This is the last in the series and I intend to end it by presenting the evolution of the administrative, social, and academic life of physicians professing anaesthesia as a domain of modern medicine.
We will start by looking around to see who in fact was administering anaesthesia in the operating theatres after 1846 (the so called “Morton’s year”) as this new technique became an indispensable part of surgery in the second half of the 19th century. Morton was a dentist, J.Y. Simpson a surgeon-obstetrician, and John Snow a doctor involved in London’s hygiene and water supply. Other physicians involved in providing anaesthesia, in the USA, Britain, France, Russia, and Austro-Hungary, were surgeons. Later, pharmacists, nurses, and other professionals, as well as sometimes non-medical staff, became involved in administering anaesthesia. Most of the names cited as contributors to the development of anaesthesia methods and devices were surgeons such as J. Lister and W. Squire in Britain, A. Velpeau and J.F. Malgaigne in France, N. Pirogov in St. Petersburg in Russia, or Russ in Iassy, Romanian Moldavia.
Starting in 1846 ether anaesthesia spread quickly throughout the US and Europe and beyond. This global effect, all over the world, supposed a good communication system permitting the circulation of journals, documents, and even contacts between interested persons. This happened by all existing means: letters, publications, scientific and daily journals, professional visits, meetings, and conferences, most of them organized on a spontaneous basis.
Anaesthesia as a separate medical domain
In the second half of the 19th century, in spite of the immense services it provided (along with antisepsis and sterility in surgery), anaesthesia had the status of a stepchild and was regarded, especially by surgeons, as a second hand preoccupation usually to be entrusted to the youngest newcomers in the department, to nurses, or even to nonmedical staff. One of the late effects of this attitude was the creation of the profession of nurse anaesthetist, still existing these days in some countries.
Along with the practice of the new volatile administration, the concept of anaesthesia as a new medical domain began to spread and people concerned with this practice met and, with time, constituted professional and scientific associations of specialists, which, with increasing numbers of members, started not only to exchange knowledge but also to spread the idea, using every means, and more specifically medical journals. Later, the same associations fought to impose recognition of the specialty in the administrative and academic fields.
At the beginning the association had only limited scientific and practical goals but soon new problems imposed the specification of the position of anaesthesia in medical administration, which implied economic, but also academic, aspects.
The strong wish of some physicians to consider themselves as being entirely devoted to anaesthesia arose very soon after 1846; we already mentioned J. Snow as the first dedicated physician anaesthetist. We also know about some other names such as Clover, Waller, Hewitt, Featherstone, McIntosh, Maggill, McKesson, Boyle, Schmidt, Von der Poorten, and Kilian, who considered themselves anaesthesiologists and tried to create associations and later to oblige the professional and official administration recognition of this new specialty. As anaesthesiology was born inside surgery, which itself was a very strong and self-conscious guild, most of the surgeons considered anaesthesiologists as their subordinates, keeping them as such in their departments. So the battle to establish this new specialty became a struggle for independence. The battle usually started with the constitution of professional associations in the US, Britain, and France before WWI. In fact the first one was the Long Island Society of Anesthesiologists founded in 1905. In 1911 it became The New York State Society of Anesthesiologists. With the refusal of the American Medical Association to create a section of anaesthesia in that early period, it was only in 1936 that the American Society Anesthesiologists (ASA) was created and the American Board of Medical Specialties recognized Anesthesiology as a new medical specialty.
In Britain the Association of Anaesthetists was founded in 1932 by H.W. Featherstone. This trend continued with the introduction of the DA (diploma of anaesthetics), constituting the certification of a specialty that had dedicated journals since 1923 (British Journal of Anaesthesia) and textbooks edited by C.F. Hardford.
More scientific journals showed up: Anesthesiology in 1940 in the US, and Anaesthesia and Synopsis of Anaesthetics in Great Britain in 1946 and 1947, respectively.
