When the newly constructed Stanford University Medical Center hospital opens in 2017, it will include a suite of 28 interventional procedure rooms named after Caroline B. Palmer, MD, the first chief of anesthesia at Stanford Medical School. The American West’s first medical school was founded under a charter from the University of the Pacific in 1858 by Dr. Elias Cooper (1822–1862), an industrious and prominent local surgeon. The school, called the Medical Department of the University of the Pacific in San Francisco, was located above Cooper’s medical office in San Francisco. The school failed after Cooper’s death in 1862 but was revived in 1882 by his nephew, Dr. Levi Cooper Lane (1830–1902) who assumed the school’s leadership, renaming it Cooper Medical College. An affiliated facility, Lane Hospital, was built by Dr. Lane with his own funds. Lane Hospital was opened in San Francisco in 1895. In 1908, the Board of Directors of Cooper Medical College voted to cede the school, its properties including Lane Hospital, and all its equipment to Stanford University. The transfer was completed by 1912. The new medical school was initially called the Medical Department of Stanford University but was subsequently renamed the Stanford School of Medicine in 1914. The first class of students entered Stanford’s Medical Department in September 1909. The final class of Cooper Medical College graduated in May 1912.
After Stanford’s acquisition of Cooper Medical College, the medical department was organized into 10 separate divisions (or departments): anatomy, bacteriology and immunology, physiology, chemistry, pharmacology, pathology, medicine, obstetrics and gynecology, hygiene and public health, and surgery. Within the division of surgery, a separate section was dedicated to anesthesia.
In the decades following Morton’s demonstration of ether anesthesia on October 16,1846, surgical anesthesia in the United States was administered largely by nonphysicians including medical students, nurses, dentists, and even orderlies. This remained standard practice well into the 20th century.
In 1897, Dr. Mary Botsford of San Francisco became the first Californian physician, and possibly the first physician in the United States, to dedicate her practice exclusively to anesthesia.1 Botsford graduated from the University of California Medical School at San Francisco in 1896 and began a medical practice at the Children’s Hospital in San Francisco (CHSF). CHSF had been founded in 1875 to provide educational and practice opportunities for female physicians. Few hospitals offered internship positions to women, who often had to continue their postgraduate education at dedicated “women’s hospitals” like CHSF. Botsford taught anesthesia to CHSF interns and medical students. She later became the first faculty member and chief of the Department of Anesthesia at University of California Medical School at San Francisco and their first clinical professor of anesthesia.
Caroline B. Palmer (1872–1947) graduated from Cooper Medical School in 1906. Like many other women graduates of western medical schools, Palmer continued her postgraduate studies under Botsford at CHSF. Her choice of anesthesia reflected the prevailing attitude that anesthesia was a field especially suited for women (women represented 19% of the American Association of Anesthetists membership in 1916, but nationally only 3.6% of all practicing physicians).2 In 1920, Oschner summarized the attitude of surgeons toward female anesthetists: “…the best anesthetics are conducted by women….because it is possible to select women with the highest degree of intelligence and judgment for this work, while medical men possessing these qualities can almost never be induced to elect anesthesia as a specialty.”3 Additional factors contributing to the disproportionately high number of women choosing anesthesia may be related to both the relatively poor financial compensation for anesthetists1 and the lack of opportunities to enter other surgical and medical specialties that preferred male physicians.
After completion of training at CHSF in 1907, Palmer was appointed to the staff of Cooper Medical College, working at Lane Hospital. In 1909, Henry Gibbons, dean of Cooper Medical College, appointed Palmer to lead a new department with the responsibility of providing safe anesthesia. She accepted and served as associate professor of surgery (Anesthesia) and chief anesthetist at Lane Hospital and became the first chief of anesthesia at Lane Stanford Hospital when Stanford assumed control in 1912.4 After her retirement in 1937, Dr. William Neff (1905–1997) was appointed to succeed Dr. Palmer. In 1960, after Stanford Medical School’s relocation to Palo Alto, CA, John Bunker (1920–2012) was appointed as chair of the new, independent department of anesthesiology.
