Robert Emmett Farr (1875–1932): A pioneer of pediatric regional anesthesia

The early years

Robert Emmett Farr was born on 15 February 1875 in Montello, Wisconsin. Robert’s parents William (b circa 1836) and Ann Farr (b circa 1843) were both born in Ireland but married in America. William is listed in all census records as being a farmer. Several reports indicate that William’s parents Joseph and Ellen Farr also lived with them, suggesting that William migrated to America with his parents in 1846. Robert had several siblings, six older and one younger than him. His oldest brother Richard was born in 1862 in Pennsylvania which suggests that Robert’s parents lived in Pennsylvania before moving to Wisconsin, and that William and Ann Farr were married before 1862 when Richard was born.

Robert Emmett Farr’s early education took place in the local Wisconsin schools, but he left his home state to pursue medical school in Chicago at Rush Medical College, graduating in 1900. ¹ . In medical school, as he did later in his professional life, he managed to balance medical scholarship and the pursuit of his passions as the captain of the Rush Medical football team and as a football coach for Macalester College ¹ (Figure 1). OPEN IN VIEWER

Farr relocated to Minnesota for his internship at St. Mary’s Hospital in Minneapolis. ¹ Following his training, he was a member of the surgical teaching staff at the University of Minnesota from 1902 to 1914 and at the Minneapolis General Hospital from 1906 to 1914.^1,2 At the age of 27, he married Mary Beatrice Scallen (age 25) on 29 April 1902 at Holy Rosary Church in Minneapolis, Minnesota, an event that was covered in the local newspapers. Their only child, Paul Wallace Farr was born on 19 February 1903. Robert Emmett Farr’s devotions extended beyond medicine to his wife and son. ¹ Although he attempted throughout his professional life to free patients from unnecessary pain, his personal life was rippled with misfortune. He lived through the deaths of two of his nephews. ² He discovered an advanced malignancy while operating on his own sister. ² While attending medical school, his son died tragically in a swimming accident in Cedar Lake, Minneapolis on 11 May 1926 at the age of 23.^2,3 The lake was a popular destination for swimmers during summer, and an autopsy confirmed that Paul’s cause of death was accidental drowning. ⁴ A newspaper reported that a 17-year-old-woman dove into the lake and even succeeded in bringing Paul ashore where resuscitation efforts failed. ⁵ Another man also drowned in the same lake that day. Several years later, yet another tragedy was to strike the Farr family when Robert’s wife committed suicide on 10 March 1932 by jumping out of the window of the Curtis Hotel in Minneapolis. ⁶ These experiences were the source of tremendous grief. He wrote, “One must be able almost to feel any pain or indignity which the patient is forced to undergo with more keenness than the patient himself does.” ⁷ It is easy to surmise that the pain he experienced in his personal life motivated his pursuits in anesthesiology, so that he might offer to his patients the ultimate in comfort and care.

Local preferences

During the early part of the 20th century, American surgeons either administered anesthetics to their patients or trained nurses to do so. General anesthesia with open drop ether was used commonly for children, but complications included pulmonary aspiration of gastric contents, respiratory obstruction, nausea and vomiting, among others. Regional anesthesia offered a safer option, a technique exploited by Farr. However, general anesthesia was becoming safer as nurses or physician anesthetists devoted their time exclusively toward such practice. In a chapter on the surgical treatment of pyloric stenosis, a seminal American textbook of pediatric surgery written about a decade after Farr’s death states, “The anesthesia of choice is ether administered by the drop and open-mask method.” It continues, “we have employed this form of anesthesia in 99% of our cases, and have found it extremely satisfactory.” The author adds that no fatality was observed and admitted that novocaine (procaine) infiltration of the abdominal wall was routinely used in some clinics, remarking that this would no doubt be preferable where trained anesthetists were not available. ⁸

Farr explored other options and in 1919 he wrote, “At the present time a vast majority of surgeons believe that general anesthesia is the method of choice, and that local anesthesia should be reserved for minor and for extreme cases.” ⁹ These cases included inguinal hernia repair and other procedures for which patients were deemed unfit for general anesthesia. ¹⁰

At the time, procaine was acknowledged as the safest known local anesthetic, but local anesthesia was rarely employed during abdominal surgery. ¹⁰ Farr’s rationale for the preference for general anesthesia was that regional anesthesia “constituted in the surgeon’s mind, an extra amount of labor and time, necessitating the mastering of numerous technical details.” ¹¹ This sentiment irked Farr, who believed that these skills were easily acquired.^9,10 He wrote, “I believe that the almost universal acceptance of [this] deprives thousands of patients of the large margin of safety, reduced morbidity, and increased comfort assured by the use of this anesthetic.” ¹⁰

Indeed, Farr had adopted local anesthetics, including cocaine and procaine, in his practice, expending considerable effort to research their toxicity and efficiency for the best results. ² Farr administered his own regional anesthetics, but a nurse or physician would administer general anesthesia if necessary. In 1916, he wrote that he had been successfully using procaine and local anesthetics during abdominal operations for several years. ¹⁰ This abdominal work included satisfactory results in children, whom he noted needed little restraint during operations of obstruction, hernias, and appendicitis (Figures 2 and 3).^9,10 This was somewhat revolutionary, because during the early 1900’s, local anesthesia was not considered a viable option for children (with a few exceptions, namely cocaine for eye surgery) because the drugs were relatively more toxic in children and put them at greater risk for complications, and because children might be easily frightened by the “warlike instruments” employed during surgery.^12,13 OPEN IN VIEWER

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Figure 3.

