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Chapter: Clinical Anesthesiology: The Practice of Anesthesiology

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Evolution of the Specialty

Following its first public demonstration in the United States, ether anesthesia quickly was adoptedin England.

EVOLUTION OF THE SPECIALTY

British Origins

Following its first public demonstration in the United States, ether anesthesia quickly was adoptedin England. John Snow, often considered the father of the anesthesia specialty, was the firstphysician to take a full-time interest in this new anesthetic. He was the first to scientifically investi-gate ether and the physiology of general anesthesia. Of course, Snow was also a pioneer in epidemiol-ogy. He helped stop a cholera epidemic in London by proving that the causative agent was transmitted by ingestion of contaminated well water rather than by inhalation. In 1847, Snow published the first book on general anesthesia, On the Inhalationof Ether. When the anesthetic properties of chloro-form were made known, he quickly investigated and developed an inhaler for that agent as well. He believed that an inhaler should be used in adminis-tering ether or chloroform to control the dose of the anesthetic. His second book, On Chloroformand Other Anaesthetics, was published posthu-mously in 1858.

After Snow’s death, Dr. Joseph T. Clover took his place as England’s leading anesthetist. Clover emphasized continuously monitoring the patient’s pulse during anesthesia, a practice that was not yet standard at the time. He was the first to use the jaw-thrust maneuver for relieving airway obstruc-tion, the first to insist that resuscitation equipment always be available during anesthesia, and the first to use a cricothyroid cannula (to save a patient with an oral tumor who developed complete air-way obstruction). After Clover, Sir Frederic Hewitt became England’s foremost anesthetist at the turn of the last century. He was responsible for many inven-tions, including the oral airway. Hewitt also wrote what many consider to be the first true textbook ofanesthesia, which went through five editions. Snow, Clover, and Hewitt established the tradition of phy-sician anesthetists in England. In 1893, the first organization of physician specialists in anesthesia, the London Society of Anaesthetists, was formed in England by J.F. Silk.

The first elective tracheal intubations during anesthesia were performed in the late nineteenth century by surgeons Sir William MacEwen in Scot-land, Joseph O’Dwyer in the United States, and Franz Kuhn in Germany. Tracheal intubation during anesthesia was popularized in England by Sir Ivan Magill and Stanley Rowbotham in the 1920s.

American Origins

In the United States, only a few physicians had spe-cialized in anesthesia by 1900. The task of provid-ing general anesthesia was often delegated to junior surgical house officers or medical students, if they were available.

The first organization of physician anesthetists in the United States was the Long Island Society of Anesthetists formed in 1905, which, as it grew, was renamed the New York Society of Anesthetists in 1911. The International Anesthesia Research Soci-ety (IARS) was founded in 1922, and in that same year the IARS-sponsored scientific journal CurrentResearches in Anesthesia and Analgesia (now called Anesthesia and Analgesia) began publication. In1936, the New York Society of Anesthetists became the American Society of Anesthetists, and later, in 1945, the American Society of Anesthesiologists (ASA). The scientific journal Anesthesiology was first published in 1940.

Four physicians stand out in the early devel-opment of anesthesia in the United States after 1900: F.H. McMechan, Arthur E. Guedel, Ralph M. Waters, and John S. Lundy. McMechan was the driving force behind both the IARS and Cur-rent Researches in Anesthesia and Analgesia, andtirelessly organized physicians specializing in anesthesia into national and international orga-nizations until his death in 1939. Guedel was the first to describe the signs and stages of general anesthesia. He advocated cuffed tracheal tubes and introduced artificial ventilation during ether anesthesia (later termed controlled respiration byWaters). Ralph Waters made a long list of contribu-tions to the specialty, probably the most important of which was his insistence on the proper educa-tion of specialists in anesthesia. Waters developed the first academic department of anesthesiology at the University of Wisconsin in Madison. Lundy was instrumental in the formation of the American Board of Anesthesiology and chaired the American Medical Association’s Section on Anesthesiology for 17 years.

Because of the scarcity of physicians specializ-ing in anesthesia in the United States and the per-ceived relative safety of ether anesthesia, surgeons at both the Mayo Clinic and Cleveland Clinic began training and employing nurses as anesthetists in the early 1900s. As the numbers of nurse anesthetists increased, a national organization (now called the American Association of Nurse Anesthetists) was incorporated in 1932. The AANA first offered a certification examination in 1945. In 1969 two Anesthesiology Assistant programs began accept-ing students, and in 1989 the first certification examinations for AAs were administered. Certified Registered Nurse Anesthetists and Anesthesiolo-gist Assistants represent important members of the anesthesia workforce in the United States and in other countries.

Offcial Recognition

In 1889 Henry Isaiah Dorr, a dentist, was appointed Professor of the Practice of Dentistry, Anaesthet-ics and Anaesthesia at the Philadelphia College of Dentistry. Thus he was the first known professor of anesthesia worldwide. Thomas D. Buchanan, of the New York Medical College, was the first physician to be appointed Professor of Anesthesia (in 1905). When the American Board of Anesthesiology was established in 1938, Dr. Buchanan served as its first president. In England, the first examination for the Diploma in Anaesthetics took place in 1935, and the first Chair in Anaesthetics was awarded to Sir Rob-ert Macintosh in 1937 at Oxford University. Anes-thesia became an officially recognized specialty in England only in 1947, when the Royal College of Surgeons established its Faculty of Anaesthetists. In 1992 an independent Royal College of Anaesthetists was granted its charter.

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