed with developing further separate anesthesia departments in the hospitals around Copenhagen. Hospitals like the Kommunehospital where Dr. Ibsen had also been newly appointed that same day, but in the Department of Surgery, as a senior registrar practicing anaesthesia. Hoping to push the concept of independent departments— separated from the surgeons—along a bit, Ibsen settled on an ingenious idea; occasioned by his being asked to consult on a resistant tetanus patient at the Blegdamshospital. Dr. Mogens Bjørnboe consulting him again (Dr. Lassen was on an extended trip to China) to help with a ten-year-old who was dying from tetanic spasms. Ibsen and colleagues decided to fully anesthetize the young boy with nitrous oxide (50%) and pentobarbitone, paralyze him with curare, and ventilate him round the clock using the to-and-fro system; young assistants from the anesthesia service forming a team to provide four-hour shifts: Ibsen present at the start and end of each shift—camping out in the hospital overnight, in an adjacent room—to ensure that all went well. Seventeen days of continuous anesthesia later, Dr. Christiaan Thorshauge advised Dr. Ibsen that the boy could be weaned from the anesthetic—he switched it off, and, upon the young man's opening his eyes, Ibsen asked him for a hand shake. He got it! The boy fully recovering from the ordeal, his grandparents gratefully sending Ibsen a reproduction of a famous Danish picture: Michael Ancher's: 'Life Boat Being Taken through the Dunes'—a painting depicting ordinary men—as heroes. An article published in the Berlingske Tidende, championing the heroic story entitled "Little Bjarnes Handshake" was put to immediate use—

Leadership in Anaesthesia

269

Ibsen submitted an enormous anesthetic bill (of 10,000 DK ~ $2,000.00) for 17 days of continuous anesthesia to the Danish National Health Service: probably helping settle the issue of separate departments of Anesthesia once and for all. The cost of anesthesia services in future accruing to the department in question—rather than the ministry. We do not know in what measure this exorbitant bill for anesthesia services helped to sway the National Health Service, but do know as a fact that the government body had already been studying a voluminous report from the Second Commission on the Future Organization of Anesthetic Services for Copenhagen's Municipality published in 1950, and co-authored by Surgeon Otto Mikkelsen. (Betaenkning 1950) And that Dr. Ibsen started as the Chair of Anesthesia 13 in a new separate department at the Kommunehospital, on 1 April 1954—aided by one assistant, one secretary, and four nurses to provide anesthesia and recovery room services. And know also that he started a separate recovery room—he called it an Observation Room—on July 1, the previous year. Located on the first floor of the Kommunehospital—with windows facing out onto the Botanical Gardens across the street—this was a converted nurses' classroom: blackboards remaining on the walls—fitted out with ten sturdy patient beds tightly packed into the small space. How did this come about?—one might wonder. What surgeon would allow a mere anesthetist to look after their patients? After all anesthetists were considered second class citizens at best in the medical hierarchy of the day. Conflict resolution. Is the answer to the question. Ibsen was a master at conflict resolution. (He was provocative, tendentious, and sought out controversy, but he was also a master at conflict resolution). The problem had been that the Chairman of Surgery, Dr. Otto Mikkelson, had two Senior Surgical Registrars with diametrically opposing views on post-surgical intravenous fluid therapy. One wanted liberal fluids administered, the other none. As they took care of patients on alternative days, standardized patient care was seriously compromised by this battle of wits. So Dr. Ibsen offered to take care of the situation for Dr. Mikkelson, and, if successful, manage all postsurgical care in the Observation Room. Not just for a few post-surgical hours, but for as long as it took. 13

And was paid the same salary as the other surgical chairs, and, hence was not required to perform clinical work in order to achieve a salary. Dr. Ibsen was thus able to use his time to lead and manage the organization of the department as is the norm today in most academic anesthesia departments around the world.

270

7. Bjørn Ibsen

Resolving the issue by using the classroom blackboards. On evening rounds, Ibsen would chalk three goals for each patient on the black board: goals for urine output, and plasma urea and creatinine values, that the Senior Surgical Registrar had to achieve for each surgical patient by morning rounds the next day. Solving the standard of care problem that Dr. Mikkelson had wanted addressed almost immediately—literally, overnight. (Berthelsen and Cronqvist 2003) Offered as a round-the-clock-service from 1 December 1953, the Anesthesia Department's Observation Room was provided to all hospital departments whose patients required intensive therapy: respiratory or circulatory support to stabilize them. (Ibsen and Kvittingen 1958) Borrowing from what he had learnt managing patients in Blegdamshospital G block dedicated to polio patients during the epidemic, as well as in Pavilion 40, dedicated to tetanus patients (having spent ten sleepless nights there recently); Ibsen wanted to consolidate all patients suffering from respiratory or circulatory insufficiency into one unit where the necessary expertise to manage such patients could be concentrated. In short, he wanted to combat the prevailing fatalism, the therapeutic nihilism, that surrounded the management of the severely ill patients at the time; replacing this with an optimistic and aggressive approach at resuscitation in order to maintain life at all costs. Strategically—Ibsen was known to be a canny chess player—he mandated that the admitting service certify in the patient's record that they were moribund—about to die—before transfer to the unit was approved. He was fearful that otherwise the Observation Room would be blamed for killing the patient, and, should the patient survive, he wanted to make absolutely sure that the unit received the necessary credit for the positive outcome of the intensive therapy. (Berthelsen and Viby-Mogensen 2007) Hence, the first patient—admitted for round the clock care—was not a surgical patient at all. Nor a drug overdose, tetanus, or polio patient, that had been managed in separate units at Copenhagen's hospitals in the past. No, the first patient admitted on December 21—the (unofficial) start date of the Observation Room that would become the first true multidisciplinary intensive care unit in the world: was a medical patient, a 43-year-old man who had tried to hang himself—in destitute circumstances. Managed primarily by the anesthesia department, but with wide consultation from other services, the full array of intensive care therapy was brought to bear on him in an attempt at resuscitation.

Leadership in Anaesthesia

271

Agitated, confused, cyanotic, with labored breathing and shock— the patient's X-rays showing bilateral infiltrates—and the Millikan oximeter showing declining saturation; his trachea was intubated with a red rubber tube so that he could be anesthetized (with nitrous oxide) and ventilated: his arterial blood gases—analyzed in Dr. Astrup's laboratory—demonstrating adequate respiratory support; as the full spectrum of services were added to attempt to save his life: blood transfusion, egg and milk nutrition through a stomach tube, and a tracheostomy placed by the E.N.T. surgeons, to allow long-term ventilation. To no avail. On Christmas day, the patient's legs became paralyzed, his pneumonia worsened, and his heart failed—despite penicillin therapy and wet blankets—applied to combat his exceedingly high body-temperature; the hapless patient died the next day of cardiopulmonary failure. † Realizing the need for teamwork, so essential to successful collaboration with colleagues from different departments, Ibsen was early in championing collegiality: Intensive Care being a team sport after all—he set up a multidisciplinary "Dinner Club" comprising all manner of specialties, including: radiology, pathology, surgery, neurology, as well as forensic and internal medicine representatives, who met 6-8 times yearly, at his home, to socialize, review papers, and address mutual concerns. His daughter, Brigitte, fondly remembering these events as a teenager when she was often asked to play the piano, recite a poem, or change the record playing in the background, as they gathered around the dinner table—before the more formal program was conducted over drinks late into the evening. Ibsen hoping to ameliorate the internecine conflicts undermining collaborative patient care that were the order of the day in the Kommunehospital. As a case in point, witness the antagonism between two surgical departments at the time—two prominent professors on call for emergency services on alternate intake days, serving Division C and D respectively. Division C, overrun with surgical admissions, their operating rooms backed up with emergency patients to be cared for: Professor Kjaergaard stepped over to offer his help to look after the flood of patients, suggesting the use of Division D's operating rooms—standing empty and unused.

272

7. Bjørn Ibsen

But—Prof. Kjaergaard was summarily dismissed with the curt comment that Division C could always manage their own workload! Thank you very much! When the shoe was on the other foot, the next day, and Division D was in turn over-run; while C's operating rooms were mostly empty, foreseeably, Professor Dahl-Iversen's offer of help was in turn sourly rejected. Not surprising then, that when Professor Dahl-Iversen was asked about his arch-enemies retirement date? He could reel it off exactly: 2 years, 3 months and 11 days. (Ibsen 1990) These two professors of the Kommunehospital exhibiting the antithesis of the teamwork that Ibsen felt would be required for the good functioning of the first intensive care unit. To avoid such conflicts and build better relationships instead; Ibsen instituted daily, collaborative, Observation Room rounds to which specialists like surgeons, cardiologists and neurologists were invited; and weekly, collegial, Department Case Rounds, where complicated patients were presented—the case histories catalogued for future reference.14 Troubleshooting his present-day problems of collegiality and collaboration; Ibsen envisioned Intensive Care's technology rich future. While implementing new equipment for the ongoing monitoring of patient welfare: oximetry, capnography, blood gas measurement, spirometry, electrocardiography, electroencephalography and temperature measurement to name a few; Ibsen drew a parallel between early pilots that flew by their senses—coming into land having to guess wind-strength and altitude; now relying on instruments to make it almost foolproof—he exhorted anesthesiologists to embrace the newly designed equipment and do the same. Admonishing that, not to avail oneself of the full benefit of patient monitoring, was just a result of laziness or lack of money. And, besides, Bjørn pointed out: monitor readings can serve as a very good teaching tool—had he not demonstrated carbon dioxide retention, using the Carbovisor capnograph, to explain the cause of Vivi Ebert's critical problems?—in so doing persuading an unbelieving Lassen, during his crucial clinical presentation. Ibsen predicting that in the future we would likely have a universal 'amplifier' into which were plugged additional monitoring modules, and, to

14

Ibsen used selected cases from these Department Case Rounds in his monthly contribution to 'Memento': a section in the Journal Acta Anaesthesia Scandanavica that he inaugurated.

Leadership in Anaesthesia

273

minimize variation and so confusion, we should standardize the new monitoring devices as ever newer techniques were developed. 15 And, then there was the question of air-conditioning in order to control patient temperature, feeding to assure their nutrition, and rehydration to combat their shocked state; quite apart from the 'Intensive Contamination' that needed antiseptic measures brought to bear to counter the cross infection of the patients packed tightly together in the ten bedded Observation Room. Finally he foresaw, that not just respiratory life support would be administered, but that other failing organ systems would also need to be supported in the future: dialysis for kidney failure and heart-lung machines for failing lungs—enhancing the intensive care units (ICU's) armamentarium: potentially keeping patients alive with multi-organ failure. Lamenting that Intensivists had to manage respiratory and other complications—like hyper glycaemia from uncontrolled diabetes— postoperatively, that could easily have been pre-empted; he championed preoperative optimization envisaging the discipline we know today as Perioperative Medicine. 16 Far ahead of his time, he saw that the preoperative state of the patient predicted their post-surgical outcome; setting in place protocols to optimize patients preoperatively—control their blood sugar with insulin, improve their lungs with physiotherapy if they were respiratory cripples— in so doing still further expanding the anesthesiologists role beyond the operating room: indeed inserting an anesthetist into the patient's care preceding the operating room. Prompting, Sir Robert Macintosh, Professor of Anaesthetics at Oxford and one of the recognized leaders of the specialty of the era, to state at an International Conference, when introducing Dr. Ibsen for one of his lectures: "Bjørn you brought the anesthetist out of the operating room." Ibsen's rejoinder, concluding his Monograph: From Anaesthesia to Anaesthesiology: (The title eloquently describing progression of the specialty from an art or craft to a science.) 15

This prediction of advanced monitoring technology would become realized in the 'integrated' anesthesia machines that we use today; but the lack of standardization of monitoring equipment, and the fact that such equipment still does not 'talk' with the electronic medical records in modern Intensive Care Units, is still a major technological problem to address. 16 Perioperative Medicine is now considered part and parcel of the discipline of Anesthesiology. The author's Department is named the Department of Anesthesiology and Perioperative Medicine.

274

7. Bjørn Ibsen

"It is surprising that this work has been done by people in an unrecognized, not pre-existing specialty; who by doing this work showed its importance." (Ibsen 1975) Interpretation. Fittingly anointed the "Father of Intensive Care" for his efforts in launching the specialty in the converted nurses' class-room at the Kommunehospital; Dr. Bjørn Ibsen was also the first to publish fiveyear outcomes from this endeavor—irrevocably staking his primacy in the matter. (Zorab 2003, Ibsen and Kvittingen 1958, Berthelsen and Cronqvist 2003) For: 'In science, the credit goes to the man who convinces the world, not the man to whom the idea first occurs' according to Sir William Osler. (Berthelsen and Cronqvist 2003) This 'first' was directly attributable to one of Ibsen's greatest leadership strengths—he was rarely satisfied with, and so battled, the status quo. At the time joining battle with the poor state of the art of resuscitation: the often half-hearted, eventually futile attempts to resuscitate patients, usually from respiratory insufficiency. Combatting the therapeutic nihilism that was so prevalent at the time—finding this totally unacceptable, he set out to change the situation. His dismay at the state of affairs illustrated well by an event he had witnessed in 1948—five years before he established the Observation Room. It concerned a patient with myasthenia gravis who had undergone a surgical thymectomy—a surgery performed to improve the patient's failing muscle strength. Admitted to the chest unit, the patient was in respiratory failure: "The anesthesiologist and the chest surgeon had some ambulance people set up a mechanical respirator and watched how the technical personnel handled the patient, but three hours later the patient was dead. Knowledge of the proper way to handle a case like this simply was not available at the time." (Ibsen 1952) Throughout his career Ibsen used story-telling to make his points—relating patients' predicaments from their case histories—to affect change in medical management. He did this in his national and international presentations and, as one of the founding co-editors of the Danish Medical Journal Nordisk Medicin and of Acta Anaesthesiologica Scandanavia, he used these journals as fora to present his case observations and the lessons that could be learned. (He never produced randomized controlled trials— the gold standard of medical science: he either did not have the diligence, or he thought that his clinical observations were sufficient to affect the change he desired.)

