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Australian–American Collaboration Across Distance and Time

2015; Lippincott Williams & Wilkins; Volume: 121; Issue: 1 Linguagem: Inglês

10.1213/ane.0000000000000744

1526-7598

Christine Ball,

Anesthesia and Sedative Agents

It is certainly challenging to realize that the whole structure of modern surgery, a great part of medical practice and most laboratory research would go crashing into the abyss of oblivion if anesthesia were to be blotted from the world. Francis McMechan, MD Foreword to Practical Anesthesia, 19321 THE FOURTEENTH ANNUAL CONGRESS OF ANESTHETISTS, 1935 The Fourteenth Annual Congress of Anesthetists at the Hotel Chelsea, Atlantic City, NJ, promised to be a wonderful event. The Congress was to run over three and a half days from June 10 to 14, 1935. It offered a packed program with all the latest facilities: “A projector for lantern slides with daylight screen and projectors for 16 mm. and 35 mm. movie films with silver screen will be available...”2 The Con gress was to be opened by the founder of the International Anesthesia Research Society (IARS), Dr. Francis McMechan (1879–1939). The program was littered with famous names: John Lundy (1894–1973), Brian Sword (1899–1956), James Gwathmey (1862–1944), Harold Griffith (1894–1985). It even included an Australian anesthetist, Dr. Gilbert Troup (1896–1962), from Perth, the capital of Western Australia. He had traveled for thousands of miles over many weeks to present “Anesthesia in Australia with Special Reference to Some of Its Problems (Lantern Slide and Motion Picture Demonstration).”3 The Congress dinner in the Music Salon, Hotel Chelsea, was not to be missed: “Be sure and bring your ladies to enjoy this auspicious occasion and also invite your Surgeon and Specialist Friends and their Ladies to attend.” A note at the end added “Special honors will be bestowed for Meritorious Researches and Services to the Specialty.” The business minutes of the Congress note that these special honors included 3 “Silver Plaques of Recognition.” One was awarded to Sir Francis Shipway (1875–1968) of London, one to Dr. Gilbert Brown (1883–1960), President of the Australian Society of Anaesthetists, and the third to “the Anesthetic Staff of the Alfred Hospital, Melbourne, Australia, and the Baker Institute of Research for the splendid text on ‘Practical Anaesthesia.’”4 The 2 Australian plaques were accepted by Dr. Gilbert Troup on behalf of the recipients, packed carefully into his luggage and carried halfway around the world. He delivered them some months later at an auspicious meeting in Melbourne that had been advertised at the Congress. “During the Centennial of the founding of the City of Melbourne, the British Medical Association will hold a meeting in Melbourne in September, 1935 … Immediately following this meeting, a general meeting of the newly founded Australian Society of Anaesthetists will be held.” The plaques were handed over at this meeting to their recipients. Gilbert Brown’s plaque is now stored in the Australian Society of Anaesthetists archives. The plaque awarded to the staff of the Alfred Hospital and Baker Institute, apart from a brief mention in Gwen Wilson’s history of the Australian Society of Anaesthetists,5 had not been heard of since. A PLAQUE REDISCOVERED The archives of the Alfred Hospital in Melbourne are located in a dimly lit, rabbit warren of rooms in the brick subbasement, 2 stories below the ground, away from the howling ambulance sirens and the thrumming of the helicopter winding its way to the 21st-century trauma center. It is a place that time forgot; operating theater records from the 1870s sit on the shelves with ancient annual reports and medical student magazines. Recently, the archivist came across a plaque on these shelves. This is the plaque presented by the IARS to the anesthetists of the Alfred Hospital 80 years ago. It is a plaque that tells a story, a story of the early days of the specialty, the teaching of anesthesia, the development of research, and, above all, of international friendships and collaborations. FRANCIS MCMECHAN AND GEOFFREY KAYE The IARS was founded in 1925a by Francis McMechan to foster international research, collaboration, and publication in anesthesia.6 Despite being unable to work as a clinical anesthesiologist due to crippling rheumatoid arthritis, McMechan had a huge influence on the specialty, working tirelessly to achieve these goals.7 The young Australian anesthetist Geoffrey Kaye was greatly influenced by McMechan. Kaye met McMechan at a British Medical Association Congress in Sydney in 1929. Then a young man of 26, Kaye later said of the Congress: “Well, it changed the careers of all of us. The principle guest at that Congress was Francis Hoeffer McMechan … His arrival was absolutely electric. We found out from him that abroad there were places where anesthetists were expected to pay pre and post-operative visits to their patients, to chart their blood pressure, to keep proper operating records, and to know something about the basic