The staggering numbers of wounded produced by the Civil War (1861–1865) engendered the development of surgeons, but did nothing to develop anesthetists or further anesthetic delivery:

…ether or chloroform poured or dropped on a towel, a rag, or other vaporizer was the accepted method for anesthetizing the many wounded soldiers of the Union and Confederate armies during the Civil War, and for most patients during the rest of the nineteenth and the early twentieth centuries in America. Surgeons directed all aspects of treatment of their patients. They recruited anesthetists from the operating room personnel, such as nurses, hospital porters (orderlies), janitors, and even the surgeons’ secretaries…the anesthetist was regarded as the ‘low man on the totem pole’ during the late 1800s and the early 1900s [6].

The surgeon supervised anesthetic delivery, a demanding responsibility that distracted from his primary task. Anesthesia continued to be dangerous as suggested by an 1885 survey by the Scandinavian Society of Surgeons giving an anesthetic mortality of 1 in 2,000–3,000, perhaps more with chloroform than ether [7]. Concerns regarding the safety and the availability of anesthetic service may have prompted US surgeons in the Midwest to employ Catholic Sisters (nurses) to provide anesthesia on a full-time basis. Thus Mary Bernard at St. Vincent’s Hospital in Erie Pennsylvania, was recruited in 1877. At first directed by the surgeon, these anesthetists increasingly gained experience by trial and error. Unlike the part-time anesthetist, they had the advantage of frequently repeated opportunities to learn their craft.

By the 1880s, more than 90 Midwest Catholic hospitals used sisters for anesthesia, thereby providing a more consistent and likely safer service than did the part-time anesthetist, physician or not. Most famously, in the late 1880s, sisters Edith and Dinah Graham became the first nurse anesthetists at the Mayo Clinic. In 1893, the Mayo brothers recruited Alice Magaw, the most celebrated nurse anesthetist of the nineteenth century. Magaw replaced the Graham sisters. The Mayo brothers soon added Florence Henderson.

The Mayos had given the job to Miss (Edith) Graham and then to Miss (Alice) Magaw in the first place through necessity; they had no interns. And when the interns came, the brothers decided that a nurse was better suited to the task because she was more likely to keep her mind on it, whereas the intern was naturally more interested in what the surgeon was doing [8].

Although the brothers provided initial training, Magaw and Henderson then independently perfected the smooth and safe delivery of anesthesia with ether.

The situation differed in other parts of the US. Anesthesia in the US had no distinction in the medical community. Training of physicians in anesthesia and the reputation of the physician anesthetist (in contrast to the nurse anesthetist) was abysmal. The 1894 experience of Harvey Cushing, later the father of neurosurgery, as a student at Harvard illustrates anesthesia’s low standing and the disasters that ignorance brought [9]:

My first giving of an anaesthetic was when, a third-year student, I was called down from the seats and sent in a little side room with a patient and an orderly and told to put the patient to sleep. I knew nothing about the patient whatsoever, merely that a nurse came in and gave the patient a hypodermic injection. I proceeded as best I could under the orderly’s directions, and in view of the repeated urgent calls for the patient from the amphitheatre it seemed to be an interminable time for the old man, who kept gagging, to go to sleep. We finally wheeled him in. I can vividly recall just how he looked and the feel of his bedraggled whiskers. The operation was started and at this juncture there was a sudden great gush of fluid from the patient’s mouth, most of which was inhaled, and he died. I stood aside, burning with chagrin and remorse. No one paid the slightest attention to me, although I supposed I had killed the patient. To my perfect amazement, I was told it was nothing at all, that I had nothing to do with the man’s death, that he had a strangulated hernia and had been vomiting all night anyway, and that sort of thing happened frequently and I had better forget about it and go on with the medical school. I went on with the medical school, but I have never forgotten about it.

