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an online version of the magazine Fall 2009
Annals of Hopkins

Under Surgery’s Yoke

Physicians specializing in anesthesia struggled for decades to achieve the same respect accorded to other medical specialties.


By Maria Blackburn


Curt Richter
In the early days of anesthesiology, cones were used to “drop” ether on patients. By the 1950s, anesthetists here had advanced to using tanks of cyclopropane (above).
Photos by Chesney Medical Archives

On a winter morning early in 1946, 29-year-old Merel Harmel walked out of the operating room devastated. Harmel ’43, had just supervised Olive Berger, the Hospital’s chief nurse anesthetist, as she administered anesthesia to a child undergoing one of chief surgeon Alfred Blalock’s famous “blue baby” operations. The child had died on the operating table. This was an operation that Harmel knew well. He had been in the OR on November 29, 1944, when Blalock pioneered the lifesaving procedure for children born with a severe heart defect. Since then, he had acted as Blalock’s anesthetist dozens of times. Now, within minutes, the young resident was being summoned by Blalock. This child’s death, the surgeon said, had been Harmel’s fault.

On that morning 64 years ago, instead of using the standard inhaled ether to anesthetize the patient, Berger had asked Harmel to supervise her as she administered a less-tried anesthetic: cyclopropane. “Blalock ripped me up and down,” Harmel, now 92, recalled in a phone conversation from Chapel Hill, N.C. “He was very upset at the death of this child, and I became the object of his frustration. What right did I have to use cyclopropane instead of ether and not inform him?”

Harmel, who still teaches a class at Duke Medical School on the history of anesthesiology, never forgot the episode. Until then he’d been considering an offer from Blalock to stay on at Hopkins since Anesthesia’s head, Austin Lamont ’34, had left for the University of Pennsylvania. Anesthesia was changing quickly in those days just after World War II: Sophisticated intravenous and regional anesthetics were coming into use, and physicians back from the front were rushing to establish techniques they’d learned in the field. Lamont had recognized those advances and tried to create an independent anesthesia department with a full-scale residency program and physician-researchers who served as the primary anesthetists. Blalock, however, focused on strengthening surgery, had been vehemently opposed to such plans. The Hospital’s advisory board and faculty sided with the powerful surgeon.

Now, Harmel’s own incident with Blalock became his case study for why the specialty couldn’t succeed here. “Blalock and his surgeons wanted to dominate the scene,” he says. “If I stayed, I would have just been his whipping boy.” For those who know today’s highly regarded Department of Anesthesiology and Critical Care Medicine, the idea that for most of Johns Hopkins’ first 100 years anesthesia remained only a sub-service of surgery may seem surprising. But according to George Bause ’81, the honorary curator of the Wood Library-Museum of Anesthesiology in Park Ridge, Ill., the reasons for this had much to do with anesthesia’s image nationally. In the early 1900s, etherizing patients was so unchallenging, Bause explains, that many hospitals allowed the janitor or chaplain to “drop” the substance. Using surgical house staff or specialist nurses as anesthetists, therefore, made complete sense for Hopkins surgeons. And once the Hospital had established its own Johns Hopkins School of Nurse Anesthesia in 1917, a steady supply of those nurses was available.

One of the few early surgeons who did place a higher premium on the role of the anesthetist was Harvey Cushing, recognized today as the father of American neurosurgery. Cushing joined the Hopkins faculty in 1901 insisting that he only wanted a physician to anesthetize his patients. After several disastrous experiences (including at least one patient death) administering anesthesia as a Harvard medical student, Cushing and a classmate had popularized the idea of keeping an anesthetic record during surgery that tracked the patient’s pulse rate and respiratory rate. After adding continuous blood pressure monitoring to this record, Cushing preferred that this kind of detailed monitoring be provided by a physician anesthetist.

But Hopkins, like many early academic hospitals, had no such full-time position on its staff. (Training programs for physician-anesthetists, Bause says, were almost always based at small—often homeopathic—hospitals.) So Cushing arranged for the innovative physician-anesthetist Samuel Griffith Davis to walk the two blocks from Church Home Hospital to work with him. The relationship proved fruitful, but once Cushing left in 1912 to return to Harvard, anesthesia here returned to its previous model.

It took another 40 years for the specialty to begin differentiating itself. “It was a turf battle at its worst,” says John Ulatowski, the current director of Anesthesiology and Critical Care Medicine. “Developing the department at Hopkins was about wrenching control of anesthesia away from surgery.” The result, though, was Anesthesiology, a new study within medicine for Johns Hopkins.

In 1956, Donald Benson became the first head of anesthesia to have completed a residency in the specialty (from the University of Chicago Clinics). With the support of senior surgeon George Zuidema, Benson began organizing a formal anesthesiology residency program and recruiting physicians and staff. “He felt like a pioneer,” remembers his daughter Jane Benson ’80, an assistant professor of radiology and pediatrics at the School of Medicine. “Anesthesiology had always been the handmaiden to surgery. Now the whole specialty was being born at Hopkins, and here was Dad trying to put it on equal footing with surgery in the operating room.”

Finally, with the appointment in 1989 of Mark Rogers as director of the department that he renamed Anesthesiology and Critical Care Medicine, the specialty achieved full academic status here.

As for Merel Harmel, the young resident who turned down Blalock’s offer in 1946 to remain in anesthesiology at his alma mater, he never looked back. Over the next 25 years, Harmel went on to found three esteemed anesthesia departments: SUNY Downstate Medical Center, the University of Chicago, and Duke University. Back on campus last May to present Grand Rounds, he observed that Anesthesiology at Hopkins—now considered a national leader in research and training clinical experts in anesthesia care—“had a stormy history.”

In the end, it may have been Donald Benson who best defined the importance of his specialty: “Anyone can put you to sleep,” Benson used to say, “but it takes an anesthesiologist to wake you up.” 1

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