Chapter 1. The Evolution of Anesthesiology as a Clinical Discipline: A Lesson in Developing Professionalism

1. The history of anesthesiology is an interesting and complicated story of professionals seeking to understand the anesthetic state and to anesthetize patients safely.

2. Shortly after the first public demonstration of ether anesthesia on October 16, 1846, the news spread across the world. At first anesthetics were given based on written accounts, often in the lay press.

3. John Snow, a London physician, worked out the physics of vaporization of volatile agents by observation off ether and chloroform and used this information to design vaporizers and anesthetic techniques that were safer for the patient.

4. The first professional organization devoted to anesthesia was the London Society of Anaesthetists founded on May 30, 1893. The first similar group in the United States was the Long Island Society organized by Adolph Frederick Erdmann in 1905. The Long Island Society eventually became the American Society of Anesthesiologists.

5. Francis Hoffer McMechan organized professional anesthesia. He helped create the first national organization, the Associated Anesthetists of America in 1912, and went on to found several national and international organizations, of which the International Anesthesia Research Society (IARS) remains active. He was the founding editor of the first journal in the world devoted to the specialty, Current Researches in Anesthesia and Analgesia, which is currently published as Anesthesia and Analgesia.

6. Ralph Water is credited with the first department of anesthesia within an academic setting at the University of Wisconsin in 1927. Much of the current residency structure comes from this seminal department that helped establish the specialty on an equal footing with other medical specialties and created a method to train physicians in the art and science of anesthesia.

7. John Lundy, working at the Mayo Clinic, organized the Anaesthetists Travel Club, whose members were the leading young anesthetists of the United States and Canada. These individuals helped create, by 1938, the American Board of Anesthesiology, which defined what it meant to be an anesthesiologist in the United States.

8. The need for physician specialists in World War II exposed a large number of young men to anesthesiology who would not have otherwise considered the specialty. After the hostilities ceased, these physicians returned and helped create the tremendous growth in the 1950s and 1960s that the specialty enjoyed.

9. In the mid-1950s, the World Federation of Societies of Anesthesiologists (WFSA) was formed. It was the culmination of a dream that dated to the late 1930s. The WFSA made it possible for nations with a long tradition of physician specialization in anesthesia to help train and create the specialty in countries where it did not or does not exist.

10. In the 1980s, the Anesthesia Patient Safety Foundation (APSF) and the Foundation for Anesthesia Education and Research (FAER) were created. They are additional examples of the professionalism demonstrated throughout the history of anesthesiology. These two organizations work to create a safe anesthetic environment. In addition, they support educational and research efforts in the specialty.

The quest for insensibility to the surgeon's knife is a primordial one. Stretching back to antiquity, physicians have sought ways to render a patient pain free while an operation was being performed. Many different regimens were tried, with varying success, until October 16, 1846, when surgical anesthesia was publicly demonstrated at the Massachusetts General Hospital by William Thomas Green Morton. Yet there remained a long road from that fall day in Boston to the current operating room full of electronic machines whose sole purpose is to measure the physiologic parameters of the anesthetized patient. How did anesthesiology evolve from a simple glass globe inhaler to the vast array of machines that makes the modern operating room?

The history of anesthesiology is the history of the men and women who have devoted their career to the administration of anesthetics. Without physicians interested in the anesthetic state and the ability to adapt to new conditions demanded of anesthesiologists by surgeons, there would be neither modern surgery nor the specialty of anesthesiology. Yet each individual was a real human, many displaying professionalism beyond what was required or expected; others seem reprehensible by "modern" standards. Although many of the individuals in this story would not consider themselves specialists in anesthesia, their contributions were critical in moving the specialty forward. The development of anesthesiology can be told as the history of involved physicians who dedicated themselves to providing safer, focused care of the patient, first in the operating room and later in the critical care unit and pain clinic. The story begins in ancient Egypt and continues to evolve in untold ways.

Imagine for a moment that there is no surgical anesthesia. The Edwin Smith Papyrus describes 48 surgical cases done between 3000 and 2500 bc. Although there is no specific anesthetic agent, within the papyrus there is evidence of compression anesthesia. In one instance, a surgeon is compressing the antecubital fossa while operating on the hand; in another instance, the patient is compressing his brachial plexus while the surgeon operates on his palm.1 The ancient Chinese reported the use of an anesthetic for surgery in the 2nd century bc.2 The use of hemp smoke as an anesthetic was noted in India3 long before Western medicine developed crude forms of anesthesia.

