To the Editor:—
The history of anesthesiology as a physician specialty in the USA is fragmented at best. A handful of books, numerous articles, and piles of primary source documents must be read to fashion a coherent picture of historical events and social forces responsible for transforming anesthesia from a merciful craft to the medical specialty. Dr. David Waisel's article about physicians’ roles in education and organization of anesthesia during World War II contributes in this regard. 1It joins Courington and Calverley's article about anesthesia during World War I to fill a gap in our specialty's history about professionalization. 2
However, like many anesthesiologist–authors before him, Dr. Waisel overstates the role technical skills in drug administration play in explaining why nurse anesthetists arose in America alongside physicians. In his article he states 1:
In contrast to the development of anesthesia in the United States, anesthesia developed as a physician specialty in Great Britain because of the complexity of administering chloroform and the precedent of the physicians administering anesthesia in Great Britain.
This explanation is suspect in an otherwise scholarly article. It is small comfort that as an explanation for an extremely complex historical process, others still invoke it as dogma. Indeed, the myth that British chloroform required more skill in administration than American ether cannot serve to explain, in total, the American origins of the anesthesia care team. Nonetheless, a version of this explanation is also found in a recent edition of a popular basic anesthesia textbook. 3
The notion that a simple but deterministic dichotomy existed between American and British anesthetic preferences is referred to as the Great Trans-Atlantic Debate. About it, Greene, the same author Waisel references, said 4:
Purposeless, tedious, and often irrational on both sides, the Debate accomplished little except ultimately detract from the stature of those involved. The acrimony generated by the Debate and the unscientific hyperboles indulged in by those involved, did little to augment the stature of anesthesia as a scientific field in the eyes of objective observers.
That chloroform was used more than occasionally in the United States between 1846 and 1900 is an established fact. During the War Between the States, chloroform found favor in America (mostly in the Confederacy) because of its availability, lower flammability, and smoother emergence properties compared with ether. 5However, this does not mean that some greater bias toward ether did not also exist at the same time, especially where it was available.
That the Debate should resurface in contemporary form speaks to the persistent need for anesthesiologists to better understand the specialty's history differently. 6If acknowledged as such, the Great Trans-Atlantic Debate might be better understood as “The Fallacy of Pharmacologic Determinism.” As the phrase implies, a damaging falseness lies at the heart of any claim that skill in drug use is the most important determinant justifying the existence of any medical specialty, including anesthesiology. Consideration of multiple historical, social, and ethical factors best explains how physicians came to dominate anesthesia care early on in Great Britain but not the United States. To simply imply physician dominance was rooted in more skillful use of the preferred drug obscures the role other more important factors played in our specialty's professional history. 7–10