Painting of an operating room, with a nun on the left acting as assisting nurse,and several other men in aprons surrounding the patient

The Handmaids of Surgery: The Role of Nurse Anesthetists

Imagine the horror of waking up in the middle of your surgery – or worse, never being asleep at all. In the early days of surgery, this was a reality. Patients were awake throughout procedures, given alcohol and something to hold on to in order to endure the pain.

The introduction of general anesthesia made surgery safer and more efficient. Prior to its development in 1846, only thirty-four patients a year were operated on at the Massachusetts General Hospital; five years later, that number had tripled.[1] Yet at the time of its debut, administering anesthesia was considered a subordinate task. In History of Anesthesia: With Emphasis on the Nurse Specialist, Virginia Thatcher wrote that “some (doctors) became anesthetists because they thought that since even a nurse or intern could administer an anesthetic it should be one of the easiest specialties to master.”[2]

Several women in scrubs and wearing face masks crowd around another woman who appears to be administering anesthetic
Nurse anesthetists being trained at the University of Virginia in 1939. (Image courtesy of the University of Virginia.)

Prior to the development of anesthesia, surgery was painful and caused significant distress and suffering. For these reasons, surgeons sought to develop a more effective process that would allow them to operate while the patient was asleep and comfortable. Anesthesia allowed patients to be placed in a medically induced coma for the duration of the procedure. To be safe and effective, administering anesthesia required the sole attention of a physician to carefully monitor how much medication was being used and ensure the patient remained asleep throughout the procedure.

However, physicians considered administering anesthesia a menial task and were unwilling to give up surgery to do it. Fellow surgeons who might be recruited to administer the anesthesia were often distracted observing the surgery and were more likely to hurt patients during the procedure. Physicians needed someone who would be content with a subordinate role and make anesthesia their sole interest, focusing only on that during a surgical procedure. Women were the natural solution. They found women had “a natural skill” for administering anesthesia and would be content with the low pay the role offered. The so-called natural skill was likely an aptitude for anesthesia and science in general. The female nurse anesthetist emerged as the solution to the problem.[3]

Portrait of a woman in a nun's habit and glasses
Painting of Sister Mary Joseph Dempsey who was one of the first anesthetists to work with the Mayo Brothers. (Courtesy of Mayo Clinic.)

In the 1870s, nuns became the first to train as female nurse anesthetists. Sister Mary Bernard was the first, beginning in 1877 at St. Vincent’s Hospital in Erie, Pennsylvania. Nuns from several different orders across the country followed suit. They had no formal training and were simply working to care for patients in a Catholic hospital. Surgeons relied upon the nuns after just a few training sessions, expecting them to learn largely on the job.

Employing nuns as surgical anesthetists became more common when the practice was adopted by the Mayo brothers at St. Mary’s Hospital, newly built in 1889 by the Sisters of St. Francis. William and Charles Mayo, physicians from Rochester, Minnesota, created a surgical clinic known for its surgical experiments and research capacity.[4] Sister Mary Joseph Dempsey became William J. Mayo’s first surgical assistant in 1890. In 1906 she opened St. Mary’s Hospital School for Nurses to train both sisters and laywomen in the art of anesthesia.[5]

Several white men in lab coats sit or stand on raised platforms surrounding an operating table, where a person is being operated on by Charles Mayo, also a white man in a lab coat
Visiting surgeons observe Charles Mayo performing surgery. (Image courtesy of the Mayo Clinic Archives.)

The Mayo Brothers aided the creation of a new profession for women as nurse anesthetists by training those who worked with them and encouraging other nurses to learn at the Mayo Clinic. These nurse anesthetists then trained other nurses, creating an education network for nurses and future nurse anesthetists. This training, which consisted largely of observing a nurse anesthetist at work, served as an informal internship, giving nurse anesthetists credibility within the medical community, though the program was not accredited and nurses received no certification. The work of nurse anesthetists allowed for more successful surgeries at the Clinic, drawing doctors from across the country and Europe to observe.

Nurses, such as Alice Magaw, were drawn to the Mayo Clinic to study anesthesia from their fellow nurses. Magaw was born in Rochester, Minnesota, in 1860 and began working at the Mayo Clinic in 1893. Magaw became one of the most prominent nurse anesthetists, learning new methods of using ether and developing her own method of administering anesthesia. Marianne Bankert has argued that Magaw is the reason the nurse anesthetist profession survived. Magaw worked to build and develop the field of anesthesia, but it was not only her achievement and work at the Mayo Clinic that made her stand out. While very few nurse anesthetists left behind any records, Magaw documented and published her work. Charles Mayo himself referred to Magaw as the “Mother of Anesthesia.”[6]

Most nurse anesthetists worked exclusively with one physician. These partnerships formed the foundation of the profession and gave nurses a degree of freedom. The male surgeon granted their nurse anesthetist the ability to focus on research and the development of new anesthesia methods and practices without being expected to complete other nursing responsibilities. For example, Agatha Hodgins worked at Lakeside Hospital in Cleveland, Ohio, with Dr. George Crile, who personally selected Hodgins to work with him. With Crile’s support, Hodgins developed her own method of administering anesthesia. Their partnership lasted for decades and resulted in tens of thousands of successful surgeries.[7]

A group of white men and women pose in front of a narrow operating table. They're all dressed in white
Photo of surgery team of Lakeside Hospital in Cleveland, Ohio. Agatha Hodgins is seated at the head of the table (on left). (Image courtesy of Case Western Reserve University.)