During the Middle Ages and early Renaissance, a mixture of herbs purported to induce anesthesia was created. Boiled into a sponge, at the time of surgery the sponge was placed in water and the vapors inhaled. Although the vinca alkaloids were a major component of the drugs used in the spongia somnifera, the resultant anesthetic was less than satisfactory. Another Renaissance solution was the use of parallel lines of ice, with the incision placed between them. This was effective for simple operations and found use in the Russo-Finnish War of 1939-1940.4 Alcohol, when drunk in sufficient quantities, was noted to render individuals insensible. Thus the age-old intoxicant was used as a standard against which all anesthetics could be measured.3

In the early 1840s, the effects of nitrous oxide and diethyl ether were well known. Both drugs were well known to medical students as intoxicants. Humphry Davy had described the intoxicating effects well in his book, Researches Chemical and Philosophical: Chiefly Concerning Nitrous Oxide, published in 1800. Ether, which had been first synthesized in the 1500s, had been observed to lessen the "air hunger" of asthmatics.5 In January 1842, in Rochester, New York, a medical student, William E. Clark, anesthetized the sister of a classmate for the extraction of a molar using ether. Instructed not to pursue this observation, as it most likely was a "hysterical reaction of women," Clarke continued his training and became a respected physician in the Chicago, Illinois, area.6

Two months later, in rural Georgia, a country doctor, Crawford Long, who had hosted parties where ether was used as an intoxicant, used the drug to render James Venable insensitive for the removal of tumors from the back of his neck. Long charged Venable $2 for the anesthetic, thus delineating anesthesia as part of a physician's professional service. Two years later, in 1844, Horace Wells, a dentist in Hartford, Connecticut, would gain the insight that, during a nitrous oxide (N2O) show, when an individual was intoxicated by N2O, pain was abolished. Wells then tried this idea on himself for the removal of one of his teeth by his partner, and it was successful. Soon he was using "painless dentistry" as part of his professional advertisement. Wells even attempted to demonstrate a painless tooth extraction at the Massachusetts General Hospital in 1844, but the patient groaned, although later had no memory of the event, and the demonstration was considered a failure.7

Clearly, by the middle of the 19th century, there were sufficient observations about specific agents that could potentially abolish the pain of surgery. On a limited scale in rural Jefferson, Georgia, surgery with ether anesthesia was happening. Yet Long felt he lacked sufficient cases to study the effects of this new agent.8 Wells's use of N2O was groundbreaking, yet he lacked the emotional stability to overcome his failed demonstration.9 Thus the stage was set for another dentist to demonstrate reproducible surgical anesthesia and give birth to what would grow and develop into the specialty of anesthesiology.

On October 16, 1846, William Thomas Green Morton, a dentist and medical student, provided surgical anesthesia for Gilbert Abbott for the removal of a tumor of the jaw at Massachusetts General Hospital. The events of that day are well known.10 Upon completing the operation, the surgeon, John Collins Warren, remarked, "Gentlemen, this is no humbug." The miracle of pain-free surgery so impressed the Boston medical establishment that letters were sent to colleagues across the world. Considerable scholarship has been spent discerning when these letters arrived, where they arrived, and who provided anesthesia first in the new location. For example, the generally accepted view of the spread of anesthesia to the United Kingdom is a letter from Jacob Bigelow to Francis Boot. However, by careful study of the ships sailing between Boston and Liverpool, another letter, written almost 2 weeks before Bigelow's and only 12 days after the public demonstration of ether, arrived in England on November 1, 1846. Interestingly, this letter was to a patent attorney.11

Morton wanted to patent the process by which ether was administered, so writing to the foremost patent attorney in England to secure rights to the administration of ether in the United States and the United Kingdom,9 and perhaps the world, is not surprising. He also tried to patent ether itself, calling his anesthetizing mixture "Letheon." However, the distinctive odor of ether gave away the true nature of the concoction. The Boston medical establishment had convinced Morton to allow Massachusetts General Hospital to use Letheon without charge. With ether a well-known and easy-to-synthesize compound, and its effects reproducible without the "Morton's Inhaler," the patent was unenforceable. Morton would spend the rest of his life attempting to be compensated for patent infringement, fighting with the medical establishment and into the halls of Congress.8 Morton clearly was not the embodiment of medical professionalism as we currently understand it.

News of Morton's achievement did travel, and quickly, given the nature of communication in the 1840s. On December 16, 1846, ether anesthesia, in the form of a letter, arrived in London. On December 19, the first ether anesthetic was given in the United Kingdom for the removal of a tooth. On December 21, Robert Liston, the famous surgeon, amputated the leg of a butler and uttered the famous words, "This Yankee dodge beats mesmerism hollow." By early 1847, anesthetics were being given across Europe. In June of that year, the news had spread to Australia.12 Peter Parker, minister and physician missionary in China, gave the first anesthetics there on October 4, 1847.13

For the history of the specialty of anesthesiology, what is interesting is how willing physicians and dentists were to use ether to induce insensibility. Consider for a moment that outside of Boston, none of the recipients had actually witnessed surgical anesthesia. Many accounts, especially those reaching South Africa and Australia, were newspaper articles or letters to the editor, often signed by a pseudonym. The hope of these medical professionals, their desperation at their inability to alleviate pain, and their desire to help patients may well have motivated them to try this new technique. Yet when viewed from the perspective of current 21st-century medical practice, this willingness to go on purely written accounts, often in the lay press, without the collaborating voices of the medical profession, seems to be dangerous and without regard for the basic principle of medicine: first do no harm.

