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Henry Cabot Lodge (1850-1924) wrote in the gilded age of the1890's:

I was taught in my youth, and vigorously taught, that it was not goodmanners to discuss physical ailments in general society.... I now hearsurgical operations, physical functions, disease and its remedies, freelyand fully discussed at dinner and on all other occasions by the ingenuousyouth of both sexes.'

Offended as were the New England sensibilities of persons ofLodge's cultivation, it was to be admitted that medical science,and particularly surgery, was at last something to talk about.

The leadership came from the German surgeons. They not onlywere the first to develop sound principles of asepsis in surgery butthey also emphasized the importance of a knowledge of chemistryand physics as a starting point in the approach to medical problems.Therefore, to Germany went a host of American students to discoverhow it was done. The application of these principles, particularlythose of asepsis, had a phenomenal effect, which Mettler describedas follows:

[The] numerous advances which pathology and physiology had accum-ulated formed a great storehouse of information against which surgerywas suddenly able to draw, once the aseptic principle had been mastered.The rapid progress which was then made was really a process of passivepropulsion and many men of mediocre merit, carried along by theobvious and irresistible indications of pathology, physiology, and in-ternal medicine, found themselves famous overnight.2

1Beard, Charles A., and Beard, Mary R.: The Rise of American Civilization, NewYork, Macmillan, 1947, vol. 2, p. 389.

2Mettler, Cecilia C.: History of Medicine, Philadelphia, Blakiston, 1947, p. 890.

47

48 History of Anesthesia

Effects were also apparent elsewhere. With the multiplication ofsurgical procedures, surgeons increased their demands for moreoperating rooms. Operations that formerly were unsafe in the hos-pital now became comparatively unsafe in the home, and hospitalconstruction to support aseptic surgery and commercial enterpriseto supply instruments, sterilizers and other equipment flourished.

In 1888 a ward with operating room attached

was built [at the Massachusetts General Hospital] for clean cases ofabdominal and head surgery, and was the first building erected in thecountry for aseptic surgery alone. No doctor, nurse or student, who hadthe slightest infection of any kind, or even so much as a scratch uponthe skin, was allowed to remain in the ward, or to cross the thresholdof the amphitheatre. Here, asepsis reigned supreme. 3

In 1892, at ceremonies after the remodeling of the PhiladelphiaHospital, Roland G. Curtin described what had suddenly becomepasse:

The old amphitheatre or operating room, which stood between thewalls that now surround us, was not up to the requirements of modernscience. It was unsafe for operations; it was dark and poorly ventilated.... The post-mortem room and dead house, where all the germ-exhalingbodies were carried after death... opened into a hall that communicateddirectly with the old operating room. 4

The new surgery, combined with the new knowledge of otherpractical aspects of bacteriology, stimulated organized efforts to setstandards of education and service in all phases of medical care.It is hardly a matter of coincidence that there were founded theAmerican Society of Superintendents of Training Schools for Nurses(1893), the Nurses' Associated Alumnae of the United States andCanada (1896) and the Association of Hospital Superintendents(1899), and that the American Medical Association was reorganized(1901) within a little more than a decade after the introduction of

asepsis.

Swept along with these developments, the hospital nurse and thepublic health nurse began to surpass in importance the nurse doinghome nursing, and in the hospital an expansion of nursing func-

3Myers, Grace W.: History of the Massachusetts General Hospital, Boston, Griffith-Stillings Press, 1929, pp. 98-99.

4 Lawrence, Charles: History of the Philadelphia Almshouses and Hospitals, Phila-delphia, Charles Lawrence, 1905, pp. 339-340.

From Ether Cone to Esmarch Mask 49

tion took place rapidly. In 1892 the surgical staff at the Massachu-

setts General Hospital recommended "that a nurse be on duty

in the Amphitheatre throughout the day, and for the care of the

surgical dressings," and, in 1899, at the same hospital,

[permission] was given, for the first time, for head nurses to give hypo-

dermic injections in case of need... upon the written request of the

house officer in charge.5

Results of operations being no longer confused by septic deaths,

attention turned rapidly to the abuses in the administration of anes-

thesia. Several excerpts will suffice to show how anesthesia was

"done."

The patient was anaesthetized by being placed on the table, a broad

leather strap passed over the abdomen and another one over the legs,

both tightly belted to the table. The narcotizer having prepared a cone

made of a newspaper, stuffed it with either cotton or cheesecloth on

which he had poured the entire contents of a 100-gram can of ether.

Placing a towel over the patient's eyes, he slipped the cone over the

patient's mouth and nose, then motioned to the orderly and nurse

who were standing by to throw their weight on the arms and legs of

the victim and the battle was on. The patient struggled, the concentra-

tion of the anaesthetic induced spasm, and in the middle of the fight the

poor victim crowed like a rooster with an attack of whooping cough.6

The ether cone [was] made from a section of the "Morning World"

and a towel, [and in the presence of] the alcohol lamp, the naked red

hot Paquelin cautery, the open gas jets . . . the anesthetist [poured]

ether ignorant of any explosion except perhaps from the surgeon.7

The room had been prepared and the space for visitors roped off.

The patient was placed on the table in the correct posture. The anes-

thesia was managed by a member of the House Staff with the barbaric

open ether inhaler. At the slightest sign of reaction the ether was pushed

almost to the drowning point. Everything in readiness, Munde, stripped

to the waist, except for a short-sleeved thin undershirt far from con-

cealing his splendid torso, his trousers covered by a rubber apron,

entered the arena under the ropes, the veritable picture of a superb

prizefighter.8

During the period of antisepsis there had been harbingers of

what was to come. In 1882, speaking of the obligations and the respon-

5Myers, Grace W.: op. cit., pp. 122, 173.6The Story of Lenox Hill Hospital, New York, 1947, p. 29.