sciences. It was obvious that if one wanted to become a serious anesthetist, one had to go overseas for it, and the place to go was North America.”8 Kaye presented a paper at the meeting on deaths due to anesthesia in Australia from 1919 to 1929. So impressed was McMechan that he offered to organize a trip to the United States for Kaye, putting him in touch with many anesthesiologists in North America and helping him with his itinerary. This was a generous offer, especially given that McMechan was already extremely ill and the trip to Australia was to leave him bed-ridden for 2 years. With McMechan’s introductions, Geoffrey Kaye traveled widely and met with specialists in Britain, Europe, and the United States. It was also largely due to the influence of Francis McMechan that Kaye was to help found the Australian Society of Anaesthetists and assist with the establishment of one of the first specialist qualifications in Australia, the Diploma of Anaesthesia at Melbourne University in 1946.9 The paper Geoffrey Kaye presented at the meeting in 1929 was an accident of history, an accident with far-reaching consequences. Kaye had compiled the paper with Fred Green (d. 1939), a senior Honorary Anesthetist at the Alfred Hospital. Honorary staff were unpaid, working at the public hospitals partly as a charitable service, and partly to make connections and grow their private practice. Green was to deliver the paper but suffered a myocardial infarction before the meeting, leaving his young protégé to present it. This paper not only attracted the attention of the visiting Francis McMechan, but also that of William Penfold (1875–1941), the Director of the Baker Institute of Medical Research, a research facility affiliated with the Alfred Hospital. Geoffrey Kaye, appointed to the Honorary Medical Staff at the Alfred, also had a research position at the Baker working in pharmacology, particularly with anesthetic agents.10 Penfold asked Kaye to be the organizing editor of the first in a series of monographs planned by the Institute. “His [Geoffrey Kaye’s] analysis of the available records showed that there had been unnecessary deaths and, in consequence, a saving of life was to be expected if a more thorough acquaintance with the modern practice of anesthesia could be secured by our young graduates.”1 The Baker Institute was committed to applying research to address the practical problems of clinical medicine.10 The monograph series was printed with this in mind. The first monograph was published “by means of donations and subscriptions received from members of the staff of the Hospital, and from the Board of Management, and one or two outside friends.”11 Practical Anaesthesia seems to have filled a need. The first print run of 1000 copies sold out within months, and a second set was printed the following year.10 It received very positive responses from the international press with enthusiastic reviews in the British Medical Journal, the British Journal of Anaesthesia, the Journal of the American Medical Association, the Journal of the Canadian Medical Association, and (of course) Anesthesia & Analgesia.11 The Board of Trustees of the Baker Institute retained copyright of the first monograph and controlled its distribution, promotion, and sales. Subsequent monographs were managed by publishers such as Messrs Churchill, of London, to assist with the escalating costs of printing and distribution. The monograph series, covering a wide range of topics, continued until the 1970s, running to 9 volumes in all. THE BOOK: PRACTICAL ANAESTHESIA Practical Anaesthesia was published in December 1932 and is a compilation of papers by the various honorary anesthetists at the Alfred Hospital (Fig. 1.). It was the first Australian textbook on anesthesia, reducing Australian’s reliance on textbooks from overseas (e.g., Gwathmey’s Anesthesia12 or various UK publications such as Hewitt’s,13 Boyle’s,14 or Gardner’s15). The papers in Practical Anaesthesia were intentionally didactic, aimed at the junior doctor who might be called upon to administer an anesthetic “during his term of service at the hospital or in his early years of general practice.”1 The intention was to teach simple, safe anesthesia and avoid techniques that were not routinely used at the hospital or were regarded as more suited to the specialist anesthetist. Each author was an expert in his or her area, unusual at a time when few in Australia were proficient in anything but the most basic anesthesia.Figure 1: Front page of Practical Anaesthesia.The authors were 7 anesthetists and one surgeon. Unfortunately, none of the 17 chapters have author acknowledgements, making it difficult to establish who was responsible for which chapter. The authors are in alphabetical order. Geoffrey Kaye gets no special treatment, despite being the editor. The book is attributed only to “The Anaesthetic Staff of the Alfred Hospital” and dedicated appropriately to “Edward Henry Embley (1861–1924), a pioneer of Australian Anaesthetic Research.” Edward Embley was an anesthetist and researcher at the Royal