The Anaesthetist, 1890-1960: A Historical Comparative Study between Britain and Germany (review)

Systematic international comparisons of medical specialization are still relatively rare. In this well-structured monograph Pöll, an anesthetist and medical historian, explores the development of anesthetics, the techniques and technologies to administer them, and the personnel who applied them in England and Germany between the 1890s, when modern hospitals with surgical departments and operation theaters had become standard, and the early 1960s, when anesthesiology had become a well-established medical specialty in both countries. Pöll divides these seventy years into five distinct periods—the turn of the century, the Great War, the interwar years, the Second World War, and postwar—and then undertakes thematic comparisons within each. His three-phase model of specialization follows the schema first developed by George Rosen in the 1940s.

It has long been asserted that England was at the forefront of anesthesiology and that Germany lagged behind, but Pöll was clearly dissatisfied with the standard explanations for this, most of which blamed narrow-minded German surgeons. Instead Pöll explains the different rates of specialization by emphasizing the different roles of surgeons, structures of hospitals, and conceptions of the human body in the two nations but without uncritically endorsing the assumption of German backwardness. In England surgeons were at the apex of the medical profession and had adopted a mechanical conception of the human body. Surgeons restricted themselves to "cutting, cauterizing, and stitching" (p. 190). Hospitals were either private or charitable and functioned as open markets in which various types of medical practitioners could ply their trades. Therefore, in cities like London surgeons had no objection to general practitioners earning their livings by administering anesthetics. In Germany, by contrast, hospitals were organized by specialized medical departments, like university hospitals, with a military hierarchy. Surgeons held a holistic view of the human body and the chief surgeon was responsible for total patient care. Hence, the administration of anesthesia was usually assigned to an assistant surgeon and the study of anesthesia was subsumed within surgery. Pöll denies any necessary connection between war and specialization. Indeed, given the shortages of surgeons, German military medicine in both wars favored radically simplified techniques of anesthesia and in many instances relied on nonphysicians, including nurses, to apply anesthetics. In Britain the Second World War did advance anesthesiology as a specialty but only because of the assiduous efforts of Association of Anaesthetists of Great Britain, which demonstrated the indispensability of expert anesthetists who had mastered the latest innovations including intravenous anesthesia, endotracheal intubation, and the Oxford vaporizer. As this suggests, one major contribution of this book is its extensive explication of the close relation between specialization and the development of new techniques and technologies. It was only during the decades after the Second World War when a new generation of German physicians trained abroad began pressing for anesthetic specialization and the holistic approach collapsed in the face of the increasing fragmentation of surgery into subspecialties that Britain and German finally converged.

Taken as a whole this is an excellent and persuasive study. The author's obiter dicta are sometimes jarring, however, such as the claim that all wars are caused by economic interest (p. 90) or that the United Nations Security Council became the new world power after the Second World War (p. 166). Generally these idiosyncrasies don't matter, but unpersuasive is the argument that the neglect of endotracheal intubation in Germany during the interwar period was attributable to Germany's exclusion from the international rubber trade (pp. 123-26). At times issues could have been further pursued, such as the reasons German nurses seemed so willing to abandon administering anesthetics after the Second World War.

The book rests on an impressive foundation of primary sources ranging from surgical and anesthetic textbooks, to hospital operation registers, to catalogues of manufacturers of medical supplies. The production values of the book are superb. There are footnotes rather than endnotes; apposite...