Pioneers of Cardiac Surgery available in Hardcover
- ISBN-10:
- 0826515940
- ISBN-13:
- 9780826515940
- Pub. Date:
- 07/28/2008
- Publisher:
- Vanderbilt University Press
- ISBN-10:
- 0826515940
- ISBN-13:
- 9780826515940
- Pub. Date:
- 07/28/2008
- Publisher:
- Vanderbilt University Press
Hardcover
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$99.95Overview
The profiles are edited transcripts of interviews videotaped between 1996 and 2004. They tell of the development of new techniques such as the "blue baby operation," the first heart-lung machine, the first artificial heart valve, and the first coronary bypass operation. They also tell the unusual life stories of the surgeons and allude to professional and institutional rivalries. A particularly valuable part of the book is the author's brief history of cardiac surgery, designed to orient the reader for reading the profiles that follow.
Product Details
| ISBN-13: | 9780826515940 |
|---|---|
| Publisher: | Vanderbilt University Press |
| Publication date: | 07/28/2008 |
| Pages: | 648 |
| Product dimensions: | 7.80(w) x 10.60(h) x 1.50(d) |
About the Author
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Pioneers of Cardiac Surgery
By William S. Stoney
Vanderbilt University Press
Copyright © 2008 Vanderbilt University PressAll rights reserved.
ISBN: 978-0-8265-9243-9
CHAPTER 1
A Short History of Cardiac Surgery
Since the time of Hippocrates, there has been a difference between those who practice medicine and those who practice surgery. Internists practice the "art" of medicine, while surgeons lean more to the "craft." These two divisions have taken different paths over time. Medicine has slowly, but steadily, progressed as new information has been published, scientific discoveries have been made, and pharmacology has advanced. Surgical progress, on the other hand, has been held in slow motion by the long absence of anesthesia and the problem of postoperative infections. Although there have been many inventive and gifted surgeons in the past, operations remained relatively rare because of the horror of pain and the risk of infection. When an operation was necessary before the discovery of anesthetic agents, all efforts were concentrated on speed and speed alone. Major amputations could be done in one or two minutes, and the celebrated London lithotomists of the early nineteenth century could remove a bladder stone in one minute flat.1 Even so, most operations that are common today were totally out of the question until 1846 when a dentist, William Morton, successfully demonstrated the use of ether as an anesthetic at the Massachusetts General Hospital. Suddenly, an operation could be carried out in an orderly manner without pain. Abdominal operations, obstetrical procedures, eye surgery, and numerous other operations became practical. However, there was still a problem: the risk of postoperative infection. A practical anesthetic came into use twenty years before the recognition and understanding of microorganisms.
In the late 1860s, Joseph Lister, Regius Professor of Surgery at the University of Glasgow, began using a dilute solution of carbolic acid to clean and irrigate the wounds of compound fractures after reading the reports of Louis Pasteur. In 1867 Lister reported in the Lancet his success in treating eleven compound fractures. Nine of the eleven patients healed with no infection. The use of carbolic acid to sterilize wounds was called "antisepsis." He next began using a continuous carbolic spray over incisions and the hands of the surgeon during elective operations, with astonishing results. Instead of the usual postoperative infections, his patients recovered without fever or purulent drainage. It took time for this new technique of antiseptic surgery to be adopted by others, especially the older generation of surgeons, but within the next ten years the craft of surgery began to blossom. In the 1880s, surgeons in Germany took this concept a step further and began boiling all gowns, drapes, instruments, sutures, and anything that would come in contact with the surgical field. Aseptic surgery replaced carbolic acid. Once anesthesia and asepsis were in place, surgery finally became a full partner with internal medicine.
Huge advances in abdominal surgical techniques occurred in the 1880s and 1890s. Advances in ophthalmology and ear, nose, and throat surgery developed in the first part of the twentieth century, and they became the first surgical specialties in 1916 and 1924.
For the most part, advances in medicine and surgery followed new technology, new pharmacology, and new surgical procedures first worked out in experimental laboratories. Since the beginning, surgery, more than any other branch of medicine, advanced only as new technology evolved. Of the surgical subspecialties, cardiac surgery has been the most dependent on evolving technology; hence its development did not really begin until one hundred years after the introduction of anesthesia.
