Crosby, Gregory MD; Culley, Deborah J. MD
Seventy-six years elapsed between one of the greatest experiments in medicine, the public demonstration of ether anesthesia for surgery at Massachusetts General Hospital in 1846, and publication of a journal devoted to the art and science of the new field of anesthesiology. The year was 1922 and that journal, Anesthesia & Analgesia (A&A), is celebrating its 90th anniversary this year. So much has changed in 9 decades!
When the journal was born, life expectancy in the United States was approximately 58 years, the Nobel Prize in Physiology or Medicine was awarded for work on muscle physiology, the American Pro Football Association was renamed the National Football League, and Babe Ruth signed a 3-year contract with the New York Yankees for $52,000 a year. Women were not allowed to compete in Olympic gymnastics or track and field, Marconi began regular wireless broadcasts from Essex, England, and the first facsimile was sent over phone lines. A new model Chevrolet cost $490. And the stock market crash of October 1929, which set a record of 13 to 16 million shares traded in a single day, was 7 years away.
Medicine in 1922 was vastly different too. The Band-Aid had just been invented (1921), and insulin was first used successfully to treat a diabetic patient. It would be 1 year before a vaccine was developed for diphtheria, 5 years before the iron lung was invented, and 6 years before a tuberculosis vaccine was first used successfully. Expenditures for health care (physicians, nurses, hospitals, medicines) in the United States were estimated at $1.4 million annually, or approximately $10 to $12 per capita.
Then, hospitals were fast becoming the best place to care for the ill and injured, but surgery and anesthesia were still occasionally performed in the kitchen. At that time, the anesthesia apparatus was simple and could be held in 1 hand, whereas most industrial machinery was massive.
Medicine was an unregulated cottage industry. Some states required physicians to be licensed, but many did not. Delivery of anesthesia was still the domain of lay people, medical students, and junior surgeons. Physician practitioners of anesthesiology were few and just beginning to organize. The National Anesthesia Research Society (forefather of the International Anesthesia Research Society) was founded in 1922. The American Society of Anesthesiologists followed in 1935, although it originated as the Long Island Society of Anesthetists in 1905. There were no licensing examinations, and no continuing education requirements. No anesthesia practitioner was board certified because the American Board of Anesthesiology did not exist until 1937.
Physicians learned the art of anesthesia by apprenticeship; education occurred by doing, whenever and wherever the opportunity presented itself. The Council on Medical Education published its first guidelines on approved internships in 1919 and only a minority of physicians bothered to do one. The first university training program in anesthesia, established by Ralph Waters in Madison, WI, did not appear until 1927. Then, as quaint as it seems now, the doctor had a contract with the patient.
And what of A&A? The journal was first published as Current Researches in Anesthesia and Analgesia in 1922, with just 3 issues (August, October, and December). All together, they contained a total of 23 manuscripts, 4 editorial commentaries, and a total of 117 pages of text. There were 26 authors, or 1.1 ± 0.3 per manuscript; 4 authors were dentists, 1 was a woman, and all hailed from North America. No author mentioned an academic affiliation, as there were no university departments of anesthesia at the time.
In 1922, only case reports, case series, and personal observations filled the journal. Authors described the nuts and bolts of anesthesia practice, writing mostly from personal experience about “how to.” The focus was on practical everyday aspects of administering anesthesia. Animal experiments were mentioned only in passing.
There were just 2 hand-drawn figures and 1 quasi-table in the entire first volume. None of the articles in 1922 mentioned a source of funding. No articles published in A&A in 1922 cited a reference, although on occasion they did attribute observations to previous workers.
The words statistics or statistical appear in the 1922 issues, but not a single manuscript reported statistically meaningful data or applied statistical methods. Zero included a control group. Then, the journal was printed on paper and delivered by mail, or was available only in a library. An annual subscription cost $3.
The broad topics discussed on the pages of A&A then included anesthetic pharmacology and equipment, obstetrical and pediatric anesthesia, regional anesthesia, patient safety, preoperative evaluation, and postoperative pain. Preoperative evaluation of cardiopulmonary function consisted of a breath-holding test,1 and safety measures consisted of checking skin color and pulse.2,3 Bad events were so commonplace that patient survival was the main objective, and local anesthetic-induced syncope (seizures?) was dismissed as being of psychic origin.4 They wrote of drug shortages because so few had been discovered (ether, chloroform, nitrous oxide, morphine, novacaine). And, they debated whether nurses and other medical workers were qualified to practice anesthesia.5
Now, life expectancy is approximately 80 years, Nobel Prizes in Medicine or Physiology are given for molecular work on topics such as telomeres or innate immunity, marquee baseball players make more than $52,000 per time at bat, female United States Olympic Team athletes garner more gold medals in the Summer Olympic Games than men, and no one but banks and lawyers uses the facsimile. Now 200 to 300 million shares are regularly traded daily on the New York Stock Exchange and you’ll pay about $490 every month just to gas up that new Chevy.
We put Band-Aids on complex organizational problems as well as minor wounds, replace lungs, and spend approximately $2,708 billion on health care annually, or roughly $8700 per capita.
