Introduction: At the beginning of the 20th century, most anesthetics were administered by medical students and surgical residents in hospitals, or by general practitioners in private clinics or homes. The few specialist anesthetists who existed were usually self-trained and poorly respected by practitioners in other fields. The development of formal anesthesia training was a driving force for anesthesia gaining acceptance as a specialty. Methods: We reviewed published histories of the three countries' national anesthesia associations and examining bodies, biographies of key individuals, and searched medline and the internet. Results and Discussion: In 1935, the Association of Anaesthetists of Great Britain and Ireland, through the Royal College of Surgeons, introduced the Diploma in Anaesthetics (DA), setting a training standard to establish the specialist nature of anesthesia in the UK. Across the Atlantic, the New York Society of Anesthetists (later re-named the American Society of Anesthesiologists) successfully lobbied for national qualification in anesthesia three years later. Influenced by the events in the UK and the USA, the Royal College of Physicians and Surgeons of Canada approved anesthesia as a specialty in 1942, and introduced the Certificate in Anaesthesia. The Canadian Anaesthetists' Society was formed in response and helped organise programs to prepare candidates for examination. World War II demonstrated the need for properly trained physician-anesthetists. Short courses were offered at the University of Wisconsin, Madison in the USA; at McGill University, Montreal in Canada; and at the Nuffield Department, Oxford in the United Kingdom. Demobilisation resulted in the return of anesthetists at various levels of competence, led to the expansion of existing departments, and necessitated more stringent testing. Certification by the Canadian Royal College could only be obtained through examinations as of 1947, and the British DA was expanded to two parts in 1948. Early residencies in all three countries lasted 1 year, but were gradually superseded by multiple-year training to secure equal respect to other specialties and adequate remuneration.

We question the premises on which Asai bases his opinion that use of the laryngeal mask airway is contraindicated during laparoscopic cholecystectomy (Asai. Anaesthesia 2001; 56: 187). His opinion that tracheal intubation is mandatory for laparoscopic surgery, or that the laryngeal mask airway is contraindicated, could equally be applied to gynaecological laparoscopy. The popularity of the laryngeal mask airway in gynaecological laparoscopy, despite the head-down position that might be expected to facilitate passive regurgitation, stands in sharp contrast to the rarity of reported pulmonary aspiration [1, 2]. This suggests that the danger is more apparent than real. Asai quoted one case report from 10 years ago to justify his concern of 'high risk' of pulmonary aspiration [3]. No large-scale randomised study has compared the incidence of clinically significant pulmonary aspiration between tracheal intubation and laryngeal mask, but the incidence appears to be similar (1 in 5–10 000) in the general population of healthy patients undergoing elective surgery [1, 4, 5]. Pulmonary aspiration has not been reported in studies that compare efficacy and safety of these methods of airway management for laparoscopic cholecystectomy [6, 7]. Active vomiting under inadequate depth of anaesthesia can force gastric contents past and into the laryngeal mask airway to reach the pharynx and lungs. However, passive regurgitation occurs at baseline intragastric pressure of 9–15 mmHg [8], which is less than the pressure needed to bypass a correctly placed laryngeal mask airway [9]. Distension of the abdomen by gas insufflation does not increase the risk of regurgitation unless the patient has an incompetent lower oesophageal sphincter. Rather, it causes a reflex increase in the tone and therefore the barrier pressure of the lower oesophageal sphincter [10]. Cholangiogram dye is emetogenic and, unless gastric suction is used following intra-operative cholangiography, 'regurgitation' (active vomiting) of bile-stained gastric fluid is common during emergence from anaesthesia when anaesthesia is light. We have not seen vomiting during the surgical procedure for which we maintain anaesthesia at 1.0–1.5 MAC. Georgiou's concern in his case report [11] about inflation of the stomach is relevant if the laryngeal mask airway is not the correct size, or if it is incorrectly positioned and causes airway obstruction. We found that gastric distension was not a problem when we used the laryngeal mask airway for airway management with positive pressure ventilation during laparoscopic cholecystectomy [7]. We randomised 104 healthy, non-obese patients with no history of gastro-oesophageal reflux to tracheal intubation or laryngeal mask airway. The surgeons, who were blinded to the airway device, scored the size of the stomach 0–10 at entry of the laparoscope and before its removal at the end of surgery. The degree of change in stomach size was similar in both groups, and the surgeon only requested deflation of the stomach in one patient – in the intubation group!