7Stuart, George R.: A History of St. Vincent's Hospital in New York City, New York,

1938, p. 32.8The Story of the First Fifty Years of the Mount Sinai Hospital, 1852-1902, New

York, 1944, p. 79.


sibilities of an anesthetist, F. D. Weisse declared to the Medico-LegalSociety of New York:

an administrator of any anaesthetic should, to a certain extent, beresponsible in the selection of his patients. If he is not a physiciancapable of judging as to the [patient's] condition . . , he should requirea certificate from the patient's family physician, of fitness to take ananaesthetic.... The reckless manner in which ... [nitrous oxide] is dailygiven in our city is but another evidence of the laxity of our laws, inprotecting the community from those unqualified to administer rem-edial agents to the human organism.... My sole object will be attainedif I succeed in intimidating some of the many who administer anaes-thetics, especially nitrous oxide gas.... Had I the power to make andenforce law, I would make a law forbidding the administration of anyanaesthetic, except by or in the presence of a regular graduated doctorof medicine or dental surgeon. The majority of those who are todaygiving nitrous oxide are mere amateurs... who understand but littleof the practice and less of the theory of anaesthesia.9

Then, during the 1890's came a flood of complaints, in Britainwhere the specialist physician anesthetizer claimed status, as wellas in the United States where the duty in most hospitals was assignedto a medical student or intern and where in rural practice it wasanybody's job or that of a general practitioner.* In 1892, W. M. L.Coplin wrote:

We now come to the consideration of the anaesthetizer. There is adecided tendency among the older members of the profession to havea medical student administer the anaesthetic, or it may be a young graduatewho is called upon to assume the responsibility. For my part, .. . I shouldprefer that the student do the operation and that the surgeon administerthe anaesthetic.... The man who gives an anaesthetic should do thatand absolutely nothing else. He cannot see the operation.O

9 Weisse, F. D.: The obligations and responsibility of an administrator of an anaes-thetic, Papers read before the Medico-Legal Society of New York, 2nd series, NewYork, W. F. Vanden Houten, 1882, pp. 144-160.

1oCoplin, W. M. L.: Some practical suggestions for the guidance of those who admin-ister anaesthetics, and for those who have anaesthetics administered, Therap. Gaz.8:370, 1892.

*A popular story told of Charles H. Mayo illustrates the point: During the early1880's an accident occurred which resulted in his becoming anesthetist to his father,W. W. Mayo. The occasion was one on which a doctor well known in Rochester,Minn., fainted while administering an anesthetic for Dr. Mayo, and Charlie, whoattended his father when he made calls and performed operations, stood on a crackerbox and finished the job. (Clapesattle, Helen: The Doctors Mayo, Minneapolis, Univ.Minnesota Press, 1941, pp. 175, 176.)


In 1893 an anesthetist of the time was described in this way:

He arrives late with everyone waiting and produces cumbersome

equipment. He starts the anesthetic, pushing the ether until the patient

starts coughing; then he pushes more ether until it is necessary to use

artificial respiration. And then the patient vomits. Finally all is going

well again and the operation begins. The anesthetist becomes so en-

grossed in the operation that the patient shows signs of asphyxiationrequiring resuscitation again, and finally the anesthetist finds he has

no battery at hand, or having one on hand, it is not in order, so no

faradic stimulation can be given.11

An editorial in the Denver Medical Times for 1894 commented

in the same vein:

The deaths from anaesthetics in Denver, so far as we have been able

to learn, were due in the majority of instances, to the bungling and

improper way in which it was administered, rather than to the anaes-

thetic itself.... A certain doctor in Denver, a well known and reputable

physician doing a large practice, said to the writer not long since when

discussing the remuneration of a physician who had given an anaes-thetic, "Oh, five dollars is enough for him, too much, in fact, for anyonecan give ether." 12

In the Medical Record for 1894, reference was made to a scheme

that permitted the anesthetizer to exact fees without attending the

patient throughout the course of anesthesia:

In closing we cannot refrain from alluding to a dangerous practice

which we have noticed in some hospitals, that of allowing a nurse to

hold the ether-cone while another patient is being anaesthetized. This

is a dangerous custom (to which we plead guilty), and in the event of

medico-legal investigations would be extremely difficult to justify in a

court of law. As a fact, considerable stress was placed upon this point

in the case of Dr. Mary Dixon-Jones vs. the Brooklyn Eagle.13

And from England:

Although the present state of our knowledge leaves much to be de-

sired, we may, I think, congratulate ourselves upon the advances which

have been made during recent years.... With all these additions to our

storehouse of knowledge the question may well be asked "Why do not

deaths from anaesthetics show signs of diminution?" The reply is that

the responsibilities involved in administering anaesthetics are not yet

llMiel, quoted by Stein, Hermann B.: Anesthesia in Colorado in the nineteenth

century, Rocky Mountain M.J. 44:805, 1947.

l2Death from anaesthetics in Colorado, Denver M. Times 14:219, 1894.

18A plea for public anaesthetizers, M. Rec. 46:239, 1894.


fully realised; that the administration is too often placed in the handsof comparatively unskilled men.1 4

[Even] in these modern days the aid of a nurse or the surgery porteris sometimes thought ample and sufficient.15

The British Medical Journal summarized the situation in 1901:

For years past the profession in general has been acutely aware that,for surgical anaesthesia, it is advantageous to have an administrator ofsuch large experience as to make him more or less a specialist.... Theannual death-roll from surgical anaesthesia is an increasing one. Thenumber of deaths registered as due to anaesthetics in England and Walesis now more than double what it amounted to ten years ago.16

In their totality the criticisms were destructive and the recom-mendations unpromising of fruitful results. The "ideal," the edu-cated specialist physician anesthetist, even in England where thespecialist anesthetist was an accepted figure in the medical scene,could not be realized for the same reasons that it failed to obtainin the United States:* (1) the subordinate position necessarily as-sumed by the anesthetist, (2) the more lucrative and distinguishingsituations open in other phases of medical practice to the man un-handicapped by poor health or psychologic adjustment, (3) thelimitations of practice in any but large urban centers and (4) thelow remuneration for any but the extremely skillful person withgood connections. As is still being discovered, a poor substitutewas the general practitioner whose mediocre supervised experiencewas limited to his hospital days, when his concentration as he poured

14 Hewitt, F. W.: The past, present, and future of anaesthesia, Practitioner 57:347,1896.

15Sheild, Marmaduke: The need for better instruction in the administration of anaes-thetics, Practitioner 57:387, 1896.