Stab Wounds of the Heart
In 1896 Ludwig Rehn of Frankfurt, Germany, successfully closed a stab wound of the left ventricle with three silk sutures. After Rehn's case report, other surgeons adopted his technique. The first successful repair of a stab wound of the heart in the United States was done by Luther L. Hill of Montgomery, Alabama, in 1902. He had presented a review of the reported cases of wounds of the heart to his local medical society, advocating surgical closure, and, as a result, was called to the home of a young man who had been stabbed in the chest and was in shock. Anticipating that some type of surgery would be needed, Dr. Hill took with him an anesthetist and an assistant. The operation was done on a kitchen table with a kerosene lantern for light. The pericardium was opened, clots were evacuated, and the patient's condition improved. A wound of the right ventricle was closed with a single catgut suture and the patient survived. An interesting footnote to this story is that Hill had named his son, Lister, for Lord Lister, the founder of antiseptic surgery. Lister Hill later became a U.S. senator from Alabama and was responsible for the Hill-Burton Act in 1946, which provided federal funds to community hospitals for modernization. Over six thousand hospitals received such funds and, in return, were required to provide a certain amount of charity care.
Alexis Carrel and Charles Guthrie
The publication in 1904 of a series of articles on vascular surgical techniques and experimental organ transplantation by Alexis Carrel and Charles Guthrie laid some of the foundation that would be used in the future by vascular and cardiac surgeons.
Alexis Carrel was born in Lyons, France, in 1873. He graduated from the University of Lyons medical school in 1900 and remained on the faculty as a junior member of the Department of Surgery. His interest in vascular surgery began with the death of the French president from a stab wound of the abdomen that lacerated the portal vein. The president's surgeons had no experience with vascular repair, and no attempt was made to suture the portal vein. Carrel began a study of experimental vascular surgical techniques, but, disappointed by his failure to attain a permanent academic appointment in Lyons, he moved first to Montreal and, later in 1904, to the Department of Physiology at the University of Chicago, where he first met Charles Guthrie. Carrel and Guthrie worked out a variety of techniques for vascular surgery, including meticulous asepsis, noncrushing instruments, small tapered needles, very fine silk lubricated with Vaseline, and a triangulation technique that kept tension on a continuous vascular suture line, thus avoiding a purse-string effect. They described interposition arterial grafts, vein grafts as an arterial substitute, end-to-end and end-to-side anastomoses, autografts (using the animal's own tissue), homografts (using tissue from another animal of the same species), and xenografts (using tissue from an animal of a different species). They performed successful kidney autografts and limb transplants in cats and dogs, and an orthotopic (added on rather than replacing the heart) heart transplant. Recognizing that autografted kidneys could function indefinitely but that homograft kidneys always failed, they postulated that it might be possible to "discover a means of recognizing the individuals, if such exist, between whom organs can be interchanged with impunity." What is most remarkable about these experiments is that they were accomplished without the use of an anticoagulant. Heparin was only discovered in 1916, by a preclinical Johns Hopkins medical student named Jay McLean, but it was not available clinically until the mid-1930s.
Carrel and Guthrie published a series of articles between 1904 and 1906 describing these vascular techniques and experiments. They then separated, with Guthrie becoming chairman of the Department of Physiology at Washington University, and Carrel moving to the Rockefeller Institute for Medical Research in New York, where he continued his organ and tissue transplant experiments for the next twenty-seven years.
Carrel was awarded the Nobel Prize for Physiology or Medicine in 1912 for this marvelous work. It was the first Nobel Prize given for research done in the United States; Carrel, however, remained a French citizen for the rest of his life. His Nobel lecture summarizes the techniques for vascular anastomosis and the various limb and organ transplant procedures that he developed. The Nobel committee did not include Guthrie in the award.
Carrel joined the French army at the beginning of the First World War in 1914. He became the head of a small military hospital that was dedicated to the treatment of wounds and, in particular, wound infections. Along with his colleague, Henry Dakin, a chemist, he developed the use of dilute sodium hypochlorite, an antiseptic that proved to be extremely useful in dealing with the grossly contaminated wounds during that conflict. Dakin's solution is still used today.
He returned to the Rockefeller Institute after World War I and worked there during the 1920s and 1930s, spending the summer months on an island off the coast of France. During the 1930s he associated with Charles Lindbergh, whose sister-in-law had severe rheumatic mitral valve disease. Lindbergh postulated that her valve could be repaired or replaced if there were a method of temporarily supporting the circulation, such as a heart-lung machine. Together, he and Carrel began working on a tissue perfusion device, which was successful for small organs such as the thyroid, but the project never advanced beyond that stage. Their work is frequently mentioned, probably because of the fame of Lindbergh, but it was not important to the actual development of the heart-lung machine.