To prepare for her leadership role as chief anesthetist, Palmer travelled extensively throughout the country visiting and observing at major medical centers where anesthetics were given. In addition, to learn more about the anesthetic agents, she visited sites where the drugs were manufactured. Palmer taught and wrote about the basics for organizing a hospital anesthesia department based on her experiences at Lane Stanford Hospital.5 Her recommendations, published in 1923, were clearly ahead of their time and are nearly indistinguishable from those currently practiced by anesthesia departments in university hospitals.6
Palmer noted that it was in the best interest of patients, surgeons, and the hospital to appoint a single individual as “chief anesthetist” to assume administrative responsibilities involved in directing activities of a department of anesthesia. In her view, the chief’s role included organizing the daily surgical schedule and overall responsibility for insuring the availability of only qualified physician anesthetists for all surgical procedures including emergencies and unscheduled obstetrical cases. She considered herself a physician anesthetist, as the American connotation that an “anesthetist” refers to a nonphysician, whereas the term “anesthesiologist” is reserved for a medical school graduate practicing anesthesia, which did not become widely accepted until after the American Board of Anesthesiology was established in 1938.
Palmer noted that the operating room schedule should be sufficiently flexible to provide for delays from surgeons arriving late and for operations that required more than the estimated time. Palmer recommended assigning specific physician anesthetists to cases based on the experience and skill of that individual and the special requirements of the task. She maintained an on-call schedule along with weekend and night anesthesia coverage on a rotating basis, meaning that a physician anesthetist was always available day or night. She recognized that anesthetists working the previous night without sleep should be excused from working the following day in the interest of patient safety. She felt that anesthetists should receive reasonable professional fees for their work, similar to the compensation of other medical consultants.6 In addition to departmental income from professional fees, the hospital was required to contribute funds for maintenance of anesthesia equipment and to ensure that adequate amounts of all necessary supplies were always available.
Perhaps anticipating by decades what ultimately became anesthesia preoperative assessment clinics,7 Palmer insisted that physician anesthetists examine their patients before surgery to assess the patient’s physical condition and medical history, reflecting her opinion that the anesthesia plan depends on the patient’s underlying condition. She rejected the practice by nonphysician anesthetists, and even some of her physician colleagues, to use the same anesthetic technique regardless of the individual patient’s condition and/or the requirements of the specific procedure. Palmer believed that modifying the anesthetic plan to reflect the patient’s condition was expected of a medical practitioner.5 It seemed obvious to Palmer, as it still does to those practicing anesthesia today, that it is unacceptable to anesthetize a patient because someone else has certified the patient as “okay for anesthesia.”
In addition to providing coverage for the daily surgical schedule, Palmer’s anesthesia department provided for all obstetric anesthesia and analgesia services. When Palmer first arrived at Lane Hospital, anesthesia for labor and delivery was provided by nonphysicians. Under her leadership, beginning in 1916, the anesthesia department at Lane Stanford Hospital assumed the responsibility for all obstetric anesthesia. She felt that to be prepared for complex emergencies, anesthetists must be familiar with managing routine cases. Therefore, they needed to be present and participate whenever an anesthetic was requested. In publishing recommendations for the conduct of obstetric anesthesia in 1918, Palmer was among the first specialized obstetrical anesthetists in the United States.8 Long before epidural analgesia for labor and delivery became the norm, she expressed her wish that “painless childbirth” would someday become a reality.
Nitrous oxide/oxygen was then considered the safest inhalation anesthetic technique and was used (often supplemented with barbiturates or ether) in the majority of patients at Lane Stanford Hospital. Only small gas cylinders were available on the West coast. Botsford at CHSF arranged for large gas cylinders to be shipped to San Francisco from the East at half the cost of the locally produced cylinders. The large cylinders were initially stored in the basement of Dr. Palmer’s apartment building. In 1924, Dr. Donald Baxter began manufacturing nitrous oxide in Glendale, California. Palmer visited his plant to check on the quality of his product. Once satisfied, she had Baxter’s gas cylinders shipped to Lane Stanford Hospital. Eventually Baxter opened a manufacturing plant called Certified Laboratories Products Company in San Francisco, significantly reducing the cost of anesthetic gases for Lane Stanford Hospital. The plant was later forced to move across San Francisco Bay to Berkeley because of the concern that the ammonium nitrate used in the production of nitrous oxide could cause an explosion. It remains unclear why an explosion in Berkeley was considered preferable to an explosion in San Francisco.
