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September 2000
Volume 64 |
Number 9
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| The Genesis of
the American Society of Anesthesiologists |
Bradley E. Smith,
M.D.
At the outset of the 21st century, ASA has become the world's
largest anesthesia society with more than 36,000 members and has
been responsible for many advances in the worldwide practice,
science and teaching of anesthesiology. Nevertheless, ASA today
finds itself beleaguered with demands and restrictions from business,
legislature and the courts that seem to directly attack our profession.
In this time of stress, we can perhaps extract some solace, and
certainly tremendous pride, from a review of the tribulations
of our professional forebearers who established and nourished
ASA. One will not be surprised to see that the establishment and
maintenance of professionalism in the practice of anesthesiology
was a central theme of our predecessors, even before ASA was established!
Depending on definitions and sources, the first full-time anesthesia
physicians in the United States may have been Isabella Herb, M.D.,
of Chicago and the Mayo Clinic; H.O. Hermance, M.D., of Philadelphia;
Mary Botsford, M.D., of San Francisco or Thomas Bennett, M.D.,
of New York City. At any rate, there were precious few physicians
specializing in anesthesia even 50 years after the discovery of
ether, and their numbers continued to expand slowly for another
50!
In 1912, James T. Gwathmey, M.D., published that American mortality
rates for anesthesia were one death in 5,623 anesthetics, three-fold
greater than in the United Kingdom where physician anesthetists
by then were on duty in almost all major hospitals. He was the
first to widely publicize his opinion that the unfavorable comparison
was due to the lack of training of physicians in the United States
and the common use of nurses to administer anesthesia.
In 1909, he made a clear statement of the problem of professionalism
in anesthesiology that could almost have been written today. He
wrote, "a curettage performed even by a trained nurse is
by statute a crime punishable by imprisonment. Yet there is less
reason that a nurse should administer an anesthetic than to attempt
a curettage." During these early years, the surgeon paid
either a physician anesthetist or an ether nurse from his surgical
fee. Many physicians who desired to practice anesthesia could
not become established under this abusive system. Gwathmey also
stated that "the anesthetist should as was already the practice
in the United Kingdom] send his bills directly to the patient,
thus establishing his identity and independence. Under this system,
the anesthetist can stand as high in the profession and make as
good a living as other physicians."
The world's very first anesthesiology society was the London
Society of Anaesthetists, formed in 1893. In 1905, Adolph F. Erdmann,
M.D., and eight other New York physicians formed the first anesthesia
society in the United States, the Long Island Society of Anesthetists.
Its purpose was "to promote the art and science of anesthetics."
In 1912, this society reconstituted itself into the New York Society
of Anesthetists (NYSA), whose first president was Dr. Gwathmey.
(Dr. Gwathmey also was simultaneously president of the American
Association of Anesthetists, a direct antecedent of the International
Anesthesia Research Society.)
In the next two decades, there were almost as many anesthesia
societies as anesthesiologists, each with regional, national or
international interests. Two strong factions emerged. The first
group was those who would totally abstain from any form of recognition
or collaboration with nurse anesthetists, led by Francis H. McMechan
(who also established Anesthesia & Analgesia in 1922). The other
group, centered in the NYSA, identified with Paul M. Wood, M.D.,
and others and favored maintenance of an educational and supervisory
role of the physician for nurse anesthetists. They eventually
received the support of Ralph M. Waters, M.D., and John S. Lundy,
M.D. As a result, the NYSA became in 1936 (after some name adjustment
later) the American Society of Anesthesiologists, Inc. that we
know today.
Also in 1936, for the first time, the "hospital standards"
issued by the American College of Surgeons stated: "It is
unfortunate that a large number of hospitals fail to recognize
the necessity and value of a well-organized department of anesthesia.
As the administration of anesthesia is generally conceded to be
the practice of medicine, it is only reasonable to expect medical
supervision."
