In the latter part of the 1890s, a few US anesthesiologists assumed teaching and leadership roles. Two women established the beginnings of what might be thought of as departments in the early 1900s. Isabella Herb practiced anesthesia at Augustana Hospital in Chicago, in 1922 becoming president of the first nationwide anesthesia society, the American Association of Anesthetists (AAA). In 1898, Mary Botsford practiced anesthesia at the Children’s Hospital of San Francisco. In 1922, she led the effort to found the Anesthesia Section of the California Medical Association, and was its first president. In 1930, Botsford became president of the Associated Anesthetists of the United States and Canada, an organization that evolved from the AAA.

Although many giants contributed to the development of the specialty in the 1930s, three stand out, leaders who dramatically expanded the depth of training, clinical care, and research in anesthesia. These were Ralph Waters, Henry Beecher, and Robert Macintosh.

A chance visit by Ralph Waters to the University of Wisconsin, and the desire of the then chair of surgery, Erwin Schmidt, to improve the quality of anesthetic delivery at Wisconsin, led to Waters’ appointment as an Assistant Professor of Anesthesia in January 1927. Surgery was beginning to repay its debt to anesthesia! Waters thus chaired the first department of anesthesia (as opposed to a division of a department of surgery) in the US [13]. (¹However, an alternative “first” may exist.) [19]

Waters developed an academic department dedicated to optimum patient care, education of medical students and interns, post-graduate education, and research into the scientific foundations of anesthesia. Roughly following the example set by departments of surgery, he created a 3-year post-graduate residency program. He expected graduating residents to serve as leaders, thereby imposing his vision for academic anesthesia across the country. His graduates, and, in turn, graduates of their programs established most US academic programs. For example, Saidman, an editor of this book, held the chair at the University of California, San Diego. He traced his academic heritage back through Stuart Cullen (UCSF), through Emory Rovenstine (Bellevue), and then to Waters (U Wisconsin). The University of Wisconsin residency program also served as a model for early programs in GB and Canada.

In contrast to Waters’ emphasis on clinical care, the second great department in the US emphasized research. In 1936, Harvard appointed a partially trained surgeon, Henry Beecher, as an instructor in anesthesia and, incidentally, the Anesthetist-in-Chief in the Division of Surgery. That is, Harvard designated someone with no training in anesthesia to oversee anesthetic delivery.

“Beecher responded to the challenge by teaching himself how to give anesthetics, by writing a textbook on The Physiology of Anaesthesia, and by introducing the basic principles of laboratory research to the clinical practice of anesthesia. His efforts were rewarded when he was appointed Henry Isaiah Dorr Professor of Research and Teaching in Anaesthetics and Anaesthesia, a Chair that had been funded originally in 1917. In 1938, he thus became the first incumbent of the first Chair to be endowed in anesthesia.” [13]

“Dr. Beecher’s ‘hands on’ clinical performance was not the cause of many accolades.”² Conversely, Beecher was a superb investigator whose work reflected well on anesthesia. He advanced our understanding of the power of the placebo [20]. He observed that the brain controlled the perception of pain [21]. He gave us one of the first outcome studies (more about that later), a study that stands today as one of the best of its kind, one showing that anesthesia could kill patients [22]. And finally, he established ethics as an important arm of anesthesia and medicine (more about that, too, later) [23]. He truly was a giant.

Academic anesthesia in GB owes much to bicycles built by William Morris (Lord Nuffield) [13]. His successful business morphed into the profitable production of automobiles, first the Morris Bullnose that went 50 mph, got 50 miles to the gallon, and defeated Ford in Great Britain. Fortunately for anesthesia, Morris enjoyed golf and purchased the Huntercombe Golf Club, a club frequented by physicians, including New Zealand born anesthetist, Robert Macintosh. Morris wished to found a school of medicine at Oxford and told his physician friends that he intended to underwrite the establishment of chairs in medicine, surgery, and obstetrics, the then dominant triumvirate. Macintosh smiled and asked why anesthesia had been omitted? Morris had been pleasantly anesthetized by his friend Macintosh, and after a bit of reflection, Morris added a fourth’an anaesthetic’chair to his potential bequest. Oxford first refused (anesthesia was unworthy) but relented when Morris threatened to withdraw his offer for all of the endowment. He also sweetened the bequest from 1.2 million pounds to 2.0 million pounds. So was born the Nuffield Chair of Anaesthetics in 1937, the first occupant being Macintosh, later Sir Robert. World War II dictated a clinical direction for the first years of the department, and only after that war did Oxford contribute information vital to the basis for anesthesia, continued under the guidance of Sir Keith Sykes, one of the contributors to the present history.