Consistent with contemporary environmental concerns about anesthetic waste, Palmer arranged for the nitrous oxide and oxygen cylinders to be transferred from the operating room to a separate presurgical anesthetic induction room once the pressure decreased to low levels. The final bit of pressurized gas was used for induction of anesthesia, where large quantities were not necessary for maintenance. This not only allowed the maximum use of the expensive gases but also saved having to exchange an empty gas cylinder in the middle of surgery.
After observing several anesthetic-related deaths, in 1895, Boston medical students Harvey Cushing (1869–1939) and Ernest Amory Codman (1869–1940) developed the first intraoperative anesthetic record.9 They observed and recorded respiratory rate and palpated pulse rates in anesthetized patients. In 1901, Cushing added blood pressure measurements using sphygmomanometry, respiratory rate, and heart rate monitored by auscultation using a precordial stethoscope. Lane Hospital anesthetists adopted the use of anesthetic records in 1907. Palmer strongly encouraged this practice. In addition, Palmer made anesthetic records available to other physicians and hospital administration for audits and research.
In addition to carrying out her administrative roles as chair, Palmer was an active clinical anesthetist, publishing extensively on many aspects of clinical anesthesiology.10,11 She described the different anesthetic techniques then used and the risks and benefits of each.10 She recognized that none of the commonly used inhaled anesthetics (nitrous oxide, ether, or chloroform) were perfect. She correctly anticipated that no single anesthetic agent would ever meet the requirements for a perfect anesthetic. Although many anesthetists did not recommend preanesthetic medication for the very young or the elderly, Palmer wrote that all patients could benefit from anxiolytic premedication.11 The use of premedication in children was actively debated during the authors’ residency training in the 1960 to 1970s and only recently have data suggested that even very small children may benefit from premedication, as Palmer recommended nearly a century ago.12
Palmer and Dr. Emile Holman, her surgical colleague, described their experience using IV sodium amobarbital either alone or as an adjunct to local and/or inhaled anesthesia in 150 patients.13 They concluded that it was impractical to use long-acting barbiturates as the sole anesthetic because the large doses required to prevent movement depressed ventilation and circulation and delayed awakening up to 18 hours. This was especially problematic because supplemental oxygen was not routinely used in the recovering patients. However, they also observed that sodium amobarbital as a supplement to local or with general anesthesia reduced the concentration of inhaled nitrous oxide or ether and reduced postoperative complications.
Palmer found that the addition of oxygen to ether decreased the pungency and thus airway irritability of open drop ether (likely the result of diluting the inspired concentration of the ether), improving the patient tolerance of ether induction. She designed a vaporizer attached to an oxygen cylinder and continued to improve the apparatus during the course of her long career.
Palmer noted the importance of “posture” (i.e., patient position) on respiration, circulation, muscle and joint strain, and pressure on nerves. Palmer recommended placing pillows under the patient’s head and flexing the patient’s thighs to improve patient comfort and relax the abdomen.14 She reviewed 10,000 anesthetic records at Lane Stanford Hospital to see whether her recommendations regarding posture were correct. She found that attention to posture improved the ease and rapidity of induction of anesthesia and increased muscle relaxation during surgery. Thus, proper positioning reduced the amount of anesthesia required (because deeper levels of anesthesia were no longer needed for adequate muscle relaxation). She also documented that proper positioning improved operative conditions for the surgeon and decreased postoperative discomfort for the patient.14 Under Palmer’s direction, Stanford anesthetists attempted to maintain normothermia during surgery, used IV fluids to maintain intravascular volume, and took special care in transferring patients to and from their gurneys. These supportive measures, first instituted by Palmer, are common practice today.
Palmer’s lifelong goal was to have anesthesiology recognized as a separate medical specialty distinct from surgery. After introduction of anesthesia for surgery in the 1840s, ether became the agent most often used in this country, whereas chloroform was the drug of choice in England. In England, only physicians provided anesthesia, and anesthesiology was always considered a medical specialty. In the United States, the majority of anesthesia providers were nurses and other nonphysicians working under the supervision of surgeons. Anesthesiology was not considered a branch of medicine.