Leadership in Anaesthesia

275

He also addressed the vexed question of leadership and teamwork in medical care. Who should be the leader of the clinical team? Which doctor was ultimately in charge of the patient's complex clinical care? Ibsen being strongly of Abraham Lincoln's persuasion: that one mind needed to oversee all—he posed the rhetorical question whether that should be either the physician: because the patient has diabetes; or the surgeon: because they need an operation; or the anesthetist: because of the patient's respiratory failure? He used the example of a complicated patient from 1962 to illustrate his point. A 45-year-old diabetic male, who had had his stomach resected, suffered an intra-op cardiac arrest, needed prolonged ventilation and treatment for 17 days in the ICU, but was ultimately discharged to the ward and eventually returned to full-time work. Arguing cogently that such complex care should be overseen by one clinical leader. The Intensivist—who would bring other specialists to consult on medical conditions that they in turn are more expert in. Foretelling the foundation of the approach for modern day intensive care. 17 Seeking to address this issue at least for his own department— conferring complete ownership of the patient to the Intensivist—Ibsen was able to persuade the hospital authorities, by 1958, that the Department of Anesthesia be assigned their own patient beds; where patients could be directly admitted (from referring hospitals) and receive care coordinated by one clinical leader. Ibsen was also a master at conflict resolution. Just as well because it was crucial that people got on with each other as a team. Witness the way he defused the situation with Dr. Ib Andersen; the Chief Registrar on the thoracic service unhappy with his new assistant, by pointing out that his children, congregated around the dinner table every night; eager to hear what the thoracic surgeon had had to say to Ibsen in the operating theater that day. Ibsen fully realizing that he needed to generate team spirit in the operating rooms and intensive care unit to assure the collaboration necessary to manage these complex patients; often suffering from multiorgan failure and so needing multiple specialists to render optimal care.

17 Unfortunately this issue is still contentious today in Intensive Care Units around the world; there being two schools of thought on the matter: an 'open ICU' where any physician may write the orders for a patient, versus, a 'closed ICU' where only the Intensivist in charge may write the orders for a patient in the unit.

276

7. Bjørn Ibsen

Nevertheless, Bjørn could be highly controversial, contentious, and uncompromising—attributes that will be mentioned here, and will become more self-evident as Ibsen's story unfolds. Having been severely disappointed, indeed extremely bitter, that he had not been chosen to be Head of the Rigshospital Department of Anesthesia, Ibsen put his considerable energy into the Kommunehospital instead. Egged on by his wish to prove the authorities wrong in not appointing him to the Rigshospital; he strove to be remembered for establishing the first ICU at the Kommunehospital, and was downright uncompromising in achieving his goals. Needing to battle with colleagues, hospital, and municipal authorities like the Mayor of Copenhagen to get what he wanted, he was always worried about the "knife in the back" in the hyper aggressive environment of the day: being frustrated or undermined by others; as not only was he the youngest Chair (by about 20 years) in the 1,700 bed Kommunehospital, he was also regarded as an upstart—having failed as a surgeon and become an anesthetist—at a time when there was little to no respect for the new specialty. Nevertheless he knew well how to win friends and influence people: on the one hand flattering Mayor Julius Hanson who had been a great supporter of the hospital; but on the other, Ibsen could be intemperate and not beyond a snide comment when frustrated by his successor: Mayor Edel Sauntes (they bitterly disliked each-other)—on hearing that the new Mayor was allowed to park her car directly in front of City Hall, Ibsen loudly commented that he imagined that for Edel Sauntes a place had been reserved in front of the Dragon Fountain—the center of attraction—on City Hall Square. 18 The stresses of such professional battles leaching into Ibsen's personal life. He spent little time at home, and a lot at work. Much favored by the ladies—some considering him a ladies' man—Ibsen was left for another by Doris his first wife; resulting in an acrimonious divorce in 1959. Forever saddened and disappointed by this turn of events, Bjørn married Ingrid Starklind, the theater nurse he had been working with for many years, leaving his six-year-old son, Thomas, and three daughters with Doris—his new wife laboring mightily to separate Ibsen from his children, which he was too weak to resist; Ingrid succeeding to separate the family for many years as Bjørn was a far from empathetic father—especially to his 18 There are no parking places in front of the Dragon Fountain, because it centers a roundabout.

Leadership in Anaesthesia

277

son. The situation coming to a crisis with Thomas, when already a Medical Student at the University of Copenhagen, his father refused to let him take a year out of his training to establish a leper colony clinic abroad. Cutting off Thomas completely when he embarked on this endeavor in Bangladesh nevertheless—the fracture with his only son showing well how uncompromising and difficult Ibsen could be. The break with his children only resolved after Ingrid died of cancer in 1986, when Ibsen sought to bring the broken family together again—finding a third partner, Edel Hagen, who he ultimately was the happiest with (third time lucky according to one of his children). Nonetheless, despite the personal turmoil, Dr. Ibsen's work in building the new discipline of intensive care in the converted nurses' classroom, brought world-wide acclaim. It was thus not a surprise when he was asked to give a historical survey of the subject at the World Congress of Anaesthesiologists held at the Royal Festival Hall in London, September, 1968, where he concluded: “Summing up: at the beginning of intensive therapy it was a problem to keep the patient alive—today it has become a problem to let him die." Foretelling the self-inflicted firestorm that was about to engulf him. †

Life and Death "Do we prolong the death process?" Unabashed, straightening himself in the chair as he leaned forward to speak bravely into the microphone, Ibsen replied: "Yes, and often times it would be much more humane to give morphine, peace and comfort to patients with no hope of surviving." "Have you done that?" "Yes, I have." Ibsen responded emphatically to a live radio interview dealing with the weighty subject of life and death entitled: "Who helps when a human being is going to pass away" broadcast at 20h.20: 7 August 1974—then shifted, somewhat discomfited, in his seat totally unaware that police inspectors were listening carefully and avidly taking notes; having been alerted to the broadcast of the program. The investigators surprised to note Ibsen's answers to the questions posited by radio announcer, Christiaan Stentofte, that, yes, on occasion,

278

7. Bjørn Ibsen

Ibsen had found it necessary to stop respiratory therapy in patients who were inevitably dying. Igniting a conflagration in the national media in the following days: A front-page article in the Danish National Newspaper— Berlingske Tidende—raising the alarm: CHIEF PHYSICIAN TURNS OFF RESPIRATOR: LETS THE HOPELESSLY ILL DIE IN PEACE Active Euthanasia is documented in the first radio interview. The article going on to relate that the well-known radio announcer had interviewed Dr. Ibsen on public radio because he had suspected that the celebrated Intensivist might be performing euthanasia. Christiaan Stentofte, in turn interviewed for the newspaper article, referred to the book 'Causeri'19 that Dr. Ibsen had published five years earlier in which the doctor had championed a physician's right to act in the interests of his patient: having a much better understanding (than the patient or family) of the futility of prolonging life in the face of inevitable death; their being recently equipped with the means to do so—ventilators to combat respiratory failure. † August 8, 1974: At least two national newspapers fueled the story: INVESTIGATION AGAINST CONSULTANT: B. IBSEN National Board of Health Intervenes with Doctor. Medical Director, Dr. Soren K Sorenson, 20 stating that an investigation would be launched to evaluate whether there had been any contravention of the legislation surrounding paragraph 17 of the Exercise of Medical Device Act as: “Physicians are subject to supervision by the National Board of Health." Adding, that to ensure impartiality, he had engaged the Danish Police Force to launch an investigation, knowing that they had the expertise to conduct such a review—all the better to ensure that the public could be secure in the knowledge that the investigation would be both impartial and thorough in its execution. Adding, that doctors should not help patients to die, but rather should help with the process of death. And that this should be a matter for 19 20

'Causeri' is a French word meaning an informal presentation or a 'chat'. Who happened to be an anesthesiologist.

Leadership in Anaesthesia

279

the doctor and the patient to decide and not for the relatives to have to endure; as such decisions were likely to be an excessive burden to them. Adding that he felt that it was high time that these important issues were surfaced. An Associate Professor of Criminal Justice going on to opine that this would commonly be described as murder, but had not been adequately discussed, nor had the appropriate legislation been promulgated to prosecute. "Did he expect an arrest at this time?" "No there is insufficient evidence to support that." DEPARTMENTAL NURSE I Helped Switch Off the Ventilator. "It is unworthy of me to lie:" Ruth Leve claimed, stating that she had left the hospital back in 1968 and was now working in a nursing home. The Deputy Director of the General Danish Medical Association, Prof. Francis Zachariae, opining that the specifics of Bjørn Ibsen's case histories might be far more nuanced than publicized; given that the matter of brain death and euthanasia had not yet sufficiently been worked out—but that active euthanasia, if found to be the case, was illegal under Danish law. † By the next day the politicians had marshalled their thoughts rendering their opinions in the local newspapers. POLITICIANS WANT NEW DEBATE ON EUTHANASIA. Minister of Justice, Nathalie Lind to call for a new debate on the death criteria. August 9, 1974. Gustav Holmberg: "Bjørn Ibsen's practice is dangerous; active euthanasia should not be allowed."

280

7. Bjørn Ibsen

Ole Esperson: "Politicians should not be legislating 'Death Criteria;' Doctors standing by the bedside should make the decision." Adding that politicians are in fact involved in 'passive' euthanasia (the patient in question anonymous to them) when they do not appropriate sufficient respirators to hospitals: forcing doctors to make triage decisions. Mr. Esperson went on to argue that the matter should be left to the doctors who are obliged to make life and death decisions all the time—based on available resources. Jens Moller: "Doctors should be asked to develop criteria for death certification which should be incorporated as an act of the Danish Parliament for adjudication by the Board of Health." † DEBATE ON DEATH August 12, 1974. Crediting Dr. Ibsen with unlocking the debate on public radio (rather than an academic journal), the journalist, recognized the complexity of the issue: "Now that medical science can prolong life, should it be, and in all instances?" "No one would require doctors to try and save a 120-year-old heart patient by heart transplant. But where is the defining line?" "It is a doctor who has raised the debate about death, but whether a person's life is worth saving, ultimately has nothing to do with science." "In this time when there are evermore keys on the medical keyboard that the doctor can play, society may have to have input to limit the full register that is made available. However, until that time, the individual doctor is not exempt from his promise to save an individual life, and should not judge whether it is worth saving." The newspaper man going on to state that although a recent Gallup Study had confirmed the public's support for the 'Brain Death' criteria, needed for heart and kidney transplantation, this 'Debate on Death' was a whole new territory: "The Problem is whether Dr. Bjørn Ibsen is just exercising his right of having an opinion or performing an illegal act." †

Leadership in Anaesthesia

281

Interpretation. In admitting that he had stopped respirators in hopelessly sick patients in 1974—was this a considered strategy to kickstart a very public conversation on the subject?—in the hope of surfacing the reality of what was happening in intensive care units around the country, or had Bjørn Ibsen just put his foot in it? After all, back in 1968 he had stated at the World Congress: "At the beginning of intensive therapy it was a problem to keep the patient alive—today it has become a problem to let him die." Furthering his thoughts on the matter, with a speech—21 May 1969—as the guest speaker for A Jubilee Presentation at the Rotary Club in Copenhagen, Ibsen entitled his talk: "Causeri—on a serious subject." Publishing this talk for wide distribution in booklet a short while later. (Ibsen 1969) Using his developed ability of story-telling, and eschewing theological considerations, Ibsen witnessed multiple case histories in discussing life and death in the small book—embroidering further that this was a serious subject that anesthesiologists have a deep understanding of given that they bring patients near to death with anesthesia; then resuscitate them from that state, and regularly have to deal with life and death situations in the intensive care units. Units that he helped create where life can often be prolonged—at times fruitlessly. Recognizing that many have great anxiety about the suffering that could be associated with death, he wished to allay some of those fears by bringing the debate into the open: extemporizing further on the dualism of life and death—we cannot speak of light without knowing darkness; work without rest; goodness without evil, and certainly not about life without contemplating death—thereby death does not become the enemy of life; rather it is the agency making it possible to recognize life as such. Wishing to combat the prevailing dogma that life should be preserved at all costs, Ibsen, pointed out that we treat our pets better than our fellow human beings (implying that we euthanize our pets to avoid their suffering when they are terminal). Pointing out the single most common question he is asked by relatives who witness their loved one's attached to a respirator: 'Liderhan?' do they suffer? Ibsen felt comforted that he was always able to reassure the family members that there were ways and means to avoid this; he nonetheless made his concerns indubitably clear: "What I want to point out is that I should be allowed to close a respirator and let the patient have peace if I think that is the best for him,

7. Bjørn Ibsen

282

based on my experience on how things will go in the long run. It is of no use to anyone to have a patient die after three months on a respirator." Intensive care therapy had let the genie out of the bottle. The ability to prolong life—brought about by Ibsen in combatting the therapeutic nihilism of the past—had wrought unintended consequences: the need to identify when death was inevitable, and futile interventions should cease; in order to limit anxiety and suffering. Most doctors of the day taking the issue in their stride, having been trained to take matters of life and death into their own hands. God-like, almost, in saving the sick, and keeping death at bay. A tacit understanding between a patient and her doctor that society had sanctioned, if not fully comprehended; at a time when therapy could easily be withheld and did not require the physical 'switching off' of a lifesupporting device. Ibsen having saved multiple lives through his ingenuity, now accorded himself the right to make life and death decisions in the patient's best interest; but, honorably, felt duty bound to surface the issue for wider discussion in the Causeri speech and subsequent book that he distributed. 21 Both unlocking the debate he felt society needed. † DANISH DOCTOR IN CHIEF: I WANT TO BE ALLOWED TO LET THE PATIENT DIE. It cannot be right that nobody is allowed to die without spending a month on a respirator first. September 2, 1969. † Mayor Edel Saunte (an attorney) who Ibsen had vilified in the past, nevertheless came to his rescue: CHIEF OF STAFF: THE DECISION IS HIS. The matter should be left to the doctors not the administrators. September 3, 1969. †

21

Two printings: 3,000 books.