Albert Woolley and Cecil Roe were healthy, middle-aged men who became paraplegic after spinal anaesthesia for minor surgery at the Chesterfield Royal Hospital in 1947. The spinal anaesthetics were given by the same anaesthetist, Dr Malcolm Graham, using the same drug on the same day at the same hospital. The outcome for the patients and their families was devastating, as it was for the use of spinal anaesthesia in the UK. At the trial 6 yr later, and against the opinion of leading neurologists, the judge accepted Professor Macintosh’s suggestion that phenol, in which the ampoules of local anaesthetic had been immersed, had contaminated the local anaesthetic through invisible cracks. In an interview 30 yr after the verdict, Dr Graham believed that the tragedy was caused by contamination of the spinal needles or syringes during the sterilization process. The subsequent explanation that, on the day in question, descaling liquid in the sterilizing pan had not been replaced by water, supported his belief and finally offered a credible explanation. We review the Woolley and Roe case, the status of spinal anaesthesia before and after 1947, and the relevant medico–legal judgments in claims for negligence in the early days of the National Health Service.

T HE primary principle of airway management in anaesthesia is to establish and maintain a patent airway to permit effective ventilation. When necessary, airway management also includes provision of a mechanical barrier to pulmonary aspiration of foreign material. The ASA Difficult Airway algorithm I is predicated on a gold standard of a cuffed endotracheal tube to meet both considerations in every case. This elevates the risk of aspiration to equal priority with effective ventilation, even when no risk factors for regurgitation or aspiration are present. When faced with a d i f f icul t airway, t h e t i m e h o n o u r e d a p h o r i s m o f anaesthe t i s t s is, I f in doubt, intubate the patient awake. The correctly positioned laryngeal mask airway (LMA) can provide a clear airway in 99% of cases. 2 It protects the lungs from aspiration of foreign material from above its cuff, but not from gastric contents. Therefore, when the threat of aspiration of gastric contents is present, even with an easy airway, use of the LMA is not recommended. The incidence of clinically significant pulmonary aspiration of approximately 1 in 10,000 in healthy patients undergoing elective surgery is similar for the LMA 2 and tracheal intubation or face mask. 3 If the patient's aspiration risk is low and total lung compliance is near normal, a correctly positioned LMA that allows effective ventilation meets the criterion of a secure airway with minimal risk. Aaaaesthetic practitioners have developed a variety of oropharyngeal and nasopharyngeal airway devices during the past hundred years, a including the LMA which became commercially available in the United Kingdom in 1988. Formulation of the ASA Difficult Airway Algorithm began in 1991, but the LMA was not released in the USA until October of that year. This algorithm has had a profound influence on anaesthetists' attitudes and education in the management of the difficult airway. When the algorithm was published in 1993, American experience of the LMA was limited and it did not receive mention. Since then, as experience has accumulated, the LMA has been promoted from a hands-free substitute for a Guedel airway in short, minor procedures with spontaneous respiration to an alternative to tracheal intubation in selected prolonged, major procedures with positive pressure ventilation. 2 Few individuals achieve and maintain a full repertoire of strategies and skills with all airway devices. Cormack has pointed out that, because of the rarity of genuinely difficult airway cases, controlled trials are not easy to do and anecdotal evidence can be useful, s Faced with uncertainty, few anaesthetists set aside the collective wisdom of the ASA Difficult Airway algorithm. However, the algorithm implies that tracheal intubation is the preferred management of every airway. Benumof has now indicated five points in the ASA algorithm where the LMA may have a role, 6 the evidence being based on numerous case reports that attest to its successful use in patients in whom difficult intubation was known or anticipated. 7 Intubation is either a success or failure, and failure leads to alternative second choices of mask ventilation, surgical airway, regional anaesthesia or cancellation of surgery. 'Difficult airway' is an umbrella term which does not distinguish among situations as disparate as tmsatisfactory face mask fit, difficult direct laryngoscopy, and pathological or congenital distortion of the larynx or trachea. Widespread experience with the LMA has challenged the practice of routine intubation in elective, healthy patients with normal and difficult airways. In this issue of the Journal, Giraud e t al. s report a series of nine patients in whom they used the LMA as the initial airway device in elective patients with recognised predictors of difficult intubation, but no risk fac-