And what of the surgeons? Tolerance of the pain of surgery limited operations to those that could be performed quickly. Anesthesia obviated the need for speed, presenting the possibility of operating within the visceral cavities for hours rather than seconds. But as the physician responsible for the patient, long before the specialty of anesthesiology would be defined, why were these professionals willing to risk lives to find an anesthetic? What does this behavior say to the modern student of medical professionalism?

As reprehensible as Morton's actions appear in patenting his "discovery," he was acting within the ethics of his time. The American Medical Association (AMA) was only just beginning to be formed. Meeting for the first time in May 1846, 5 months before the public demonstration, the National Medical Convention adopted a resolution to write a code of medical ethics. A year later, the code was adopted. Morton's actions were covered under section 4: "Equally derogatory to professional character is it, for a physician to hold a patent for any surgical instrument, or medicine, or to dispense a secret nostrum, whether it be the composition or exclusive property of himself or others. For, if such nostrum be of real efficacy, any concealment regarding it is inconsistent with beneficence and professional liberality."14

Thus at the time when Morton was trying to patent either ether or the apparatus for its vaporization, medicine was starting to organize and promulgate statements against such behavior.

In contrast, John Snow (Fig. 1-1), a London physician, began to study the chemical and physical properties of ether, and by 1847 he had developed a vaporizer. "Snow never patented any apparatus he designed. On the contrary, he published clear descriptions, including engraved figures, so that others could copy them if they chose."15 Snow, by careful observation, worked out the vaporization characteristics of ether. His vaporizer (Fig. 1-2) was temperature compensated, being made of coiled copper (Fig. 1-3), an excellent heat-conducting metal, housed in a water bath to ensure constant temperature of the ether. Thus Snow was able to calculate the amount of ether a patient required for anesthesia within a few years of the discovery of anesthesia.13

Following the introduction of chloroform as an anesthetic in 1847 by Edinburgh obstetrician James Young Simpson, Snow began to investigate this second anesthetic agent. Snow used his experience with ether as a guide for investigating the properties of chloroform. He concluded that it was far safer to give this new anesthetic in measured quantities through an inhaler and did not favor the handkerchief method, whereby chloroform was applied to a cloth and held close to the nose and mouth because the anesthetic depth of the patient could not be adequately controlled. His deliberate nature and strong powers of observation allowed Snow to create a calibrated, temperature-compensated vaporizer for chloroform as well.13

Snow was unique among his colleagues in the 1850s in London. In a day when operations were still rarely performed, Snow specialized in anesthetics. In some ways, his expert knowledge allowed him entrée into the upper echelons of both social and physician circles, a status he could not have obtained had he not limited his practice. Perhaps this is best illustrated by his attendance on Queen Victoria for the birth of her last two children. Although Snow did not use his inhaler, he also did not induce the full anesthetic state in the queen. Rather, he strove for analgesia with chloroform, and in so doing, he created a form of obstetric analgesia, chloroform à la reine, which would persist in various forms over the next century.13

Aside from working out the physics of vaporization, Snow was intensely interested in outcome data. He studied every report concerning a death under anesthesia and oftentimes had data in advance of the published reports of death. He commented extensively on the death of Hannah Greener, thought to be the first death under anesthesia in the world.16 In his posthumous book, On Chloroform and other Anesthetics,17 published in 1858, Snow compiled the first 50 deaths under chloroform, with comments about the pathophysiology present. Snow's spirit of inquiry, which went from the bench top to the pathologic findings at death, helped him understand the nature of the anesthetic process and the agents that produced insensibility, thus the scientific underpinnings for a specialty.18

After Snow's untimely death, anesthesia faded into the medical background again. In larger cities, there were those who made most of their clinical income from providing anesthesia, yet it would not be until the advent of Listerism and the "taming" of infection that operations would become more frequent. As the number of operations increased, so did the need for anesthesia, and, unfortunately, mortality became an issue. Chloroform was responsible for deaths that seemed unexplainable. Ether appeared to be safer, yet the side effects of nausea and vomiting, and the prolonged induction when compared with chloroform, made ether a less-than-ideal agent. Surgeons began to search for alternative methods for the administration of anesthetics.