Leadership in Anaesthesia

283

And his former nurse: Ruth Leve added her support; fearful that patients could suffer unnecessarily. DEATH SHOULD BE PEACEFUL "Tattoo 'don't touch me' on my chest for the moment I need to leave." September, 21, 1969. † Beyond Ruth Leve's tattooed 'medic alert' suggestion, others also added their public voice to the debate, writing articles such as: "Worse than death: unconscious patient trapped in the public health care system" and a book review of Causeri, extolled the virtues of Ibsen's message—although cautioning that the writing would benefit from closer editing. The debate, however, seemed to peter out—taken over by a national debate on the need for establishing brain death criteria; driven by the news of the first heart transplants being performed in South Africa (1967) and the United States (1968) as Denmark embarked on its own transplantation program. † Until, that is, Dr. Bjørn Ibsen sought to rekindle the debate five years later by announcing that he would be willing to be interviewed on Denmark's National Radio by Christiaan Stentofte to air his views on the most serious of subjects: a matter of life and death, and the doctor's role in it. Provoking an emotionally heated dialogue by admitting to making a dying patient comfortable—a wide-spread practice at the time—that had not properly been brought to the public's attention; propelling a considerable public reaction and bringing an unwanted Police investigation to bear, and Ibsen's well-meaning action into disrepute. The central question hotly and very publicly debated: whether he was just offering an opinion or had actively committed euthanasia; a mercy killing in other words. † NEXT TIME IT WILL BE THE MENTALLY ILL THAT WILL BE AT BJØRN IBSEN'S MERCY. Elesebeth Nilsson August 12, 1974.

7. Bjørn Ibsen

284

The author vilifying Ibsen for the stupidity of his confession on national radio, added, that Bjørn was breaking-down further the already tenuous trust that the public had in the hospital services; she went on to motivate for strict guidelines so that patients would not be subjected to the whims or religious sensibilities of the doctors who took care of them. † A number of "Letter's to the Editor" then followed in the popular press blowing both hot or very cold: "Our society should be careful in judging this great doctor; he has his conscience in order. Medical Director, keep your legislation away from this man. We must trust Dr. Ibsen's ethical approach." "Dr. Ibsen and Ruth Leve have my respect: we can count on their ethical attitude." "I think I speak for all of Dr. Ibsen's patients: He has great courage to speak up. Can we afford to silence him?" "Did he just state an opinion or transgress to a killing?" "When we demand the right to live. We demand also the right to die. Saving a person's life against their wish is murder! Is it not the duty of science to find a way that we can die that is acceptable to us?" † Then the hammer fell: INVESTIGATIONS IN THE BJØRN IBSEN CASE INITIATED August 14, 1974. 'Dr. Bjørn Ibsen has been interviewed by Copenhagen's Chief Medical Officer: Dr. Heck Knipshildt, and the report has been sent to the Director of Police: Peter M Christensen, together with a transcript of the radio interview held on August 7th.' † Meanwhile, Dr. Ibsen was giving no personal interviews and many papers were using the word 'MURDERER' in their headlines in Denmark and the surrounding Scandinavian Countries.

Leadership in Anaesthesia

285

† DEATH AID: NOT AS CRIMINAL AS EXPECTED August 27, 1974. 'Reporting on Dr. Heck Knipshildt's comments, the article went on to add that Norwegian Newspapers were claiming that the Danish authorities wished to shut the case down for fear of patients negative reactions to a prosecution of Dr. Ibsen.' † And then relief: CONSULTANT IBSEN: NO EUTHANASIA - WAS MISUNDERSTOOD September 3, 1974. Dr. Soren K Sorenson verifying that the National Board of Health had acquitted Dr. Ibsen and that the Police would not bring charges. Adding that although an official warning had not been issued by the Medical Board, Dr. Ibsen would do well to consider this so: given that he had not clearly explained what he had meant on the radio station interview and so had brought great disrepute to Denmark—going on to cite headlines in Belgian and other National Newspapers referring to the case; which alleged that a Danish Doctor had administered death injections to the sick, and so Ibsen's actions, according to Sorenson, had further sullied the countries' already blemished reputation as Europe's pigsty—because of the free abortion and pornography that the Danes permitted at the time—Denmark's reputation now blackened even further by Ibsen's exploits (in assisting the sick to die): resulting in the country being painted as walking in Hitler's footsteps—by exterminating the weak. † BJØRN IBSEN: I DO NOT GIVE ACTIVE EUTHANASIA Neither the National Board of Health nor the Police will take any further action in the Bjørn Ibsen Case. September 3, 1974

286

7. Bjørn Ibsen

The article outlining that patients can be reassured that euthanasia is not occurring in Denmark's Hospitals, and that Dr. Ibsen had given morphine only to ease the patient's post-operative course: concluding that the issue had been overdramatized and misunderstood in the radio broadcast. † Interpretation. But did interviewer Christiaan Stentofte really misunderstand Dr. Ibsen when he answered the question in his national radio broadcast? No he didn't. Nor did Bjørn Ibsen. Stentofte had played back the tape-recordings of the interview to Ibsen before broadcasting it—far and wide. Ibsen reflecting later that when he was asked the question (about whether he had given morphine to make a patient comfortable) he was thinking about a single case: a patient in whom they had found toxic gangrenous bowel, at operation, due to vascular ischemia—a certainly preterminal condition, and, given the extent of the problem, there was nothing else that could be done, but to make him comfortable. Christiaan himself interviewed on the matter later reporting: "Dr. Ibsen had some misgivings about airing the tape-recording, but agreed to it, and thought that the interview had brought out the essential message. Dr. Ibsen was well aware that he had gone a step further than intended, by seeming to admit to active euthanasia; he however felt it essential to broadcast the interview to unlock the necessary debate." Christiaan closing the interview by stating he was well pleased that Dr. Ibsen was not being prosecuted. But he definitely did not misunderstand Bjørn. Dr. Ibsen's statements were far from mistakes: they were intentional. And did the radio interview and subsequent polemic have Ibsen's desired effect?: to surface the discussion around maintaining life and prolonging death that the development of intensive care units had necessitated. In a large measure yes. Reporter Henning Ziebe (who had followed the story as it unfolded over the years) summarizing the outcome in 1981 in a newspaper article entitled: "One should not extend death." The text—surrounding a photograph of an ICU nurse looking down at an intubated and ventilated patient—starting with:

Leadership in Anaesthesia

287

"The debate about active or passive euthanasia started in earnest in 1974 when Dr. Bjørn Ibsen gave a radio interview..." Going on to add: that as a result of the polemic, the National Board of Health had mandated, and Parliament legislated, a Medical Act that mandated that the responsible doctor was required to perform a concrete assessment of the patient's condition and not prolong the death process: it not being contrary to a Doctor's actions not to initiate, or continue, measures that would delay death's inevitable occurrence. Guiding doctors to prolong life, not death, and in so doing allow people to die in peace; administering pain killers to assure this if necessary. Ziebe going on to ask, that, given the medical profession's technical progress and the ability to artificially keep patients alive using respirators—when are patients considered dead? When their heart stops beating? Or when the newly developed brain death criteria were present? Adding that these considerations, and others, had provoked much anxiety amongst the population at large with respect to a hospital's ability to prevent people from dying; patient advocates, and the Medical Association, had worked together closely to create "Living Wills" outlining for doctors, the patient's wishes (when still of sound mind) as to the intensive care they would be willing to undergo should the occasion arise. Ziebe going on to offer Ethics Committees as another way to address such problems in the absence of Living Wills. In conclusion, Ziebe stated, Bjørn Ibsen's case had sparked a very necessary societal debate; resulting in the majority of Danish people, and most assuredly the National Board of Health, being in favor of not extending the death process by artificially prolonging a patient's life—that intensive therapy had made technically possible to do. Bringing Dr. Bjørn Ibsen's medical career full circle: first saving Vivi Ebert's life against all odds using artificial means; then initiating intensive care unit therapy; and finally publicly questioning its use to prolong death. † Bjørn Ibsen going on to have a contented and productive life. Becoming a Full Professor of Anesthesiology at the University of Copenhagen, and an Honorary member of the Royal College of Surgeons of Dublin, the European Association of Intensive Care, the European Association of Resuscitation, The Danish Society of Anaesthetists and the Scandinavian Society of Anaesthesia and Intensive Care.

288

7. Bjørn Ibsen

But his first love was the Department of Anaesthesia that he established at the Kommunehospital in 1954, and the Observation Room within it. Retiring from the Department in 1986; a time of great sadness and great joy. Great sadness because of the death of his second wife Ingrid, but great joy because of the reconciliation with his broken family; he worked avidly, and successfully, to bring all together again. Dying peacefully in the garden one warm August day in 2007: of old age: he was 91. †

Post Mortem With respect to the historical stage within which Dr. Bjørn Ibsen provided his leadership, he traversed the Group-Goal Age of 1950-1960, the Behavior Age of 1960-80 and the Leadership vs. Management Age of 19802000. The Group-Goal and Behavior Ages were invested in examining the leadership behavior that helped to build relationships—in order to persuade rather than coerce followers—focusing a lens on how organizational behavior might be improved. While the Leadership vs. Management Age sought to differentiate the roles and psychological underpinnings that contrasted what leaders, as opposed to managers, brought to the situation. The famous Harvard Business School professor of the time: J.P. Kotter, bewailing the current state in North America: "Most U.S. companies are over managed and under-led." Going on to differentiate the two: managers were responsible for coping with increasing complexity, by planning, organizing, budgeting, controlling, staffing and monitoring of the work done—in so doing creating predictable order and efficiency. In contrast leadership was something quite different although complementary, in being required to set direction, motivate, inspire and align people to a common cause: often envisioning the future state for them that galvanized followers to commit to the cause at hand. (Kotter 2001) Dr. Bjørn Ibsen embodied both—not only did he envision the future of Intensive Care he managed its development, combining leadership and management ably in his long career in medicine.

Leadership in Anaesthesia

289

We will again review key 'body parts' of the Leadership Skeleton to examine Dr. Bjørn Ibsen's leadership profile, best captured using the rubric: Creative LEADER. Leadership Skeleton: Creative LEADER max score: +++, min score: 0.

Bjørn Ibsen

Creativity/Innovation/Imagination

+++

Legitimacy/Authenticity/Credibility

++

Emotional Competence/Psychological makeup/Personality Adaptability to Change

++

Determination/Passion

+++

Empathy

+

Resilience

+++

Total Leadership Score

17/21

+++

Creativity (+++). "The best leaders are creative innovators who have big ideas." (Stoll 2019) Ibsen's creativity lay not in the invention or the manufacture of novel devices—nor in scientific endeavor—but in providing strategic solutions to major problems. The logistical problem of managing respiratory support for hundreds of patients dying from polio by providing a simple solution of a to-and-fro breathing apparatus and, in the first intensive care unit, strategically concentrating expertise in one location—both advances that were responsible for saving hundreds of lives over the ensuing years. A further example of the benefits of concentrating expertise in the ICU is worth telling: Ibsen relating that when the blood transfusion supply had become contaminated at the Kommunehospital, because the sickest patients (who commonly received blood transfusions) were concentrated in one place; the diagnosis of this problem could easily be made by the attending doctors. Had the patients, in contrast, still been spread throughout the hospital in independent wards, the source of the patients' problems

290

7. Bjørn Ibsen

would likely not have been diagnosed early enough to avoid a catastrophe. (Ibsen 1975) Legitimacy (++). As the "Father of Intensive Care," Dr. Ibsen had unquestioned legitimacy, credibility and authenticity, indeed adoration from many who followed him in the nascent field. Although some have stated that he was humble—he really wasn't—quite the opposite; he was conceited and loved to provoke controversy, particularly when championing a cause. As he rightly did in starting the conversation on "Life and Death." Bringing a heap of opprobrium upon himself which probably helped to frustrate Dr. Ibsen's attempts to instigate the necessary committee to motivate for a Nobel Prize in Medicine on his behalf. And possibly undermined other attempts at providing him with the appropriate recognition for his work, because, beyond his leadership positions at the Kommunehospital—Ibsen did not hold any Nationally or Internationally, and, so, despite the Danish Anesthesia Society wishing to pay for a "Bjørn Ibsen Platz" centered in his beloved Kommunehospital: the Danish Ministry blocked the proposal. Emotional Competence (++). The best leaders are narcissists and Bjørn Ibsen was likely one. (Coutu 2004) His charm, ambition and courage obvious to all he met as he sought to achieve his goal of becoming the Chair for a department of anesthesia in order to develop a vision for the specialty. At a time when anesthesia was a fledgling specialty that got no respect, Ibsen had the fortitude, interpersonal skills, and political nous to keep fighting for what he thought needed to be done to position the discipline at the center of the hospital's functioning; using the allegory of an umbrella to make his vision clear. An umbrella tented wide—all possible diseases scattered over its black cloth, they group themselves along the stretched struts, symbolizing the various medical and surgical specialties. The struts in turn collecting in the umbrella's shaft which represents the commonality of the circulation and respiration necessary to sustain life—the Anesthesiologist holding the handle of the shaft deploying the umbrella, and so supporting the hospital, in treating the sick. (Ibsen 1990) Adaptability to Change (+++). Ibsen was a change agent. Greatly dissatisfied with the status quo—therapeutic nihilism in resuscitation—he set about changing things.

Leadership in Anaesthesia

291

First at the Blegdamshospital, demonstrating how Vivi Ebert could be helped, and so hundreds of polio patients like her. And then at the Kommunehospital in establishing its first Anesthesia Department and then ICU. Could he adapt to the inevitable change that occurred when the Kommunehospital shifted many of the 'best' departments to a new hospital in Hvidovre in 1975, despite his strenuous attempts to the contrary? Well yes, Ibsen now approaching 60, decided to focus on Pain Clinic Work instead of continuing to practice anesthesia—again using anesthetic techniques beyond the operation room. Determination (+++). Nothing would stop Ibsen from achieving his vision to make a success of the Department of Anesthesia at the Kommunehospital. Having been frustrated and extremely disappointed by not being appointed the Chair at his first choice: the Rigshospital—he compensated by putting all his energy into making this a success and as a result, established the first ICU in the world. Empathy (+). It is not clear how empathic Ibsen was. Certainly he was able to develop the necessary team spirit to make a success of a multi-disciplinary unit, but he had multiple interpersonal problems in his family, and had a tendentious personality, often provoking others unnecessarily. However he was quite good at resolving interpersonal conflicts as demonstrated when resolving the intravenous fluid administration question in the Observation Room, and was adept at managing his students to become better anesthetists—receiving a wealth of letters of gratitude and plaudits from his patients and students alike. Resilience (+++). Resilient people are able to improvise and bounce back from disappointment. (Heifetz and Linsky 2002, Coutu 2002) Ibsen demonstrating both in spades: he improvised anesthetic techniques—taking the specialty out of the operating room—and bounced back from multiple professional and personal reversals: becoming one of Anesthesiology's unimpeachable leaders and reconciling with his family— becoming a much-loved grandfather.

