The Second World War proved to several surgeons that modern anaesthesia had to be medicalised.
The battle against the ‘Almighty Surgeon’ and gain recognition for the anaesthetists would be bitter, as much for teaching as for the Social Security, the Ordre de Médecins (the French medical registration authority), hospitals and the universities.
Formal anaesthetic teaching started in 1947 with a course for doctors and nurses, lasting 6 weeks with a 6 months attachment. It was reserved only for doctors in 1948, with an examination. In 1949 a special certificate of training in anaesthesia was introduced. (the CESA). In 1966 this was altered to the CESAR to accommodate the addition of resuscitation to anaesthesia. In 1982, anaesthesia – resuscitation moved into specialist training with a period of 4 years (now 5 years) making a total of 11 years for specialist training with a basic medical degree.
From the Social Security, only surgeons received fees, one tenth of which was paid to the anaesthetist. The anaesthetists at that time were known as ten percent doctors. In 1947 anaesthesia delivered by a specialist was remunerated separately but subjected to the discretion of the social security! It was not until 1953 that all patients could benefit from modern anaesthesia. Finally in 1960 anaesthesia was separated from surgical interventions (K) with a specific designation (Kar).
In 1947, article 42 (or 45 in 1955 of the Ordre des Médecins) stated that the surgeon had the right to choose his operating assistants including the anaesthetist. In 1950 a Commission for qualification in anaesthesia was created becoming, in 1970 Specialist in Anaesthesia and Resuscitation. It was not until 1979 that article 45 was rescinded finally giving the anaesthetist total responsibility for his actions.
Hospitals
In 1947, a competition for 15 unpaid posts of Hospital Assistant was held in Paris as a temporary measure. The anaesthetist worked for nothing in the hospital during the morning and earned a living in the afternoon by working in private clinics delivering general anaesthesia.
In 1958, the hospital reforms of Robert Debré created full time posts of departmental heads, but it was not until 1960 that anaesthesia became organised into two bodies: university hospital and hospital.
In the university sector, the first professors of anaesthesia were created in 1961 and in 1963 the first established chairs were created. By 1970, the battle to establish the speciality had been won.
The evolution of anaesthetic techniques from 1946 to the present day
This display only concerns general anaesthesia. Local and regional anaesthesia is covered in the previous display.
Modern general anaesthesia uses three types of essential agents: hypnotics, analgesics and muscle relaxants (the ‘triangle’ of balanced anaesthesia). Techniques have evolved with the discovery of new products and the development of physiological theory.
Thiopentone (Pentothal) was the leading short acting hypnotic agent of choice until 1970. From 1956 – 1987 20 different similar agents were developed with shorter or longer durations of action. Nowadays, only five or six products are used, with volatile agents being phased out due to environmental considerations.
Morphine and pethidine (Dolosal) were used up to 1956, but from that time new analgesics appeared which changed the face of anaesthesia. The last of these, remifentanil (1974) had a very short duration of action and could therefore be used in continuous infusion.
The first use of muscle relaxants by Griffiths in Canada was in 1942. This allowed the surgeon to operate without muscle contraction. But the use of relaxants required the use of artificial ventilation. The degree of relaxation was measured using a nerve stimulator.
Anaesthetic monitoring and safety
Before 1965, monitoring during anaesthesia was purely clinical by checking the pulse, blood pressure, and respiration (frequency, auscultation of airways, colour of the face and mucous membranes) as well as observation of the corneal and pupillary reflexes.
From 1965, monitoring developments permitted the detection of developing problems and thus avoiding accidents. This display presents the arrival of various monitoring devices.
Some interesting figures: while the number of anaesthetics given in 1970 was around two millions, the Social Security system estimated the figure at thirteen millions in 2022, due to an increasingly ageing population affected by a wide range of pathologies.
The number of specialist anaesthetists increased from 169 in 1960 to 9930 in 2022. This improvement was due, in no small way to the quality of anaesthesia required and to the appearance of a Decree which required and anaesthetic consultation more than 24 hours before an operation and another less than 24 hours before the start of surgery. It also required suitable equipment and monitoring to be available during the operation and especially for the patient to go to a recovery room if consciousness had not been regained by the end of the procedure.