In 1884, Carl Koller, a resident in ophthalmology in Vienna, was introduced by Sigmund Freud to a new crystalline substance called cocaine. Koller sought a local anesthetic to replace ether anesthesia for operations on the eye; because fine suture material to close the eye wound did not exist, any postoperative retching potentially could cause the loss of vision. Thus when Koller's tongue became numb from droplets of a solution containing cocaine, he made the conceptual leap that this same solution could be applied to the cornea with similar anesthetic effects on the eye. Using the facilities of the laboratory in which he worked, Koller soon numbed the eyes of several animals, a fellow investigator, and himself. He took this new topical anesthetic to the clinic and used it with great success. On September 15, 1884, Koller's paper on the subject was accepted at the German Ophthalmological Society meeting in Heidelberg. Too poor to travel, his colleague, Dr Josef Brettauer, presented the paper for Koller.19

While Koller continued his career in ophthalmology, eventually emigrating to the United States, other physicians modified this new form of anesthesia into an alternative to general narcosis. One of the early practitioners was William Halstead, future chair of surgery at Johns Hopkins University, who was in Vienna at the time of Koller's discovery. Using cocaine topically, Halstead dissected down to a nerve and directly anesthetized it. Much of the work he did on himself, becoming addicted to cocaine in the process.20 Another of the pioneers of regional anesthesia was the German surgeon Carl Ludwig Schleich, who developed the technique of infiltration anesthesia.21 Combining infiltration techniques with the newly discovered lumbar puncture, August Bier, another academic German surgeon, initiated spinal anesthesia in the late 1890s. Working with his fellow, August Hildebrandt, Bier successfully cannulated the subarachnoid space of Hildebrandt and produced a satisfactory anesthetic state. Hildebrandt was unsuccessful in cannulating Bier's subarachnoid space; however, both men suffered postdural-puncture headaches.22 Ten years later, Bier described an intravenous regional anesthetic technique that is still referred to as the Bier block.23

At the same time when regional anesthesia was being developed in Germany, concern over the safety of chloroform, especially when compared with ether, was developing. In India, then a colony of England, a Chloroform Commission was seated in Hyderabad to attempt to determine which anesthetic agent was safest. Funded by the Nizam of Hyderabad, the 1888 study of anesthetic agents was an effort to find out if there was an intrinsic mortality associated with chloroform. The findings were tainted by the British medical officer in charge, Dr Edward Lawrie, who was a strong chloroform proponent, having trained in Edinburgh, chloroform's birthplace. The findings of the Hyderabad Chloroform Commission were not conclusive, and a second was ordered, which also was inconclusive. But what was important in these commissions is that physicians were studying anesthesia and trying to increase patient safety. For many physicians, the need for a specialty practice of anesthesia was slowly becoming apparent.24

Early in the 20th century, the AMA set up a commission to study anesthetics. A preliminary report was issued in 1908.25 All forms of anesthesia were accounted for, including spinal anesthesia and various combinations of inhalational agents. The conclusions of the report are interesting, for they foreshadow the development of a separate specialty:

[A]ll the newer methods demand expertness, experience, and special apparatus. They appeal especially to the surgeons who are equipped with the paraphernalia of expensive and highly specialized clinics. They are little suited to physicians in general practice. For the latter great class of practitioners, the old general anesthetics, chloroform and ether, will probably hold their own until increasing experience has enabled us to simplify and to make safe the newer and more novel methods.25

The commission had three very interesting recommendations:

1. That for the general practitioner, and for all anesthetists not specially skilled, ether must be the anesthetic of choice—ether administered by the open-drop method.

2. That the use of chloroform, particularly for the minor operations, be discouraged, unless it is given by an expert.

3. That the training of skilled anesthetists be encouraged and that undergraduate students be more generally instructed in the use of anesthetics.25

The third suggestion of the commission would take almost the entire 20th century to implement.

In 1905 in Brooklyn, New York, a group of 8 physicians and a medical student, led by Adolph Frederick Erdmann (Fig. 1-4), gathered to discuss the problem of anesthetics. These young physicians thought, like the AMA commission, that there was more to the giving of an anesthetic than simply dropping ether on a cloth held near the patient's face, and that discussions and a free exchange of scientific and practical information were needed.26 This was the second specialty group in the world that was created. The first was the London Society of Anesthetists in 1893, and it would become the catalyst for the development and recognition of physicians who were specialists in anesthesia.27 Thus the Long Island Society of Anesthetists was born. The society met quarterly, in the evening, with a short business meeting followed by the presentation of 2 or 3 papers and perhaps the demonstration of a new anesthetic technique or apparatus. Science aside, the society provided a support group for those seeking to improve their anesthetic skills and a forum at which to exchange ideas and deal with problems beyond the science of anesthesia.26

The group flourished and, in 1912, moved across the river to New York City, changed the organization's name, and became the New York Society of Anesthetists. Over the next 24 years, the society would grow, both in membership and in scope. Starting out as a New York City group, by the mid-1920s, the group encompassed all of the state. By 1936 it had become a national organization.28 The transformation focused on the recognition of physicians who primarily anesthetized patients as specialists.

The first significant political move of the New York Society was a motion put before the House of Delegates of the AMA asking for a Section on Anesthetics in 1912. The members of the society were concerned about nonphysicians giving anesthetics, and they echoed some of the findings of the AMA's Commission on Anesthetics some 6 years earlier.28 James Gwathmey (Fig. 1-5), the society's president, was developing a new method of anesthesia: rectal ether. Like chloroform, rectal ether could be unpredictable and needed to be administered by someone very familiar with its use and with the effects of anesthesia in general.29 The quest for a section within the AMA was, in some ways, the beginning of a quest for patient safety in anesthesia, a movement that would take the specialty by storm in the latter half of the 20th century.