292

7. Bjørn Ibsen

Leadership Insights We will again surface a few leadership insights that can be devolved from Dr. Bjørn Ibsen's biography. x Find the gap and fill it. x Refuse to accept the status quo. x Encourage teamwork. x Use story-telling to drive change. x Be accountable for what you have wrought. x

Find the gap and fill it. Ibsen was both ambitious and strategic. Upon completing medical school close to the bottom of his class, he had to spend five years on the Jutland Peninsula building his resumé to get accepted into surgery at the University of Copenhagen. Calculating that the chances were slim (2%) that he would get a surgical consultant position and seeing that there was a great need for anesthetists in Denmark—where it was not yet a defined specialty—he found a gap for potential rapid advancement by availing himself of a training opportunity at the epicenter of anesthesia: the Massachusetts General Hospital where it had all started. In so doing, ambitiously preparing himself—as one of the only overseas trained anesthetists in the country—to fill a leadership gap as a head of a future department of anesthesia. Ibsen identifying and filling many other gaps throughout his career: Intermittent positive pressure ventilation outside the operating room. Concentrated round-the-clock intensive therapy in an "observation room." Preoperative medical optimization and post-operative pain management.

Refuse to accept the status quo. We define our culture by what we refuse to accept. Ibsen's great leadership strength was that he refused to accept the poor state of patient resuscitation of his time. Having been trained in anesthesia with all that that entailed in terms of airway management, respiratory support therapy and resuscitation, he dared—despite very obvious resistance—take those techniques beyond the operating theater and into the hospital to resuscitate x

Leadership in Anaesthesia

293

patients there. 22 Forever expanding the role of anesthesia and helping to mature the specialty—as he put it—from: Anaesthesia to Anaesthesiology: from a largely technical discipline, to a much more scientific one, encompassing medicine. Encourage teamwork. 'A team is a small number of people with complementary skills who are committed to a common purpose, performance goals, and approach for which they hold themselves mutually accountable.' (Katzenbach and Smith 2002) Far ahead of his time in promoting teamwork and setting treatment goals in the Observation Room where different medical disciplines were asked to intersect for the betterment of the very complex patients managed there—Ibsen was an early promoter of working together, rather than in silos, in the interest of improved patient outcomes; treating 259 patients in this first ICU over the first five years of its existence with only 93 dying. Given that the referring service had to testify that the patients were moribund before they could be admitted—these statistics speak well of the teamwork that was brought to bear to help save patient lives. (Ibsen and Kvittingen 1958) x

Use story-telling to drive change. In the long-arc of history, people have always responded well to stories. (Gallo 2016) Ibsen was a master story-teller. Using case histories from his department files he would use every speaking or writing opportunity to tell these stories. Usually as a means of affecting change. So on one occasion when asked to represent Scandinavian Anesthesia at the 200-year celebration of Columbia University School of Medicine in 1967: 'I pulled an old-fashioned chair out into the center of the oldfashioned amphitheater, sat down and addressed the audience: I have six cases to present to you, all related to anesthesiology." 23 x

22

He also helped set up a helicopter service to transport patients and travelled to the injured in ambulances. 23 It is quite possible that Dr. Ibsen met Dr. Virginia Apgar at this 200-year celebration and also very likely that they met at the Fifth International Polio Conference held in Copenhagen in 1960, which Virginia attended in her capacity as the Director of Congenital Malformations for the March of Dimes.

294

7. Bjørn Ibsen

And on another, when he presented his Causeri talk on life and death, he used case histories to drive home the important message that while death itself should not hold fear—prolonging death should: hoping to initiate a societal discussion about the use of medical techniques that he had helped create, that could artificially prolong life, fruitlessly.

x

Be accountable for what you have wrought. In bringing the life-saving measure of intermittent positive pressure ventilation out of the operating room and into the first multidisciplinary intensive care unit, Ibsen had created a many sided ethical and moral conundrum for society to grapple with: he had demonstrated the means to prolong death. As the 'Father of Intensive Care' he clearly felt accountable for the dilemma that this brought and took on the responsibility of addressing this openly. Not only through speaking and writing about it, but also, through very publicly—on national-radio—broadcasting the fact: that yes, on occasion, when death was inevitable, he had switched off the respirator—going as far as to put his own good reputation at risk in the interest of being accountable for his actions. Leadership at its finest! †

8. A LEADERSHIP RECKONING

William Morton

Virginia Apgar

John Snow

Arthur Guedel

Bjørn Ibsen

"The signs of outstanding leadership appear primarily among the followers." —Max DePree

Leadership is like beauty—obvious when you see it but hard to characterize; manifesting very differently in different people and differing circumstances. To illustrate this timeless truism we have told the stories of five pioneers who helped transform the crude practice of anesthesia to the specialty of anesthesiology; subjecting them in turn to a 'post mortem'

8. A Leadership Reckoning

296

analysis using a 'leadership skeleton' comprising the 'body parts' of: Creativity, Legitimacy, Emotional competence, Adaptability to change, Determination, Empathy and Resilience in order that we might compare these leaders' profiles in a final Leadership Reckoning. Because the reader can be left in little doubt as to the effectiveness of these pioneers in advancing the historical transformation of anesthesia from their preceding life stories—this concluding chapter does not seek to compare their relative effectiveness as leaders, but rather consider this a given, and instead, strives to compare and contrast the 'body parts' that led to this success. And, also seeks to achieve a further two goals: (1) To devolve a series of themes that surface from the leaders' biographies, as well as: (2) To use their stories to answer some of the enduring questions that surround the study of the subject of Leadership. To these ends we will first highlight a few common themes, then attempt to answer a number of enduring questions, and close with a Leadership Reckoning—a final accounting of the differing leaders' profiles that underpinned the five pioneers of the deadly quest for surgical insensibility. †

Leadership Themes A number of Leadership Themes emerge from the foregoing biographies that can be usefully summarized under the following headings. x x x x x x

Advocacy for a cause. Combatting the status quo. Finding the professional gap and filling it. The psychological drivers of leadership. Leaders shape ideas. The role of charisma. †

Advocacy for a cause. All five pioneers became advocates for various causes, often having quite differing motivations from those offered as the drivers of x

Leadership in Anaesthesia

297

human behavior by Plato—the loins, heart and head: desire, emotion and knowledge. Dr. William Morton advocated for his primacy in the Ether Discovery; motivated by money. 1 Dr. John Snow advocated for Safe Anesthesia, Chloroform, Public Health, and the destitute of London's Cholera Epidemic; motivated by the thrill of scientific discovery and the fame of the many publications he produced. Dr. Arthur Guedel advocated for Safe Anesthesia for the American doughboy on the Western Front and the professional development of Anesthesiology as a specialty; motivated by a willingness to do well for others and an unstoppable work ethic. Dr. Virginia Apgar advocated for Mothers and Children; motivated by an unrelenting spirit of concern for her fellow man. Dr. Bjørn Ibsen advocated for the development of Anesthesiology, Perioperative Medicine, Intensive Care and Patient Rights (of selfdetermination); motivated by his wish to ensure that optimal medical care was brought to bear in the interests of his patients. All five pioneers engaging their considerable talents of communication to add the weight of their well-considered words to the causes that they vociferously advocated for. Combatting the status quo. According to Dr. Linda Hill from the Harvard Business School, leaders should imagine a future state different from the status quo. They should innovate. They should bring creative solutions to improve on the present state; producing constructive change. (Hill et al. 2014) Dr. John Snow, Dr. Arthur Guedel, Dr. Virginia Apgar, and Dr. Bjørn Ibsen all serving as excellent examples of anesthesia pioneers who were unhappy with the current state of affairs they found themselves in and so combatted the status quo. Dr. Snow, at first a therapeutic skeptic, 2 turned to public health matters—combatting the prevalent miasma theories that were thought to explain the rampant cholera epidemic of the time, with shoe-leather epidemiology; he exploded the miasma myth through diligent scientific investigation and so helped to resolve the water pollution problem that x

1

The actual motivation for the protagonist's behaviors may not ever be known to anyone but the person themselves, so please accept this as supposition or conjecture only. 2 One who believes that man heals himself and thus is not in need of medicines as therapy.

8. A Leadership Reckoning

298

plagued London and its environs—removal of the Broad-Street pump handle, one of the nails in the epidemic's coffin. Dr. Guedel railed against the inadequately provisioned anesthesia services he encountered on the Western Front—the American doughboy too often being a casualty of both the War effort and anesthesia: he fashioned an easy to use Anesthesia Pocket Chart and monitored anesthesia care by motorcycle. Dr. Apgar was dismayed at the neglect afforded to the newborn. Put aside while the clinicians focused on the mother, the baby had to fend for itself—often faltering and dying; to be declared a stillborn. Apgar focusing attention on the problem by creating a Newborn Baby Score that necessitated looking at the baby at one minute after birth to see if she was alright. And if the baby was not, she employed resuscitation techniques developed from a scientific investigation of the problem. Dr. Ibsen protested the therapeutic nihilism of his day. Witnessing the half-hearted attempts at resuscitation provided to polio victims, he knew he could do better using simple anesthetic techniques learnt in the operating theater. Putting this to good effect (the approach was said to have saved one hundred lives), he spearheaded the development of intensive care. Finding the professional gap and filling it. All the leaders saw the practice of Anesthesia as a professional gap to be filled with advantage. Dr. Morton had not planned to pursue anesthesia (he just saw anesthesia as useful for painless tooth-pulling), but was kidnapped by Dr. Henry Bigelow, the ambitious Boston Surgeon, into promoting its practice and so progressed his anesthetic career as a business opportunity. Dr. Snow, having previously studied newborn resuscitation and ether as an inhalant for respiratory ailments, was thrilled to witness one of the first ether anesthetic demonstrations in Gower Street, London, in 1847— immediately recognizing its potential: he saw that anesthesia offered a twofer: a golden opportunity for further scientific investigation, and a professional direction to increase his practice. (He didn't really like the fact that for most of his patients at the time there were very few truly effective remedies that could be prescribed, while anesthesia administration produced both an effective therapy and a great opportunity to increase his patient numbers in the competitive city.) Quite apart from his excitement about the fact that anesthetics were expunging the excruciating pain marring surgery. Dr. Guedel also saw anesthesia's potential early. Graduating from medical school in 1908, he taught himself anesthesia with ether and chloroform during his internship year in Indianapolis so that he could open x

Leadership in Anaesthesia

299

a private practice. Doing so the next year; dedicating mornings to anesthetic practice and afternoons to a less than busy general practice. Hoping to increase the former, so he could give up the latter; Guedel started developing novel anesthetic techniques and equipment to win new surgical patients. Eventually becoming one of the key American pioneers of anesthetic practice and a champion for its transformation to the specialty of Anesthesiology. Dr. Apgar too saw the gap. Early on. Having set out to be a surgeon in 1934, she was soon persuaded that there was very little future in it as a woman: "Not even females will go to a female surgeon" in New York City. Apgar becoming increasingly convinced by Dr. Alan Whipple's guidance on the matter, and his promise that she would head the first Division of Anesthesia at Columbia University, if she was willing to undergo training in anesthetic practice. Apgar reasoning accordingly: "Maybe this wasn't such a bad idea. To be a bigger fish in a smaller puddle, because it would take three or four more years in surgery and [so] it was purely financial that I changed to anesthesia, which was not a bit dramatic, it's the truth." She planned for a future career in anesthesia, there being very little female physician competition in the field, while the inevitably male surgeons were very well disposed to females in anesthesia; after all most of the anesthetics were being administered by nurses at the time. (Houston 1974) Dr. Ibsen was probably the most calculated in the matter of filling the gap. Having joined a "Young Doctor's Committee" in Copenhagen in 1948 as a young surgical registrar, he had calculated the chances of a successful career in surgery as 2%. And opportunities for a career in Anesthesia wide open; there were only a handful of specialists in Denmark at the time, and having earlier experience of anesthesia as a medical student in Holbaek Hospital (replacing a secretary in the position), he set off for Boston in America for one year of residency training at its mecca; The Massachusetts General Hospital and Harvard Medical School, the place where anesthesia had begun—kickstarting his trailblazing career. The psychological drivers of leadership. Notwithstanding psychiatrists admonishment that no psychiatric or psychological diagnosis should be made without a full examination of the patient in question; it nevertheless remains instructive to make a number of general observations from the pioneers' biographies presented—given the historical trajectory of the study of leadership from one based on philosophy, to that of psychology (and psychopathology). (Ghaemi 2011) x