16The method of surgical anaesthesia, Brit. M. J. 1:655, 1901.*Perhaps the first physician specialist in anesthesia in the United States was Thomas

L. Bennett. According to a history of St. Margaret's Hospital in Kansas City: "Anaes-thetics as a supervised department at St. Margaret's Hospital began in the year 1894.During the next three years the first anaesthetist, Dr. Thos. L. Bennett, carried outexperiments with the then anaesthetic agents commonly used, viz.; chloroform, ether,and mixtures of these with alcohol. During the time Dr. Bennett was anaesthetist heinvented and perfected the Bennett apparatus for ether administration." (St. Mar-garet's Hospital, Kansas City, Kans., 1887-1937, p. 37.) Bennett went from Kansas Cityto New York City where, according to the annual report of the New York Hospital,he was anesthetist to that hospital during 1898, 1899 and 1900; according to the annualreport of the New York Mt. Sinai Hospital he received a similar appointment to thathospital in 1905.

In 1897 W. Oakley Hermance was appointed instructor in the administration ofanesthetics at the Philadelphia Polyclinic and anesthetizer at the Polyclinic Hospital.(M. Rec. 51:522, 1897.)


ether was more often on the field of operation than on the patient,where it should have been. The poorest substitute was the medicalstudent or house officer while he was getting this experience. As un-satisfactory as were the administrators of general anesthesia,* noless unsatisfactory were the methods commonly used in the UnitedStates-the barbaric cone and the far from perfect technics and ap-paratus for administering nitrous oxide as well as the volatileagents.t

The apparent need was for anesthetists who would (1) be satisfiedwith the subordinate role that the work required, (2) make anes-

thesia their one absorbing interest, (3) not look on the situation of

anesthetist as one that put them in a position to watch and learnfrom the surgeon's technic, (4) accept comparatively low pay and(5) have the natural aptitude and intelligence to develop a high

level of skill in providing the smooth anesthesia and relaxation that

the surgeon demanded. Long before the furor about the disgraceof anesthesia in the 1890's, such anesthetists had been quietly goingabout their business, and from among their numbers a new methodof general anesthesia was to receive its greatest impetus.

With no fuss and perhaps totally unaware of the controversyraging about physicians and physicians-to-be as anesthetists, certain

*In addition to general anesthesia, other forms were being developed and admin-istered by surgeons by the end of the nineteenth century.

In 1873 Alexander Bennett studied the pharmacologic properties of cocaine-analkaloid of coca leaves obtained in pure form in 1860 by Albert Niemann-, and in

1879 it was introduced as an anesthetic by Vasili Konstantinovich Anrep (1852-c.1918).In 1884 Carl Koller (1857-1944) reported on the value of cocaine for local anesthesiaof the eye. In 1885 William Stewart Halsted (1852-1922) introduced nerve block anes-

thesia with cocaine, and that same year it was used by James Leonard Corning (1855-

1923) as a spinal anesthetic. (Bennett, Alexander: An experimental inquiry into the

physiological actions of cocaine, Edinburgh M.J. 19:323, 1873; Anrep, V. K.: Ueber die

physiologische Wirkung des Cocain, Pfluger's Arch. f.d.ges. Physiol. 21:38, 1880; Koller,

Carl: Ueber die Verwendung des Cocain zur anasthesirung am Auge, Wien. med.

Wchnschr. 7:1352, 1884; Halsted, W. S.: Practical comments on the use and abuse

of cocaine; suggested by its invariably successful employment in more than a thousand

minor surgical operations, New York M.J. 42:294, 1885; Corning, J. L.: Spinal anaes-

thesia and local medication of the cord, New York M.J. 42:483, 1885.)

tIn reintroducing nitrous oxide as a dental anesthetic in the early 1860's, Coltonhad believed that 100 per cent of the gas had to be used to obtain adequate anesthesia.Most physicians accepted this belief, although, in 1868, Edmund Andrews had recom-

mended the use of oxygen with nitrous oxide, and during the early 1880's, the experi-

ments of Paul Bert (1833-1886) had shown that oxygen could and should be added

to nitrous oxide to prevent asphyxia. However, the mixture was used by S. Klikowitschof St. Petersburg in 1881, by Viennese and German dentists, and, during the late

1880's and early 1890's, by F. W. Hewitt in England. (Duncum, Barbara M.: The De-

velopment of Inhalation Anaesthesia, London, Oxford, 1947, pp. 34-35, 363.)


surgeons in the United States had accepted in this capacity a classof persons for whom they had learned to have deserved respect andfrom whom they had obtained commendable assistance and service-the Catholic hospital Sister.

In 1877 Sister Mary Bernard, who, in 1888, founded the Sistersof St. Joseph of Wichita, entered St. Vincent's Hospital in Erie, Pa.,to take up nursing and within the year was called upon to assumethe duties of anesthetist.17

Several years before, the groundwork had been laid for a similarservice to be offered surgeons in the Midwest. In November, 1875,two Sisters of the Third Order of the Hospital Sisters of St. Francisfrom Muenster, Germany, journeyed from a community in Alton,Ill., to Springfield, where after living several months with the Ursu-line Sisters they moved into a little house and did visiting nursing.This small community of Franciscan Sisters prospered, and in 1878they were able to lay the cornerstone for St. John's Hospital, whichwas dedicated on June 22, 1879. There, in 1880, the administrationof chloroform and ether was taught by the surgeons to Sister AldonzaEltrich (1860-1920), a frail nun who did lace work when not oc-cupied with anesthesia. Also, that year Sister Vanossa Woenke(1861- ) was trained as an anesthetist.