The first department of anaesthesia was founded in 1937 in Oxford: The Nuffield Department of Anaesthesia, attributed to Sir Robert McIntosh. In the USA the specialty was certified in 1938 and in Canada in 1942 under H. Griffith, who introduced curare in the current practice of anaesthesiology. All other countries in Europe and elsewhere recognized anaesthesiology as a specialty only after the end of WWII. In 1950 the Scandinavian Society was born as an initiative of T. Gordh. 1953 was the birth year of the World Federation of Societies of Anaesthesia (WFSA) in Scheweningen, near The Hague in The Netherlands. We must mention that at the time many countries had no societies of anaesthesia and thus some of them were represented at this important meeting by anaesthesiologists, but also by surgeons and other specialists as was the case with Romania, which was represented by my surgical boss and great supporter of anaesthesia, the late N. Hortolomei. At that time only some countries had societies of anaesthesia, but many others had sections of anaesthesia of national surgical societies. There were, still, some countries with no professional anaesthesia associations whatsoever.
To my knowledge, at that time, the year of creation of WFSA, only Britain, Brazil, Czechoslovakia, France, Germany, India, Italy, Holland, the Scandinavian countries, Israel, and the USA (the list might be incomplete) had real societies of anaesthesia. The majority of other countries created similar societies later on and we can assume that as per today almost all of the existing countries in the world have their anaesthesiology societies.
Anaesthesia as an academic field of activity
The academic involvement of anaesthesiology had a similar evolution. At the beginning there was no organized teaching in this domain. Anaesthesia was not taught, it was copied or ‘stolen’ by observation or in demonstrations. Regional anaesthesia, especially, progressed due to surgeons like Schleich for local, Bier and Thoma Ionescu for spinal, Dogliotti for epidural technique, and Kulenkampff for brachial plexus anaesthesia. Medical teaching in general was dominated for many years by pioneers, and since anaesthesia was in its beginning phase of evolution, the few existing specialists made what they could by writing books and teaching other physicians any time they had a chance to do it. It is worthwhile to mention the fact that some surgical manuals and textbooks included chapters on anaesthesia, which was considered a surgical activity. Anaesthesia was taught in the surgical curriculum of oral courses for students. The necessity for teaching anaesthesia as a separate specialty was first mentioned by Frederick W. Silks, who pleaded for a ‘systematic teaching in anaesthesia’ to ‘parallel’ the progress made by surgery (cited from A. Mody), and also in the 1898 editorial of the Journal of the American Medical Association, which advocated that ‘only a competent man should administer anesthetics’ and advised to get rid of ‘indifferent’ anesthetists (cited from A. Mody). Once started, the process evolved step by step due to leading minds in both UK and the USA. Other countries came from behind. It seems that organized education in anaesthesia started in Great Britain with the initiative of D.W. Buxton (University College Hospital), who proposed the inclusion of performance of 50 anaesthetic procedures in the final year of medical student education. In 1912 F. Hewitt introduced in the British Parliament an initiative to forbid the performance of anaesthesia by non-medical personnel. Later on, the General Medical Council included the ‘bona fide’ study of anaesthesia (cited from A. Mody). But in fact real standardized education in anaesthesia started in the USA in Madison, Wisconsin, where the chief surgeon Erwin Schmidt in 1927 called on Ralph Waters to establish an academic program for anaesthesia at the local medical school. The program of Waters, who also introduced, in cooperation with Arthur Guedel, an original tracheal tube, included a 3-year post-internship. From the same city, Madison, came the idea of organizing structured teaching programs in anaesthesia, later reaching New York with E. Rowenstine, Sweden with Gordt, India with B. Sucar, and many other places. In fact Sweden was, along with Great Britain, the only European country to introduce structured teaching in anaesthesia before WWII.
After 1945 many countries became exposed to US and British modern views on anaesthetic practice and teaching. Sir Robert Macintosh, already professor at Oxford, was one of the most loved and appreciated ambassadors of modern anaesthesia. The diploma of Fellow of the Faculty of Anaesthesia of the Royal College of Surgeons (FFARCS) was introduced in 1953. In 1992 it became the Diploma of the Royal College of Anaesthesia (FRCA). Many young doctors from countries all over the world went to UK and the US and brought back home the newly acquired knowledge and experience. While Czechoslovakia and Poland from the Eastern countries had early contact with Western anaesthesia, in others, like my own country (Romania), this was forbidden and we had to proceed on our own with scarce literature and a lot of imagination. In France the first professor of anaesthesia was a surgeon, J. Baumann (1958), and only later Guy Vourc’h, an English-instructed anaesthetist, took the chair.
After 1960 the majority of European countries had their anaesthesia speciality recognized, the specific societies constituted, and the academic-teaching system included in universities’ curriculum. Many countries issued their own journals of anaesthesia and critical care.
