t appears that 1905 was a propitious year for Adolph Frederick Erdmann, M.D., to begin to organize what later turned out to be ASA, if alone for the fact that 1905 was the ANNUS MIRABILIS of Albert Einstein. He not only received his Ph.D. degree, but also published four extraordinary papers on light, including the Theory of Relativity. 1905 also heralded the first Russian Revolution, the complete defeat of the Russian Navy in the Battle of the Straits of Tushima by the Japanese and a peace treaty between Russia and Japan brokered by U.S. President Theodore Roosevelt. Robert Koch garnered the Nobel Prize in Medicine for his work on tuberculosis, and Alfred Einhorn synthesized procaine.

In the United States during 1905, the five leading causes of death were pneumonia and influenza, tuberculosis, diarrhea, heart disease and stroke; the average life expectancy was 47 years; only 14 percent of homes had a bathtub; there were only 8,000 automobiles and only 144 miles of paved roads; more than 95 percent of the births in the United States took place at home; sugar cost 4 cents a pound and eggs 14 cents a pound.

By 1905 the anesthesia cupboard included sulfuric ether, nitrous oxide and chloroform as the mainstays of the inhalational agents; cocaine, stovaine and procaine being available for regional anesthesia, and barbital just recently synthesized. Numerous inhalers and vaporizers had been developed as well as devices that proportioned and delivered the inhalational agents. Oral intratracheal intubation was known, and the introduction of intratracheal tubes through a direct vision laryngoscope was a reality, as well as the use of intravenous fluids. Educationally a significant number of anesthesia texts existed, and established medical journals contained reports on anesthetic uses. The landmark six-volume Medical and Surgical History of the War of the Rebellion had been finalized in 1888, containing an important chapter on anesthesia morbidity and mortality using statistical methods.

The British Society of Anaesthetists (London) was formed in 1893. Extensive work had been done in the areas of regional, subarachnoid, epidural, infiltration and nerve block anesthesia. Clinical monitoring was very primitive with the emphasis on pulse rate and respiration. On January 19, 1903, Harvey Cushing, M.D., and George Crile, M.D., presented their findings on the use of blood pressure measurements during surgical procedures to a committee from the Department of Surgery at Harvard Medical School, with the verdict being that “the palpation of the pulse was a much better indicator of the circulatory status clinically than a pneumatic device!” Dr. Cushing measured blood pressure with the Riva-Rocci sphygmomanometer, and Dr. Crile with a Gaertner apparatus. Unfortunately, even like today, valid estimates of anesthesia-related mortality and morbidity were not readily available prior to 1905, although deaths from the use of chloroform were an important issue.

The cover of the first issue of the British Society of Anaesthetists Proceedings, 1898.

The dawn of a new century and the formation of ASA found that the practice of anesthesia in the United States was mostly performed by surgeons, nurses and general practitioners, with scientific enterprise limited to those working in but a few academic institutions and hospital centers. Formal training and certification were virtually nonexistent. With these characteristics, how do we account for the advanced state of anesthesiology as we know it today in the United States, with our research on molecular mechanisms underlying anesthesia, our ever-upgrading technology, numerous pharmacological adjuncts, disciplined educational programs and an institutional membership in the area of 40,000?

Seminal Events
During the course of the century following 1905, there were significant epochs and seminal events that influenced the development of anesthesiology in general and the American experience in particular. Finite achievements are often the result of the infinite contributions of others, and the naming of an individual for a specific accomplishment in no way detracts from those whose work supplied the building blocks of an idea, theory, experience or philosophy.

The Bowles Stethoscope, from 1901. Image courtesy of the Wood Library-Museum of Anesthesiology.

The “guts” of medical education reside in the medical school; and in 1910, a committee headed by American educator Abraham Flexner changed the whole face of American medical education by setting standards for the organization and curriculum of North American medical schools. This, of course, impacted on the quality of those physicians entering the anesthesia arena. Anesthesiology often is driven by advances in the basic sciences and the medical, surgical, pediatric and obstetrical specialties, and because of the nature of our specialty, we find ourselves to be the consummate clinical synthesizers. Thus the advances in physiology, chemistry and physics throughout the 20th century elicited an important feedback response, allowing anesthesiologists to incorporate these findings into their practices. World War I and World War II were important epochs and had far-reaching effects on the development of anesthetic progress. Some important moments that had a major impact on anesthesiology involved the discovery of blood types in 1901 and 1925, allowing for the use of blood products; the introduction of a gas machine in 1911; the development of a carbon dioxide absorber in 1915; the entrance of intravenous thiopental into the anesthesia armamentarium; the use of curare for muscle relaxation in 1941; and the perfection of the PO₂ and PCO₂ electrodes in 1956 and 1958 to open up the vista of perioperative rapid acid-base determinations and critical care.

A rough sketch of Riva-Rocci’s “sfigmomanometro.” Image courtesy of George S. Bause, M.D.

The end of World War II heralded a new era in technology with the discovery of the transistor, then followed by remarkable advances leading to the computer, which has changed the face of medicine. With this progress, we must not forget the advances in patient care monitoring ranging from automatic blood pressure measurement to echocardiography. Other monumental changes that were taking place included the development of modern immunology that made transplantation possible. The delineation of the molecular structure of DNA began our understanding of the genetic code in the 1950s and has had repercussions affecting the fundamental basis of many of our anesthesia concepts.

Curare and darts used by hunters in the Amazon jungle. These items were brought back from Ecuador by Richard Gill.

Anesthesia record of the first application of curare by Drs. Griffith and Johnson in Montreal.  E. M. Papper, M.D., considered this event the second revolution in surgical anesthesia, the first being the discovery of ether and chloroform.

With the profound realization of the role of anesthesia in making the progress of surgery possible, this milieu mandated the separation and independence of anesthesiology with the establishment of independent departments. We also must not forget that the incredible advancements in surgical specialties led to the formation of the subspecialties in anesthesiology and the reorientation of our educational system. Included in this response is the pioneering role that anesthesiology has played in critical care and pain management medicine.

1952 commemoration of the first clinical application of curare for surgical operation by Harold R. Griffith, M.D., and Enid Johnson, M.D., in January 1942.  Dr. Griffith appears in the middle with his resident, Dr. Johnson, to his left. Lewis H. Wright, M.D., then Medical Director of E. R. Squibb Pharmaceuticals, is on the left. Squibb manufactured Intocostrin, which Dr. Wright provided to the Montreal team.

Yes, we have come quite a distance since Dr. Erdmann and his colleagues met and formed the predecessor to ASA. In all humility, though, our tasks and responsibilities have become enormous. Our use of modern statistical techniques and evidence-based medicine have indicated that we still have a significant 24-hour postoperative death rate. This is an added incentive to redouble our efforts in an area of medicine that we in anesthesiology have pioneered — the pursuit of patient safety. The bombardment of technological advances on our psyche appears to often dull our sensibilities to a point of desensitization so that we regard the target of our therapy, the patient, with a dangerous sense of depersonalization.

It is hoped that the next century of ASA activity will carry with it an even greater dedication to succor mankind.

Maurice S. Albin, M.D., M.Sc. (Anes.), is Professor of Anesthesiology in the David Hill Chestnut Section on the History of Anesthesia, University of Alabama School of Medicine in Birmingham.