The motion was denied by the AMA House of Delegates. However, Gwathmey and Francis Hoeffer McMechan (Fig. 1-6) gathered the defeated physician anesthetists and created the American Association of Anesthetists (AAA). This was the first national group of physician anesthetists in the United States who met the following year, 1913, for a day of papers, mostly clinical in origin, and a dinner, with spouses (Fig. 1-7). A day devoted to the science of anesthesia is memorable; the evening meal signified a group, however small, that was willing to be recognized as specialists in anesthetics and by uniting, to move the field forward.28

The AAA, and its successor, the Associated Anesthetists of the United States and Canada, were run by Francis Hoeffer McMechan. A third-generation physician who entered anesthesia against the advice of his physician father, McMechan had crippling rheumatoid arthritis and was out of clinical practice by 1911. He was a visionary who hoped to see, on a worldwide scale, the elevation of anesthesia to "stand shoulder to shoulder" with surgery and internal medicine. He realized that without a place to publish papers on the specialty and without a place to gather the news of the various societies and names of physicians practicing anesthesia, the specialty would be doomed. Convincing his friend Joseph McDonald, the editor of the American Journal of Surgery, to publish a supplement on anesthesia gave the physician specialty its first US quarterly. McMechan also edited the Yearbook of Anesthesia between 1914 and 1919, compiling all the papers published in the specialty in the preceding year into a single volume.30

McMechan also understood that the specialty would never develop as a discipline within medicine without a strong scientific underpinning. To that end, first nationally, and internationally in the mid-1920s, McMechan organized a society devoted to research in anesthesia. The International Anesthesia Research Society (IARS) brought together basic science researchers and the physicians most in need of their talents. Most importantly, the IARS sponsored the first journal in the world devoted to anesthesiology, Current Researches in Anesthesia and Analgesia.31

The education of physician specialists, especially in the postgraduate period, was another of McMechan's concerns. Partnering with Ralph Waters, an opportunity emerged at the University of Wisconsin in 1926 as the medical school transformed itself from a 2-year institution offering only basic science education into a 4-year curriculum with all the clinical sciences. One addition was a section on anesthesia, headed by Waters, in the Department of Surgery. Waters immediately began to teach anesthesia to medical students and interns. He collaborated with the basic science researchers, at first on problems of carbon dioxide absorbance, and later, through various members of his department, on all aspects of anesthesiology. Perhaps most importantly, Waters established the first residency training program in an academic center. The training was 3 years beyond the intern experience. Years 1 and 3 were clinical, with year 2 devoted to laboratory research. Two weekly conferences were established, one discussing the week's cases in a format similar to current morbidity and mortality conferences, and another devoted to the current literature in anesthesia. By 1933 the teaching program was the envy of the world, and Waters understood that one final step had to be taken. He sent one of his faculty members, and an early graduate of the program, Emery Rovenstine, to Bellevue Hospital and New York University to try to replicate the University of Wisconsin department. Rovenstine was successful beyond any expectation and, in some ways, his graduates would eclipse the contributions of Waters's graduates in the development of academic anesthesiology across the country.32

In 1929, the year of the stock market crash and the beginnings of the Great Depression, another pivotal event occurred in anesthesiology. The Anaesthetists Travel Club was organized by John Lundy at the Mayo Clinic. The group was created along the lines of the Society of Clinical Surgery, with members going to other members' institutions to see their anesthetic practice in action. It was a young man's group, with the oldest member Lahey Clinic anesthesiologist Lincoln Sise at 55 years of age and the youngest the Philadelphian and future first editor of Anesthesiology Henry Ruth at 30 years of age, and Mayo resident Ralph Tovell at 28 years of age. The average age was just 40 years. These young, influential anesthesiologists were those "standing in line" in the McMechan organization or those who believed that McMechan's international vision of the specialty, although important, would not solve domestic issues. The Travel Club would come to dominate the New York Society and become the nidus of leadership for the effort to create the American Board of Anesthesiology.33

Once there was an organization in place to address national issues, regular meetings of a society devoted to the specialty, a university presence, ongoing research into clinical problems, and a residency training program to continue to retain and transmit the knowledge already gained, some recognition of a physician practicing the specialty was important. The gains in clinical practice in the 1920s and 1930s are best summed up by Harold Griffith, a leading Canadian physician-anesthetist of the time when he wrote, in 1939, the following:

Seventeen years ago when I began to give anesthetics, the anesthesia equipment in the small hospital which has ever since been my hospital home, consisted of bottles of ether and chloroform and a few face masks. This was typical of the fairly well-equipped hospitals of that time. Today in that hospital there are eight gas machines of various models, suction equipment in every room, oxygen- and helium-therapy equipment, at least fifteen different anesthetic agents, and much technical equipment for their administration. This transformation has been taking place everywhere in anesthesia.34