The stomach is rarely completely empty because saliva is swallowed and gastric secretion continues, albeit at low rates, even during periods of fasting. Preoperative fasting guidelines are intended to ensure an empty stomach to minimize the risk of pulmonary aspiration of gastric contents during anaesthesia. Gastric emptying of liquids occurs very rapidly because they can pass immediately through the pylorus, whereas solids must first be digested to semi-fluid chyme. In healthy individuals, 80% of clear liquid empties within 1 h and almost completely within 2 h. Easily digestible solids empty in 3–5 h whereas large particles of indigestible solids may remain in the stomach for much longer. Clinical studies in adults and children demonstrate no difference in volume or pH of residual gastric contents between those patients who have nothing to eat or drink after midnight and those who are allowed to drink clear liquids freely until 2–3 h before induction of anaesthesia. When gastric emptying is delayed for physiological (metabolic, endocrine) or anatomical (pyloric obstruction) reasons, indigestible solids are affected early, followed by digestible solids, whereas clear liquids are affected only at a late stage. Fasting guidelines for healthy, elective patients should not allow solids on the day of surgery, but should allow clear liquids until 3 h before the scheduled, or 2 h before the actual, time of surgery.

We describe the use of a laryngeal mask airway in three adult patients whose mouth opening varied from 12 mm to 18 mm. The first patient’s incisai opening was 12 mm. His airway was otherwise normal and the standard laryngeal mask was used as the definitive airway for the 90 min revision of facial scars and bone graft to mandible. The second patient, who had an incisai opening of 18 mm, was scheduled for posterior fossa craniotomy. She adamantly refused awake fibreoptic tracheal intubation. Following induction of general anaesthesia, a standard laryngeal mask was inserted and, through this, fibreoptic intubation was performed. The third patient, in addition to a mouth opening of only 18 mm, had limited neck movement from previous flap reconstruction following mandibulectomy, hemiglossectomy and radical neck dissection. For three more reconstructive head and neck procedures that ranged from 90 min to nine hours, the flexible reinforced laryngeal mask was inserted under topical anaesthesia and its correct position confirmed by fibreoptic laryngoscopy before induction of general anaesthesia. Maintenance of anaesthesia in all cases was uneventful and there were no postoperative complications.

Most surgical patients are first seen by an anaesthetist after admission to hospital, either the evening before or on the day of surgery. Some medical ethicists believe that an approach by an anaesthesia researcher made after admission is unethical because the hospital itself is a coercive environment, and patients have insufficient time for reflection or consultation. Others believe that an approach prior to admission may be an invasion of the patient's privacy and confidentiality. The implications of these views for anaesthesia researchers may not be apparent to research ethics boards (REBs). To determine current practice, a questionnaire concerning the membership and function of REBs and the time of obtaining informed consent was sent to each research representative of the 16 Canadian university departments of anaesthesia. Membership of REBS was similar, but not identical, in all centres. Most representation was from medical disciplines. Consent was generally obtained following the patient's admission to hospital. In one centre, the REB always requested informed consent to be obtained before the patient's admission to the hospital. Surgeons had no involvement with consent for anaesthesia research in 14 centres while in the other two they gave permission for their patients to be studied and informed patients of the potential approach by anaesthesia researchers. We conclude that it is ethically acceptable to obtain informed consent for most low-risk clinical anaesthesia research after the patient's admission to hospital.

In 1985 the University of Calgary in Canada and Tribhuvan University in Kathmandu, Nepal Jointly established the Diploma in Anaesthesiology (DA) programme in Nepal. To evaluate the impact of the DA Programme and provide a data base for long-term planning we conducted a national survey in 1992. We sought to describe anaesthesia manpower and workloads, and to make an inventory of facilities, equipment, and supplies in different sized hospitals. Twenty-seven hospitals providing surgical services were included, nine inside and 18 outside the Kathmandu valley. Seventeen of the 21 respondent hospitals had at least one specialist anaesthetist. The results identify both strengths and weaknesses in Nepal's anaesthesia services and provide important guidelines for planning. When the DA course was launched there were only seven specialist anaesthetists in Nepal. The shortage of anaesthetists was an important factor limiting surgical services, and after DA graduates were posted to zonal (50 bed) and regional (150-200 bed) hospitals the surgical case loads doubled. There are now about 40 specialist anaesthetists in the country, of which half are DA graduates, but many hospitals have only one anaesthetist. That isolation, plus lack of continuing education (CME), are important factors threatening quality of care. Recognizing the singular role of the DA programme in alleviating Nepal's shortage of anaesthetists, we conclude that it should be renewed and strengthened to meet the needs of the next decade. Techniques commonly used at the zonal level: regional, draw-over, and total IV anaesthesia, should be stressed. At the same time fresh initiatives are required in CME and higher education for the renewal of teaching staff.(ABSTRACT TRUNCATED AT 250 WORDS)