A photograph of a seven-year-old boy under local anesthesia. ¹⁰

Farr believed that local anesthetic techniques would be accepted more readily by surgeons if better equipment were available for injecting the drugs, and also if a larger quantity of drug could be injected safely. ¹⁰ He then proceeded to work on both these matters to encourage the use of these techniques by his surgical colleagues. As one colleague reflected: “His work with local anesthesia, no doubt, had much to do with creating the spirit of change from the old system of anesthesia.” ³

Historical context

A spirit of change was occurring in the world of regional anesthesia when Farr appeared on the scene. In 1884, William Stewart Halsted (1852–1922) was the first to demonstrate the efficacy of brachial plexus block when cocaine was injected under direct vision. ¹⁴ In 1911, Georg Hirschel (1875–1963) reported a successful axillary plexus block after percutaneous injection. ¹⁵ Also in 1911, Diedrich Kulenkampff (1880–1967) reported his method of supraclavicular brachial plexus block, and this became the technique Farr adopted for children.^16,17 In 1920, Farr was the first to report experience with brachial plexus anesthesia in children. ¹⁸ Although his article, published in Archives of Pediatrics, was not widely circulated among anesthesiologists, his enthusiasm for regional anesthesia techniques resulted in many publications on the subject. By 1948, the literature on pediatric anesthesia was reporting that brachial plexus blocks were becoming popular for certain types of surgical operations in children. ¹⁹ The operations included treatment of dislocations of the shoulder and elbow, resection of tumors, repair of lesions of the tendons, and surgical treatment of injuries. The technique was elaborated on and received wide publicity in 1951 and remains popular to this day.^20–24

Farr wrote extensively about the use of other regional techniques as well, including infiltration of local anesthetics for pyloromyotomy and harelip repairs, as well as caudal blocks for lower abdominal procedures.^9,18 In 1923, he published Practical Local Anesthesia and its Surgical Technic, a text in which he elaborates on his approach to local anesthetic techniques during various surgical operations that previously could only be performed under general anesthesia.

In addition to describing techniques of regional anesthesia, Farr went further and wrote extensively about its safety, efficacy, and its many advantages. These included a lower risk of sepsis, hemorrhage, and shock; moreover, such patients experienced fewer circulatory, renal, and pulmonary complications, in addition to reduced post-operative nausea, vomiting, and thirst. Furthermore, he noted that local anesthetic techniques were associated with less injury to the tissues, since they required surgeons to handle the tissues more gently and with more attention to detail.^9,10,18 Although modern anesthetic techniques are so safe that the differences between morbidity and mortality associated with general and regional anesthesia are minimal, this was not the case in the 1920s.

Farr’s most convincing argument for using local anesthesia was, perhaps unsurprisingly, driven by the interest of the patient. Since local anesthesia could be administered easily in the surgeon’s office, he argued that patients who feared hospitals might present earlier for ailments for which they might otherwise have delayed treatment. ²⁵ Farr was extremely enthusiastic about regional anesthesia and advocated its use in almost all sorts of operations unimaginable today. There were others who were equally enthusiastic, ²⁶ but the majority of surgeons preferred general anesthesia because of greater reliability, better surgical exposure, reports that local anesthetic agents were more toxic in children, and difficulty in obtaining cooperation from children. Nonetheless, the work of Farr and others brought together individuals interested in promoting regional anesthesia. The founding of the American Society of Regional Anesthesia (ASRA) in 1923 provided a unique venue for the dissemination of information concerning regional anesthesia for both surgery and chronic pain management. ²⁷ However, rapid changes were occurring in the field of anesthesia toward the end of Farr’s career, with better drugs, equipment, and the availability of trained personnel to administer the general anesthesia. As a consequence, techniques advocated by Farr and other enthusiasts lost most of their appeal during the mid-20th century. Yet, a prominent surgical textbook from 1940 recommended regional anesthesia for surgery on the lower extremities, especially in diabetic patients. ²⁸

Newer and better

As certain as he was about the benefits of regional anesthesia, Farr also knew that simple changes could greatly alleviate fear and anxiety amongst his young patients during surgery. As early as 1914, he played music in the operating room using a phonograph and used tables that allowed the patient to be tilted at various angles to enhance the surgical exposure (Figure 4).^2,7,10 Obstetrician LaVake of Minneapolis wrote, “It was a privilege to watch him operate. Every mechanical and environmental device was present for the patient’s comfort, mental and physical …” ²⁹ OPEN IN VIEWER