Not all successful nurses operated within the safety of a surgeon partnership, though. Laura Mabel Davis led the nurse anesthetist program at the University of Michigan from 1919 to 1938 and served as chief anesthetist in the hospital. Davis oversaw most anesthesia teaching and work for decades, yet she was neither recruited nor trained by a specific physician. Rather, she worked independently to develop her own methods and trained hundreds of nurse anesthetists. Davis was responsible for creating the nurse anesthetist training program at the University of Michigan and assisted with thousands of surgeries during her tenure at the school.[8]

Such partnerships created a model for the rest of the medical profession. The female nurse anesthetist was called upon while the medical profession was working to make surgery more feasible. With the support of an institution or partnering surgeon, nurse anesthetists could do research and make scientific discoveries to further the field. Yet, following World War I, efforts to professionalize the medical field led male physicians to marginalize the female nurse anesthetists they had so desperately needed only decades earlier.

By the 1920s, physicians began challenging the credibility of female nurse anesthetists. They undertook efforts to remove them from the profession while simultaneously creating more formal anesthesiology programs. These programs focused on recruiting physicians to reclaim the profession they had deemed undesirable only decades before.

One way physicians challenged the role of nurse anesthetists was by questioning their education and training. Though the majority had been trained by male physicians or experienced female nurse anesthetists, the lack of official professional standards hurt their reputation. Many of the nurse anesthetists did have formal nursing degrees, but their specialist standing as nurse anesthetists was informal.

Physicians also used the courts to push nurse anesthetists out of existence. Physician anesthesiologists sued nurse anesthetist Dagmar Nelson, for example, challenging her authority and ability to administer anesthesia as part of a larger attempt to prevent nurse anesthetists from practicing in California and to undermine the profession as a whole. Ultimately, the work of a nurse anesthetist was upheld, but only under the distinction that it was not medical work. Moreover, the court case left some nurse anesthetists wary of continuing their work.[9]

This lawsuit pushed nurse anesthetists to formally organize their own professional organization outside of the American Nurses Association (ANA). Founded in 1931, the American Association of Nurse Anesthetists worked to fight off these attacks against the profession and to unite practitioners across the country. As part of efforts toward professionalization, education standards were quickly determined and implemented.[10]

Nonetheless, in the 1920s and 1930s, physicians began reclaiming previously discarded specializations like anesthesia. Now that anesthesia was a respected and valued field of medicine, male physicians sought to dominate it. Surgeons who worked side-by-side with nurse anesthetists did what they could to maintain those partnerships, but ultimately it was not enough. The subordinate nature of their work left nurse anesthetists with little recourse as their teaching responsibilities were taken over by male physicians. Their place in the operating room was gone, and they were replaced by formally trained male anesthesiologists. By the time nurse anesthetists were pushed out of and demoted within the profession, surgeons were at the top of the medical hierarchy. Their position at the top was only made possible by the work of the female nurse anesthetists.

Notes

    1. Virginia S. Thatcher, History of Anesthesia: With Emphasis on the Nurse Specialist (Garland Publishing, 1984) 15.
    2. Thatcher, History of Anesthesia, 25.
    3. Michael Brown, “Surgery and Emotion: The Era Before Anaesthesia,” in The Palgrave Handbook of the History of Surgery, ed. Thomas Schlich (Palgrave Macmillan, 2017), 327–348.
    4. Encyclopedia Britannica, s.v. “Mayo Family,” accessed March 1, 2021, https://www.britannica.com/topic/Mayo-family
    5. Encyclopedia Britannica, s.v. “Sister Mary Joseph Dempsey,” accessed October 17, 2020, https://www.britannica.com/biography/Sister-Mary-Joseph-Dempsey
    6. Jeanne Pougiales, “The First Anesthetizers at the Mayo Clinic,” AANA Journal (June 1970): 235–241; Marianne Bankert, Watchful Care: A History of America’s Nurse Anesthetists (American Association of Nurse Anesthetists, 1989) 12 and 17.
    7. Thatcher, History of Anesthesia, 74–75; and Virginia Gaffey, “Agatha Cobourg Hodgins: She Only Counted Shining Hours,” AANA Journal (April 2007): 97–100.
    8. Alexandrea Penn, “Laura M. Davis: A Nurse Anesthetist,” Michigan History, November/December 2020, 47–49.
    9. Bankert, Watchful Care, 90-95.
    10. Ira P. Gunn, “The History of Nurse Anesthesia Education: Highlights and Influences,” Journal of the American Association of Nurse Anesthetists 59, no. 1 (February 1991): 53–61.

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