“Great facilities will be offered to those who are disposed to avail themselves of what now promises to be one of the important discoveries of the age.”
With these words, Dr. Henry Jacob Bigelow concluded his description of the administration of ether anesthesia by Dr. William Morton on October 16th, 1846. Dr. Bigelow also described several subsequent cases of ether administration at Massachusetts General Hospital.1 This lowly case report is among the most important papers in the history of medicine.a It gave birth to an entire medical specialty: ours.
The following year Dr. James Young Simpson reported several cases of chloroform anesthesia.2 It wasn’t long before the toxicity of chloroform was reported in a case report. Hannah Greener, a 15-year-old girl, died while receiving chloroform to render her unconscious for the resection of an ingrown toenail.3
Case reports are deeply woven into the history of our profession. In 1899, August Bier reported the effects of intrathecal cocaine for spinal anesthesia.4 The same case report described postdural puncture headaches, including his own. Epidural anesthesia was first described in a 1921 case report by Fidel Pagés.5 Fatal cardiac arrest after caudal injection was described in a 1979 case report by Jerry Prentiss.6 Case reports first described intraoperative awareness,7 halothane hepatitis,8 methoxyflurane nephrotoxicity,9 malignant hyperthermia,10 chloroprocaine arachnoiditis,11 and cauda equine syndrome after continuous spinal anesthesia via spinal microcatheters.12 These case reports alerted clinicians to potential toxicities. The same reports generated testable hypotheses. Entire careers have been devoted to investigating the mechanisms responsible for patient injury and therapeutic alternatives to reduce the risk of anesthesia, based on observations initially described in case reports.
Despite the profound contributions of case reports in advancing patient care, journals have become reluctant to publish case reports. For example, Anesthesia & Analgesia only considers case reports that are “truly exceptional.”13 Just 5% of the reports submitted to Anesthesia & Analgesia meet this stringent requirement. The reason is that case reports are rarely cited, which drags down a journal’s impact factor. The impact factor is the standard metric that authors, readers, promotion committees, and journal owners use to judge the quality of the journal and the performance of journal editors.14
In November 2012, Anesthesia & Analgesia announced that we would no longer accept case reports. The same announcement introduced a new journal, Anesthesia & Analgesia Case Reports. In creating A&A Case Reports, the International Anesthesia Research Society affirmed the value of case reports in our discipline. A&A Case Reports will publish case reports that benefit patient care, regardless of whether they will ever be cited. It will take at least 6 months for the new journal to be indexed with Medline/PubMed. It is my hope that A&A Case Reports will never be encumbered by an impact factor.
Dr. Lawrence Saidman will be the Editor-in-Chief of A&A Case Reports. Dr. Saidman served as Editor-in-Chief of Anesthesiology from 1986 to 1996, and has served as Correspondence Editor for Anesthesia & Analgesia since 2007. Dr. Saidman understands the value of case reports, having published one of the first case reports describing malignant hyperthermia.10 Dr. Saidman will be supported in his role as Editor-in-Chief of A&A Case Reports by the Editorial Board of Anesthesia & Analgesia.
A&A Case Reports seeks case reports that make an important teaching point or scientific observation in disciplines related to anesthesiology: perioperative medicine, critical care, and pain management. “They may describe unusual and instructive cases, novel anesthetic techniques, novel use of equipment, or new information on diseases of importance to anesthesiology… Case reports are frequently suitable for documenting unusual cases of toxicity or equipment failure. They are almost never appropriate for describing efficacy of a drug or a treatment, which should be demonstrated by an adequately powered and well-controlled clinical trial. The only exception is a demonstration of efficacy in a population, or a clinical scenario, so uncommon that a clinical trial cannot be performed. Case reports describing successful management of complex cases will only be considered if they make a truly exceptional observation.”10 Case reports must include a statement that the patient, the patient’s family, or the responsible IRB gave written permission to publish the report.
Case reports have introduced new paradigms, alerted patients and physicians to severe complications, and saved countless lives. They have generated hypotheses leading to proper laboratory and clinical studies. Our specialty sprung from the case reports of early pioneers. With the support of clinician-authors, the interest of clinician-readers, and under direction of an experienced and respected Editor-in-Chief, A&A Case Reports acknowledges the profound contributions of case reports to our discipline. A&A Case Reports will continue that tradition to the benefit of our patients.
Dr. Steven L. Shafer is the Editor-in-Chief for the Journal. This manuscript was handled by Dr. James G. Bovill, Guest Editor-in-Chief, and Dr. Shafer was not involved in any way with the editorial process or decision.
Name: Steven L. Shafer, MD.
Contribution: This author wrote the manuscript.
a http://blogs.nejm.org/now/index.php/the-most-important-article-in-nejmhistory/2012/11/01/. Accessed December 9, 2012.
1. Bigelow HJ. Insensibility during surgical operations produced by inhalation. Boston Med Surg J. 1846;35:309–17
2. Simpson JY. On a new anaesthetic agent more efficient than sulphuric ether. Lancet. 1847;50:549–50
3. . Fatal application of chloroform. Lancet. 1848;51:161–2
4. Bier A. Versuche über cocainisirung des rückenmarkes. Dtsch Z Chir. 1899;51:361–9
5. Pagés F. Anestesia metamérica. Revista Espanola de Cirugia. 1921;3:3–30
6. Prentiss JE. Cardiac arrest following caudal anesthesia. Anesthesiology. 1979;50:51–3
7. Winterbottom EH. Insufficient anaesthesia. Br Med J. 1950;1:247
8. Brody GL, Sweet RB. Halothane anesthesia as a possible cause of massive hepatic necrosis. Anesthesiology. 1963;24:29–37
9. Crandell WB, Pappas SG, Macdonald A. Nephrotoxicity associated with methoxyflurane anesthesia. Anesthesiology. 1966;27:591–607
10. Saidman LJ, Havard ES, Eger EI 2nd. Hyperthermia during anesthesia. JAMA. 1964;190:1029–32
11. Reisner LS, Hochman BN, Plumer MH. Persistent neurologic deficit and adhesive arachnoiditis following intrathecal 2-chloroprocaine injection. Anesth Analg. 1980;59:452–4
12. Rigler ML, Drasner K, Krejcie TC, Yelich SJ, Scholnick FT, DeFontes J, Bohner D. Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg. 1991;72:275–81
13. . 2010 Anesthesia & Analgesia Guide for Authors. Anesth Analg. 2010;111:525–38
14. Bornmann L, Marx W, Gasparyan AY, Kitas GD. Diversity, value and limitations of the journal impact factor and alternative metrics. Rheumatol Int. 2012;32:1861–7