During the 1880's other Sisters from this same community wereassigned to serve as anesthetists at St. John's Hospital and at otherhospitals managed by the Order throughout the Midwest:* in 1884Sister Julitta Grimming (1861-1924); in 1885 Sister Cassiana Lueke(1843-1926) and Sister Meinulpha Dahloff (1855-1900); in 1886Sister Secundina Mindrup (1868-1951), Sister Archangela Ost-heimer (1864-1944) and Sister Silveria Vogt (1864-1941); in 1888Sister Eutychiana Freese (1864-1911) and Sister Sigwina Bultmann(1862-1925); in 1889 Sister Scholastica Schlautmann (1866- ).Sister Secundina, (see Fig. 5) so named because when first broughtto the convent she was only 12 and played with dolls and had tobe sent home again, relates how she became an anesthetist: "The

17Mother Superior of the Sisters of St. Joseph of Wichita: Personal communication.*Between 1884 and 1888 the Missouri Pacific Railroad established five hospitals for

its employees in which the Hospital Sisters of the Third Order of St. Francis wereengaged to perform nursing service: St. Luke's in Decatur, Ill.; St. Ann's in Peru,Ind.; St. Luke's in Springfield, Ill.; St. Peter's in Independence, Mo.; and St. Patrick'sin Kansas City, Mo. (One Hundred Years Franciscan Pioneering: Springfield, HospitalSisters of St. Francis, 1944, p. 30.)


doctors would come with their assistants to give the anesthesia, butthen they would need the assistant for something else and would teachthe Sister how to give the anesthesia." Sister Secundina devised herown method for judging when more ether or chloroform or alcohol-chloroform-ether mixture should be given-a decade of prayers onher rosary and it was time to give a little more. In an apron withtwo split pockets she carried everything that anyone in the hospitalmight want, and in one of the pockets she secreted a bottle of chloro-form. This she quietly and judiciously used to supplement the etheranesthesia when the surgeon required more relaxation.18, 19, 20

Other Sisters from the Third Order of the Hospital Sisters of St.Francis became anesthetists during the 1890's: in 1890 Sister Law-rence Niehoff (1864- ); in 1891 Sister Alexia Dieckhaus (1869-1944) and Sister Gregoria Gerding (1870- ); in 1896 Sister Steph-ana Miller (1873-1922), Sister Praxedes McBride (1874- ) andSister Euphrasia Glandorf (1874- ); in 1897 Sister Marka Rieffert(1871-1922); in 1898 Sister Dematria Peters (1876- ); in 1899Sister Nicola Boismeune (1876-1924) and Sister Obdulia Luecke(1875-1949). Sister Lawrence first assisted at operations by helpingto hold the instruments; she was taught to give anesthetics whena physician who came from Litchfield, Ill., to perform this serviceexpressed a desire to learn more about surgery. When the occasiondemanded, Sister Lawrence would put two patients to sleep at once.Placed with their heads together, first one and then the other wouldbe anesthetized, and then she would sit on a stool between the twoheads and watch them both.21

In 1886, from another community of the Sisters of St. Francis, atSyracuse, N. Y., Sister Mary Cyrilla Erhard traveled to Hawaii andthe following year was established at the Malulani Hospital, Wai-luku, Maui, where for 42 years she administered anesthesia in con-nection with her nursing duties.22

These records, fragmentary as they are, not only give a glimpseof what was undoubtedly a prevailing practice in many Catholichospitals but also show the beginning of a trend. Even more frag-

18Mother Magdalene: Personal communication.19Sister Securia: Personal communication.20Sister Secundina: Personal communication.21Sister Scholastica: Personal communication; Sister Lawrence: Personal communica-

tion; Sister Vanossa: Personal communication.22Mother Mary Carmela: Personal communication.


mentary are the records of nurses' administering anesthesia in layhospitals, the practice of putting the anesthetist's name in the casebook or on the patient's chart being unheard of until the twentiethcentury. However, from the history of the Augustana HospitalSchool of Nursing, Chicago, we learn that in 1885 Lotta Frejd, thematron, "When necessary . . . acted as cook, laundress, anesthetist,janitress, and carried patients up and down stairs."23

At still another hospital organized by the Sisters of St. Francis,that in Rochester, Minn., the lay nurse anesthetist was to gain na-tional recognition. In 1883 Mother Alfred, the Mother Superiorof the Rochester Community, approached William Worrell Mayo(1819-1911), the versatile country physician whose two sons, CharlesHorace (1865-1939) and William James (1861-1939), reached thepinnacle of international fame during the golden age of surgeryafter asepsis, with the proposition that the Sisters would erect a hos-pital if he would take charge of it. The hospital was opened onOctober 1, 1889, with 13 patients, 3 surgeons (William W., WilliamJ. and Charles H. Mayo) and 5 Sisters (Sister Hyacinth, Sister Con-stantine, Sister Sylvester, Sister Sienna and Sister Sidelis). EdithGraham (1871-1943) was put in temporary charge of the nursingstaff. She was a Rochester girl, whose mother was a practical nurseand midwife. Edith, with her sister, Dinah (1860-1947), graduatedfrom the School of Nursing at the Woman's Hospital in Chicagoto become the first trained nurses in town. However, within a fewweeks, the Sisters took over all the nursing as well as the housekeep-ing tasks, and Edith and Dinah Graham engaged in the work forwhich they were variously employed during the early years of thehospital. At St. Mary's Hospital it was not the Sisters but these twograduate nurses who, from the beginning, administered the anes-thesia, in addition to acting as the Mayos' office nurse, general book-keeper and secretary. The Mayos saw no reason why an intelligentnurse should not make an able anesthetist, and William W. Mayoundertook their instruction. (See Figs. 6-11.)

Dinah Graham gave anesthetics for only a short time, leavingEdith to carry on alone until her marriage to Charles H. Mayo in1893. It was Edith's successor, Alice Magaw (1860-1928), who

23Schjolberg, Amy 0.: A History of the Augustana Hospital School of Nursing,1884-1938, Chicago, The Alumnae Association of the Augustana Hospital School ofNursing, 1939, p. 5.


brought to the profession of nurse anesthetist as well as to the Mayo

Clinic no little fame at a time when poor anesthesia was the major

worry of most surgeons. Alice Magaw, whose family was in the

grocery business in Rochester and who was a good friend of Edith

Graham's, followed her example and took a course in nursing at the

Woman's Hospital in Chicago. While there she also received special

instruction in the use of the microscope in order that she might

help with the examination of pathologic specimens. She returned to

Rochester and in March, 1893, took over Edith Graham's duties as

anesthetist. (See Fig. 12.)Early in its history St. Mary's Hospital became a gathering place

for surgeons who went there for the purpose of observing operations

performed with the outstanding skill of the Mayo surgeons. And

while they saw impressive surgical work, they saw something else

that provided a subject for thought and conversation when they got

home: anesthesia, beautifully conducted by a method that satisfied

the demands of the surgeons while providing the ultimate in com-

fort and safety for the patient. This was Alice Magaw's technic of

open-drop chloroform and ether anesthesia.*

About 1860 James Young Simpson began to use a single layer

of towel held puffed out into a fan shape and laid lightly over the

patient's nose and mouth, on which chloroform was not poured,

but dropped. In 1862 Thomas Skinner, obstetric physician to the

dispensaries in Liverpool, published an account of a similar method.