A major problem that slowed the recognition of anesthesiology
as a specialty was the astounding official attitude of the American
Medical Association (AMA). For over 35 years, the AMA held the
position that anesthesiology had "not yet progressed enough"
to be recognized as a section of the AMA! Gwathmey in 1912, and
again in 1921, was not successful in his attempts to achieve AMA
recognition for the specialty, but with the diplomatic suggestions
by Thomas D. Buchanan, M.D., the help of surgeon Erwin Schmidt,
M.D., of Wisconsin (who had been solicited for help by his friend
Waters) and with the urging of Lundy, he finally overcame 35 years
of AMA resistance. Anesthesiology became a subsection of the Section
of Surgery of the AMA in June 1940. Due to the welcome assistance
of the American Board of Surgery (ABS), the American Board of
Anesthesiology (ABA) was established as a "sub-board"
of the ABS in 1938 and as an autonomous "board" on August
31, 1940.
The advent of World War II found anesthesia practice little changed
for over 100 years. A few leaders such as Gaston Labat, M.D.,
had been experimenting with regional anesthesia and others were
beginning to explore thiopental (Dr. Lundy) and cycloproprane
(Dr. Waters and Dr. Rovenstine). However, in 1941 the overwhelming
majority of anesthetics in America were still being administered
with diethyl ether. There were no muscle relaxants in clinical
use until 1942. But after years of pleading with others, Lewis
H. Wright, M.D., persuaded Harold R. Griffith, M.D., of Montreal,
Quebec, Canada, to introduce the first muscle relaxant, d-tubocurarine
(curare), into clinical practice.
On the eve of World War II, ASA was composed of only about 500
members, and the ABA had only 105 diplomates. By 1943, our military
services still contained fewer than 50 physicians with any training
in anesthesiology. But the realities of war brought revolution
to the practice of anesthesiology. Early reports indicated that
a startling proportion of battle deaths at Pearl Harbor might
have been avoided by better application of anesthesiology techniques
that were then already available. This and other battle experience
led the War Department to appoint a system of consultants for
anesthesiology in the various war theaters. These men included
Ralph M. Tovell, M.D., Henry K. Beecher, M.D., Emmanuel M. Papper,
M.D., and other outstanding early experts. They were given broad
powers, and they literally dragooned many untrained young physicians
into brief anesthesia training, followed by intense battlefield
anesthesia experience.
The rewards of this rough-and-ready solution included not only
a notable decrease in direct anesthesia deaths at the battlefront,
but also the creation of a host of surgeons who now demanded physician
anesthesia and hundreds of other newly inspired young doctors
who clamored for further anesthesia training. During the four
years of World War II, total membership in ASA skyrocketed to
1,977. By 1946, 739 were still in active military service, but
there were still only 300 diplomates of the ABA.
In the immediate post-war period, new problems appeared on the
national scene. Publications suggested that death due to anesthesia
in American civilian hospitals was increasing rapidly and may
have reached one in 1,600 anesthesia administrations. This rate
was three times worse than that reported by Dr. Gwathmey in the
United States 40 years previously! This new danger, alleged by
Dr. Beecher and others, was due to a general ignorance of the
dangers of the newer anesthetics and muscle relaxants. These findings
cried out for the establishment of better anesthesia training,
research into new agents and techniques and greater emphasis on
professional medical participation in anesthesia care.
Thus the first annual meeting of ASA in St. Louis, Missouri
in 1948 found a strong new organization with real problems to
solve. The amazing successes of ASA in addressing these problems
in the second half of the 20th century demonstrate the mature
exercise of professionalism by this Society. Sustained and effective
programs of ASA have encouraged and facilitated scientific research;
improved relationships with and recognition by other physicians,
government and the public; created and supported innovative contributions
to medical education; encouraged and facilitated new clinical
advances in the delivery of health care; and have established
bellwether programs for effective quality control and patient
safety. Many of these ASA programs have been used as models by
other medical organizations and by government.
Finally, let us all share deep gratitude and respect for those
who have so valiantly struggled step by step to establish ASA
and, through it, to improve both our lot and that of humankind!
Bradley E. Smith, M.D., is Professor of
Anesthesiology, Vanderbilt University, Nashville, Tennessee.
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