Iconography in Anesthesiology

Abstract

(Bacon) Assistant Professor, State University of New York at Buffalo Department of Anesthesiology; Chief, Anesthesiology Service, Veteran's Affairs Healthcare System of Western New York.Received from the Anesthesiology Service, Veteran's Affairs Healthcare System of Western New York. Submitted for publication September 7, 1995. Accepted for publication April 18, 1996. Supported by a Wood Library-Museum Fellowship.Address reprint requests to Dr. Bacon: Chief, Anesthesiology Service/128, Buffalo VAMC, 3495 Bailey Avenue, Buffalo, New York 14215. Address electronic mail to: BACON.DOUGLAS R@Buffalo.VA.GOV.AS the number of physicians involved in the practice of anesthesia grew during the years between the world wars, small professional societies began to be organized to help disseminate information concerning advances in the field. [1]These groups also served as political forums for the physician anesthetists* to debate the issues of the day and to take cooperative action. [2]Another key issue these societies addressed was the public's perception of the physician specialist in anesthesia and his role in the delivery of medical care.In developing both their professional and public image, these early societies created organizational seals to symbolize the mission of their organization. The seal was ubiquitous, appearing on professional stationary, publications, advertisements in professional journals, and meeting announcements. Four basic types of symbolism were used in the creation of these seals: contemporary figures, Greco-Roman mythologic, conventional, and historical. Thereby, these insignias served multiple purposes and helped develop a sense of community amongst the early physician anesthetists. These seals also delivered a message about the importance of the physician specialist every time the seals were displayed, and they served as an identifying mark of professionalism in anesthesiology.The New York Society of Anesthetists was founded in 1911, and adopted its seal (Figure 1) in 1932. Four years later, the group changed its name to the American Society of Anesthetists, but kept the seal. It consists of… the pilot wheel, perfect circle, shield, stars, clouds, moon, ship, sea and lighthouse. The motto is VIGILANCE. The patient is represented as the ship sailing the troubled sea with clouds of doubt, waves of terror, being guided by the skillful pilot (the anesthetist) with constant and eternal (stars) vigilance (motto) by his dependable (lighthouse) knowledge of the art of sleep (moon) to a safe and happy outcome of his voyage through the realm of the unknown. The perfect circle denotes unity of a closed group (the Society).**The seal of the American Society creates a dynamic image that fully expresses the important role of the physician anesthetist.Using color to create an even more vivid and powerful image of the physician anesthetists' role was another consideration of the seal's designer, Paul Wood. He suggested… silver for the stars, gold for the moon, gray to black for the clouds, brown for the lighthouse base, white for the beams, blue for the ship, brown for the pilot wheel, letters black [with the] entire background medical green.***Unfortunately, the colors were never officially approved. However, the Society has struck medallions in color for the past presidents, incorporating many of Wood's ideas. Finally, the three dots after the founding date of 1905 were put there by Wood to symbolize the name changes of the Society, from the original Long Island Society of Anesthetists, to the New York Society of Anesthetists, to the American Society of Anesthetists, and then the name under which the Society was incorporated, the American Society of Anesthesiologists.***By far, the most popular symbols for society seals during the 1920s and 30s contained figures from Greek and Roman mythology. The Canadian Society of Anesthetists, organized in 1920, chose for its insignia a Figure ofMercury**** standing at the entrance to a dark cave (Figure 2). In his left hand is a poppy plant in flower, the plant from which some opiates are derived. In his right hand, he holds a cup from which drips a liquid, presumably the juice of a poppy plant. At the bottom of the cave are thistles***** on the right and poppies on the left. The motto, in Greek, chosen by the Society, is “we safeguard those who sleep.”