Organization of anaesthesia departments
Quite the same evolution characterized the evolution of the independent departments of anaesthesia. Everything started with anaesthetic sections, as part of the surgical department, being thus directly under surgical control. From there it continued to different forms of independent departments or institutes (in Germany and Austria), but not being outfitted with beds. Later a recovery room (sale de reveil in France) functioned under anaesthesia. A turning point occurred in 1952 during the polio epidemic in Denmark. A new pattern of evolution of the disease showed up, its bulbar form replacing the classical Landry ascending form. Until then, the only classical respirators were the cuirass respirators. They were not suitable to be used on patients with swallowing problems. This led H.C.A. Lassen, professor of infectious diseases in Copenhagen, to call on B. Ibsen, an anaesthesiologist, to solve the problem of aspiration of gastric content and ventilation. Ibsen intubated and then tracheostomized the patients and ventilated them with Waters anaesthesia breathing systems. This crucial episode led to extension of the method to other types of respiratory insufficiency and later to interdisciplinary respiratory units under the control of anaesthetists. As in the case of respiratory insufficiency, renal acute insufficiency could also be treated by dialysis, a new invention (1943-45) of W. Kolff. The artificial kidney joined the ventilators in special units called Intensive Care Units (ICU). These new units appeared and developed in parallel directions, as surgical, general, interdisciplinary, or medical IC units. In some places ICUs were included in the anaesthesia departments, in others they appeared as separate departments, generating in some countries a separate specialty. In France the medical and surgical trends developed simultaneously by J. Mollaret, while J. Lassner, Kern, and G. Vourc’h developed the surgical branch (the so called Reanimation). In many other countries, such as East Germany, Austria, Romania, Poland, and Czechoslovakia, the anaesthesia profession included from the beginning the intensive care branch, in the beginning only surgical and only later general intensive care.
The anaesthesia profession continued to develop and in some countries pain clinics created by J.J. Bonica (Seattle) and R. Frey (Mainz) showed up. Both were also the initiators of pre-hospital Intensive Care Emergency Medicine.
To conclude, for the time being, there is no standardization in the organization of the mentioned components of anaesthesiology. Solutions vary from centralized units including operating room (OR) care, pre- and post-OR care, general intensive care, emergency receiving sector, pre-hospital emergency care, and pain clinics. The names of departments also differ widely. We already mentioned some, such as Anaesthesia Department, Anaesthesia-Intensive Care Department, Reanimation, Reveil, Cardiac Intensive Care, and Neurological Intensive Care. For the time being the whole administrative concept is under debate, all parties pretending to offer a satisfactory service to patients. And that is the main problem: which one is really best? Hopefully, the future will give us the answer.
Maybe the solution would be the decision to have one big domain, Anaesthesia and Intensive Care Medicine, with sub-specializations for every specific activity in different working places, acting in accordance with specific regulations in each country.
As time is flowing, working conditions are continuously changing and adapting to the progress of medicine and of science in general and so the curriculum in training centres, in universities, as well as in the administration’s organization have to keep pace with this progress.
What will be, will be, but administrators of the medical system have the duty to assure the best care to our patients and not to serve the narrow interests of some staff members.
The end of a long successful history
We reached the final point, the last data in the long series of dramatic events that have led to the appearance and consolidation of anaesthesiology (or anaesthesia for some) as a completely separate medical profession, acting in a well-established framework and with tremendous successes regarding patient safety and outcome of anaesthesia practice. The history is a dynamic science; nothing stays in the same place.
Soon there will be a need for other people to take the story from this very point and move on. I wish them good luck and a feeling that they belong to a successful specialty, and with a very promising future.
Chief Editor’s note
More than three years ago I asked my mentor and guru, Prof. Dr. George Litarczek, the founding father of Romanian anaesthesiology, to accept the challenge and start writing a 12-episode history of modern anaesthesia.
Today we have reached the final episode.
As already mentioned in the last ESA Newsletter issue, Prof. Litarczek is today 90 years old, still active in the domain of teaching new generations of young anaesthesiologists and sharing with them some of the most interesting and dramatic stories of our profession.
The time comes to thank George Litarczek, not only for the superb job done for this Newsletter, but also (or mainly) for his tremendous contribution to the development of Anaesthesiology as a modern medical field, for educating thousands of professionals, and for his permanent dedication to our common profession and to the safety of our patients.
Geo, we all wish you years of health and personal satisfaction.