Melbourne Hospital who established that chloroform toxicity was based on its cardiac effects, not its respiratory effects.16 The foreword of Practical Anaesthesia is written by Francis McMechan. The chapter topics reflect the scope of anesthesia at the time: preoperative assessment and medication, a chapter on each of the common anesthetic agents (ethyl chloride, ether, chloroform, and the gaseous anesthetics), accidents, endotracheal anesthesia, and chapters on regional and local anesthesia. Basal narcosis, dental anesthesia, and midwifery supplement the list. The book concludes with a chapter on deaths during anesthesia, Kaye’s special interest. Today, this book is a treasure trove of history. It is illustrated with 70 line drawings and black-and-white photographs. It provides invaluable information about the use of equipment displayed today in museums, like Shipway’s apparatus, the Kelly Mott machine, and Junker’s chloroform apparatus. It contains advice from another era, such as the suggestion that the patient who is required to be prone for the operation should be secured comfortably in that position before the induction of anesthesia: “To alter materially the position of an anaesthetized patient is very difficult and involves the production of a good deal of shock.”1 But much in the book remains of relevance today. It is, as advertised, a practical guide to anesthesia with sound advice, some of which had apparently been forgotten until recent times: “…all patients should receive at least an ounce of glucose two hours before operation.” The authors are a mixed group. Some became very famous. Others are barely traceable. Geoffrey Kaye is probably the best known, and his history has been described in detail elsewhere9 (Fig. 2). He made an enormous contribution to Australian anesthesia, organizing the specialty, promoting education and research, and presenting many significant papers. His legacy is preserved at the Australian and New Zealand College of Anaesthetists in the Geoffrey Kaye Museum of Anaesthetic History, now one of the most significant historical collections of anesthetic equipment in the world.Figure 2: Geoffrey Kaye administering anesthesia. Photograph from Practical Anaesthesia (courtesy of the Geoffrey Kaye Museum of Anaesthetic History).The first listed author of Practical Anaesthesia, Adam Gibson Brydon (1877–1953), resigned from the hospital in 1930, stating his regret but saying that unforeseen circumstances required him to return to Armidale in New South Wales and resume General Practice. At this time, Brydon was 53 years old and one of the few doctors in Australia with an MD by thesis. Little was known of Brydon until recently when his thesis was uncovered in the archives at the Australian Society of Anaesthetists. This 27-page thesis was submitted for an MD at Edinburgh University and is entitled “Anaesthesia in War Surgery.”17 Brydon had extensive experience of anesthesia during World War I and was proficient with most methods of administration of anesthesia and resuscitation. Interestingly, he independently received a medal from the IARS in 1937, presumably for his thesis. Neither the medal, now in the possession of his family, or the IARS archives record the details of this award. Little is known of 2 of the authors, Bruce Hallows (1899–1976) and Newport White (1870–1938). Both were honorary anesthetists at the Alfred and members of the Australian Society of Anaesthetists. There is one letter in the archives of the Australian and New Zealand College of Anaesthetists from Bruce Hallows which, oddly enough, relates to the plaque. Written in 1974 to Tess Brophy, then Dean of the Faculty of Anesthetists at the Royal Australasian College of Surgeons, the missive records that the plaque was “still hanging in the Honories’ room at the Alfred Hospital.” This is its last known location, indicating it was on display for some decades. Leonard Lillies (1885–1965) was one of the 7 founding members of the Australian Society of Anaesthetists, with Geoffrey Kaye and others at the Hadley Hotel in Hobart in 1934. Lillies introduced ethylene anesthesia into Australia and contributed to the chapter on gaseous anesthetics in the book.5 He remained on the honorary staff of the Alfred Hospital until 1946 but, like many of his generation, his interest in anesthesia waned when the war was over and a younger group of doctors returned to Melbourne. Newer techniques and a more scientific approach to anesthesia alienated many founding specialists who chose to retire after the war rather than adapt to the new methods. Only one woman appears on the list of authors. Dr. Marjorie Hughes (1898–1995) was a Foundation Fellow of the Faculty of Anaesthetists at the Royal Australasian College of Surgeons, and held a Diploma of Anaesthesia. She had honorary appointments at the Alfred, Prince Henry’s, the Eye and Ear Hospital, and the Queen Victoria Hospital. She traveled extensively to India, Europe, England, and the United States. Her small archival file at the Australian and New Zealand College of Anaesthetists contains a