Economic reasons played a role in the need to define a specialist in anesthesia, for physician anesthetists were not well compensated and faced competition from a number of groups. Surgeons, for example, could hire a nurse to help in the office and give anesthetics. The surgeon could then charge each patient a fee for anesthesia in addition to the fee for surgery. The income generated from the anesthetic fee was in excess of what he paid the nurse, and thus profitable. Likewise, hospitals could hire nurses to give anesthetics, charge a fee that cumulatively was in excess of the salaries, and make a profit. Finally, general practitioners would refer cases to surgeons with the caveat that they could give the anesthetic and collect the anesthetic fee.35

McMechan proposed an International College of Anesthetists and certified the first fellows in 1935. There were two serious problems with his certification process. First, and foremost, the clinical criteria were weak. The applicant only had to document 10 anesthetic cases, with lessons learned, to be eligible. In one instance, an intern on the anesthesia service for 1 month wrote up the necessary cases and was certified. In another, a surgeon who occasionally gave an anesthetic completed the necessary paperwork and was certified. With certificate in hand, he attempted to become the head of a hospital division of anesthesia. Second, the college had no standing with the AMA, and the certificate meant nothing "official" in the United States.36

Members of the Anaesthetists Travel Club, especially Paul Wood, John Lundy, and Ralph Waters, believed that certification was essential if anesthesiology was going to be recognized as an equal with all other specialty practices. Using AMA criteria, which included documentation of either postgraduate training in the specialty, or 2500 cases where the applicant had administered the anesthetic, Wood and his colleagues at the New York Society created a special classification of members called "fellows." This new form of membership was extremely popular, and the membership of the New York Society skyrocketed. Now national in membership, the society changed its name to the American Society of Anesthetists in February of 1936.37 In 1945 the American Society of Anesthetists became the American Society of Anesthesiologists (ASA).

The AMA took note largely through Lundy's efforts, and Waters, working closely with Erwin Schmidt (Fig. 1-8), the chair of surgery at the University of Wisconsin, was able to secure an agreement for the American Board of Anesthesiology (ABA) to be created as a subboard of the American Board of Surgery. Using AMA criteria, which included, in addition to the heavy clinical training, the stipulation that the physician had to be in full-time practice of the specialty, the ABA was created in 1938. The first written examination of the ABA was held in March 1939. It was an essay format, with 5 subject subheadings: pharmacology, anatomy, physics and chemistry, pathology, and physiology. There was an oral examination and a practical one at the candidate's place of practice.38

The New York World's Fair opened on April 30, 1939, the eve of World War II. In the Hall of Man, an anesthesiology exhibit (Fig. 1-9) allowed the general public to learn more about the specialty. The exhibit was paid for by the Winthrope Chemical Company at a cost equivalent to several million dollars today. This is important for two reasons: First, it demonstrated that anesthesia had enough of a market impact that industry was willing to spend lavishly to support such a display. Second, the clinical practice of anesthesiology had become both complex and commonplace enough that the lay public would recognize and want to learn about it.39

At the same time, Lewis Wright was hired by Squibb Pharmaceuticals to investigate new anesthesia drugs, among them curare. Wright was a self-taught anesthesiologist who, in midcareer, took a leave of absence from his job at Squibb and did a residency with Emery Rovenstine at Bellevue Hospital.40 It was to Rovenstine and Emmanuel Papper that he gave some of the first commercially prepared curare. Papper felt that the agent was a poor anesthetic because all the test animals stopped breathing when it was administered to them.41 It was Harold Griffith and Enid Johnson, of Montreal, who discovered the true value of curare in anesthesia.42

As the United States plunged into World War II, the anesthesia community was determined not to repeat the mistakes of World War I. Physician anesthetists had been in short supply and often ran from unit to unit training corpsmen in the administration of ether by open drop.43 By the early 1940s, anesthesia had become too complex for this to be successful. The leaders of the ASA worked with the advisers to the armed forces and developed short 90-day courses to train medical officers in the basics of anesthesia. These young physicians managed many horrific clinical situations and, applying what they learned, were able to decrease mortality.44 The case of Samuel Lieberman, who won the Legion of Merit for his work in the South Pacific, is illustrative. By using continuous spinal anesthesia, he decreased the mortality from abdominal wounds from 46% to 12.5%.45

Returning from the war, these physicians had tremendous clinical experience, especially with regional anesthesia. Nerve blocks were invaluable because corpsmen could take vital signs and talk to the soldier while the operation was ongoing, freeing the anesthesiologist to treat others. These military anesthesiologists had extensive experience with transfusion and fluid therapy. Returning to the United States, approximately 40% sought additional formal training. Thus the specialty expanded tremendously, not only because of the returning physicians, but also because surgeons exposed to the field work of the anesthesiologists demanded physician involvement in anesthesia.44