This terrible event embodied the state of anesthesia in some parts of the US: an orderly directed a third year medical student in the administration of an anesthetic to a seriously ill and ill-prepared patient. As he promised, Cushing never forgot about it. Moreover, to the benefit of anesthesia, he did something about it. With Codman, in 1895 he developed the anesthetic record with intraoperative recording of heart rate and blood pressure (itself, a new measurement in medicine) in that record at five-minute intervals. That record persists to the present, albeit now in an electronic form [10,11]. The record was adopted in the US, but its use in other countries might vary. In the UK, use of anesthetic records, indeed, measurement of heart rate and blood pressure in the operating room, only began in the last half of the twentieth century.

Thus, by the beginning of the twentieth century in the US, the quality of anesthesia had a tri-modal distribution. First, nurse anesthetists, particularly in the Midwest, pursued anesthesia as a full-time occupation and honed their skills by regular practice. They took pride in what they did and did it well. They might know little about the science of anesthesia, but they were likely to give anesthesia safely and smoothly, and they taught other nurses how to do the same. Second, the part-time anesthetist, physician, medical student, nurse, orderly, or secretary, was also likely to know little about the science of anesthesia, but in contrast to the full-time nurse anesthetist was unpracticed in the art, and relied on the equally limited surgeon to provide direction. Anesthesia given by such persons was neither smooth nor safe (note Cushing’s experience, above). Third, a small, but growing, number of physicians elected to pursue a full time practice of anesthesia, and like the Midwest nurses, might acquire skill in anesthetic delivery. Unlike nurses, these physicians might be driven to a career in anesthesia by their ineptness as physicians. In the 1900s, we find that “… the dean of Harvard Medical School wrote to the president of Harvard that the practice of anesthesia ‘…is so narrow a subject that a good man would not want to tie himself down to that and would hardly be willing to do so.’ [12,13]” But some of them, particularly women, would be leaders. For example, in the latter part of the 1890s, Isabella Herb practiced anesthesia at Augustana Hospital in Chicago, in 1922 becoming president of the first nationwide US 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.

Soon after the 1846 demonstration of ether anesthesia and the 1847 demonstration of chloroform anesthesia, Great Britain embraced anesthesia as part of the practice of medicine. Physicians, not nurses or orderlies, gave anesthesia. Perhaps this resulted from a preference for the use of the more dangerous anesthetic, chloroform, possibly a provincial response to chloroform’s discovery as an anesthetic in Scotland. Perhaps this resulted from the power of John Snow’s studies and writings and those of other giants (Simpson, Clover and more) who accompanied him.

Regardless of the reason, a cadre of physicians gave anesthesia in the UK from the beginning of the history of anesthesia. Buxton advocated the compulsory study of anesthetics in medical curricula. Hospital residents or family doctors gave most anesthetics in Australia where deaths associated with chloroform repeatedly brought calls for full-time chloroformists, calls that were ignored. Commonly the surgeon invited the referring general practitioner to be the “chloroformist”. The low professional and economic status of anesthetists impeded the attraction of young doctors into the specialty as full-time practitioners, a condition that continued worldwide to the mid-twentieth century

Surgeons were not fools. They realized the risks imposed by the inept or ignorant anesthetist. In the early 1900s, they popularized regional anesthesia with enthusiastic reports and textbooks describing virtually all modern block techniques in some form. By using regional anesthesia, they could continue to control anesthetic delivery and give safer anesthesia into the bargain. In 1901, Cleveland Clinic founder, surgeon George Crile, showed that regional techniques blocked “surgical shock”, presaging “pre-emptive analgesia”.

Unlike the situation in GB, where physician-anesthetists controlled anesthetic delivery, in Germany, surgeons directed anesthesia and devised methods for anesthetic delivery. In 1894, Schleich unsuccessfully advocated specialization in anaesthesia. In 1895, Witzel continuously dripped liquid ether or chloroform from bottles onto masks invented by Esmarch and Schimmelbusch, progressively increasing the anesthetic concentration, a technique used for the next half century or more. The direction by the German surgeon of part-time anesthetists, was the model for much of the anesthetic world outside of the US and the UK. In summary, by the 1900s, the anesthetic world consisted of three kinds: the nurse anesthetist/physician anesthetist/surgeon-directed model used in the US; the part-time/full-time physician-anesthetist model adopted in the UK and Commonwealth; and the surgeon-directed model used in most other places.