In 1939 Carrel returned to France, and, after the German occupation, he joined the pro-German Vichy government as director of the Carrel Foundation for the Study of Human Problems. He died of an acute myocardial infarct in Paris in 1944, his reputation somewhat tarnished by his association with the German army of occupation and by a book he authored, Man, the Unknown, which advocated eugenics.
Trendelenburg and Pulmonary Embolectomy
Today, the sudden collapse and death of a postoperative patient from a pulmonary embolus (blood clot) is relatively rare, but this was not always so. In the first half of the twentieth century it was fairly common. The reduction in postoperative venous thromboembolism has been brought about by a variety of changes, the most important being early ambulation and attention to proper hydration and fluid therapy during and after operations. Also, the ubiquitous use of aspirin and aspirin-like substances today must have played some part in altering the risk. Today, patients are commonly started on anticoagulation drugs after hip replacement and other selected procedures to avoid postoperative venous thrombosis.
Starting in 1905, Freidrich Trendelenburg of Leipzig began a study of this problem. At that time, peripheral arterial embolism was well-known, and femoral embolectomy had been successfully carried out. He proposed that the same procedure could be done for a pulmonary embolus. His research showed that death from a massive pulmonary embolus was usually not instant. There was often an interval of fifteen minutes or more, sometimes an hour or more, from the onset of symptoms to death. He proposed that the clinical picture was frequently clear enough to recognize the problem, and the interval between onset and death was long enough to attempt an embolectomy. The biggest problem was that there was no infallible way to diagnose pulmonary embolism. Acute myocardial infarction could produce a similar clinical picture. Indeed, in later years, more than once a patient was rushed to the operating room with a suspected pulmonary embolus, only to find that there was no clot and that the problem was a myocardial infarct. In spite of this uncertainty, Trendelenburg worked out a surgical technique in the experimental laboratory. Through a parasternal incision he would occlude the main pulmonary artery, with a tourniquet, as close to the heart as possible. He would next open the pulmonary artery distal to the tourniquet, remove the pulmonary embolus, close the pulmonary artery temporarily with a clamp, and release the tourniquet. To avoid operating on a patient that might otherwise survive, he planned to take the patient to the operating room, have him prepared and draped, and not begin the operation until the patient was at the point of death. Trendelenburg attempted this operation on three patients in 1906 and 1907, but all three patients died, the first two in the operating room, and the third patient several hours later of bleeding from the internal thoracic artery. Attempts by others also failed until Trendelenburg's trainee, Martin Kirschner, did a successful pulmonary embolectomy in 1924. Still, it was never a procedure with much hope of success.
Years later, however, this operation was the stimulus for John Gibbon to begin his research to develop a heart-lung machine. In 1934, as an intern, Gibbon was involved with an unsuccessful pulmonary embolectomy in Boston. He recognized that temporary extracorporeal circulatory support would make this procedure practical. After nineteen years of research, he developed a heart-lung machine in 1953. While the Trendelenburg operation has fallen into disrepute because of the reported 90 percent mortality, the present-day use of radioisotope studies, pulmonary arteriograms, and open-heart surgery have made pulmonary embolectomy a reasonable strategy for massive pulmonary embolism.
Trendelenburg's idea that embolectomy would be beneficial for massive pulmonary embolism was exactly right. It failed at that time because vascular surgery was in its infancy. The only safe and realistic way to remove a pulmonary embolus involves cardiopulmonary bypass. The Trendelenburg operation is an example of a procedure that was proposed and carried out long before the technology necessary for success was available.
Mitral Stenosis in the 1920s
Another cardiac disorder, mitral stenosis (narrowing of the mitral valve), also appeared to have a surgical solution. Although it was known to be caused by rheumatic fever, many physicians at that time believed that the symptoms of shortness of breath, cardiac enlargement, and heart failure were due to rheumatic injury to the myocardium and not due to stenosis or leakage of the valves. Elliott Cutler at the Peter Bent Brigham Hospital in Boston was one of the first to challenge this view; he reviewed autopsy specimens of patients who had died of mitral valve disease and concluded that valvular stenosis was frequently the principal cause of the symptoms. His theory was that mitral regurgitation was less important than mitral stenosis. He proposed an operation to incise both leaflets of the mitral valve to convert mitral stenosis to "mild" regurgitation. His first operation was done in 1923. He inserted a valvulotome through a stab wound in the apex of the left ventricle of a twelve-year-old female patient with severe mitral stenosis and successfully incised both leaflets. The patient survived and was improved but eventually died of additional cardiac problems four years later. Cutler operated on six patients for mitral stenosis, but the only survivor was the first.