McMechan's vision of an international community of anesthesiologists came to fruition in the 1950s. The first world meeting of anesthesiologists had been scheduled for Paris in the spring of 1940 but was canceled as the German army took the city. By the early 1950s, Europe was starting to recover from the effects of the war and the original French organizers were still interested in seeing the meeting become a reality. Working within the European community and Canada, and with help from the World Heath Organization, preliminary meetings were organized and the structure of the World Federation of Societies of Anesthesiologists (WFSA) was created. The first World Congress, held at The Hague in the Netherlands in 1955, was a success despite the absence of the ASA. The WFSA wanted to bring the best clinical practice of the specialty to the fore; the World Congress was a way to bring first-, second-, and third-world anesthesiologists together to discuss problems and to seek solutions. The WFSA set up programs to share information with those in need of it.46

However, it would not be until the end of the 1950s that the ASA would join the WFSA. The reluctance on the part of the Americans was multifactorial. First, because dues to the WFSA were on a per capita basis, the ASA felt they would be providing most of the finances of the organization without an equal voice in its government. There was also reluctance on the part of some American anesthesiologists to join an organization that had communists among its members. Time, dialogue, and the performance of the WFSA eliminated those fears.47

Along with the international concerns, the specialty faced a challenge in the United States as well. There was a significant part of the anesthesiology community that believed no physicians should accept a contract for services and allow a third party, such as a hospital or other employer, to bill in the physician's name. Enforcement of this edict was done by the component societies of the ASA, for an anesthesiologist could not be a member if he or she was not a component society member. Furthermore, to be eligible to take the ABA examination, an anesthesiologist had to be an ASA member.48 In response to this, the Association of University Anesthesiologists (AUA) was formed. Most academic anesthesiologists were employed by the university for a salary, in violation of the ASA edict. The establishment of the organization is important not only as a protest, but because it underscores how important academics had become to the fledgling field in the 30 years between the creation of the Waters department to the first AUA meeting.49 It was a rapid expansion and one that continued to delineate the scientific underpinnings of the specialty. The AUA was also the first subspecialty society formed in anesthesiology and worked to promote scientific research and teaching in anesthesiology.

In the 1960s, the US federal government sought to support medical research and created the National Institutes of Health (NIH). Emmanuel Papper (Fig. 1-10) was invited to Washington DC, to help organize the new agency. Papper worked tirelessly to see that anesthesiologists were treated fairly by the NIH and were eligible for funding. However, he was unable to secure an independent study section for anesthesia, and the battle to obtain this for the specialty remains a leading agenda item for many.41

The 1970s was a decade of crisis for anesthesiology. To ensure billing commensurate with services, the ASA had endorsed a relative value guide that helped place a unit value on work done by the physician. Other specialties, including orthopedics and radiology, had adopted similar guides, but the Federal Trade Commission (FTC) thought this was a monopolistic practice. All of the specialties but anesthesiology agreed to cease and desist; the ASA went to court. After a 2-week trial, the judge ruled that the relative value guide did not represent a monopolistic practice; rather, it was simply a tool that applied monetary value differently in different parts of the country. In one of history's little ironies, 30 years after the verdict, the federal government now states the relative value guides are the preferred billing methodology. The 1970s also saw another federal government suit against the ASA for the fee-for-service rule. While there was little chance of a successful suit, the federal government, cautious after its defeat, agreed to a cease-and-desist order.50

The 1970s also oversaw the beginnings of the subspecialty movement in anesthesiology. Just before the beginning of the decade, the Society for Obstetric Anesthesia and Perinatology was formed in 1968. The group remains diverse with anesthesiologists, obstetricians, and perinatologists all presenting work of interest to the group.51 Likewise in the early 1970s, Maurice Albin and others interested in neuroanesthesia created the Society of Neurosurgical Anesthesia. John Mitchenfelder was the first president in 1973.52 Two years later, the American Society of Regional Anesthesia (ASRA) was reformed, although without knowledge of the group formed by Gaston Labat in the 1920s. Dedicated to the promotion of regional anesthesia, which also meant teaching and research, the society has grown and prospered. Publishing the first subspecialty journal, Regional Anesthesia, the society provided a place for a peer-reviewed publication in regional anesthesia. Coupled with the annual meeting, where information and demonstrations about the topic were presented, the society also provided a forum for anesthesiologists interested in pain medicine to interact. Eventually the society would change its name to the American Society of Regional Anesthesia and Pain Medicine and the name of journal to Regional Anesthesia and Pain Medicine emphasizing the importance of this emerging field in anesthesiology.53 Mid-decade, the Society of Cardiovascular Anesthesiologists came into being. This group disseminated information about cardiac bypass and the emerging fields of vascular surgery.