This was to drop chloroform from a specially adapted bottle onto a

small wire frame covered with domette (a wool and cotton fabric)

and held over the patient's face. The bottle had a drop tube attach-

ment and "at no single inversion ... [could] more than thirty or

less than ten minims escape until it . . . [was reinverted]." On the

Continent, particularly in Germany, Skinner's mask was used fre-

quently. An important Continental modification of Skinner's mask

was the simplified version devised about 1879 by the German mili-

tary surgeon, Johannes Friedrich August von Esmarch (1823-1908) .24

24Duncum, Barbara M.: op. cit., pp. 13, 247, 251.

*In the 1870's O. H. Allis' ether inhaler was introduced into American anesthesia

to replace the cone method. The inhaler consisted of an oval metal slotted frame,

which gave it a fencelike appearance, and through these slots bandage was woven

back and forth, and the whole encased in a cover, open top and bottom. While it was

designed to allow free access of air, the dead space in this inhaler prevented it from

being classed as an open-drop inhaler in the generally accepted sense of the term.

Ether was poured on it from a drop bottle. (Duncum, Barbara M.: op. cit., pp. 352, 353.)


In the United States one of the first to use the open-drop methodfor administering not only chloroform but also ether was G. N.Kreider, the German surgeon who taught the Sisters at St. John'sHospital in Springfield, 111.25 Another was James E. Moore (1852-1918) of Minneapolis, who, in 1885, went abroad and brought homewith him from Germany an anesthetizer skilled in the use of chloro-form by the drop method.26 From this anesthetizer the surgeons

FIG. 2. Esmarch's mask.

of the district, including the Mayos, learned this technic of chloro-form anesthesia. The popularization of the method was the workof L. H. Prince of the Augustana Hospital in Chicago. In 1895,according to Prince, chloroform at the Augustana Hospital wasgiven by the drop method, an Esmarch mask being used, while etherwas still given by cone.2 7 In 1897 Prince stated that for two yearshe had been using the Esmarch mask for drop-ether anesthesia andwas having a larger mask made.28

Whether the technic of the open-drop method of anesthesia forboth chloroform and ether, as used by Alice Magaw at St. Mary's

2 5Sister Secundina: Personal communication.2 6Littig, Lawrence W.: Anesthesia fatalities in Iowa, Tr. West. Surg. & Gynec. Soc.

17:133, 1907.27 Prince, L. H.: Observations in five hundred consecutive anesthesias in the service

of Dr. A. J. Ochsner at the Augustana Hospital, Chicago M. Rec. 8:365, 1895.2 8 Prince, L. H.: Technic of administration of chloroform and ether, Chicago M.Rec. 12:232, 1897.


Hospital, originated with James Moore of Minneapolis or came

through the close association of the Mayos with Albert John Ochsner

(1858-1925) at the Augustana Hospital in Chicago is debatable.*

However, the results were not. In 1900 Alice Magaw was able to

report on 1,092 cases of anesthesia for which she used the Esmarch

mask with two thicknesses of stockinette; she had both ether and

chloroform ready to give, whichever was indicated by the condition

of the patient. Six hundred and seventy-four operations were per-

formed with ether, 245 with chloroform and 173 with a mixture

of the two, without an accident, the need for artificial respiration

or the occurrence of pneumonia or any serious results.29 By 1904

the total had grown to 1,000t and by 1906 to over 14,000 without

a death directly attributable to the anesthesia.3 0 Nor was it for insig-

nificant operations that these anesthesias were administered. By

1904 surgery at St. Mary's Hospital had risen to such an ascendancy

that only 14 patients were treated medically during the year. Of the

3,131 operations performed by the Mayos, "twenty-five were on the

cranium, 165 on the eye, 215 on the face, 135 on the neck, forty-

eight on the breast, twenty-seven on the chest, twenty-four on the back,

29Magaw, Alice: Observations on 1092 cases of anesthesia from Jan. 1, 1899 to Jan.

1, 1900, St. Paul M.J. 2:306, 1900.SOMagaw, Alice: A review of over fourteen thousand surgical anaesthesias, Surg.,

Gynec. & Obst. 3:795, 1906.*James E. Moore, Minneapolis: "In 1885 I went abroad, and stopped at Berlin and

found them there using Esmarch's inhaler. I brought some of these inhalers home,

and also brought home with me from abroad an anesthetizer skilled in the use of

chloroform by the drop method, which I introduced into the City of Minneapolis and

the Northwest." (Littig, Lawrence W.: loc. cit.)

James' E. Moore, Minneapolis: "[Miss Magaw] . . . gives me credit for having

brought to this country the drop method. I never made any claim to that credit.

In 1885 I went to Germany, and while there I had an extensive experience that I

could not have had here.... [From Berlin] I brought that man with me in 1886,

and he remained here nearly a year. He gave my anesthetics, and I was pleased to

loan him all about. I wrote this up for publication, and Dr. Mayo says he learned the

use of the drop method from that...." (Magaw, Alice: Observations drawn from an

experience of eleven thousand anesthesias, Tr. Minn. M.A. pp. 91-102, 1904.)

"During the past six years I have acted as anaesthetist in the service of the Drs. Mayo,

at St. Mary's Hospital. In a general way the anaesthesia has been conducted under the

direction of Dr. A. W. Stinchfield, or, in his absence, by Dr. Christopher Graham ....

[We] finally fell into the use of the Esmarch mask and drop method introduced in

the Augustana Hospital by Dr. L. H. Prince in the service of Dr. Ochsner." (Magaw,

Alice: Observations in anaesthesia, Northwest. Lancet 19:207, 1899.)

t"It is needless to say that ether is, and has been, our preference at St. Mary's Hos-

pital. In 1902 out of 1,852 anesthesias, 1,511 were ether, and in 1903 we gave 2,091

anesthesias, and 1,771 were ether, out of which number 1,234 were given by the author."