In 1925 in London, Sir Henry Souttar also operated on a patient with mitral stenosis. He used the left atrial appendage to approach the valve and inserted his finger through a purse-string suture. Although there was some regurgitation, he was able to open the valve along the commissures and the operation was considered a success. This method of opening the valve along the commissures rather than cutting the leaflets at right angles to the commissures would prove to be the most satisfactory operation twenty years later. However, Souttar's medical colleagues remained convinced that the myocardium was the problem and that valve disease was only of secondary importance. Although Souttar's patient did well and lived for several years, no other patient was referred. Years later, when asked by Dwight Harken why he did only one operation, he said, "It is of no use to be ahead of one's time."
Patent Ductus Arteriosus
In the 1930s the possibility of surgical closure of a patent ductus began to attract attention, not only because of heart failure and pulmonary hypertension, but also because of the possibility of bacterial "endocarditis" at the site of the ductus. The ductus arteriosus is a communication between the pulmonary artery and the aorta that remains open during fetal development but closes spontaneously at birth. If it remains open, it is called a patent ductus. The first such operation was done by John Strieder at Massachusetts General Hospital in 1937, in a patient with acute progressive bacterial endocarditis. The ductus was partially closed by sutures, and the murmur was gone postoperatively. Unfortunately, the patient died on the fourth postoperative day, of acute gastric dilatation.
A year later, in August 1938, Robert Gross successfully ligated a patent ductus at the Boston Children's Hospital. Gross had prepared for this operation by careful study of autopsy specimens. His chief, Dr. William Ladd, was unwilling to give Gross permission to proceed, but Ladd always took a month-long vacation in August, so Gross scheduled the operation when Ladd was out of town. It was a success, and was soon repeated at Boston Children's and elsewhere. Despite the success, Gross had proceeded against Ladd's advice, and the resulting strained relationship between the two was never completely resolved.
(Continues...)
Excerpted from Pioneers of Cardiac Surgery by William S. Stoney. Copyright © 2008 Vanderbilt University Press. Excerpted by permission of Vanderbilt University Press.
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Table of Contents
Contents
Acknowledgments
Preface
Significant Events in the Development of Cardiac Surgery
A Short History of Cardiac Surgery
Stab Wounds of the Heart
Alexis Carrel and Charles Guthrie
Trendelenburg and Pulmonary Embolectomy
Mitral Stenosis in the 1920s
Patent Ductus Arteriosus
Coarctation of the Aorta
Tetralogy of Fallot and the Blue Baby Operation
World War II
Post-World War II Developments (Dwight Harken and Charles Bailey)
Development of the Heart-Lung Machine
Lillehei and Cross Circulation
DeWall and a Practical Heart-Lung Machine
The Starr-Edwards Valve
Coronary Artery Surgery
Cardiac Transplantation
Total Artificial Heart
Pioneer Cardiac Surgeons
The Early Years
William P. Longmire
Viking O. Björk
C. Walton Lillehei
Richard A. DeWall
William H. Muller
Harris B. Shumacker Jr.
Geoffrey Wooler
Michael E. DeBakey
C. Rollins Hanlon
Frank C. Spencer
Henry T. Bahnson
Congenital Heart Surgery
Judson G. Randolph
Anthony R. C. Dobell
Paul A. Ebert
Harvey W. Bender
Denton A. Cooley
J. Alex Haller Jr.
Valvular Heart Surgery
Albert Starr
Donald N. Ross
George J. Magovern
Robert B. Wallace
Francis Robicsek
Alain F. Carpentier
Vincent L. Gott
Alden H. Harken and Dwight E. Harken
Coronary Artery Surgery
René G. Favaloro
George E. Green
W. Dudley Johnson
John L. Ochsner
Floyd D. Loop
Thomas J. Fogarty
Transplant-Artificial Heart
Norman E. Shumway
Christiaan Barnard
James D. Hardy
Sir Terence English
William C. DeVries
Arrhythmia Surgery
Will C. Sealy
James R. Jude