AnaesthesiaVolume 48, Issue 3 p. 273-273 Free Access Bite guard for laryngeal mask airway J.R. Maltby, J.R. Maltby Foothills Hospital, Calgary, AB, Canada TN2 2T9Search for more papers by this authorR.G. Loken, R.G. Loken Foothills Hospital, Calgary, AB, Canada TN2 2T9Search for more papers by this authorJ.S. Low, J.S. Low Foothills Hospital, Calgary, AB, Canada TN2 2T9Search for more papers by this author J.R. Maltby, J.R. Maltby Foothills Hospital, Calgary, AB, Canada TN2 2T9Search for more papers by this authorR.G. Loken, R.G. Loken Foothills Hospital, Calgary, AB, Canada TN2 2T9Search for more papers by this authorJ.S. Low, J.S. Low Foothills Hospital, Calgary, AB, Canada TN2 2T9Search for more papers by this author First published: March 1993 https://doi.org/10.1111/j.1365-2044.1993.tb06934.xCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume48, Issue3March 1993Pages 273-273 ReferencesRelatedInformation

AnaesthesiaVolume 48, Issue 5 p. 453-453 Free Access Chewing gum during the pre-operative fast J.R. Maltby, J.R. Maltby Foothills Hospital, Calgary, Alberta, Canada T2N 2T9Search for more papers by this author J.R. Maltby, J.R. Maltby Foothills Hospital, Calgary, Alberta, Canada T2N 2T9Search for more papers by this author First published: May 1993 https://doi.org/10.1111/j.1365-2044.1993.tb07052.xCitations: 4AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. References [1] Griffin RM, Hatcher IS. Aspiration pneumonia and the laryngeal mask airway. Anaesthesia 1990; 45: 1039– 40. [2] Brain AIJ. The laryngeal mask and the oesophagus. Anaesthesia 1991; 46: 701– 2. [3] Nanji GM, Maltby JR. Vomiting and aspiration pneumonitis with the laryngeal mask airway. Canadian Journal of Anaesthetists 1992; 39: 69– 70. [4] Stanley TH, Leiman BC, Rawal N, Marcus MA, Van Den Nieuwenhuyzen M, Walford A, Cronau LH, Pace NL. The effects of oral transmucosal fentanyl citrate premedication on preoperative behavioral responses and gastric volume and acidity in children. Anesthesia and Analgesia 1989; 69: 328– 35. Citing Literature Volume48, Issue5May 1993Pages 453-453 ReferencesRelatedInformation

Fifty patients scheduled for cataract surgery under peribulbar block were randomised to receive either plain (pH 5.4) or pH-adjusted (pH 6.8 range 6.7–6.9) 0.75% bupivacaine. Hyaluronidase was added to both solutions prior to peribulbar block. The time of onset of akinesia of the globe and the need for supplementary injections were recorded by an independent observer. Patients who returned for surgery to the second eye received the alternative local anaesthetic solution for the second peribulbar block. The relative efficacy of the different anaesthetic solutions was compared in patients who underwent unilateral surgery (Group A, n = 50). In 12 patients (Group B) who underwent bilateral surgery, direct comparisons between eyes in the same patient were possible. In both groups of patients, eyes receiving peribulbar block with the pH-adjusted solution showed a shorter time to partial akinesia of the globe (P < 0.05). However, there was no difference between the solutions in the time to complete akinesia of the globe, but the number of supplementary injections required for an effective block with the pH-adjusted solution was increased. Onset time to akinesia of the lateral and superior rectus muscles was shortened in patients receiving the pH-adjusted solution but there were minimal effects on the medial and inferior recti.