letter to the Commonwealth Bank, which she required to obtain foreign currency. Her frequent travels led to a paper at the Australian Society of Anaesthetists meeting in 1949 relating to postanesthetic observation rooms, something she had experienced in the United States and Canada. Her paper emphasized problems repeatedly encountered in Australia due to the lack of adequate recovery facilities.18,19 Of course, at the time of writing Practical Anaesthesia in 1932, no such facilities were available anywhere and patients were recovered in either the ward or a corridor adjacent to the operating room. The final anesthetist involved in the book was of great significance to Australian anesthesia. Douglas Renton (1899–1969) was never in good health. A ruptured appendix early in his career left him with a legacy of adhesions, operations, pain, and anxiety.20,21 Like McMechan, despite ongoing disability, he had a lengthy and productive career. After the war, he became increasingly politically active. A strong believer in education and training, he was an examiner for the Diploma of Anaesthesia in Melbourne. He became the President of the Australian Society of Anaesthetists in 1949 and was among those responsible for the formation of the Faculty of Anaesthetists in 1952. As first Dean of the Faculty, he was able to influence the uniformity of training and certification in Australia. He had a long clinical association with the Alfred Hospital, as well as a career in private practice. One of the first Australian anesthetists to become salaried, when the hospital changed its system of remuneration in the late 1940s, Renton became the anesthetist to the neurosurgical unit, continuing his working relationship with the head of neurosurgery, Mr. Hugh Trumble (1894–1962). The inclusion of a surgeon on the list of authors is interesting. This was a collaborative work, and attitudes were changing: “Most surgeons are coming to realize that the anaesthetist is not so much a necessary evil as a helpful collaborator and an essential part of the operating team.”1 Wisely, the book also states “Tact and consideration should never be forgotten. When the surgeon is in obvious difficulties and is concentrating his every faculty on the problem before him, it is not only unwise, but grossly unfair, to distract him by a comment on the patient’s condition.” Mr. Balcombe Quick (1883–1969) seems to have been a good choice for this collaboration, selected presumably because he was the Senior Surgeon to the hospital and a member of the Board of the Baker Institute. Following his involvement in World War I as a surgeon at the Australian Casualty Clearing Station in Rouen, Quick had a very successful career at the Alfred. He was a lecturer at Melbourne University and a founding member of the Royal Australasian College of Surgeons where he served on the Council and later as Treasurer. He was highly regarded by his colleagues and students and “sartorially impeccable down to his spats, he spoke with precision and wrote concisely.”22 THE PLAQUE The plaque itself is silver coated, mounted on a polished wooden board bearing the mark of the silversmith, Wallace, on the back (Fig. 3). The names of the authors and the Director of the Baker Institute are inscribed on the plaque. The rest of the inscription reads:Figure 3: The plaque awarded to the anesthetists at the Alfred Hospital by the International Anesthesia Research Society (postrestoration).AS A TOKEN OF RECOGNITION AND APPRECIATION FOR SPLENDID ACHIEVEMENTS IN FOSTERING RESEARCH, EXTENDING TEACHING, DEVELOPING THE PRACTICE AND ORGANIZING THE SPECIALTY OF ANESTHESIA AND ANALGESIA. ALSO FOR THE PREPARATION AND PUBLICATION OF THE MERITORIOUS CURRENT TEXTBOOK OF “PRACTICAL ANESTHESIA” FOR THE WORLD CONQUEST OF PAIN ON BEHALF OF SUFFERING HUMANITY. PRESENTED BY THE INTERNATIONAL ANESTHESIA RESEARCH SOCIETY JUNE 12 1935 The plaque itself and the inscription are ringed in leaves. The seal of the IARS is displayed in relief at the top of the plaque, complete with the robed lady holding a lamp and a branch of leaves, and the owl ringed by the sun atop a pile of books. The plaque, when discovered, was pitted and tarnished, in need of restoration. It has now been restored and will be displayed in the Department of Anaesthesia and Perioperative Medicine at the Alfred Hospital. From the outset, the IARS awarded prizes for significant achievements at its annual meetings: medallions, scrolls of recognition, plaques, and a few “loving cups” for particularly meritorious service. McMechan himself was awarded a loving cup by the Society on its 15th anniversary in 1937, an award he was not present to receive due to his increasing frailty.23Practical Anesthesia was a great achievement. It fulfilled all the requirements for an award, promoting education and collaborating with the research unit at the Baker Institute. It was not surpassed until the next Australian textbook, also edited by Kaye, Anaesthetic Methods in 1946.24 It is unfortunate that Kaye was not present when the plaque was presented. He had been at the dinner a few