Why Waters, Beecher, and Macintosh? Is it the Willie Sutton Principle? Recall that Sutton, a bank robber, was asked why he robbed banks? Answer: “Because that’s where the money is!” Waters, Beecher, and Macintosh because that’s where the physician-anesthetists of the world were’half in the US and much of the rest in GB.

In 1929, in Australia only Rupert Hornabrook and Fred Green in Melbourne, and Gilbert Brown in Adelaide were full time anesthetists. Geoffrey Kaye, a young and enthusiastic doctor had shown a keenness for anesthesia, despite it being considered “suitable only for the physically unfit or the unambitious”. He attended the Australasian³ Medical Congress, which had newly established a section of anaesthetics, and met Francis McMechan. He was to become McMechan’s protégé leading to lifelong communication with Waters, McKesson, Lundy and others. In 1932,Practical Anaesthesia, the collated work of several anaesthetists, edited by Kaye, appeared in Australia.

In 1934, the Australian Society of Anaesthetists was founded. A diploma course began at Sydney University in 1944, and at Melbourne University in 1946. In 1946, Kaye established the teaching centre at Melbourne University, together with a library and museum, and in 1948, Kaye assisted in forming The New Zealand Society.

In 1949, Harry Daly, President of the Australian Society of Anaesthetists, negotiated with the College of Surgeons (representing both Australia and New Zealand) to establish the Australian Faculty of Anaesthetists.

In 1932, Henry Featherstone and Ivan Magill guided the founding of the Association of Anaesthetists of Great Britain and Ireland (AAGBI).

In 1935, Magill assisted in the inauguration of the Diploma in Anaesthesia (DA), awarded by the Anaesthetic Section of the Royal Society of Medicine. The Diploma was not quite awarded by anesthetists [13]. Magill and the Association of Anaesthetists of Great Britain and Ireland struggled to provide the diploma, but it could not be awarded by the Association because the Association was not “an Examining Body”. To bypass this impediment, a Conjoint Board of the Royal Colleges of Physicians and Surgeons (surgeons again to the rescue) conducted the examination. Anesthetists gained control of the process after World War II, in 1948.

Soon after the conclusion of World War II, universities at Bristol (1946), Newcastle-upon-Tyne (1949), Cardiff (Welsh National School of Medicine; 1952) and Liverpool (1959) created Departments of Anaesthesia. Cecil Gray and his colleagues popularized the use of curare (d-tubocurarine), creating the ‘Liverpool technique’ a forerunner of balanced anesthesia. Research blossomed in support of new surgeries that required controlled ventilation and circulation.

In 1948, AAGBI Diplomates were in place when anesthesia was recognized as a medical specialty in GB. The Faculty of Anaesthetists formed within the Royal College of Surgeons, and the Fellowship Diploma was instituted (FFARCS). AAGBI representations to the Spens Committee led to equal status and pay of the all-too-few anesthetists with other hospital-based specialists.

In 1934, the French Society of Anesthesia and Intensive Care (originally the Société Française d’Etude de l’Anesthésie et de l’Analgésie’name changed to the current one after 1957) was founded, but became inactive during World War II. It was reborn in 1946, the Société Française d’anesthésie et d’analgésie (SFAA) with 117 members, mostly French surgeons but including 17 anesthetists.

Until 1947, surgeons directed anesthesia and received all fees, with about 10% given to “assistants”. Anesthetists provided all drugs and equipment, prompting the use of the least expensive approaches to anesthesia. In 1947, the newly created Chair of Surgical Techniques in Paris assembled a 6-week course supplemented by a 6-month hospital assignment supervised by surgeons or physicians. Students (doctors and nurses) completing this course received a “Certificate of Anaesthesia”. Article 45 of the code of practice gave the French “surgeon… the right to choose his operating assistants as well as the anaesthestist.” Anesthesia was only a “competence”. From 1947, “Special anaesthesia” given by a qualified anesthetist was paid separately from the surgeon’s fee. Progress!