8. A Leadership Reckoning

300

In this vein, narcissists, especially productive ones, make the best leaders. Wishing to be admired, narcissists are often creative innovators who seek power and glory and can envision the future. Dr. William Morton envisioning the first locum anesthesia practice throughout the northeastern U.S.A., and Dr. Bjørn Ibsen, the first Intensive Care Unit; both providing the charismatic leadership necessary—and having the intestinal fortitude to deal with the inevitable set-backs such plans entail. (Coutu 2004) Hypomania confers resilience while depression confers a better sense of realism. It is interesting to note, that Morton, Apgar, and Guedel were variously thought to have had elements of the hypomanic personality trait, while both Morton and Guedel suffered from bouts of depression; usually brought on by understandably difficult circumstances that they encountered in their lives. (Morton severe reverses of fortune, and Guedel the untimely death of his daughter; too much for anyone to bear.) Leaders shape ideas. According to Abraham Zaleznick, a leader is very different from a manager: they shape rather than respond to ideas. They seek to expand the available options and seek to change what people think is possible. (Zaleznik 2004) Witness Dr. John Snow and his mission to find "an anesthetic which might be inhaled with absolutely safety" and Dr. Arthur Guedel's development of anesthesia machines: first the "Old Gray Mare," an anesthesia sleep machine on wheels, and then, when he needed a portable version—Guedel found a way to save anesthetic gases using a cuffed endotracheal tube first—allowing his design of a yoked lightweight 'Midget' anesthesia machine. And Virginia Apgar's development of the APGAR Score. Hoping to focus attention on the problem of neglect of the newborn baby—in order to signal the need for action, she shaped the idea of resuscitation science, which was then carried further in Bjørn Ibsen's first Intensive Care Unit, where patients requiring respiratory support were concentrated into a single specialized 'Observation Room.' x

The role of charisma. The sociologist Max Weber had suggested that charismatic leadership serve as the counter to the burgeoning bureaucracy of the late nineteenth century, while C. Northcote Parkinson had championed charisma in the next; terming this personal magnetism—he considered this one of the six key elements that the art of leadership required. x

Leadership in Anaesthesia

301

Robert House going on to expand on the subject in 1976 having published a theory of charismatic leadership in which he espoused that such charismatic leaders were often strong role models, appear competent, and usually champion ideological goals; he might as well have been referring to both Dr. Virginia Apgar and Dr. Bjørn Ibsen. She championed looking after the mother and child, while he championed concentrating respiratory crippled patients in an Intensive Care Unit; House going on to point out that charismatic leaders also communicated high expectations to their followers—APGAR Score post-delivery, overnight goals set for fluid therapy on the blackboard in the Observation Room—and imbued in their followers a great sense of trust and shared values, much as both Virginia and Bjørn did. Both Weber and House agreeing that there were a number of positive effects that flow from such charismatic leadership—encountered with both Dr. Apgar and Dr. Ibsen; in that their followers believed in their goals, identified emotionally with them, and witnessed great trust in their leadership. (Goffee and Jones 2000, Parkinson 1970, Northouse 2018) †

Leadership Questions There are a number of enduring leadership questions that do the perpetual rounds for discussion. A few can be addressed here from the biographies told. x x x x x

"Are Leaders born or made?"—do circumstances produce the leader or does the leader create the leadership opportunity? Can leadership be learnt? Must leadership be ethical to be effective? Is leadership contextual? Is there a right or wrong leadership style? †

x

"Are Leaders born or made?"—do circumstances produce the leader or does the leader create the leadership opportunity? Thomas Carlyle, one of the first to ask the seminal question: "Are leaders born or made?" surfaced the idea as early as the mid-1800's;

8. A Leadership Reckoning

302

believing firmly that leaders themselves created the situation which resulted in the progress for which they were revered. (Clinton 1992) While others were of the opposite persuasion: that it was the circumstances that created the leader—the presented biographies suggest that in reality the answer is more likely, a bit of both. (Clinton 1992) Dr. Morton was most likely more a product of circumstance; he happened on the idea of using sulphuric ether (from Dr. Charles Jackson) to still the pain from tooth pulling, and, in likely overdosing his patient; chanced on the 'discovery' of anesthesia, and in so doing—notwithstanding his shady past—was thrust into the glaring limelight; egged on by Dr. Henry Bigelow, the ambitious Boston surgeon. On the other hand: Dr. Apgar and Dr. Ibsen very much created their own future; leading where no one else had been, developing two new medical disciplines—perinatology and intensive care. Can leadership be learnt? While Thomas Carlyle (of the Great Man Age: 1840-1900) believed that great leaders were born, and indeed could be considered superior beings worthy of emulation, Trait Age (1920-1950) theorists believed that leaders could be made; once the necessary leadership traits had been identified, these could be taught to the aspirant leader. Many in the present day would agree. While some basic talent is required, and certain personality types are helpful, much can be learnt to advance a leader's skill set. Accordingly, if, as Professor Warren Bennis has told us, "Leadership is the management of meaning and the mastery of communication." This can to a very large extent be learnt. As can, 'change management' and 'emotional management,' as taught by Professors Kotter and Goleman. (Kellerman 2001, Bennis 1994, Kotter 1996, Goleman, Boyatizis, and McKee 2001, Goleman and Boyatzis 2008) Tapping some of the stories here told—Arthur Guedel read avidly to enhance his own effectiveness and from his readings provided sound advice to Dr. Ralph Waters, his emotional confidant. When the Chairman of the first Academic Anesthesia Department in America sought his reassurance on a leadership matter, Guedel responded with his "Maintain Flying Speed" motto going on to tell him the story behind it. Relating that he had read about General Mitchel, who at the time of being the chief of aviation for the U.S. army had proclaimed the three rules of flying: "1. Keep Flying Speed. 2. Keep Flying Speed and, 3. Keep Flying Speed." Guedel provided Ralph Waters with a useful leadership lesson he had learnt from his reading. x

Leadership in Anaesthesia

303

And the biography of Dr. William Morton provides a further example of the fact that leadership can be learnt—Morton changing his strategy completely when his representations to Congress for reimbursement for his claim of being the 'discoverer' of ether anesthesia did not find favor; from a focus on providing multitudes of factual information to convince recalcitrant Representatives to, instead, winning their hearts and minds by holding extravagant parties laced with wine, oysters and fine cigars. Both Guedel and Morton learning, through reading and practice, to be better leaders. Such learned leadership practices having a basis in neurology. As leaders practice new effective behaviors (just like practicing for a talk to perfect it) this develops their brain neural networks—the winning social behaviors so learnt eventually becoming second nature, and as other people connect positively with the new actions, their brains in turn mirror this interaction releasing the neurohormones oxytocin and serotonin—setting up a virtuous positive loop to entrench the new learned behavior in the leader (and the follower); confirming that indeed, leadership can be learnt. (Campbell, Whitehead, and Finkelstein 2009) (Goleman and Boyatzis 2008) Must leadership be ethical to be effective? According to Dr. Peter Northouse, leaders' ethical landscapes fall within two broad domains: of their conduct and character, i.e. their actions, and who they are as people. Their actions in turn are measured through a lens of whether the effects of the leadership so rendered is largely positive or destructive. Both effects can be propelled by a spectrum straddling an egotistical or altruistic mindset. An egotistical leader would primarily make decisions that would benefit himself, the altruistic leader, others. Destructive leadership would occur when followers are left worse off than when the leader took on the leadership role, and is characterized by 'toxic' character traits like, managerial incompetence, erratic behavior, indecision and excessive narcissism. (Northouse 2018) Take on the one hand Dr. William Morton, and on the other Dr. Virginia Apgar's characters, as portrayed by others to navigate this longstanding question. Although both were highly effective leaders of movements: Morton the 'discoverer' and highly successful promotor of anesthesia (literally across the world); and Apgar, the highly successful promoter of healthy newborns, again across the world—they were characterized very differently. In response to Morton's machinations in his claim for primacy in the discovery of ether—his fellow citizens, of West Needham, hung a x

8. A Leadership Reckoning

304

likeness of Morton as an effigy from a high branch in a buttonwood tree centering the village. To make doubly sure who was the subject of this public vilification, the hat band of the effigy was emblazoned with 'Morton' for all to see. On the other hand, Dr. Virginia Apgar was considered quite differently. In providing a eulogy (that thousands attended 3) Dr. Stanley James, a close friend and collaborator, witnessed her character thus: "She was one of the most remarkable people I have ever known.... Integrity was her hallmark: she was utterly sincere and honest and could not tolerate any form of deception. All these qualities, and many more, together, with her magnetism and charm, contributed to her greatness.... We are remembered by the way our work is continued." (Hunt 2002) I will leave the answer to the question to the reader. Is leadership contextual? "Leadership is contextual. What works in one era, setting or organization simply doesn't apply to any other." (Kellerman 2001) Hence, in telling the stories of the five pioneers represented in this book, I have situated them within the era (and context) that they provided their leadership—as represented in the accompanying diagram. To illustrate this point further, let us contrast Dr. John Snow (Great Man Age:1840-1890) with Dr. Arthur Guedel who straddled the three subsequent 'Ages'—but who were separated by more than half a century, and, remarkably, in the long tradition of scientific development—Dr. Guedel built upon Dr. Snow's work: taking the latter's description of the five stages of ether anesthesia and advancing this through clinical observation to develop the easy to use Pocket Anesthesia Chart first applied on the Western Front; which would eventually form the basis of Dr. Guedel's text book "Inhalation Anesthesia" (1937) that would be very favorably compared with Dr. Snows "On the Inhalation of the Vapour of Ether" (1847) by Professor Robert Macintosh, of Oxford, in 1951. 4 (Macintosh 1951) Both pioneers, however, influencing the development of the specialty in different eras and contexts. Snow at its initiation. Vilified in the press for his administration of chloroform anesthesia to the Queen of England (thought an unsafe practice), Snow had to convince the populace at large of the very need x

3

A handful of individuals attended Dr. Morton's burial in Mount Auburn Cemetery, Cambridge, Massachusetts. 4 If you look very carefully you will see the top of the latter book displayed on the cover of this book.

Leadership in Anaesthesia

305

of pain relief for childbirth and surgery—while that was no longer a question that Guedel needed to address. Although they both investigated the science behind the safety of its delivery; Guedel's leadership challenge related more to whom should be administering the anesthesia in the first place to ensure its safety: nurses or professionally trained medical doctors. The problem never arising in Snow's era and context because, at anesthesia's initiation in England in 1847, only medical doctors were allowed to administer anesthetics because of chloroform's recognized lethality. Quite different to what had transpired in the interregnum in the United States. Here, largely because the much safer ether rather than chloroform anesthesia administration had taken hold, most anesthetics had been administered by a nurse-surgeon dyad. The nurse administered the ether under the direction of the surgeon. However, as a result of this fact of nurse administered anesthesia, or so Guedel and others thought—the scientific underpinnings that were necessary to develop anesthesia to its full potential, as the medical practice of anesthesiology, had become a casualty of this approach. Hence as a consequence, Guedel and others set about 'professionalizing' anesthesia's practice through scientific evaluation and equipment development, and championed the launching of residency training programs to train doctors to provide specialist anesthesia care. Consequently, Guedel's leadership was manifest in very different ways from Snow's: he had to campaign for medical doctors to be the ones that administered anesthesia, and so offered to serve as an expert witness for physicians against nurse anesthetists in the California Superior Court—all in the interests of professionalizing anesthesia practice in the United States. Hence Guedel was contending with the question who should be administering anesthesia, while Snow, present at anesthesia's initiation, some 90 years earlier, was dealing with the question of whether anesthesia should be administered at all: both seeking to advance the specialty they loved, in their different contexts and eras of practice. †

8. A Leadership Reckoning

306

†

Seven Ages of Leadership

† x Is there a right or wrong leadership style? Dr. Daniel Goleman has described six distinctive leadership styles. (Goleman, Boyatizis, and McKee 2002) x x x x x x

Visionary—envisioning a future that inspires people to follow. Coaching—supporting individual growth using training. Affiliative—connecting emotionally to support collegiality. Democratic—seeking participation through individuals input. Pacesetting—creating exciting and challenging goals. Commanding—setting direction in an emergency.

Effective leaders using these different styles interchangeably— much as an archer might use a quiver of arrows; selecting the most suitable style of leadership to fit the situation. To illustrate the use of varying leadership styles from the forgoing biographies here are a few examples.

Leadership in Anaesthesia

307

Visionary Style During the course of their long careers all five pioneers envisioned a different future: Dr. Morton, an Anesthesia Practice stretching across the Northeastern United States. Dr. Snow, the design of "An anesthetic which might be inhaled with absolute safety." Dr. Guedel, the simplification of inhalational anesthetic techniques to enhance safety. Dr. Apgar the "Well-baby." Dr. Ibsen, the concentration of patients with respiratory compromise in one "intensive care unit."

x

Coaching Style Some of the leaders were particularly good at this. Witness Dr. Guedel and the anesthesia training school he started at the Head Quarter Barracks in Chaumont in 1918; Dr. Apgar and the first separate Division of Anesthesia at Columbia University in 1938, and Dr. Ibsen as the first chair of a separate Department of Anesthesia at the Kommunehospital in 1954. x

Affiliative Style Some pioneers may have done this a little better than others; Dr. Apgar stood out in her ability to emotionally support collegiality—she would quite disarmingly sit down with pupils or colleagues and with a warm smile say: "Tell Momma all about it." Empathetically connecting with her people using her well-honed feminine leadership skills; females usually having a more holistic approach to leading: sensitive to their senses, with an emphasis on relationships and how parts interconnect when compared to males who tend to like to categorize things. Men often being more emotionally detached and, driven largely by results, not as mindful of the group processes necessary to develop the sustainable collegiality that helps to bring the group together, and so psychologically better ready for the next leadership challenge. (Green 2018) x

Democratic Style In seeking participation through canvasing others' input; both Dr. Guedel and Dr. Ibsen were champions of teamwork. Dr. Guedel championing the surgical teams, comprising a surgeon, nurse and orderly— he added an anesthetist to render care on the Western Front, travelling around on a motorcycle to monitor the situation. While Dr. Ibsen, sought input from the various different medical specialties intersecting in the x

308

8. A Leadership Reckoning

Observation Room—to the betterment of the very complex patients managed there. Pacesetting Style A pacesetting style is one of setting goals. Two pioneers stand out as having done so. Dr. Apgar and Dr. Ibsen. Although they didn't point to them at the time as being such; Apgar created the APGAR Score which became a surrogate goal to achieve for babies' outcome from the delivery process; while Ibsen instructed his Surgical Registrars to achieve three goals overnight for their patients—for urine output, and plasma urea and creatinine values—penciled on the black board in the Observation Room. x

Commanding Style An emergency requires a commanding style of leadership. Do this, do that, and quickly! Medical emergencies are a very good example—and Dr. Apgar's and Dr. Ibsen's stories again good cases in point. Dr. Apgar when dealing with a just born baby in trouble: "Time is of the utmost importance. Delay is damaging to the infant. Act promptly, accurately and gently." going on to add: "Do what is right and do it now." "Nobody, but nobody is going to stop breathing on me." And Dr. Ibsen, when faced with his two-year-old daughter, blue and near dead on the couch: Crystal having aspirated oatmeal and stopped breathing—he rummaged in his doctor's coat pocket and pulled out: 'one of the suckers used by mid-wives for newborns...... I managed to get it down the trachea and soak up mucus and oatmeal and then spit it out again.' Crystal surviving the event. Ibsen getting there just in time. Having commandeered a Rigshopital Falck Ambulance; he had ordered the driver to drive as fast as he could across the Fredensbrø Bridge to their Solvgade home. x

The presented examples hopefully demonstrating that ultimately: Is there a right or wrong leadership style? is probably the wrong question— the question is rather whether the leadership styles applied by the leader provides effective leadership. The same effective leadership that the five pioneers of the transformation of anesthesia to anesthesiology demonstrated, despite their disparate leadership profiles—an evaluation of which will now be performed in a conclusive Leadership Reckoning.