Palmer felt that allowing nonphysicians to practice medicine (i.e., anesthesiology) was not only wrong but also dangerous. She stated that no anesthetic could truly be safe unless the anesthetist can diagnose and is competent to treat changes in the patient’s condition throughout the entire procedure. She asked “can a technician do this?”15 Depth of anesthesia was difficult to gauge in an era when the only intraoperative monitors were sight, sound, and touch. Respirations, pulse, skin color, reflexes, sweating, or skin warmth had to be observed constantly. The anesthetist was expected to inform the surgeon of any changes in the patient’s condition. How could a surgeon supervising an anesthetist continually follow the patient’s condition while at the same time concentrate on performing surgery? She argued that there is no such thing as “supervised anesthesia” unless the physician doing the supervision “gives the matter his entire attention.” Hence, “what is the need for a technician?”15
She demanded that other physicians recognize and respect their colleagues who choose anesthesiology as a specialty. Allowing nurses, medical students, or other nonphysicians to provide anesthesia was counterproductive to the medical profession’s view of anesthesia as a medical specialty. Palmer stated that employing nonphysicians to do work that should be performed by physicians was not only unnecessary but also short sighted and unethical. She believed that with the recognition by their physician peers as specialists, anesthesiology would attract sufficient numbers of medical school graduates, both men and women.15
In 1933, she stated that the future of anesthesiology depends on whether the American medical profession is sufficiently ethical to keep the practice of medicine (anesthesiology) in the hands of physicians.15 She also believed that physician anesthetists must also be ethical, meaning that they should not teach or supervise nonphysicians in the practice of anesthesia.
She argued that anesthetists should not only be medical school graduates but also, in addition to their basic medical education, they should have sufficient instruction and training to meet this “difficult and exacting specialty of modern anesthesiology.”15 She believed that physicians specializing in anesthesiology had a responsibility to both teach anesthesia to medical students and other physicians and to remain aware of advances in anesthetic knowledge. All interns at Lane Stanford Hospital were given instruction on administration of anesthesia during their first few months on service.5 Her formal training course to interns consisted of 4 lectures and a minimum of 10 administrations of anesthesia under supervision by a physician anesthetist. If interns showed a “normal aptitude,” they were allowed to provide anesthesia alone, but always with a trained anesthetist nearby to help if needed. Although brief, this training period was ahead of its time because the common practice throughout the country was to allow even inexperienced individuals to provide anesthetics. For medical graduates who wanted to specialize in anesthesia (today would be considered anesthesia residents), the training was longer and more intense.
Her efforts and those of many others were followed by the formation of the American Society of Anesthetists (later changed to Anesthesiologists) in 1936. The American Board of Anesthesiology, a division of the American Board of Surgery, was established 2 years later in 1938.16 The first written board examination for qualification as a physician anesthetist was given in 1939. Finally, in 1941, the American Board of Medical Specialties formally recognized anesthesiology as a medical specialty and began certifying anesthesia residency programs and credentialing graduates of those programs.
In her address as chair of the Anesthesiology Section of the California Medical Association’s 62nd Annual Meeting in 1933, Palmer said that “The members of the anesthetic department in the institution with which I have the honor to be connected (that is, Stanford Hospital) have reason to feel fortunate in the attitude toward anesthesiology of the medical school authorities, surgeons, internists, and hospital executives.”15 She always believed that a team approach with mutual respect and cooperation among nurses, surgeons, and anesthetists was best “for the good of the patient.”
Thus, it is appropriate that Stanford University Medical Center honor the memory of this pioneering physician anesthetist by designating our new hospital’s operating suite the Caroline B. Palmer Operating Rooms.
Name: Jay B. Brodsky, MD.
Contribution: This author helped write the manuscript.
Attestation: Jay B. Brodsky approved the final manuscript.
Name: Lawrence J. Saidman, MD.
Contribution: This author helped write the manuscript.
Attestation: Lawrence J. Saidman approved the final manuscript.
This manuscript was handled by: Steven L. Shafer, MD.