(Magaw, Alice: Observations drawn from an experience of eleven thousand anesthesias,

Tr. Minn. M.A. pp. 91-102, 1904.)


104 on the rectum, 153 on the male genital organs, 287 in the field ofminor gynecology, twenty-one (miscellaneous) on the trunk, fifteenwere amputations, eight were treatment of fractures, fifty-five were onthe joints, twenty-five on bones, 108 (miscellaneous) on the extremi-ties, 171 on the stomach and first portion of the duodenum, 572 on theintestines, 308 on the liver and gallbladder, 206 on hernias, 117 onthe ovaries and tubes, 169 on the uterus, and twenty-four were miscel-laneous intraperitoneal; in all 1,567 intraperitoneal operations and121 extraperitoneal operations on the urinary organs, making a totalof 1,688 abdominal operations."3'

A comparison of this listing with that of Edmund Andrews but30 years before indicates the magnitude of the change that hadtaken place in surgery (see Chap. 3, p. 42).

The Mayos' use of nurses as anesthetists spread by word ofmouth, and, before long, testimonials began to appear in the medi-cal literature.*

3lSketch of the History of the Mayo Clinic and the Mayo Foundation, Philadelphia,Saunders, 1926, p. 19.

*In 1900 the Mayos began looking for someone who could act as anesthetist forCharles H. Mayo-he had shared the services of Alice Magaw with William J. Mayoup to that time-and who also could take over the examination of the pathologic speci-mens. For this combination of duties a graduate in medicine was required, and, throughA. J. Ochsner, the Mayos obtained Isabella Herb, a young woman who had made a spe-cial study of anesthesia at the Augustana Hospital in Chicago the year before. In 1904Dr. Herb made a trip to Europe, and Florence Henderson was hired to replace her.Florence Henderson entered nursing after a trial of school teaching and was graduatedfrom the Bishop Clarkson Hospital School of Nursing in Omaha in 1900. As superin-tendent of nurses at that hospital from 1900 to 1903, she gained some experience in theadministration of chloroform and ether. In 1903 she resigned, and in response to a letterfrom the chief surgeon of the hospital to a number of surgeons recommending her fora position, she received an offer from the Mayos to become Charles H. Mayo's anesthetist.She went to work in Rochester on December 1, 1903.

Mary E. Hines (1871- ), who was added to the anesthesia staff in 1905, was a nativeof Rochester and a graduate of the School of Nursing at the State Hospital outside thetown where the Mayos operated. Mary Hines was trained by Alice Magaw and becameWilliam J. Mayo's anesthetist when Miss Magaw married Dr. George Kessel.

As the Mayo Clinic grew and more operating rooms were added at St. Mary's Hos-pital, the system of having a nurse anesthetist for each operating room developed,all the anesthetists working at the hospital in the morning and at clerical duties in theclinic for the rest of the day. In 1905 a third operating room was opened with E. StarrJudd (1878-1935) as junior surgeon in charge. In 1911 Emil H. Beckman (1872-1916)was put in charge of the fourth operating room as general surgeon. During this time,Mary L. Shortner (1883- ), a graduate of the St. Mary's Hospital School of Nursing,was trained as an anesthetist by Mary Hines and was added to the anesthesia staff in1909. Anne Powderly (1880- ), a graduate of the Mercy Hospital School of Nursing,Chicago, also was taken on as an anesthetist during that year. (See Fig. 13.)

A section on regional anesthesia was started by Louis G. Labat, a French physician,who, in 1920, was appointed special lecturer in regional anesthesia for one year. He


James E. Moore, Minneapolis:

Had I Miss Magaw or Dr. Roberts to administer it I would not care

what anesthetic was used.3 2

Lawrence W. Littig, Iowa City, Iowa:

Many of us have had the pleasure and privilege of seeing that peerless

anesthetist, Alice Magaw, and also Miss Henderson, who anesthetizes

for Dr. Charles Mayo, "talk their patients to sleep," and we have been

charmed and instructed by the manner in which these ladies do their

work. The lessons they have taught, and are teaching, practitioners

have been carried far and wide, and practiced by men throughout Iowa

and many other states.3 3

S. Griffith Davis, Baltimore:

About a year and a half ago I first saw the drop method, during a

visit to St. Mary's Hospital in Rochester, Minn., where it was so skill-

fully administered by Miss Alice Magaw and her assistant. Later I

again was impressed with its merits by seeing it used at the Mercy Hos-

pital in Chicago, where it was equally well administered by a Sister of

Charity. 34 *

was succeeded by William R. Meeker, who in turn was succeeded by John S. Lundy

(1894- ) in 1924.By 1926, to meet the growth in the surgical staff and the number of operating rooms,

the anesthesia staff numbered 18 nurse anesthetists with John S. Lundy as head of the

Section on Regional Anesthesia. (Clapesattle, Helen: op. cit.; Sketch of the History

of the Mayo Clinic and the Mayo Foundation; Henderson, Florence: Personal communi-

cation; Shortner, Mary: Personal communication.)

32Magaw, Alice: Observations drawn from an experience of eleven thousand anes-

thesias, Tr. Minn. M.A. pp. 91-102, 1904.

33Littig, Lawrence W.: loc. cit.

34Davis, S. Griffith: The administration of ether by the drop method, Maryland M.J.

50:171, 1907.*A false impression is given in Barbara Duncum's Development of Inhalation Anaes-

thesia (p. 594) with respect to S. Griffith Davis. Using reference 34 as authority, she

stated: "Among the first hospitals to adopt open ether was St. Mary's Hospital, Roches-

ter, Min. [sic] (the Mayo Clinic), where S. G. Davis was the chief exponent of the

method." And in referring to an article by Francis W. Bailey on "An open method of

ether administration" in the British Medical Journal (2:1823, 1907), she wrote (p. 595):

"In 1906 the Annual Meeting of the British Medical Association was held in Toronto.

A number of members (perhaps at the invitation of W. J. Mayo who, as President

of the American Medical Association, attended the Toronto meeting) took the oppor-

tunity of visiting the Mayo Clinic at Rochester, Minnesota. There they saw S. G. Davis

anaesthetizing with ether by the open-drop method." We quote from the article:

"Those members of the Association who visited the Mayos' Hospital in Rochester

when at the annual meeting last year, have seen the method adopted, it is said, in every

case; but I must confess I myself would not apply it in every case, because I do not

think it suitable to all the different types of patients one meets with here in England."


