History of cardiovascular surgery, February 11, 1986

Moderator: History of Medicine Society. Tuesday, February 11th, 1986. The speaker this afternoon is Johann L. Ehrenhaft , M.D. His topic is "The history of cardiovascular surgery." Dr. Johann Ehrenhaft : Thank you for inviting me to talk here. I prepared this talk once before and gave it to the anesthesia residents about Dr. Tinker's request a few days ago. Very informal. Some of the things are very informal. Some of the things are a little philosophical. Things I like to bring, of course. You may not agree with them. But, I give them to you, anyway. Well, I'm glad to talk to you about this subject [inaudible 00:01:09] and cardiovascular surgery, in particular, primarily for the period of time, which I have personally experienced, more or less, over the last 45 to 50 years. Younger physicians today don't realize the heritage and history behind some of our routine procedures and techniques carried out today. They're taken for granted without much thought today, and they are accepted to be the correct and only way to do things. Looking back into the past is great value, and should be part of a general educational passes of every well-rounded physician of every specialty. It is impossible to name all the participants and actors in a constantly changing progression of new developments in the application and treatment of disease, however, there would be no progress in any field without the long line of plagiarism - one participant obtaining or copying information from another, and improving upon the original. Historical it often becomes impossible to really ascribe a certain fundamental idea to a single person. It probably should be attributed to a time period in which this particular person developed his concept, many of which may have been premature on the times, not accepted during his lifetime. At the present many innovations and diagnoses and treatment have come about by enormous explosive expansion of technology. One really can state that specialists in every field have been created by technology, and with it, there has been a vast growth of health personnel. For example, in 1900, there were a total of 345,000 people in the healthcare field in this country. And, one of three was a physician. In 1980, about 6 million people in the healthcare field, and one of 13 is a physician. Interestingly enough, about 180 recognized specialties in the Allied Health occupations, at the present time, not including physician specialists. Today, we are facing a crucial problem of delegation. Not only the specialty personnel, but also to machines, and above all, to computers; which, were introduced into the health field about 1960. The introduction of high technology in the computers has it's own impetus. Now, it looks for areas of further application. Machines are complex, and also, reflect human powered weaknesses. They create distances between patients and physicians. They shape the perception and thinking processes of responsible physicians, and thereby control him and make certain vital decisions, right or wrong. However, those machines have no sense of ethics, empathy with patients, or view of the past or the future. Furthermore, the acquisition of knowledge and understanding of all these highly complex technological equipment is acquired by the student and the physicians in bits and pieces as they go along. Machines can teach technical skills and problem solving, but neglect human communication, patient contact, and the art of deductive medicine - learned only by closed clinical contact with the patient. A concern, which I have expressed so far, can be easily illustrated. Artists have always been concerned with social conditions during their times. Can you turn this on? Yeah. Artists have always been concerned with social conditions during their times, and they've expressed it in their works, which are here for us to read today. Two paintings - one by Sir Luke Fields, dated 1891; and, another early Picasso, painted during his classic period, called La Caridad - transmits to us extreme concern of a physician at the bedside. In close contact with the family, and the physician's attempt to give an overall clinical impression. Most paintings relay the maximum concern and empathy of a physician, his patient, and his family. However, what is lacking here is a physician's capability to be in therapeutic control, to ameliorate or cure an illness. The next picture is today. There's no physician, para-medical personnel is in charge, and machines and computers spewing out data. There's probably maximum control, minimal concern, and empathy with the patient, and there's no family. I show you those two situations in contrast for only one reason: the development of the thoracic and cardiovascular surgery, with it's vast ramification for within the time periods between those two extremes. One cannot separate advances in cardiovascular and thoracic surgery from other major milestones in past medical history, which was the early foundation upon which all of this has been built. This involves the fields of anatomy, pathology, physiology, bacteriology, and all the other related areas, with little work having been done prior to the last century, with most of these advances have been made. I would like to show you a few examples, peeling away to the modern era. With your permission, as I go along, I will intersperse some of my own experiences in an anecdotal manner. I also will relay to you those advances, which have had an impact and have been applied at the University of Iowa. Now, there are a few big milestones in this thing. One of them, of course, is William Harvey, who in 1682, wrote this De Motu Cordis et Sanguinis, I think every medical student should have read it and if you ask medical students, none of them have. Not in Latin, or the translations. And, it also describes the fetal circulation. Jean-Baptiste Morgagni was the first one who described correctly a congenital cardiac defect, pulmonic stenosis. Anatomically there were pathologists, and, which there was an impact later on, as you will see. Another one was Leopold Auenbrugger in 1761. He described the Inventum Novum. A copy of this is in the library here, in the Martin Room. It's a very nice little thing. He was an Austrian innkeeper's son, who used to percuss his rain barrels in his father's place to find out how high the level of the fluid was, and he applied this as a physician to the chest. So, Auscultation and Percussion, René-Théophile-Hyacinthe Laennec. This is really the first instrumentation. In 1816, he described the auscultation of the chest and he was the first one after using his direct ear to the patient's chest, used a wooden stethoscope. I remember very well when my grandfather, whom I knew when he died, before he died, when I was a young boy, he used those long wooden stethoscopes. Wish I had one of those. They're hard to find. The next one is Carl Rokitansky, and I have a little booklet here, I'm circulating it. It's a textual book of my grandfather. You see