Introduction

In the United States, anesthesiology or anesthesia care is provided by two specialty groups, nurse anesthetists and anesthesiologists (physicians).   Nurse anesthetists or certified registered nurse anesthetists (CRNA) are licensed professional nurses (RNs) who undergo extensive training, become nationally certified by exam after graduation, and then provide services similar to an anesthesiologist.  CRNAs can be licensed and practice in all fifty states.  Anesthesiologists are physicians which after medical school (medicine or osteopathy), complete a one year internship and a three year residency in anesthesia.  Prior to 1 July 1986, a two year residency was required.  Following residency, they are considered board eligible in anesthesiology.   Anesthesiologists have the option of becoming board certified.   However, physician board certification is becoming compulsory by many medical or credentialing centers in order to obtain or maintain staff privileges.   As a whole, the nurse anesthesia profession is 'silent.'   Very few nonmedical layman, students, or professionals know of it's existence.   Usually, only medical professionals actively involved in surgical services are keenly aware of nurse anesthesia activities.

Most lay people and health professionals don't comprehend the world wide extent of nurse anesthesia practice.   Physician anesthesiologists mostly practice in developed and modern countries, leaving many undeveloped nations to rely nurse anesthetists.   In 1989, an international organization of nurse anesthetists was established.   The "International Federation of Nurse Anesthetists" (IFNA) has flourished in membership and has become an authoritative voice for nurse anesthetists worldwide.   They have developed standards of education and practice, and a code of ethics.  Delegates from member counties participate in the World Congress every few years.   Recent studies by the IFNA find anesthesia care worldwide is operationally a nursing function.   Researchers identified 107 countries where nurse anesthetists train and practice and 9 countries where nurses assist in the administration of anesthesia.  Nurse anesthetists participate in 80 percent of anesthesia worldwide, and are the sole providers in 60 percent of anesthesia worldwide.

Nursing sisters in the Operating Theatre, a postcard from the St. Gerardus Hospital in Bussum, Netherlands, and is postmarked 1940.   Courtesy of the Zwerdling Nursing Archives.  A sister is near one of the anesthesia set-ups, but due to the location and year, it is unclear if she administered anesthesia.  In American history, many of the first nurse anethetists were nuns.  However, a recent email from Holland nurse anaesthetist Mr. Keith Stephens-Borg who worked in Bussum confirms that the Sisters where anaesthetists.

Surgery with (most likely) nurse anesthetist at Brooklyn Memorial Hospital, New York, by W. Abbatt, c1897.

Since physician residences in anesthesia did not exist very early on, doctors attended these programs to learn anesthesia.  For example, in 1915, chief nurse anesthetist Agatha Hodgins established the Lakeside Hospital School of Anesthesia in Cleveland, Ohio.  This program was open to graduate nurses, physicians, and dentists.  The training was 6 months, and the tuition was $50.00.   A diploma was awarded on completion.  In it's first year, it graduated 6 physicians, 2 dentists, and 11 nurses.   Later, in 1918, it established a system of clinical affiliations with other Cleveland hospitals.  Ms. Hodgins was orginally appointed as anesthetist in 1908 by Dr. George W. Crile.   Under Dr. Crile's direction, she became an expert in the administration of anesthesia, and had administered 575 anesthetics by 1909.   At this time, Dr. Crile was a proponent of nitrous oxide anesthesia, feeling that ether or chloroform lead to surgical shock.

The operating room at Cleveland's Lakeside Hospital circa late 1915-1916, with Dr. Crile on the right hand side.   Agatha Hodgins uses the Teter gas-oxygen apparatus to administer a nitrous oxide anesthetic.

The only post-graduate training just for physicians in circa 1920 was a one month course in Ohio conducted by E. I. McKesson.   Even some nurse anesthetists were appointed to medical school faculties to train the medical students in anesthesia.  For example, Agnes McGee also taught 3rd year medical school students at the University of Oregon.    Nurse anesthetist Alice Hunt was appointed instructor in anesthesia with university rank at the Yale University School of Medicine in 1922.   She held this position for over 25 years.   In addition, she authored the 1949 book Anesthesia, Principles and Practice.  The photo on the left is from this book, I assume it shows Alice Hunt performing the anesthetic.

Early nurse anesthetists where also involved in publications.  For Example, in 1906, nurse anesthetist Alice Magaw (1860-1928) published a report on the use of ether anesthesia by drop method 14,000 times without a death.  She had many other publications, beginning in 1899, with some published and some not recognized, because of her status as a nurse.  Ms. Magaw was the anesthetist for the famous Drs. William J. and Charles H. Mayo, founders of the Mayo Clinic in Rochester, Minnesota.   She is often refered to as "the Mother of Anesthesia."

Recently, the city of Corunna, Michigan, discovered that Alice Magaw and family are interned in Corunna's Pine Tree Cemetery.  Follow this link for interesting information and photographs.

During World War I, America's nurse anesthetists were the major providers of care to the troops in France.  They even helped train the French and British nurses and physicians in anesthesia care.  This was also the first time the U.S. Military started training nurse anesthetists for service.  Indeed, Agatha Hodgins served in France from 1914 to 1915, two years prior to America entering the war.   It is speculated that nurse anesthetist were among the first Americans to serve during WW I.

Lakeside Unit, 1915, France.   Agatha Hodgins is on the left, sitting down, and Dr. Crile is center standing.

After much growth, the nurse anesthesia specialty was formally organized on June 17, 1931, when the American Association of Nurse Anesthetist (AANA) held their first meeting.  It was Agatha Hodgins who organized the event, inviting members from the Alumnae Association of the Lakeside School of Anesthesia and also nurse anesthetist from across the United States.  As a new organization, it had two main objectives: establish a national qualifying exam, and establish an accreditation program for nurse anesthesia schools.   The first national certification exam was held on June 4, 1945, with 92 candidates sitting for the exam.  After many years of preparation, on January 19, 1952, a program for the accreditation of nurse anesthesia schools when into effect.

Photograph of nurses administering anesthetic while physician looks on at St. Louis City Hospital.