[3].The Canadian seal has several possible interpretations. Mercury was the messenger of the Roman gods, used to inform mortals of the decrees of the Olympians. [4]Here, he is heralding the conquest of pain of surgery by the juice of the poppy, and therefore Mercury represents the physician anesthetist. A cave is a dark place, where the known can quickly become the unknown. The state of unconsciousness induced by anesthesia is, similarly, unknown, dark, and, to many patients, terrifying. Standing between the patient and the cave is the physician anesthetist as a protector from the unknown.The motto is also interesting. Physician anesthetists monitor the effect of anesthesia and surgery on the patient. For the layman, it would be comforting to know that they were safeguarded as they crossed the threshold of the cave. Sleep has long been used to describe the anesthetized state, although it is physiologically inaccurate. But by using the term sleep, layman quickly have a comfortable analogy for that which they are to undergo. What could possibly be more natural than sleep, and what more comforting than to know that the doctor was watching over you closely as your parent had done during childhood?The Pacific Coast Association of Anesthetists, also founded in 1920, chose Mercury to represent the physician specialist. This seal (Figure 3), however, is more dynamic, as Mercury's upper torso spreads across the seal from left to right. In the background is the rising sun, and along the sides are poppy plants in flower. Along the bottom of the seal is a staff with a snake entwined around it, similar to the staff of Aesculapius. Mercury is squeezing the juice of the poppy into the staff's snake's mouth. The motto, “It is godlike to relieve pain,” is written in Latin, and forms the lower portion of a circle surrounding the seal.This seal represents anesthesia as the dawning of a new era; pain-free surgery. Again, from the Olympians, Mercury is spreading the good news of surgical pain relief to mortals. The staff with a snake intertwined traditionally connotes the physician in the culture of the West. The motto elevates the job of the anesthetist beyond mortal status, and is consistent with written accounts of Adam's anesthetic for the creation of Eve, making the God of the Bible the first anesthetist.******In contrast to the Canadian Association seal, the Pacific Coast seal is dynamic. Mercury is not standing as a guardian, but striding through a new dawn, announcing the arrival of pain-free surgery. Action enhances the seal, draws the eye toward it, and consequently forces the observer to take note of it and begin to interpret its meaning.In 1922, the International Anesthesia Research Society (IARS) was formed to promote scientific investigation and international cooperation in anesthesia. The society published the first journal devoted exclusively to the specialty, Current Researches in Anesthesia and Analgesia. Francis Hoeffer McMechan, confined to a wheelchair by arthritis, and both the leading organizer of physician anesthetists from 1912–1939 and an amateur actor, [5]chose as his organizational seal symbols that have long been associated with knowledge. [1]The seal (Figure 4), containing a robed woman, owl, books, ivy leaves, lamp, and globe was organized by McMechan to convey a specific idea. He wroteThe lady represents the Figure ofmedical science; the light is the search for knowledge; the ivy leaf symbolizes truth; and the owl in front of the globe personifies wisdom. *******The Figure ofthe lady is in many ways similar to the robed Figure ofjustice. The light, ivy leaf, and owl all symbolize knowledge, attributes to which the anesthesiologist strives. Given the perception at the time that almost anyone could and did give anesthetics, specialized knowledge was critical to the work of the physician anesthetist. Even more fitting were these design elements for a society devoted to scientific research into the specialty of anesthesiology!McMechan's explanation of the symbolism reinforces the importance of research to the specialty. “Medical Science” holds “truth” in her right hand, demonstrating the importance of veracity to medicine. The owl, perched on three books, is doubly a classic reference to knowledge, and this group of figures is placed at the right foot of “Medical Science.” The lamp illuminates the scene. Although McMechan believed that the lamp was the search for knowledge, this search also is driving force behind research. It is interesting to note that the lamp is placed on a pedestal within the seal, thereby elevating the symbol and the group that revered knowledge. Perhaps McMechan is trying to emphasize the importance of scientific knowledge to a specialty often thought not to have scientific merit.McMechan interestingly avoids noting that the globe also symbolizes the worldwide nature of the organization. The motto of the Society is “We Strive Always for the World Conquest of Pain.” The seal is in purple, and McMechan used a special purple ink when writing.