Leadership in Anaesthesia

309

†

A Leadership Reckoning To compare the five pioneers described in this book we previously devolved a leadership skeleton comprised of seven key ingredients to successful leadership in a rubric entitled Creative LEADER. Composed of Creativity, Legitimacy, Emotional competence, Adaptability, Determination, Empathy and Resilience—we have used these elements in previous chapters to dissect out and lay bare the protagonists' successes or failures in order to create a putative leadership score for eventual comparison in this chapter. In deciding on the seven key ingredients to successful leadership for use in this comparative analysis we reviewed the current leadership literature and also relied heavily on C. Northcote Parkinson's earlier work. In this work, "The Law of Delay," a book written over half a century ago, Parkinson spelled out the six elements that he thought the art of leadership required: imagination (creativity), ability (legitimacy), personal magnetism (emotional competence), knowledge (adaptability to change), determination (determination), and ruthlessness (resilience), leaving out the seventh, empathy, that I have added in the leadership rubric, Creative LEADER here used for this analysis. (Parkinson 1970) These facts are presented here to persuade the reader that six of the seven elements used to assess the five pioneers' leadership profiles in this analysis, have, if nothing else, stood the test of time. †

+ +++

0 +++ +++ 0 +++ 12/21

Emotional Competence/Psychological makeup/Personality Adaptability to Change

Determination/Passion

Empathy

Resilience

Total Leadership Score

17/21

+++

+

+++

+++

0

Legitimacy/Authenticity/Credibility

+++

(1813-1858)

(1819-1868)

+++

John Snow

William Morton

8. A Leadership Reckoning

Creativity/Innovation/Imagination

Leadership Skeleton: Creative LEADER max score: +++, min score: 0.

310

16/21

+++

++

+++

+

+

+++

+++

(1883-1956)

Arthur Guedel

21/21

+++

+++

+++

+++

+++

+++

+++

(1909-1974)

Virginia Apgar

17/21

+++

+

+++

+++

++

++

+++

(1915-2007)

Bjørn Ibsen

Leadership in Anaesthesia

311

† Without a doubt, scoring each leadership ingredient from a knowledge of the pioneers' biographies—on a scale of zero to three—is a matter of opinion, arbitrary, and most assuredly open to significant criticism. But if this can be left aside, then there are some interesting observations to be had that I will use to conclude this chapter.

Firstly All five leaders witnessed undeniable Creativity, Determination, and Resilience—scoring 'three +' each across the board, suggesting that these three ingredients are essential to effective leadership. Creativity in a leader is paramount; without this, innovation will not take shape, and the constructive change that is the leader's prime responsibility, will not be achieved. (Hill et al. 2014) All five pioneers had this in spades. Dr. Morton was often creative with the truth; but his brilliance lay in his talent for promoting and publicizing practical anesthesia (and himself) to the world. Snow's creativity lay in his scientific ability. Having educated himself thoroughly, he set about researching safe anesthesia and helped solve the riddle of the origins of cholera; writing extensively on his findings in four books on the subject of anesthetics and the infectious disease. Dr. Guedel, although he had only a clawed right hand, was able to creatively design and craft new anesthesia equipment that would stand the test of time; while his writing would expand on Snow's, in simplifying even further—through close clinical observations—the safety of inhalational anesthesia administration, that would stand future anesthetists in good stead for safer practice. Dr. Apgar, not only created the APGAR Score, but beyond that shone a torch light on the needs of the 'well' newborn, and so birthed the medical discipline of perinatology. Dr. Ibsen created the first 'Observation Room,' a converted classroom where round the clock care was provided to critically sick patients, often needing ventilation to survive—in so doing inaugurating the first intensive care unit in the world.

312

8. A Leadership Reckoning

Determination too was crucial to each leader's success. Often driven by their backgrounds—for example, relentless poverty in Dr. Morton's case—the five pioneers never gave up and all worked incessantly; witness Snow and Guedel in their home laboratories, Apgar and her jetting around the world in her quest to eradicate birth defects, and Ibsen's tireless work efforts on behalf of his anesthesia department and intensive care unit. Resilience, the ability to rebound after a setback, was another striking ingredient to successful leadership. Often strengthened in the individual when the reversal is framed as a positive experience rather than a negative one, Dr. Morton should probably receive the prize for resilience in weathering the most misfortunes (often of his own making), but he was not at all alone in the matter. Guedel, losing three fingers at the age of 13, nevertheless triumphed; Apgar overcame many indignities and obstacles that women faced in the workplace of the time; and Ibsen overcame his disappointment of not achieving the Chairmanship at the Rigshospital by redoubling his efforts at the Kommunehospital, creating the Observation Room. While Snow (and the others) demonstrated another component of resilience; the ability to improvise—again and again adapting his tactics to solve the mystery of the deaths from cholera and chloroform.

Secondly The key ingredients of Legitimacy, Emotional Competence, Adaptability to Change, and Empathy varied widely—scoring 'three +' to '0'—in different individual leaders. Take Legitimacy. Here Dr. Morton got a '0'. Because he had none—being a confidence trickster and only a half-trained dentist—while the others did much better. Dr. Snow having trained diligently as a doctor and scientist 1 was considered the father of epidemiology; Dr. Guedel a trained physician had initiated the design of useful anesthetic equipment, and, Dr. Apgar, one of the first female anesthesiologists, had not only created the APGAR Score, but had initiated the field of perinatology—all scoring 'three +' in recognition of their legitimacy. In contrast, Dr. Ibsen notched only 'two +'. Although he was well trained as one of the first Danish Anesthesiologists and considered the 1

We would call Dr. Snow a physician-scientist today. Still a relatively rare individual today.

Leadership in Anaesthesia

313

"Father of Intensive Care," he did not hold any national or international leadership positions, like the others. And take Emotional Competence. Here we had the greatest variation amongst the leaders; consistent with the complex psychology that underpins leadership. Dr. Morton receiving a '0' for his hucksterism and his unstable erratic relationships; Dr. Snow and Dr. Guedel a '+'—John Snow for being an eccentric genius but a loner, and Arthur Guedel for his irascible, controversy seeking nature; being a person who fell in and out of relationships. Whereas Virginia Apgar shone: she was ever friendly, sociable, and always upbeat, earning a "three+', while Bjørn Ibsen received a 'two+', losing a '+' for the fracture that was created in his family life. Turning to Adaptability to Change, we see that all got 'three +'s' except for Dr. Arthur Guedel who got one '+'. Best explained by the fact that although Arthur was a leader of medical teams in his youth on the Western Front, he was passed over for Headship's of Departments later in life—he could not really change and adapt his clinical practice with the times, and often carped at others for the credit he thought he deserved—his leadership was thus not of men, but rested with the influence he exerted on the development of the specialty that he so dearly loved. Turning now to Empathy, the seventh 'body part' of the leadership skeleton we have used to dissect out the five pioneer's profiles; it should be recognized that 'Empathic Leadership' has only relatively recently found favor in the contemporary leadership literature, and so was added to the six elements previously described by C. Northcote Parkinson in his book "The Law of Delay" published over fifty years ago. With Empathy too we see great variability in scoring. Dr. Morton receiving '0' for his total lack of any; Dr. Snow only '+'—as "he was not the idol of the people in common practice"; Dr. Guedel just 'two +'—for he was generally sympathetic to another's plight and a good host; Dr. Apgar gained a full "three +"—as she exhibited well the feminine ability to celebrate group successes and bond followers together in common initiatives; while Dr. Ibsen received only a '+'—because although he celebrated team work, he encountered interpersonal problems in his family, was tendentious in nature, and often provoked others unnecessarily.

314

8. A Leadership Reckoning

And thirdly and finally The total leadership score was very different, in differing individuals: varying from 12/21 for Dr. Morton to 21/21 for Dr. Apgar— although each leader was nevertheless effective in diverse ways, suggesting that indeed: Leadership, like beauty, can manifest differently in different individuals and yet can flourish. †

NOTES & BIBLIOGRAPHY Book Cover Photograph The cover photograph was composed and taken by the author. It comprises: a human skull, various bottles, receptacles and devices used to both store and administer chloroform and ether; Dr. John Snow’s book on “The Inhalation of the Vapour of Ether," and one of Dr. Joseph Priestley's books describing the use of nitrous oxide: in short both the means to, and the potential deadly consequences of—the administration of anesthesia.

† Chapter 1 Credit for "An Eighteenth-century amputation scene in the men's operating theatre of old St Thomas's Hospital." This painting is property of the Royal College of Surgeons of England and held in the Hunterian Museum at Lincoln's Inn Fields, London. It's origins have been researched by the Rt. Hon. Lord Brock who ascertained that it was likely painted in 1774 as a 'press photograph' of a Polynesian Dignitary, named "Omai,'' to commemorate his visit to the St Thomas's operating theater to witness a surgical procedure; performed at the time without benefit of anesthesia. (Brock 1977) Permission to reproduce has been granted by the Royal College of Surgeons of England, 35-43, Lincoln's Inn Fields, London. England. Brock, L. 1977. "An Eighteenth-century amputation scene in the men's operating theatre of old St Thomas's Hospital." Annals of the Royal College of Surgeons 59:415-419.

†

316

Notes & Bibliography

Chapter 2 For the five Image Credits for the five pioneers' photographs, please see respective Chapter Notes. Amabile, T. M., and M. Khaire. 2008. "Creativity and the role of the leader." Harv Bus Rev 86 (10):100-9. Bartleby, A. 2018. "The fashion for agile managment is spreading." Economist July 7:51. Bennis, W.G. 1994. An Invented Life. New York: Basic Books. Bennis, WG, and B Nanus. 2003. Leaders. New York: Harper Collins. Clinton, R.J. 1992. A Short History of Modern Leadership Theory. Altadena, California: Barnabas Publishers. Collins, J. 2001. Good to Great. New York: Harper Collins Publishers. Coutu, D. L. 2002. "How resilience works." Harv Bus Rev 80 (5):46-50. Coutu, D. L. 2004. "Putting Leaders on the Couch." Harv Bus Rev January:1-8. Coutu, D. L. 2009. "Why Teams Don't Work." Harv Bus Rev May:1-8. Cuddy, A. J., M. Kohut, and J. Neffinger. 2013. "Connect, then lead." Harv Bus Rev 91 (7-8):54-61. Drucker, P. F. 1999. "Managing Oneself." Harv Bus Rev 77 (2):64-74. Drucker, P. F. 2004. "What makes an effective executive." Harv Bus Rev 82 (6):58-63. Frankl, V.E. 1984. Man's Search for Meaning. New York: Simon and Shuster Inc. Ghaemi, N. 2011. A First-Rate Madness. New York: Penguin. Goffee, R., and G. Jones. 2000. "Why should anyone be led by you?" Harv Bus Rev 78 (5):62-70. Goffee, R., and G. Jones. 2005. "Managing authenticity: the paradox of great leadership." Harv Bus Rev 83 (12):86-94. Goleman, D, R Boyatizis, and A McKee. 2001. "Primal Leadership." Harv Bus Rev December:43-51. Goleman, D, R Boyatizis, and A McKee. 2002. Primal Leadership. Realizing the power of emotional intelligence. Boston: Harvard Business School Press. Goleman, D. 2013. "The Focused Leader." Harv Bus Rev December:1-11. Goleman, D., and R. Boyatzis. 2008. "Social intelligence and the biology of leadership." Harv Bus Rev 86 (9):74-81, 136. Heifetz, R. A., and D. L. Laurie. 1997. "The work of leadership." Harv Bus Rev 75 (1):124-34.

Leadership in Anaesthesia

317

Heifetz, R. A., and M. Linsky. 2002a. Leadership on the Line; Staying Alive through the Dangers of Leading. Boston, Massachusetts: Harvard Business School Press. Heifetz, R. A., and M. Linsky. 2002b. "A Survival Guide for Leaders." Harv Bus Rev June:65-74. Hill, L. A., G. Brandeau, E. Truelove, and K. Lineback. 2014. "Collective genius." Harv Bus Rev 92 (6):94-102. Katzenbach, J. R., and D.K. Smith. 2002. The Wisdom of Teams. New York: Harper Collins. Kehoe, J. 2010. "How to Save Good Ideas: An interview with John P Kotter." Harv Bus Rev October:1-5. Kellerman, B. 2001. "Required Reading." Harv Bus Rev December:15-24. Kellerman, B. 2004. "Thinking about ... leadership. Warts and all." Harv Bus Rev January (1):40-45. Kellerman, B. 2007. "What every leader needs to know about followers." Harv Bus Rev 85 (12):84-91. Kelley, R.E. 1988. "In Praise of Followers." Harv Bus Rev Nov-Dec:141148. Kets de Vries, M. F. 2014. "Coaching the toxic leader." Harv Bus Rev April:1-11. Kotter, J.P. 2001. "What leaders really do." Harv Bus Rev December:8593. Kotter, JP. 1996. Leading change. Boston: Harvard Business School Press. Maccoby, M. 2000. "Narcissistic Leaders: the incredible pros, the inevitable cons." Harv Bus Rev Jan-Feb:69-77. MacGregor Burns, J. 1978. Leadership. New York: HarperCollins MacGregor Burns, J. 2003. Transforming Leadership. New York: Atlantic Monthly Press. McCullough, D., and F. Bronwin. 2008. "Timeless Leadership." Harv Bus Rev March:1-5. Mets, B. 2016. "Leadership in Academic Anesthesiology: Theories and Practice." Int Anesthesiol Clin 54 (3):66-82. Morse, G. 2004. "Executive Psychopaths." Harv Bus Rev October:1-2. Northouse, P.G. 2018. Leadership Theory and Practice. 8th Edition ed. London: SAGE Publications. Parkinson, C.N. 1958. Parkinson’s Law or the Pursuit of Progress. London: John Murray. Parkinson, C.N. 1970. The Law of Delay. London: John Murray. Pears, I. 1997. "The Gentleman and the Hero: Wellington and Napoleon in the Nineteenth Century." In Leadership, edited by K. Grint. Oxford: Oxford University Press.