years earlier and attended again in 1937 when McMechan spoke to him privately: “There is going to be a European war, a global war … you should go to Australia and do what you can … do everything in your power to keep international anesthetists together. We shall not meet again because long before you can return to the United States, I shall be dead.”8 By this time, McMechan was extremely disabled, confined to a wheelchair, and unable to care for himself. His ongoing involvement in anesthetic activities was due only to the extraordinary care provided by his wife, Laurette, who was his constant companion.7 Shortly after this conversation, McMechan indeed died. Kaye later stated “Anything I set out to do after that was an attempt to carry out the spirit of McMechan’s order.”8 THE LEGACY OF GEOFFREY KAYE AND FRANCIS MCMECHAN Geoffrey Kaye and Francis McMechan witnessed the immediate success of their endeavors but would be astonished at their legacy. The IARS has contributed nearly $15 million in grants since its foundation, with $1.3 million available in 2015. It currently has a worldwide membership of over 15,000 physicians, physician residents, and others with doctoral degrees.b It continues to publish Anesthesia and Analgesia on a monthly basis, as well as the new clinical companion journal, A&A Case Reports, published semimonthly. The Australian Society of Anaesthetists is now one of the largest medical associations in Australia, representing specialist anesthetist physicians, as well as registrar trainees and nonspecialist medical practitioner anesthetists. It publishes the monthly journal Anaesthesia and Intensive Care and the monthly magazine for members, Australian Anaesthetist. It also runs a major national meeting once a year with invited international speakers. THE DEPARTMENT OF ANAESTHESIA AND PERIOPERATIVE MEDICINE, ALFRED HOSPITAL Under the direction of Professor Paul Myles, the Department of Anaesthesia and Perioperative Medicine at the Alfred Hospital is a significant contributor to the world of anesthesia research, leading many multicenter international trials including B-Aware,25 ENIGMA,26 ATACAS,27 ENIGMA-II,27 and RELIEF, as well as collaborating on the Canadian POISE,28 POISE 2,29 and METS. The association with the Baker Institute continues. Recently, a joint project led by Dr. Christopher Bain, “Analysis of the impact of pre-existing differential DNS methylation on inflammatory gene expression and the inflammatory response to major abdominal surgery,” was approved and funded, with Dr. Bain winning the Harry Daly Research Award at the Australian and New Zealand College of Anaesthetists for the best research grant application. Coincidentally, another book is nearing completion. Edited by 4 members of the department, it is a collaboration among over a hundred anesthetists, physicians, and surgeons. Once again, it is a practical guide for junior doctors, this time on the subject of perioperative medicine. With many embedded videos in the eBook version, it will be an invaluable reference now, and an extraordinary historical resource in 80 years time.30 2095 In another 80 years, the specialty will be heading into a new century. We will all be long gone. However, the plaque will still exist, dusty, and possibly in need of further restoration. It may be hanging on a wall, buried under papers, or hiding in a museum cabinet. Hopefully, it will draw the attention of a young perioperative physician/anesthesiologist who will ponder its past, and reflect that whatever we have achieved as individuals or departments, we have not done it alone. We have done it with the collaboration of colleagues from around the world. We have built on the foundation of those who went before us. History teaches us that our labors now, our short-term goals and successes with their attendant frustrations and heartache, may have far greater and more wonderful consequences than we could ever imagine. DISCLOSURES Name: Christine M. Ball, MB BS (Hons), MD, FANZCA. Contribution: This author designed the study, conducted the study, and wrote the manuscript. Attestation: Christine M. Ball approved the final manuscript. This manuscript was handled by: Steven L. Shafer, MD. ACKNOWLEDGMENTS The author would like to thank Peter Frawley, BA, Grad Dip (Pub Pol), Archivist, Alfred Hospital; Samantha Hamilton, BA, BApp Sci, Object Conservator; Fraser Faithfull, BA (Hons), Grad Dip (Info Management), MA (Appl Hist), Archivist, ANZCA; Laura Foley, BA (LIS), AALIA, Manager, Knowledge Resources, ANZCA; Monica Cronin, BA, Grad Cert Musm Stud., Grad Dip Musm Stud, Curator, Geoffrey Kaye Museum of Anaesthetic History; Sophie Wallace, MPH, Research Manager, Department of Anaesthesia and Perioperative Medicine, Alfred Hospital; and the staff of the Wood Library-Museum of Anesthesiology (American Society of Anesthesiologists, Schaumburg, Illinois): Director and Head Librarian Karen R. Bieterman, MLIS; Collections Supervisor Judith A. Robins, MA; Senior Library Assistant Margaret M Jenkins; Archivist Felicia A. Reilly, MALS; Librarian Teresa Jimenez, MS LIS.