Surgery in the office is now acceptable whereas surgery in the kitchen is not, and hospital operating rooms are so cluttered with equipment they look like a garage. Unimaginably advanced technology is elegant and fits comfortably in a hand while the size and unsightliness of the anesthesia machine make it look like early 20th century industrial machinery.
Medicine is now a hyperregulated industry. Licensing and regulatory bodies are too numerous to count, much less understand. There are hospital credentialing committees, state Boards of Medicine, the NBME,a ACGME,b ACCME,c RRC,d ABA,e ABMS,f and JAHCOg to mention just a few. Testing and paperwork are seemingly endless. You’ve got the MCAT,h USMLEi or ECFMG,j ITE,k and board examinations. Just when you think you are done, there is CME,l MOC,m and SEE.n
There are now 132 accredited anesthesia residency programs in the United States, and there are strictures on what trainees can do and when they can do it. The accrediting body that regards professionalism as a “core competency” for trainees also imposes work hour limits that encourage the opposite. Penalties on training programs for allowing “service over education,” are fast moving anesthesiology’s culture of learning by doing toward one of reading about doing, as though the clinical practice of anesthesiology is a virtual exercise. As anesthesiology becomes more complicated and surgical patients are sicker and older than ever, trainees paradoxically get less supervised practice prior to entering independent practice.
Now, doctors form groups and the groups contract with other groups—health care systems, commercial insurers, and the government—leaving patients with little voice and few options.
A&A is different too. Just the August 2012 issue contained 22 original articles, 5 editorials, 4 reviews or special articles, 2 echo rounds, 1 case report, and 7 letters to the editor. This content filled 246 considerably larger printed pages and came from 177 authors, or 4.2 ± 2.3 per manuscript, representing 12 countries. All but 2 of the authors reported an academic affiliation.
Of the 23 original studies in that issue, 15 were performed on or involved humans, and 8 were conducted in animals, in vitro models, or by computer modeling. That single issue contained 113 figures, 88 tables, and 6 videos. Eight of the 23 original reports listed a nondepartmental funding source.
Now every article includes citations to relevant previous work. The August 2012 issue alone contains 1086 references, 21 of which appear in letters to the editor. These citations refer to work from each decade except the 1930s; as expected, references from the 1980s through 2012 predominate but 7 articles referenced work published >50 years ago. In the August 2012 issue, every article reporting original work had a control group and determined validity of the results by formal statistical testing.
A personal subscription now costs $140 annually and the journal, although still available in traditional form, has transitioned from paper to pdf and from dust-gathering book on a shelf to searchable electronic file in your pocket or the Cloud.
The randomized controlled clinical trial reigns supreme for informing us about what to do and the pages of the journal are filled with studies addressing why things occur, often by examining events at the level of individual cells or molecules. The journal now accepts few individual case reports but, ironically, fascination with the case is greater than ever. The advent of electronic medical records and inexpensive electronic storage and processing power allow investigators (as well as insurers and bureaucrats) to scan massive databases retrospectively looking for patterns in thousands of individual cases. Aggregated anecdote now equals evidence.
Topics covered in the pages of the journal now are not too different from those covered then, albeit with a decidedly different slant. Preoperative assessment is more likely to involve an echocardiogram than breath holding. Patient safety is defined as much by checking a list and a box as checking the patient. Things are so good we fuss about postoperative nausea and fret about patient satisfaction instead of patient survival. There is no shortage of drugs in our armamentarium, if only we could actually get hands on them. And history has given us the answer to who is capable of practicing anesthesia so we debate the conditions under which it is so.
Fortuitously, one constant bridges the decades between then and now: A&A has always been an intellectual fountain of youth. For 90 years, it has been a place to find new ideas and fresh perspectives on our profession. It is an international place where each successive generation of practitioners, scientists, and thought leaders in our continuously maturing field exchange ideas and debate issues of the day. Read it to stay professionally young and raise a glass to toast our specialty’s good fortune in having this place to tell our story, educate one another, and reflect on our profession’s failings and progress. A&A was born 90 years ago to improve anesthesia care for patients through shared experience, education, and science. Happily, some things never change.
Name: Gregory Crosby, MD.
Contribution: This author helped write the manuscript.
Name: Deborah J. Culley, MD.
Contribution: This author helped write the manuscript.
Dr. Gregory Crosby is the section editor for Neuroscience in Anesthesiology and Perioperative Medicine for the journal.
This manuscript was handled by: Dr. Steven L. Shafer, editor-in-chief, and Dr. Crosby was not involved in any way with the editorial process or decision.
a National Board of Medical Examiners. Cited Here...
b Accreditation Council for Graduate Medical Education. Cited Here...
c Accreditation Council for Continuing Medical Education. Cited Here...
d Residency Review Committee. Cited Here...
e The American Board of Anesthesiology. Cited Here...
f The American Board of Medical Specialties. Cited Here...
g The Joint Commission on Accreditation of Health Care Organizations. Cited Here...
h Medical College Admission Test. Cited Here...
i United States Medical Licensing Examination. Cited Here...
j Educational Commission for Foreign Medical Graduates. Cited Here...
k In-Training Examination. Cited Here...
l Continuing Medical Examination. Cited Here...
m Maintenance of Certification. Cited Here...
n Self-Education and Evaluation Program, American Society of Anesthesiologists. Cited Here...