******** The color purple may have been another technique to consistently identify the IARS with McMechan both publicly and privately.Another society created by McMechan in 1926 was the Associated Anesthetists of the United States and Canada (AAUSC). [6]This group functioned as the national anesthesia society until the rise of the American Society in the late 1930s. The AAUSC sponsored the annual Congress of Anesthetists, which served as the annual gathering of the physician anesthetists. The AAUSC seal (Figure 5), similar to that of the IARS, was placed on each program from the Congress and on McMechan's correspondence about the upcoming meeting.********* The seal is simple, containing a robed woman holding a burning torch in her left hand and an ivy branch in her right. Next to her is an eagle, with wings outspread.From the seal of the IARS, the woman in the AAUSC seal most likely represents medical knowledge. The torch would then logically represent the search for medical knowledge, and the ivy leaf truth. The eagle may represent the virtues of courage, faith, contemplation, and strength of the organization. [7]The out-spread wings symbolize the all-encompassing nature of the organization, covering all of North America.The Mid-Western Association of Anesthetists looked to the history of anesthesiology to provide a Figure worthyof recognition on their seal **********(Figure 6). Founded in 1921, the group decided that Wells was the person to represent their organization. Wells discovered, at a traveling laughing gas demonstration, that injury could occur under the influence of nitrous oxide without memory or pain. As a dentist in practice in Hartford Connecticut, Wells longed for a way to eliminate pain from dentistry. [8].Wells may be the most tragic Figure withinthe narrative of the discovery of anesthesia. He failed in an attempt to publicly demonstrate nitrous oxide anesthesia at the Massachusetts General Hospital in 1844. He later became addicted to the very agents he used to provide insensibility to his patients. While under the influence of chloroform on January 23, 1848, he sprayed sulfuric acid on several prostitutes in New York and was arrested. Smuggling chloroform into the Tombs prison, he partially anesthetized himself and committed suicide by lacerating his femoral artery. [9].Why then, would the Mid-Western Association choose Wells for their seal? Part of the answer lies with the group's motto “He Hath Given His Beloved Sleep.” Within the context of the seal, Wells' efforts become glorified. Forgotten is his failure in the ether dome, and his self-experimentation with inhalational agents that led to his death. Wells' suicide is alternatively interpreted as a sacrifice to the specialty, and begins his martyrdom for anesthesia. [10].The crafting of Wells' image as a romantic Figure anda martyr to the discovery of anesthesiology makes him a fitting Figure forthe seal. Rather than view his suicide as the last act of an addicted and desperate man, Wells becomes the professional who gave everything he had, even his life, to ensure that there was painless surgery in the world. Many authors have since carried his banner as the only true discoverer of anesthesia. Hence, ignoring the less pleasant portions of his story, and in an attempt to glorify the past, Wells becomes a central, worthy individual to represent anesthesia. [10].The Eastern Society of Anesthetists, founded in 1923, chose another historic Figure asthe centerpiece for their seal **********(Figure 7). William Thomas Green Morton stares out at the observer. Morton was the first person to successfully demonstrate ether anesthesia to the general public in 1846, at the Massachusetts General Hospital. Over his head are Morton's words used in conjunction with the exhibition, “Science has Control of Pain.”Morton is also a curious choice for the centerpiece of the seal. After he anesthetized Gilbert Abbott for the removal of a jaw tumor, Morton refused to divulge the substances within the inhaler that created insensibility. He attempted to patent this discovery, and only with great reluctance did he share the contents of the substance called “letheon.” During the ensuing years, Morton attempted to obtain a grant from the United States Congress for his invention. Although he failed, Morton also attempted to sue hospitals for patent infringement when using ether anesthesia. His unsuccessful suit against Manhattan Eye and Ear left him penniless and censured by the American Medical Association. [8].Like Wells before him, the need to find glorious and worthy characters within the history of the specialty led to the deification