318

Notes & Bibliography

Polelle, M.R. 2008. Leadership. Fifty Great Leaders and the Worlds They Made. Westport, Connecticut: Greenwood Press. Porter, M.E., and N. Nohria. 2018. "How CEO’s Manage Their Time." Harv Bus Rev July-Aug:1-15. Rigby, D.K., J. Sutherland, and A. Noble. 2018. "Agile at Scale." Harv Bus Rev May-June:88-96. Riordan, C.M. 2014. "Three Ways Leaders Can Listen with More Empathy." Harv Bus Rev January:1-3. Scemama, P. H., and J. W. Hull. 2012. "Developing leaders in anesthesiology: a practical framework." Anesthesiology 117 (3):651-6. Zaleznik, A. 2004. "Managers and leaders. Are they different?" Harv Bus Rev 82 (1):74-81. †

Chapter 3 Credit: Portrait of William T.G. Morton. R.S.M. Impression. Credit: Wellcome Collection. Attribution 4.0 International (CC By 4.0). Abbott, J. H. 1868. "The Discovery of Etherization." Atlantic Monthly XXI:718-25. Archer, W.H. 1944. "Life and Letters of Horace Wells Discoverer of Anesthesia." Journal of the American College of Dentists 11 (2). Bigelow, H.J. 1846. "Insensibility during surgical operations produced by inhalation." Boston Medical and Surgical Journal:310-16. Business, F. 2018. https://www.businessknowhow.com/startup/businessfailure.htm:Why Small Businesses Fail: Top 7 Reasons for Startup Failure. Clinton, R.J. 1992. A Short History of Modern Leadership Theory. Altadena, California: Barnabas Publishers. Coutu, D. L. 2004. "Putting Leaders on the Couch." Harv Bus Rev January:1-8. Fenster, J.M. 2001. Ether Day: The Strange Tale of America's Greatest Discovery and the Haunted Men who made it. New York: Harper Collinsville. Ghaemi, N. 2011. A First-Rate Madness. New York: Penguin. Green, R. 2018. The Laws of Human Nature. New York: Viking. Maccoby, M. 2000. "Narcissistic Leaders: the incredible pros, the inevitable cons." Harv Bus Rev Jan-Feb:69-77. Morse, G. 2004. "Executive Psychopaths." Harv Bus Rev October:1-2.

Leadership in Anaesthesia

319

Morton, W.T.G. 1847. Remarks on the Proper Mode of Administering Sulphuric Ether by Inhalation. Boston: Dutton and Wentworth, Printers. Osler, W. 1917. "The First Printed Documents Relating to Modern Surgical Anaesthesia." Annals of Medical History 1 (4):329-31. Perley Poore, B. 1856. Biography of W.T.G. Morton M.D. Discoverer of Etherization. With an Account of Anaesthesia. Washington: GS Gideon, Printer. Rice, N.P. 1859. Trials of a Public Benefactor. New York: Pudney and Russel. Vandam, L. D., and J. A. Abbott. 1984. "Edward Gilbert Abbott: enigmatic figure of the ether demonstration." N Engl J Med 311 (15):991-4. Wolf, R.J. 2001. Tarnished Idol. San Aselmo, California: Norman Publishing. Wolfe, R.J. 1993. Robert C Hinckley and the Recreation of The First Operation Under Ether. Boston, Massachusetts: The Boston Medical Library in the Francis A. Countway Library of Medicine. Woodward, G.S. 1962. The man who conquered pain. Boston: Beacon Press. †

Chapter 4 Credit: Portrait: John Snow, 1856. Credit: Wellcome Collection. Attribution 4.0 International (CC By 4.0). Anonymous. 1848. "Fatal application of chloroform (editorial)." Edinburgh Med Surg J 69:498. Buckingham, M., and M. Goodall. 2019. "The Feedback Fallacy." Harv Bus Rev March-April:92-101. Clinton, R.J. 1992. A Short History of Modern Leadership Theory. Altadena, California: Barnabas Publishers. Coutu, D. L. 2002. "How resilience works."Harv Bus Rev 80 (5):46-50. Editor, The. 1855. "The Public Health and Nuisances Removal Bill: Dr Snow’s Evidence." Lancet:634-5. Greene, N. M. 1975. Anesthesiology and the University. Great Britain: J.B. Lippincott. Heifetz, R. A., and M. Linsky. 2002a. "A Survival Guide for Leaders." Harv Bus Rev June:65-74. Heifetz, RA, and M Linsky. 2002b. "A survival guide for leaders." Harvard Business Review June:65-74.

320

Notes & Bibliography

Hewitt, FW. 1896. "The Past, Present and Future of Anaesthesia." British Medical Journal:347-356. Kouzes, J., and B. Posner. 2003. The Leadership Challenge. 3rd Edition. San Francisco: Jossey Bass. McNamara, J. 1923. "Ether Versus Chloroform." British Medical Journal June 9:996. Mets, B. 2018. Waking Up Safer? An Anesthesiologist’s Record. Bristol: Silverwood Books. Office, Worship Street Police. 1850. "Misuse of Chloroform." Annual Register 92:13-15. Richardson, B.W. 1858. Memoir of the Author: John Snow, Chloroform and Other Anaesthetics. London: John Chruchill. Robinson, J. 1847a. "Letter from Mr. J Robinson." Medical Times:273-4. Robinson, J. 1847b. A Treatise on the Inhalation of of the Vapour of Ether. London: Webster and Company. Shephard, D.A.E. 1995. John Snow. Anaesthetist to the Queen and Epidemiologist to a Nation. Cornwall, Prince Edward Island: York Point Publishing. Simpson, J.Y. 1847. "A New Anaesthetic Agent, More Efficient Than Sulphuric Ether." Lancet 2:549-50. Snow, J. 1838. "Arsenic as preservative of dead bodies." Lancet 39 (1):264. Snow, J. 1847a. "Observations on the Vapour of Ether, and its Application to Prevent Pain in Surgical Operations." Lancet (13 February):383-4. Snow, J. 1847b. On the Inhalation of the vapor of ether in surgical operations. London: John Churchill. Snow, J. 1849. On the Mode of Communication of Cholera. London: John Churchill. Snow, J. 1850. "The Alleged Employment of Chloroform by Thieves." London Medical Gazette XLI:327. Snow, J. 1853a. On Continuous Molecular Changes, More Particularly in Their Relation to Epidemic Diseases. Oration at Thatched House Tavern, St James Street: London. Snow, J. 1853b. "Thursday, 7th April." Case Books held at the Royal College of Physicians of London. Snow, J. 1858. On Chloroform and Other Anaesthetics. London: John Churchill. Snow, J. 1991. On narcotism by the inhalation of vapours. Edited by R.H. Ellis. London: Royal Society of Medicine. Snow, S.J. 2006. Operations without Pain: the Practice and Science of Anaesthesia in Victorian Britain. Hampshire: Palgrave MacMillan.

Leadership in Anaesthesia

321

Snow, S.J. 2009. Blessed days of Anaesthesia. Oxford: Oxford University Press. Stoll, B. J. 2019. "Reflections on Leadership: Seizing and Embracing Opportunities-Holding up Half the Sky." JAMA 321 (22):2165-2166. Vinten-Johansen, P., H. Brody, N. Paneth, S. Rachman, and M. Rip. 2003. Cholera, Chloroform, and the Science of Medicine. The life of John Snow. New York: Oxford University Press. Zaleznik, A. 2004. "Managers and leaders. Are they different?" Harv Bus Rev 82 (1):74-81. †

Chapter 5 Image of Dr. Arthur Guedel courtesy of the Wood LibraryMuseum of Anesthesiology, Schaumburg, Illinois. Ball, C. M. 2013. "The Foregger Midget: a machine that traveled." Anesthesiology 119 (5):1023-30. Baskett, T.F. 2004. "Arthur Guedel and the oropharyngeal airway." Resuscitation 63:3-5. Calmes, S. H. 2016. Who was Dr Arthur Guedel? Video Presentation Accessed. Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonovitz Library,University of California San Francisco. Calmes, S.H. 2002. "Two Men and their Dog: Ralph Waters, Arthur Guedel and the Dunked Dog “Airway”." Proceedings-The Ralph M. Waters International Symposium on Professionalism in Anesthesiology:37-43. Caton, D. 1997. "The Influence of Feminists on the Early Development of Obstetric Anesthesia." Bulletin of Anesthesia History. The Lewis Wright Memorial Lecture:4,5-23. Clinton, R.J. 1992. A Short History of Modern Leadership Theory. Altadena, California: Barnabas Publishers. Correspondence. 2019. "Sundry Letters and Correspondence Personally Accessed." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonovitz Library, University of California San Francisco. Courington, F. W., and R. K. Calverley. 1986. "Anesthesia on the Western Front: the Anglo-American experience of World War I." Anesthesiology 65 (6):642-53.

322

Notes & Bibliography

Foregger, R. 1996. "Richard von Foregger PhD. 1872-1960." Anesthesiology 84:190-200. Greene, N. M. 1975. Anesthesiology and the University. Great Britain: J.B. Lippincott. Griffith, H.R., and E.J. Johnson. 1942. "The use of curare in general anesthesia." Anesthesiology 3 (4):418-20. Guedel, A.E. 1918a. "Foreign Ether-Chloroform and Ethyl ChlorideAnesthetic Service." American Journal of Surgery: Anesthesia Supplement 32 (1):34-39. Guedel, A.E. 1918b. "Letter to the Editor." American Journal of Surgery 32 (12):309-10. Guedel, A.E. 1922. "Anesthesia." In A History of Base Hospital 32, edited by Benjamin D Hitz, 140-143. Indianapolis. Guedel, A.E. 1923. "Correspondence with Ralph Waters." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamanovitz Library, University of California San Francisco. Guedel, A.E. 1928a. "Letter to Ralph Water." April 4th. Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco. Guedel, A.E. 1928b. "Letter to Ralph Waters." April 7. Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco. Guedel, A.E. 1937. Inhalational Anesthesia; A Fundamental Guide. New York: The Macmillan Company. Guedel, A.E. 1952a. "Letter to Dr. Wesley Bourne." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco. Guedel, A.E. 1952b. "Some Errors in Anesthesia History." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco. Guedel, A.E., and D.N. Treweek. 1934. "Ether Apnoes." Anesth Analg November-December:263-4. Guedel, A.E., and R.M. Waters. 1928. "A New Intratracheal Catheter." Anesth Analg July-August:238-239. Guedel, F. 1956. "Letter to Dr John Lundy." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco. Heddy, WRH. 1918. "Anaesthetics in the Field." Journal of the Royal Army Medical Corps 31:76-79.

Leadership in Anaesthesia

323

Helen, M. 19—. Servant of Mankind. Unpublished, not dated, and unclaimed (author name not legible) incomplete biography: University of California San Francisco Archives and Special Collections. Judy, Letters. 1950. "Dear Florence and Art." University of California San Francisco Archives and Special Collections. Kehoe, J. 2010. "How to Save Good Ideas: An interview with John P Kotter." Harv Bus Rev October:1-5. Koch, B. E. 2015. "Surgeon-nurse anesthetist collaboration advanced surgery between 1889 and 1950." Anesth Analg 120 (3):653-62. Kovac, A. 2016. "Arthur Guedel World War 1 Militiary Service." Journal of Anesthesia History 2:112. Larson, M. 2006. "Arthur E. Guedel Memorial Anesthesia Center." Calif Soc Anesthesiol Bull Winter:77-80. Mani, N. 2016. "A Brief History of Oropharyngeal Airways Preceding Guedel’s Landmark Fourteen Lines." Journal of Anesthesia History 2:119. Marshall, G. 1918. "Anesthetics at a Casualty Clearing Station." American Journal of Surgery: Anesthesia Supplement 32 (4):61-62. Martin, R., S. Levin, T. Fink, and A. Levina. 2020. "Taming Complexity." Harv Bus Rev January-February:113-121. Northouse, P.G. 2018. Leadership Theory and Practice. 8th Edition ed. London: SAGE Publications. Reporter. 1911. "Local Physician Revolutionizes Obstetric Field. Familiar “Laughing Gas” Given New Application." Indianapolis Star, June 16. Scrapbook. 1956. "Scrapbook of Medical and Personal Memorablia." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamanovitz Library, University of California San Francisco. Snow, S.J. 2009. Blessed days of Anaesthesia. Oxford: Oxford University Press. Van Nest, R. L. 2006a. "The life and trial of Dagmar Nelson--Part 1." AANA J 74 (3):183-7. Van Nest, R. L. 2006b. "The life and trial of Dagmar Nelson--Part 2." AANA J 74 (4):261-5. Waters, R.M. 1952. "Eminent Anaesthetists." Brit J Anaesth 24:292-299. Waters, R.M., and A.E. Guedel. 2019. "Correspondence between Dr Guedel & Dr Waters." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco.