In 1948, examinations were added to the 6-month course for doctors, leading to award of the Diplôme d’Anesthésie-Réanimation (Diploma in Anaesthesia and post-operative care). French nurse anesthetists continued to receive the Certificate of Anaesthesia, which now required successful completion of a written examination. From 1948 to 1973, nurse anesthetist training schools opened in France and trained 1500 students. From 1960, almost all cities with universities had a nurse-anesthetists school. Passage of an examination led to theCertificat d’Aptitude aux Fonctions d’Aide Anesthésiste. Like physicians, nurse anesthetists organised training programs and trade unions, and worked in accordance with statutes that they had devised. They competed with doctors, producing antagonisms yet to be resolved. However, in contrast to the case in the US, they could not work independently.

Having trained with Beecher in 1938, in 1940, Torsten Gordh introduced anesthesia training in Sweden, occupying the first position established for an anesthesiologist in Scandinavia and mainland Europe, at the Karolinska Hospital in Stockholm. Then and in subsequent years, nurses (learning from on-the-job experiences) gave anesthesia in Nordic countries and surgeons carried the responsibility. Many surgeons argued that anesthesia should be established as a medical specialty, and positions for physician anesthetists were increasingly funded in major hospitals. Pioneer Nordic anesthesiologists usually trained abroad. They included Trier Mørch and Ole Secher (Denmark); Eero Turpeinen (Finland); Elias Eyvindsson (Iceland); Otto Mollestad and Ivar Lund (Norway); and Gordh (Sweden).

Nordic societies were established soon after World War II: the Swedish Society of Anesthesiologists was founded in 1946; the Norwegian Association and the Danish Anesthesia Association in 1949; the Finnish Society of Anesthesiologists in 1952; and the Icelandic Society of Anesthesia and Intensive Care in 1960. In 1949, Nordic pioneers founded the Scandinavian Association of Anesthesiologists.

With the return to peace after World War II, 1-to-3 year anesthesia training programs arose in Europe. The average mandated period was 2 years, matching that in the US and focusing on anesthetic delivery. In 1947, the Dutch organized a national training curriculum, and the Unitarian Service Committee sent American anesthesiologists to Austria, to lecture on and demonstrate modern anesthetic techniques.

In 1948, the Netherlands Society of Anesthesiologists was founded and anesthesia was recognized as a specialty. The Belgians and Italians began training courses.

In 1949, the World Health Organization (WHO) and Denmark (Copenhagen) jointly established a one-year course for anesthesiologists in theoretical and practical techniques of delivering anesthesia. This successful course was repeated 23 times, continuing to 1972.

While working in Germany, in 1949, American anesthetist Jean Henley completed the first modern German anesthesia textbook,Einführung in die Praxis der modernen Inhalationsnarkose (Introduction to the Practice of Modern Inhalation Anaesthesia). German authors soon followed suit. In 1981, the German Society of Anesthesiology and Intensive Care Medicine awarded Henley an honorary membership.

The Mexican Society of Anesthetists was founded in 1934. In Brazil, aspects of training in anesthesia were established and expanded to the first Brazilian specialty school in 1941. By 1946, Mexico was sufficiently large to organize its own congresses, while other Latin American countries joined regional organizations. In 1947, Marín founded the first “School of Anesthesia” for Columbian physicians, and teaching of clinical anesthesia began in Uruguay. In 1948, Vicente García Olivera created the first center for pain treatment in Mexico.

In 1934, the Nippon Dental Junior College initiated the first anesthesia department in Japan.

World War II and the following civil war had devastated China. Anesthesiology had to rebuild from the basic delivery of open-drop ether or chloroform or regional/spinal anesthesia. It spread outward from Shanghai and Beijing. Physicians, students, nurses, nuns, and technicians, and only a few professional anesthesiologists (e.g., Yueqing Ma from Peking Union Medical College) delivered anesthesia. The founders of Chinese anesthesiology (Jone Wu and Xingfang Li from Shanghai; Deyan Shang, Rong Xie and Huiying Tan from Beijing) returned from the US and Europe with modern ideas concerning anesthetic delivery. Shang established the first Department of Anesthesiology in China in the National Lanzhou Hospital.