The 1980s, by contrast, witnessed the development of two organizations that have served anesthesiology well. The Foundation for Anesthesia Education and Research (FAER) is devoted to the promotion of research within the specialty. The group has a special interest in those just beginning their careers, and it has supported a successful starter grant program. Indeed many of the leaders of academic anesthesiology in the early 21st century began their careers with a FAER grant. At the same time when FAER was being established, the Anesthesia Patient Safety Foundation (APSF) was created. Its mission is simple: No patient should ever be harmed by an anesthetic. APSF has partnered the academic, private practice, and industrial communities to work toward decreasing anesthetic risk. The establishment of the Harvard standards of monitoring, at the beginning of the APSF, was an important step in this direction. APSF and its work is the model for the patient safety movement across the country, and it is used by the AMA as a model for its patient safety foundation.54

The subspecialty movement in anesthesiology continued into the 1980s. In 1987 the first meeting of the Society for Pediatric Anesthesia was held. An outgrowth of the anesthesia section of the American Academy of Pediatrics, the society strove to be inclusive of all anesthesiologists interested in the care of children undergoing anesthesia, not simply anesthesiologists in full-time pediatric practice. Another society formed in the mid-1980s was the Society for Ambulatory Anesthesia.55 In response to the growing trend of day surgery and having patients return home on the day of operation rather than spending a night in the hospital, the society strove and continues to strive for the highest standards in anesthesia care in the ambulatory setting.56 Likewise the American Society of Critical Care Anesthesiologists was formed to establish a forum where anesthesiologists interested in critical care could meet to exchange ideas and information.57

During the 1990s, the ABA recognized the trend toward subspecialization by creating special qualifications that could be added to board certification in anesthesiology in both critical care medicine and pain medicine. This trend continues to the present with added qualifications available in palliative care and pediatrics. One of the greatest challenges before anesthesiology currently remains the proper role for these credentials in the clinical setting and which subspecialties are appropriate to endorse for them.

By comparison with most other medical specialties, the history of clinical anesthesia is short. Perhaps Francis Hoeffer McMechan summed it best when in 1935 he wrote,

Anesthesia was the gift of pioneer doctors and dentists to suffering humanity, and every significant advance in its science and practice has been contributed by doctors, dentists, and research workers of similar standing. In contrast, technicians have added nothing of any consequence. Anesthetics are among the most potent and dangerous drugs used in the practice of medicine; they penetrate to every cell and organ of the body and may cause almost instant or delayed death by their toxic effects. The dosage of general inhalation anesthetics cannot be prescribed in advance but must be determined from moment to moment during administration. The dosage of local and other anesthetics must be determined by the risk of the patient, the nature and duration of the operation to be done—certainly a challenge to the knowledge and experience of the keenest doctor. No patient should ever be given an anesthetic whose condition and risk has not been diagnosed in advance of the operation, so that every resource of medical science can be used to lessen the risk and make the recovery more assuring. Certainly in this preoperative evaluation and the selection of the safest anesthetic and best method of administration, the medical anesthetist is more in a position to act as a consultant than a technician. .

The safety of the patient demands that the anesthetist be able to treat every complication that may arise from the anesthetic itself by the use of methods of treatment that may be indicated. The medical anesthetist can do this, the technician cannot. More recent developments have extended the field of medical anesthesia to include resuscitation, oxygen therapy, and therapeutic nerve block for intractable pain, and treatment of various conditions of disease, and the rehabilitation of the disabled—all fields of practice quite beyond the capacity of the technician.58

McMechan's vision of professionalism, and its 21st-century equivalents, needs to continue to guide the specialty. The history of anesthesia is interesting, filled with fascinating events and people, and replete with the highest examples of professionalism, and the best is yet to come!

• Bacon DR. The New York Society of Anesthetists: building the foundation. In: Bacon DR, Lema MJ, McGoldrick KE, eds. The American Society of Anesthesiologists: A Century of Challenges and Progress. Park Ridge, IL: Wood Library-Museum of Anesthesiology Press; 2005:9-18.
• Bacon DR. The World Federation of Societies of Anesthesiologists (WFSA): McMechan's final legacy? Anesth Analg. 1997;84:1130-1135.
• Bacon DR, Lema MJ. To define a specialty: a brief history of the American Board of Anesthesiology's first written examination. J Clin Anesth. 1992;4:489-497.
• Fenster J. Ether Day. New York, NY: HarperCollins; 2001.
• Goerig M, Agarwal K, Schulte am Esch J. The versatile August Bier (1861-1949), father of spinal anesthesia. J Clin Anesth. 2000;12:561-569.
• Griffith HR, Johnson GE. The use of curare in general anesthesia. Anesthesiology. 1942;3:418-420.
• Johansen PV, Paneth N, Rachman S, Rip M. Cholera, Chloroform, and the Science of Medicine: A Life of John Snow. New York, NY: Oxford University Press; 2003:113.
• Smith HM, Bacon DR. The history of anesthesia. In: Barash P, Cullen B, Stoelting R, eds. Clinical Anesthesia. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:3-26.
• Waisel DB. The role of World War II and the European theater of operations in the development of anesthesiology as a physician specialty in the USA. Anesthesiology. 2001;94(5):907-914.
• Wells CJ. Francis Hoeffer McMechan. Curr Res Anesth Analg. 1948;26(Suppl):1-19