324

Notes & Bibliography

Waters, R.M., E.A. Rovenstine, and A.E. Guedel. 1933. "Endotracheal Anesthesia and Its Historical Development." Anesth Analg SeptOct:196-203. †

Chapter 6 Image of Dr. Virginia Apgar (aged 41 years), Courtesy of Mount Holyoke College Archives and Special Collections, South Hadley, Massachusetts. Apgar, V. 1942. "Continuous Spinal Anesthesia." Anesthesiology 3:522529. Apgar, V. 1953. "A proposal for a new method of evaluation of the newborn infant." Curr Res Anesth Analg 32 (4):260-7. Apgar, V. 1955. "The role of the anesthesiologist in reducing neonatal mortality." N Y State J Med 55 (16):2365-8. Apgar, V. 1962. "Untitled Notes dated: 3/2/62." Mount Holyoke Archives and Special Collections. Apgar, V. 1964. "Careers... In Anesthesiology." J Am Med Womens Assoc 19:675-80. Apgar, V. 1966. "Ginnygram.. to P.H. people and gas men everywhere." Wood Library Museum of Anesthesiology Virginia Apgar Collection. Apgar, V. 1968. "Mankind Making Progress Against Birth Defects." TimesHerald, January 28. Apgar, V., D. A. Holaday, L. S. James, C. E. Prince, and I. M. Weisbrot. 1957. "Comparison of regional and general anesthesia in obstetrics; with special reference to transmission of cyclopropane across the placenta." J Am Med Assoc 165 (17):2155-61. Apgar, V., D. A. Holaday, L. S. James, I. M. Weisbrot, and C. Berrien. 1958. "Evaluation of the newborn infant; second report." J Am Med Assoc 168 (15):1985-8. Baird, M., L. Daugherty, K. B. Kumar, and A. Arifkhanova. 2015. "Regional and Gender Differences and Trends in the Anesthesiologist Workforce." Anesthesiology 123 (5):997-1012. Beck, J. 1974. "Virginia Apgar, in memoriam." Archives and Special Collections Mount Holyoke College:xix-xxvii. Butterfield, J., and M.J. Covey. 1961. "Practical Epigram of the Apgar Score." Journal of the American Medical Association 181:353. BZ. 1974. "Ginnie Apgar Revisited." NYSSA Sphere July-August:20-22.

Leadership in Anaesthesia

325

Calmes, S. H. 1984. "Virginia Apgar: a woman physician's career in a developing specialty." J Am Med Womens Assoc 39 (6):184-8. Calmes, S. H. 1992. "Virginia Apgar, M.D. At the Forefront of Obstetric Anesthesia." ASA Newsletter 56 (10):9-12. Calmes, S. H. 1997. "And What About the Baby? Virginia Apgar and the Apgar Score." American Society of Anesthesiologists Newsletter 61:2022. Calmes, S. H. 2015. "Dr. Virginia Apgar and the Apgar Score: How the Apgar Score Came to Be." Anesth Analg 120 (5):1060-4. Census, Bureau. 1975. "Historical Statistics of the United States - Colonial Times to 1970." United States, Department of Commerce, Bureau of the Census.:49. Debendette, V. 2018. "Virginia Apgar, The Woman Whose Name Saves Newborns." Mental Floss Magazine Online Access: February 2020. Drage, J. S., C. Kennedy, H. Berendes, B. K. Schwarz, and W. Weiss. 1966. "The Apgar score as an index of infant morbidity. A report from the collaborative study of cerebral palsy." Dev Med Child Neurol 8 (2):1418. Eaton-Enochs, B. 1994. "Virginia Apgar: A Legend Becomes a Postage Stamp." P & S Journal:18-25. Finster, M., and M. Wood. 2005. "The Apgar score has survived the test of time." Anesthesiology 102 (4):855-7. Green, R. 2018. The Laws of Human Nature. New York: Viking. Greengold, M.C. 1968. "The Joint Peoples’ Commision on Accreditation of Hospitals." The New England Journal of Medicine 279:1060. Hardy, J. B. 2003. "The Collaborative Perinatal Project: lessons and legacy." Ann Epidemiol 13 (5):303-11. Hayden, G.F. 1977. "Current Status of Rubella in the United States." Journal of Infectious Disease 135 (February):337. Houston, J. 1974. Apgar Interview Transcript. Mount Holyoke Archives and Special Collections. Hudson, P.L. 1996. "Women in the Work Place."14-43. In Mount Holyoke Archives and Special Collections. Hunt, M. 2002. "Days to Remember." A Perennial Calendar. Dedicated to the Life and Times of Virginia Apgar. Columbia University Health Sciences. James, L. S. 1975. "Fond memories of Virginia Apgar." Pediatrics 55 (1):14. Mets, B. 2018. Waking Up Safer? An Anesthesiologist’s Record. Bristol: Silverwood Books.

326

Notes & Bibliography

Mets, B. 2020. Archival Material. In Mount Holyoke Archives and Special Collections. 50 College Street, South Hadley, M.A. Morishima, H. O. 1996. "Virginia Apgar (1909-1974)." J Pediatr 129 (5):768-70. Reports, Annual. 1938. "Department of Anesthesia Columbia University." Archives and Special Collections Mount Holyoke College. Senate, H. 1969. "Hearing Before the Subcommittee on Health." NinetyFirst Congress S 2264. Skolnick, A.A. 1996. "The Apgar Quartet Plays the Perinatologist's Instruments." JAMA 276:1939-40. Smith, C. R. 1974. "In Memoriam. Dr Virginia Apgar ‘29." Mount Holyoke Alumnae Quarterly 58 (3):178-9. Waters, R.M., and A.E. Guedel. 2019. "Correspondence between Dr. Guedel & Dr. Waters." Guedel Memorial Anesthesia Center Collection Archives and Special Collections: Kalamonowitz Library, University of California San Francisco. †

Chapter 7 Image Credit: Family Portrait of Bjørn Ibsen: with permission from Dr. Birgitte Bjørn Ibsen Willumsen and Dr. Thomas Ibsen. Andersen, E. W., and B. Ibsen. 1954. "The anaesthetic management of patients with poliomyelitis and respiratory paralysis." Br Med J 1 (4865):786-8.. Astrup, P., H. Gotzhe, and F. Neukirch. 1954. "Laboratory investigations during treatment of patients with poliomyelitis and respiratory paralysis." British Medical Journal April 3:780-6. Beecher, H. K., and D. P. Todd. 1954. "A study of the deaths associated with anesthesia and surgery: based on a study of 599,548 anesthesias in ten institutions 1948-1952, inclusive." Ann Surg 140 (1):2-35. Berthelsen, P. G. 2014. "Manual positive pressure ventilation and the Copenhagen poliomyelitis epidemic 1952: An attempt at setting the record straight." Acta Anaesthesiol Scand 58 (5):503-7. Berthelsen, P. G., and M. Cronqvist. 2003. "The first intensive care unit in the world: Copenhagen 1953." Acta Anaesthesiol Scand 47 (10):11905. Berthelsen, P. G., and J. Viby-Mogensen. 2007. "Bjørn Aage Ibsen (19152007): in Memoriam." Acta Anaesthesiol Scand 51:1292-1293.

Leadership in Anaesthesia

327

Betaenkning, 11. 1950. Afgivet Af Den Af Magistraten Under 28. Februar 1944 Nedsatte Hospitalskommission. Kobenhaven: J.H. Schultz Universitetsbogtrykkeri. Bjorneboe, M., B. Ibsen, and S. Johnsen. 1954. "Tetanus; a case treated with artificial respiration during 17 days." Dan Med Bull 1 (5):129-31. Bower, A. G., V. R. Bennett, J. B. Dillon, and B. Axelrod. 1950a. "Investigation on the care and treatment of poliomyelitis patients." Ann West Med Surg 4 (10):561-82. Bower, A. G., V. R. Bennett, J. B. Dillon, and B. Axelrod. 1950b. "Investigation on the care and treatment of poliomyelitis patients. II. Physiological studies of various treatment procedures and mechanical equipment." Ann West Med Surg 4 (11):686-716. Coutu, D. L. 2002. "How resilience works." Harv Bus Rev 80 (5):46-50. Coutu, D. L. 2004. "Putting Leaders on the Couch." Harv Bus Rev January:1-8. Engell, H. C., and B. Ibsen. 1952. "Continuous carbon dioxide measurement in the respiratory air during anaesthesia in thoracic operations." Acta Chir Scand 104 (4):313-28. Gallo, C. 2016. The Storyteller’s Secret. New York: St. Martin’s Press. Heifetz, R.A., and M. Linsky. 2002. "A survival guide for leaders." Harvard Business Review June:65-74. Ibsen, B. 1952. "The anaesthetist's viewpoint on the treatment of respiratory complications in poliomyelitis with special reference to the treatment of respiratory insufficiency." Proc Roy Soc Med 47:72-75. Ibsen, B. 1969. Causeri om alvorligt emne: Foredrag holdt i Kobenhavens Rotary Klub: NYT Nordisk Forlag Arnold Busck. Ibsen, B. 1975. "From Anaesthesia to Anaesthesiology. Personal experiences in Copenhagen during the past 25 years." Acta Anaesthesiol Scand Suppl 61:1-69. Ibsen, B. 1990. Gensyns-Glaede Translated from Danish using Google Translate by Shalini Maruthoti. Copenhagen Denmark: Bjørn Ibsen. Ibsen, B., and T. D. Kvittingen. 1958. "[Work in an anesthesiological observation unit]." Nord Med 60 (38):1349-55. Katzenbach, J. R., and D.K. Smith. 2002. The Wisdom of Teams. New York: Harper Collins. Kotter, J.P. 2001. "What leaders really do." Harvard Business Review December:85-93. Lassen, H. C. 1953. "A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen with special reference to the treatment of acute respiratory insufficiency." Lancet 1 (6749):37-41.

328

Notes & Bibliography

Lassen, H. C. 1954. "Poliomyelitis in Copenhagen, 1952." Glasgow Med J 35 (3):59-63. Lewis, M. C. 2007. "Ole Secher: a true hero of anesthesiology." Isr Med Assoc J 9 (3):215-6. Reisner-Selenar, L. 2006a. "Extracts from the Patient Record of Vivi E (1952)." Intensive Care Medicine; Online Resource 37:1084-86. Reisner-Selenar, L. 2006b. "Interview with Prof. Bjørn Ibsen." Intensive Care Medicine; Online Resource 37:1084-86. Reisner-Selenar, L. 2009. "The Danish anesthesiologist Björn Ibsen - a pioneer of long-term ventilation via the upper respiratory tract." Doctoral Degree Dissertation, Johann Wolfgang Goethe University. Secher, O. 1978. "The Department of Anaesthesia, Rigshospital. Personal views from 1953-78." Acta Anaesthesiol Scand Suppl 67:10-22. Severinghaus, J. W., P. Astrup, and J. F. Murray. 1998. "Blood gas analysis and critical care medicine." Am J Respir Crit Care Med 157 (4 Pt 2):S114-22. Stoll, B. J. 2019. "Reflections on Leadership: Seizing and Embracing Opportunities-Holding up Half the Sky." JAMA 321 (22):2165-2166. Sund Kristensen, H., and M. Lunding. 1978. "Two early Danish respirators designed for prolonged artificial ventilation." Acta Anaesthesiol Scand Suppl 67:96-105. Trubuhovich, R. V. 2003. "In the beginning. The 1952-1953 Danish epidemic of poliomyelitis and Bjørn Ibsen." Crit Care Resusc 5 (3):22730. Trubuhovich, R. V. 2004. "Further commentary on Denmark's 1952-53 poliomyelitis epidemic, especially regarding mortality; with a correction." Acta Anaesthesiol Scand 48 (10):1310-5. Vesalius, A. 1543. "De humani corporis fabrica." Wackers, G. L. 1994. "Modern anaesthesiological principles for bulbar polio: manual IPPR in the 1952 polio-epidemic in Copenhagen." Acta Anaesthesiol Scand 38 (5):420-31. Zorab, J. 2003. "The resuscitation greats. Bjørn Ibsen." Resuscitation 57 (1):3-9. †

Leadership in Anaesthesia

329

Chapter 8 For the five Image Credits for the five pioneers' photographs, please see respective Chapter Notes. Bennis, W.G. 1994. An Invented Life. New York: Basic Books. Campbell, A., J. Whitehead, and S. Finkelstein. 2009. "Why Good Leaders Make Bad Decisions." Harv Bus Rev February: 1-8. Clinton, R.J. 1992. A Short History of Modern Leadership Theory. Altadena, California: Barnabas Publishers. Coutu, D. L. 2004. "Putting Leaders on the Couch." Harv Bus Rev January:1-8. Ghaemi, N. 2011. A First-Rate Madness. New York: Penguin. Goffee, R., and G. Jones. 2000. "Why should anyone be led by you?" Harv Bus Rev 78 (5):62-70. Goleman, D., R. Boyatizis, and A McKee. 2001. "Primal Leadership." Harv Bus Rev December: 43-51. Goleman, D., R. Boyatizis, and A McKee. 2002. Primal Leadership. Realizing the power of emotional intelligence. Boston: Harvard Business School Press. Goleman, D., and R. Boyatzis. 2008. "Social intelligence and the biology of leadership." Harv Bus Rev 86 (9):74-81, 136. Green, R. 2018. The Laws of Human Nature. New York: Viking. Hill, L. A., G. Brandeau, E. Truelove, and K. Lineback. 2014. "Collective genius." Harv Bus Rev 92 (6):94-102. Houston, J. 1974. Apgar Interview Transcript. Mount Holyoke Archives and Special Collections. Hunt, M. 2002. "Days to Remember." A Perennial Calendar. Dedicated to the Life and Times of Virginia Apgar. Columbia University Health Sciences. Kellerman, B. 2001. "Required Reading." Harv Bus Rev December:15-24. Kotter, JP. 1996. Leading change. Boston: Harvard Business School Press. Macintosh, R.R. 1951. "Letter from Pembroke College Oxford." Northouse, P.G. 2018. Leadership Theory and Practice. 8th Edition ed. London: SAGE Publications. Parkinson, C.N. 1970. The Law of Delay. London: John Murray. Zaleznik, A. 2004. "Managers and leaders. Are they different?" Harv Bus Rev 82 (1):74-81. †