In addition to writing extensively on the application of regional anesthesia, Farr contributed much to the design of surgical instruments. He personally financed his inventions, which cost many thousands of dollars. ² As one of his former interns noted, “Dr. Farr was never satisfied with the status quo, which was undoubtedly a factor in his constant search for new and better methods of surgery.” ² These included the development of special operating room lights and retractors, which allowed an unobstructed view of abdominal viscera during surgery.^1,2,7 To create his inventions, he often collaborated with artists, master mechanics, stenographers, and medical researchers to ensure a well-designed product. ²

His most notable invention (and one that his contemporaries would later call his “greatest joy”) ²⁹ was the pneumatic injector (Figure 5), which he manufactured and marketed personally. ¹ Farr wrote, “Extended experience with this instrument … offers the surgeon the best opportunity to introduce local anesthesia solutions quickly, smoothly, equitably (sic), accurately, and painlessly of any instrument yet devised for this purpose.” ¹¹ The apparatus resembles and functions like the modern equipment used for tumescent local anesthetic injection used in many plastic surgery procedures today. It allowed for the steady flow of local anesthetics such as procaine with less effort and of most importance for pediatric patients, less jerky movement. ¹⁰ Farr’s pneumatic injector included a valve that allowed the surgeon full control during injection. Of equal importance was the ease with which the equipment could be disassembled and sterilized, a point which he mentioned repeatedly whenever an objection was made.^9,11 One of his contemporaries wrote to a journal regarding his use of the injector, saying, “In my hands the abdominal wall may be much more easily and more completely anesthetized with the Farr apparatus than by the use of any of the hand-operated syringes.” ¹¹ OPEN IN VIEWER

A rare individual

As evidenced by his prolific writing, Farr understood that pediatric patients would benefit only if information about regional anesthesia was disseminated to a large number of physicians and surgeons. In addition to lecturing and teaching at the university, he regularly hosted doctors not only from other parts of the United States but also from England, Canada, France, Australia, and Germany for instruction in his techniques. ¹ He used privately funded educational motion pictures during conferences and donated them to the profession for the education of other physicians.^1,3

On reflecting upon his experience under Farr’s service, one intern wrote, “I am certain that [his trainees] are grateful for the inspiration and training that [they] received through our association with him.” ² For some of Farr’s students and colleagues, their association with him proved especially critical to their education and training, for it was known that he provided funding for several students to complete medical school; moreover, he readily offered financial support to colleagues who were experiencing financial strain. ¹ He was remembered fondly by his colleagues, one of whom wrote, “Dr. Farr was one of those rare individuals who devoted his entire time to the advancement of medicine and surgery.” ³

The final years

Although abolition of pain was Farr’s professional focus, it ironically prevented him from working during the last few years of his life. He suffered from a condition of the spine and carried the diagnosis of hypertrophic arthritis. ³⁰ As a result of his pain, he was unable to carry on an active practice for the final four years of his life. ³ Despite this, he was able to complete the second edition of Practical Local Anaesthesia and its Surgical Technic during this time. ³ In addition, he served on the editing and publishing boards of Minnesota Medicine, which he had helped to found, until such time that his poor health became too much of a burden.^2,3 He underwent two surgical operations on his spine to alleviate his symptoms. The first operation offered little relief, and he died shortly after the second operation. ² He died on 30 June 1932 at Saint Mary’s Hospital, the same hospital where he had trained as a surgeon.^1,31

His legacy

Few major medical specialties are as closely related as anesthesia and surgery. In fact, advances in surgery could not occur until the availability of reliable and safe anesthesia. Many early anesthetists were surgeons, and few physicians were willing to devote full-time attention to the practice of anesthesia. During Farr’s career, general anesthesia with ether or chloroform was the norm, and operative monitoring consisted of monitoring pulse and respiration. Complications were common and mortality remained high. The application of regional anesthetic techniques offered a safe alternative, but surgeons were reluctant to consider employing these techniques in children. Inability to elicit cooperation, and the need to be extra gentle during manipulation of tissues were common deterrents. Farr’s bold advocacy in offering these techniques during pediatric surgery was a novel idea. In a way, this surgeon was returning the favor by advancing the emerging discipline of anesthesia.

Farr’s ultimate goal was to offer every patient, not just his own, the most satisfactory and comfortable surgical experience possible. He viewed all of his actions from the patient’s perspective. He understood that changes in surgical practice would only be brought about through education and practical demonstration, and his legacy in the world of local anesthesia includes several textbooks, films, and surgical instruments.^2,3 The countless physicians trained in his approach promulgated his work.

Farr’s contributions to the field of anesthesia were recognized by his peers around the country when several medical societies, including the Hennepin County and Minnesota State Medical Societies, nominated him for the Nobel Prize for his pioneering work in local anesthesia.^1,3,32 One individual who had been an intern under his service wrote, “The profession lost an outstanding member, often misunderstood because he had the courage to stand up for what he thought was right.” ²

Clinical advances come about when gifted individuals challenge conventional thinking and persevere with their passionate ideas. Pediatric regional anesthesia was fortunate in finding such a champion in the form of surgeon Robert Emmett Farr, who brought brachial plexus anesthesia and other regional techniques to children (Figure 6). OPEN IN VIEWER