Edward H. Ochsner (1868- ), Chicago:

The trouble does not come so much from the anaesthetic as fromthe anaesthetist.... This lack of mortality [at the Mayo Clinic] is dueto the fact that they have competent anaesthetists. We must learn thatthe giving of an anaesthetic is as important work as that of the chiefsurgical nurse, and almost, if not quite as important, as that of the oper-ator himself.... No one would think of pressing any undergraduate nurseor medical student into service as a surgical nurse, and yet this is justexactly what is done in most clinics with reference to the anaesthetist.3 5

Alexander Brownlee, England:

Miss Alice Magaw, an American lady anaesthetist, records 14,000 casesof ether administered by the drop method "without a death directly dueto the anaesthetic," and I am indebted to Mr. Lynn Thomas, who sawher practising it, for my initial instruction in it.36

J. Lynn Thomas, England:

The first time I saw the method used was at the hospital of thebrothers Mayo, of Rochester, Minnesota; subsequently, I saw it employedin Dr. Ochner's [sic] practice.3 7

Not only did the surgeons who went to watch the Mayos oper-ate profit by the exemplary method of anesthesia used, but, also,many of them sent selected nurses to Rochester to observe AliceMagaw and the other nurse anesthetists at St. Mary's Hospital attheir work. Sometimes these nurses stayed for 2 or 3 monthsand learned to give ether under supervision. Again and again inour account of other nurse anesthetists we shall have occasionto refer to their having visited the Mayo Clinic for this expresspurpose.*

Meanwhile, independently of the example being set at the MayoClinic, other institutions found the solution to the problem ofreforming anesthesia in training nurses for the work.

3 5 Royster, H. A.: Scopolamine-morphine-ethyl-chloride-ether anaesthesia, Tr. South.Surg. & Gynec. A. (1905) 18:282, 1906.

3 6 Brownlee, Alexander: An open continuous drop method of administering ether,Brit. M.J. 2:1824, 1907.

37Ibid.*"I trained a number of nurses to give ether, from different hospitals but cannot

recall the names of many of them. Among them were the first two nurses to becomeanesthetists at the Presbyterian Hospital, New York, one from Philadelphia, Seattle,Denver, a missionary nurse from China, Miss Armstrong from the Charity Hospital,New Orleans, Miss Thomas from Lynchburg, Virginia." (Henderson, Florence: Per-sonal communication.)


At the Mercy Hospital in Chicago, Sister Mary Ethelreda

O'Dwyer (1864- ) from Bausha, Tipperary, learned from the

illustrious surgeon John Benjamin Murphy (1857-1916) how to

drop ether in 1891, and the skill of this Sister of Mercy with the

open-drop technic brought fame to the Mercy Hospital as Alice

Magaw's skill had brought fame to the Mayo Clinic.3 8

In 1891 Sister Peter Chrysologus Crevier of the Sisters of Charity

of Montreal began to give anesthetics at the Providence Hospital

in Seattle. Other Sisters of the Order also took up the work during

the last decade of the nineteenth century: In 1896 Sister Andrew

Moreau (d. 1945) at St. Vincent's Hospital, Portland, Ore.; in 1896

Sister Emery Lalonde (d. 1943) at St. Patrick's Hospital, Missoula,Mont.; in 1897 Sister Mary Vincent Brown (d. 1933) at St. Mary's

Hospital, Astoria, Ore.; in 1898 Sister Oswald Dorion (d. 1919) at

St. Patrick's Hospital, Missoula, Mont.; and in 1899 Sister Mary Greg-

ory Jutras (d. 1945) at Sacred Heart Hospital, Spokane, Wash.3 9

From the Order of the Sisters of Mercy of Baltimore, the first

to be assigned to anesthesia was Sister Mary Celestine Doyle

(d. 1944), who, in 1893, began her work at the Mercy Hospital

in Baltimore.40 In 1896 at St. Joseph's Hospital in Denver, Sister

Mary Gonzaga O'Connell (d. 1939) of the Sisters of Charity of

Leavenworth took up her duties as anesthetist.41 That same year

Sister Mary Ignatius Kerns (d. 1919) of the Sisters of Mercy of

Chicago began to give anesthetics at the Mercy Hospital in Daven-

port, Iowa.42 In 1897 Sister Martha Lawler (1871-1935) of the

Daughters of Charity of St. Vincent de Paul was trained in anes-

thesia at the Troy Hospital, Troy, N. Y., by the chief surgeon,

Dr. Harvey, and embarked upon a career as anesthetist and teacher

of anesthetists that took her to St. Joseph's Hospital, Chicago,

Mary's Help Hospital, San Francisco, and Charity Hospital, New

Orleans. 43 Sister Mary Antonia Cawley of the Sisters of Mercy

of Wilkes-Barre served as the first anesthetist of that Order at the

Mercy Hospital, Wilkes-Barre, when it opened in 1898.44 From

38Sister Jean Marie: Personal communication.39Sister Vincent of Providence: Personal communication.40Mother Mary Irene: Personal communication.41Sister Cornelia: Personal communication.42Sister Mary Regina: Personal communication.43Sister Stephanie Wall: Personal communication; Anna Willenborg: Personal com-

munication.44Mother Mary Pierre: Personal communication.


the Sisters of St. Joseph, Nazareth, Mich., Sister Mary Constancebegan to give anesthetics at Borgess Hospital, Kalamazoo, Mich.,in 1898, after a special course in anesthesia at St. Elizabeth's Hos-pital, Chicago.45 Perhaps even earlier, two of the Franciscan Sis-ters of the Sacred Heart, Joliet, I11.-Sister Mary Ida (d. 1939),who entered the Order in 1872, and Sister Mary Georgia (d. 1919),who entered in 1873-were administering anesthesia at St. FrancisHospital, Freeport, Ill., and at St. Joseph's Hospital, Joliet, thedates of their assignments antedating the records of the Order.4 6

