With Gas & Needle

A unique breed of doctors gathered 800 strong in Seattle last week for their annual get-together. They were far younger than the general run of medical specialists --mostly in their 303--and so devoted to learning that they packed the meeting rooms for no fewer than 84 self-improvement lectures during the week. "They're the damndest eager beavers you ever saw," said an oldster (41) among them. They were the members of the American Society of Anesthesiologists.

Partly because their specialty is relatively new and fast gaining in importance, the anesthesiologists have none of the stuffy dignity of the oldtime, frock-coated specialist. They talk freely and colloquially about their work, often lapsing into unprofessional profanity. They have something good and they know it.

The day when an anesthetist was usually an undertrained nurse-technician, who merely slapped a mask on a patient's face or jabbed a needle into his arm, has passed. Modern anesthesiology has been developed, mainly in the past 15 years, to a complex discipline. In the best medical centers, the anesthesiologist ranks with the internist and the surgeon, has equal responsibility for the patient's care and survival. Said a noted chest surgeon recently: "The anesthesiologist is the forgotten hero. The surgeon gets the glory, but without the anesthesiologist's skill the surgeon wouldn't get very far."

Finger in the Heart. In no area of surgery has the anesthesiologist played a more vital role than in operations inside the heart. Ten or 15 years ago, little or nothing could be done for the patient with a constricted mitral valve (usually the result of rheumatic fever). Then surgeons at .Philadelphia's Hahnemann Hospital devised a finger-tip knife for opening the valves. The trick was to do it without killing the patient.

That was where Anesthesiologist Kenneth Keown came in. He devised elaborate techniques for anesthetizing the patients and running sensitive tests during surgery to make suwf that they did not slip over the line into permanent oblivion. If their hearts, at best always on the point of failure, showed signs of stopping during the drastic operation, Dr. Keown was ready with a battery of revivers. The surgeon would work better without the nagging fear and responsibility for the patient's minute-to-minute reactions. The Hahnemann team's technique has already saved thousands of lives and is becoming standard the world around.

It was to Dr. Keown that the anesthesiologists looked last week as the grand old man of anesthesia for inside-the-heart surgery. What they saw was a crew-cut man of 36, who still looks like the halfback he was in junior college (Graceland, Iowa), only 17 years ago. Appropriately, it was another young giant of anesthesiology, Chicago's Dr. Max Samuel Sadove, 39, who put a capstone on Keown's work. "Ken has shown us the way, and we've followed," said Sadove, who won wide medical acclaim for his work in keeping the Brodie twins alive through many operations, including the one to separate their brains (TIME, Dec. 29).

Delicate Dozens. With their own adaptation of Dr. Keown's technique, surgical teams at the University of Illinois hospitals have performed 200 operations on the mitral valve without a single death in the operating room (and few deaths afterward). Dr. Sadove reported. Then he spelled out the dozens of delicate steps which the anesthesiologist takes in each such case. The key steps give a good idea of how far anesthesiology has advanced beyond the mask-and-needle stage.

The patient is given barbiturates the night before the operation. In the morning, he first gets meperidine and atropine. In the operating room, needles are placed in the veins, and glucose solution is given (if the heart is especially irritable, procaine as well). Anesthesia proper begins with injections of thiopental and a muscle relaxant of the curare family;* at the same time, oxygen is given by mask. A tube is slipped down the patient's throat, into his windpipe, and he gets his oxygen that way while respiration, pulse and circulation are carefully checked.

Ether is put through the tube to produce deep anesthesia. (Oxygen is still being given.) If the pulse rate drops below 60, the anesthesiologist injects atropine. Procaine is injected into the rib cage and around the heart, and, finally, as the surgeon lays the heart bare, into the heart itself. Only then is the actual operation of widening the valve performed. The anesthesiologist injects lidocaine to block the nerves of the rib cage. As the wound is being closed, he twirls the knobs on the anesthesia machine to give a mixture of nitrous oxide and oxygen. The patient's bed is brought to the operating room, so that he can continue to receive oxygen and intravenous infusions while on his way to the recovery room. To relieve pain after he regains consciousness, he gets meperidine. (But not enough to relieve all pain because, says Dr. Sadove. that would also eliminate the cough reflex, "the watchdog and clean-up man of the chest.") Oxygen is usually discontinued within a couple of days. With that, the anesthesiologist's task is about done.

Small-Arms Fire. Few operations present so great a challenge as those inside the heart. But, in Dr. Sadove's view, the distinction between major and minor surgery disappears when anesthesia is employed, because anesthetics are such powerful and dangerous substances that their every use is a major medical event. That is why the anesthesiologist is called in on the case early, perhaps to help the internist and surgeon decide whether an operation is feasible. That is why, during the operation, the anesthesiologist is responsible for the patient's general welfare, beyond the immediate area where the surgeon is working--and if he says so, the surgeon must stop.

The greatest problems of heart surgery have cemented the relationship between surgeons and anesthesiologists so that now they tend to work more closely in many other types of cases. Dr. Sadove, who spent four wartime years in U.S. Army hospitals in England, likes to use a military metaphor: "The small-arms fire of the anesthesiologist joins the spy system of the lab to back up the surgeon's big artillery in a coordinated attack to conquer disease."

* For using himself as a guinea pig to test the derivatives of the deadly arrow poison, curare, and many other drugs, Dr. Sadove is a charter member of the Walter Reed Society.

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