The first anesthetic by Horace Wells delivered 100% nitrous oxide from a bag, thereby imposing hypoxia’interrupted by periods of inadequate anesthesia while the patient breathed room air. The former of these troublesome limitations could be dealt with as Edmund Andrews suggested in the 1860s, by adding oxygen to the nitrous oxide. Over the succeeding 30–40 years various advancements led to gas machines, such as that invented by Teter (a dentist) in 1902, that delivered a variable mixture of oxygen and nitrous oxide, each controlled by separate but inaccurate valves and without an indication of percentage or flow. Kuppers’ 1908 invention of the rotameter allowed delivery of a precisely measured gas flow and known oxygen/nitrous oxide concentrations. The German, Neu, used rotameters to precisely deliver readable flows of anesthetic gases from the Rotameter Company’s new anesthesia machine. Other machines in the 1900s allowed the addition of ether or chloroform to compensate for the limited potency of nitrous oxide.

In 1915–16, Dennis Jackson described a carbon dioxide absorption system for delivery of rebreathed anesthetic gases [24,25]. This was not immediately widely applied but laid the groundwork for modern anesthetic delivery. Jackson had suggested the use of the circle absorption system but used a solution of base to accomplish carbon dioxide absorption’an impractical solution.

By 1920, Dräger machines could deliver nitrous-oxide-oxygen-ether (the so-called gas-oxygen ether or GOE anesthetic). Gauss gave acetylene as an anesthetic, but explosions limited its acceptance. The high import costs of nitrous-oxide led to the use of rebreathing to minimize its consumption. In 1923, Waters introduced the to-and-fro carbon dioxide absorption system allowing low gas flows and rebreathing.

In 1925, Drägerwerk of Germany developed the first circle breathing system for use in their Model A anesthesia machine. There were separate hoses for inhalation and exhalation; large, low resistance, thin mica unidirectional valves that forced the gases to move in a circle; a cartridge for the soda lime; a reservoir bag, and a pressure-limiting valve’all the ingredients found in modern circle systems.

However, in 1930, McKesson departed from the direction of anesthetic equipment development described above by introducing the McKesson-Nargraf machine (Fig. 6.3). It could (deliberately) deliver lethal concentrations of oxygen, as suggested by an experience reported by Gerald Zeitlin [26]:

“Let’s return to the Whittington Hospital on the high and leafy hills of North London. The Senior Consultant in Anaesthesia was named Otto by his parents, the Belams. I called him ‘Sir’. One quiet afternoon Dr. Belam asked me if I would kindly replace him at a dental surgeon’s office in a shopfront in nearby Holloway Road.

“’All she needs for her extractions is some gas from a McKesson machine. She keeps open on Wednesday evenings for the working men. She is very quick. Get there just before six.’

“The dentist was a middle-aged lady with frosty hair. She met me in her empty waiting room.

“’Otto phoned me you’d be coming. Go in there and fiddle with his machine. The first one’ll be here in ten minutes. No fillings. Just exodontia on Wednesday evenings.’

“I had never seen such an anesthesia machine before. I ‘fiddled’ with it. I peered at the dial at the top. This indicated that by turning the dial one could deliver a mixture of two gases, in precise percentages from zero to one hundred; or from one hundred to zero. Very ingenious. And it made sense, to be able to vary precisely the percentage of oxygen the patient breathes. I read an engraved label indicating that the McKesson Company in Toledo, Ohio, had made it. I had never encountered an American machine before. I stood back to gain perspective.

“Then I saw the ugliness of my situation. The only two gas cylinders attached were one each of nitrous oxide and oxygen. Nitrous oxide is a very weak anesthetic agent: so feeble at rendering people unconscious that it has become known as ‘laughing gas’, that is, it makes you drunk and giggly. Never before had I given it without adding something more potent, ether and more recently, halothane.

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