Among the Protestant as well as the Catholic nursing ordersnurse anesthetists were to be found during the 1890's. In 1897at the Lutheran Deaconess Hospital in Minneapolis, Sister LenaNelson gained experience in administering anesthesia before goingto Austin, Minn., to carry on the work,4 7 and Sister Marie S.Anderson (1872- ), who entered the Lutheran Diaconate atOmaha in 1895, began to give anesthetics in 1898 at Dr. Dear-born's Hospital in Wakefield, Neb.48

During the same decade lay nurses outside Rochester, Minn.,were being trained to give anesthetics. In 1896 Jessie C. Fletcher(1875-1942) received training in anesthesia at the Polyclinic and

Henrotin Hospital in Chicago.49 In 1899, at the Augustana Hospitalin Chicago, A. J. Ochsner's personal choice for chief operating roomnurse, Hilma Swenson, at Dr. Ochsner's suggestion, learned to dropether under the tutelage of Isabella Herb.5 0

By and large, in the United States, the adoption of the methodof open-drop ether anesthesia and of the nurse as an answerto the need for a competent anesthetist in the hospital evolvedin the Midwest, where the expanding railroads-profiting from the

45Mother Mary Colette: Personal communication.46Sister Mary Petronia: Personal communication.47Sister Irene: Personal communication.48Pastor V. Serenius: Personal communication.49Application file of the A.A.N.A.5OSister Kathla: Personal communication. (In her long career as nurse and anes-

thetist Hilma Swenson figures prominently in the history of Minneapolis and St. Paulhospitals. At both St. Mary's Hospital in Minneapolis and at St. Joseph's Hospitalin St. Paul she was a revered instructor in the training schools, going to St. Mary'sin 1912 and to St. Joseph's in 1915. Also, during all these years she gave anestheticsand trained anesthetists. Having always aspired to become a nun, for many years shebelieved it was impossible because she was a non-Catholic, but once she learned other-wise, she took her vows as a convert to Catholicism and became Sister Kathla of theSisters of St. Joseph.)


gifts of public lands-the thriving basic industry and the richfarm enterprise supported vigorously the incentive to get thingsdone in every phase of social and economic endeavor. In contrast,Eastern conservatism favored the continued employment of con-ventional methods and of medical students, house officers or casualphysicians as administrators of anesthesia in the hospital.* In theSouth, which was making a slow recovery from the ravages of theCivil War, there was neither incentive nor funds to provide thehospital accouterments necessary to the new surgery. A concom-itant lack of house officers and interns required surgeons to de-

pend on one another to administer anesthesia and incidentallybrought into existence a new category of administrator, the privatenurse anesthetist. Not only was the Southern surgeon often forced

to operate in the home or in his office, but he was also faced withthe problem of acquiring assistance both in administering theanesthesia and in providing as nearly sterile conditions as possiblein the room where the operation was performed.

One of the earliest private nurse anesthetists in the South andthe first in Memphis, Tenn., was Ethel Baxter (1877- ), whowas taught to give ether during her nurse's training from 1899

to 1901 at Dr. Crofford's Sanitarium in Memphis. Subsequently

taking charge of a hospital in Yazoo City, Miss., for Eugene J. John-

son (1875-1938), she learned from him how to give chloroform

as well. Johnson's practice took him throughout the impoverishedsections of rural Mississippi, and with him went Ethel Baxter,traveling by any available means of conveyance, even ox cart,

sterilizing instruments in the kitchen oven, scrubbing floors anddousing the furniture in the operating room with antiseptic solu-

tion, and on one occasion constructing an operating table fromtwo planks pulled off a barn and laid across two casks, the opera-tion being performed on the porch since the flies swarmed lessviciously there than in the house. When Johnson formed a partner-ship with J. A. Crisler, Sr., (1868-1940) in Memphis, Ethel Baxter

returned with him to carry on her work as private anesthetist and

*"The drop method spread slowly. They were still using the old ways in the Massa-

chusetts General Hospital in Boston in 1890 and at the Johns Hopkins Hospital in

1895. . . . As late as 1906 a Massachusetts surgeon visiting the Mayos was surprisedto find them using 'the newest method' of giving ether." (Clapesattle, Helen: op. cit.,

p. 428.)


surgical assistant.5 Her favor in their eyes is indicated by a letterwritten when she proposed to move to California:

This is to certify that the bearer, Miss Ethel Baxter, has been workingfor us the past eight years as Head Nurse in our Infirmary and Train-ing School for Nurses. The past two years Miss Baxter has been our Anes-thetist and has had charge of all our surgical cases after operations.

We take great pleasure in recommending her as a woman of superbability and rare attainments both as the Head of an institution for sur-gical work and as an exceptionally fine anesthetist. She has assisted usin thousands of operations and is possessed of wonderful surgical judge-ment and technique. Besides this she is a splendid woman in any andall respects.

Miss Baxter is leaving for California, where she expects to reside inthe future, and we regard her leaving as a distinct loss to ourselves, butbespeak for her abundant success wherever she locates. We take thegreatest pleasure in subscribing to all the above.

Respectfully,(signed) Crisler and Johnson

October 22nd, 1913.

Upon Johnson's advice, other Memphis surgeons began to em-ploy private nurse anesthetists, who often also assisted them intheir office practice. Such arrangements between nurses and sur-geons originated independently throughout other parts of theSouth and became so well established that the private nurse anes-thetist, attending her surgeon and acting as an independent agentin providing her equipment and obtaining fees, is a familiar fig-ure in Southern hospitals today.

The hospital Sister and the lay graduate nurse assumed theduties of anesthetist under varying conditions, primarily, however,because the work had to be done and because the surgeons had theconfidence that these women could do it. Called into the specialtyby local needs, rather than by any preconceived concept such asthat fostering the physician specialist anesthetist, and trained bythe surgeons or by other nurses in the hospital for a job at hand,the nurse anesthetist received an education that was purely tech-nical and had no status that could be called professional. Whilesurgeons, impressed with the skillful technic of the Mayo nurse

5 iBaxter, Ethel: Personal communication.


anesthetists, frequently sent the nurses they selected to be their ownanesthetists to Rochester to learn through observation, no hospitalmade provision for a nurse, or, for that matter, a physician, toenter the institution as a student of anesthesia with the view ofmaking it a profession. The concept of education for specializationin both medical practice and nursing was to be a twentieth-cen-tury development.

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