of a somewhat unpleasant individual. Morton did, however, what none of his contemporaries, including Wells, could do: publicly demonstrate, on repeated occasions with different patients, insensibility to surgical pain. Those acts make him, by very definition, a central personality in the discovery of anesthesia, and worthy of representing anesthesia.The motto is also consistent with the way in which the physician anesthetists viewed themselves. As masters of applied science, [11]bridging the gap between the laboratory and the patient, the physician anesthetists believed that science would potentially solve all of their problems. The motto, for the general public, demonstrated that these physicians were serious about their efforts.During the 1920s and 30s, each seal became associated with an organization, and, in time, these seals became instantly recognizable. Today, three of the seals remain in common use--the IARS, ASA, and the Canadian Society of Anesthetists. All appear in the leading publications in the field, and the IARS proudly displays its seal on the cover of Anesthesia and Analgesia, the continuation of the founding American journal of the specialty, Current Researches in Anesthesia and Analgesia. The ASA seal appears on the top left of the cover of Anesthesiology. The Canadian Society uses its seal on The Canadian Anesthetists Journal. All use their seals in many ways to represent the society.Of more value than their longevity, the society seals created between 1920 and 1940 speak volumes about how physician anesthetists felt about their work. Outnumbered ten to one by nurse anesthetists, [12]these physicians created dynamic seals to explain who they were and their work to professional and lay audiences alike. They valued pain relief and the ability to relieve the discomfort of the surgeon's knife, above all else.Each seal depicts anesthesiology differently. Some used symbols associated with the ancient Greeks, others used common, everyday objects. Still others attempted to create heroes from historical individuals in anesthesiology. Yet, in telling the importance of anesthesiology, each created clear communication that anesthesia was a dangerous, mysterious, yet scientifically based specialty in medicine. In their diversity, these seals explain the importance placed on their work by these pioneering specialists.* During this time period, the term physician anesthetist or physician specialist in anesthesia was used to describe what would be referred to contemporarily as an anesthesiologist.** Minutes of Meeting of the New York Society of Anesthetists, April 13, 1932. Collected Papers and Minutes of the Long Island, New York and American Society of Anesthetists (1905–1945). The Wood Library-Museum Collection, Park Ridge, Illinois.*** Letter from Paul Wood to Winthrop Hall, June 5, 1961. The Collected Papers of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, Illinois.**** The Figure canbe identified as Mercury because of the wings on his helmet. One of Mercury's roles in Roman mythology was as a messenger from Jupiter. Another of his roles, ascribed to him by Virgil in the Aeneid, was that of psychopomp, a guide for souls to the underworld.***** The seal's designer, A. Sherriff Scott, was a Scotsman and, accordingly, could not resist the temptation to display the thistle, which has been described as representing the close ties of Canada to Scotland.****** Seymour E: The present status of anesthesiology and the anesthetist. California State Journal of Medicine 1920; 18:355.******* Back cover of the program, 50th Congress of International Anesthesia Research Society, March 14–18, 1976. Courtesy of the International Anesthesia Research Society.******** When signing as a founding member of the New York Society of Anesthetists in 1911, McMechan was the only physician to use purple ink. All the existent original signatures of McMechan are also in the same purple color. Collected Papers and Minutes of the Long Island, New York and American Society of Anesthetists (1905–1945), and the Collected Papers of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, Illinois.********* Programs for the annual Congress of Anesthetists may be found within the Wood Library-Museum Collection. The seal may also be seen on correspondence in the Collected Papers of Paul M. Wood, M.D., The Wood Library-Museum Collection, Park Ridge, Illinois.********** The seal of the society is on the program of the joint session of the Mid-Western Association of Anesthetists and the Eastern Society of Anesthetists for October 3–7, 1927. The Wood Library-Museum Collection, Park Ridge, Illinois.

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