Rokitansky's signature in there, if you look. Just leaf through it, I marked it. It's sometimes in the 1870's. Rokitansky is a pathologist, and he was the first one who described after Morgagni, ventricular septal defects, congenital defects. And then, Etienne Fallot, in 1888, described a patient with pulmonic stenosis in cyanosis. Prior to this time, all cyanotic disease was named bulbous ceruleus cyanotic state. There was little anatomic understanding of the physiology and flow. And, this persisted for many, many years, we'll come back to this, until the 20th Century. And even Blalock, we'll come back to him at length later on, did not initially sort out the persons and whom arctic pulmonary transfer made, because bulbus ceruleus was a catch-all. And, not all of those people were teratologists, and teratology operation of Blalock's was applied to many other cyanotic people before they were sorted out. Maude Abbott is a real first attempt to classify congenital heart disease, she is a pathologist under encouragement by from [inaudible 00:11:06]. She collected a thousand autopsy cases of patients with congenital heart disease. And it was used for statistic purposes. And when I started, in this game, I used Abbott's atlas as a reference. Of course, in 1895, Röntgen came around with his radiation and the first fluoroscopy, which made an enormous advance at that time was by [inaudible 00:11:41], in 1897. Fluoroscopy of the chest. At that time, many of the lesions in the chest and heart had to be diagnosed by deductive clinical examination only. And, E. Weill, in 1895, described the first attempts at pericardectomy in a small booklet, maladies du coeur chez les enfants, a thing which had been previously suggested by [De Laum 00:12:11], and then also taken up [Barrine 00:12:15], who I will come to later. Stephen Padgett, in 1896, made the following statement: "No new method or any kind of discovery will be able to overcome a natural difficulties that surgery of the heart offers." 1896, and Billroth was said to have said something similar, which was really never documented, "It was always told that the heart cannot be operated on," but, it's never been documented, or said to have said something similar. He was Langenbeck's pupil. At that time, people like York, Schmidt, and Bloch, three physician surgeons in Germany carried out extensive animal experimentation already in the pulmonary sections in dogs. And, poor Dr. Bloch tried to do this on his niece, for it was supposed to be tuberculous upper lobe, and it wasn't, and she died, and he was sued, and he committed suicide. You know? So, it is documented that intrathoracic surgery was done in those days; however, it was 1896 I was talking about and they said you couldn't touch the heart. And Ludwig Rehn, to prove him wrong, was the first one who sutured a cardiac wound, in Frankfurt, in Germany. At that time, Carl [Schaedy 00:13:44], [Ceurnline 00:13:44], [Meurlo 00:13:46] in Germany and many others attempting with chest walls and chest wall tumors. And in this country Carl Beck in New York, and Fowler in New York, did chest wall dissections, and rat dissections for empyema. In 1898, Paul Niehans in Switzerland was the first one who realized that cardiac arrest could be treated by open cardiac massage and resuscitation could be taken on, good result. This was totally forgotten, and I'll give you an idea of how these things go. In this hospital, we get interested in '48, '49, '50. We did some animal experiments with open cardiac massage and there was a hiatus before the time of Kouwenhoven, and external massage, and there was a bit of time when you had to hold our residents back. I think Jack remembers it, when you go and try to open up every chest on the medical service, and surgical service, to resuscitate, hopelessly dying, leukemias and so on. But, anyway, we did some experiments. And we did prove that you could save people by open-cardiac massage in acute situations. When my father died in 1952, I had a paper, which had been sent to the American Association of Thoracic Surgeons, which fell absolutely flat because they didn't get the idea at that time. And they gave the same people in Dr. Denck's clinic in Vienna, at that time when my father died, and it fell equally flat. They did not remember that it had been done previously. 1908, Friedrich Trendelenburg [inaudible 00:15:43], did the first attempted pulmonary embolectomy. Only they did not succeed, and now we're coming a little bit to the more modern area, but Martin Kirschner, in Munich, who was with Sauerbruch, in Munich, at that time, in 1923, did the first successful pulmonary embolectomy for pulmonary embolism. And, interestingly enough, Alton Ochsner, old Alton Ochsner from the Ochsner clinic, many Americans are roaming around in Europe at that time, when he was present doing this procedure, and brought it back to the idea. Now, let me go over to something a little bit different, about anesthesia problems. The problem of intrathoracic pressure, in particular, open thoracotomies, was not well understood, really until World War II. Furthermore, the animal experimentation in dogs, and in humans is quite different. The dog's intrathoracic arrangement is quite different from a human. However, Andreas Vesalius was supposed to have intubated patients in the 16th Century for experiments and Duvall in the 19th Century in France did intubations through tracheostomies in experimental animals. William Macewen, in 1880, an Englishman, fashioned the first tracheostomy tubes; and Rudolf Matas, in New Orleans, also having picked up in Europe the endotracheal insufflation methods. In 1900 used it in New Orleans. A method, which has been suggested by Tuffier, clinically in France, 20, 30 years before. And, actually used by Cohen in Castle Germany. Now, the period ... I have to backtrack a little bit. I want to show. This is Tuffier who suggested the insufflation method. Samuel Meltzer, who is a Russian, who immigrated prior to World War I, to Berlin, then to medical school, and immigrated to the states, and became a professor of physiology and internist , in New York, and his son-in-law, John Auer, in 1909, published a very famous paper called Continuous respiration without respiratory movements. And, this intubations and positive pressure insufflation. And then it's Jack's, and in 1915 was the first one who used a closed anesthesia circuit. So, you see it's a long development, and I come back to something else in a minute. How they got there, I'll show you. In 1887, [Koencky 00:19:01] wanted to open up a chest, do a lung abscess, and this is an experimental negative pressure chamber, first for the dog alone, and then with the surgeon and the dog inside. And Ferdinand Sauerbruch, in 1931, who thought of it initially was applied in Koencky's clinic. He's an interesting man. I'll talk to you about him in a minute. Resected the right ventricular aneurism using this method. He, more or less, invented the negative pressure chamber, 1904. It never caught on very much, except in Mikulicz’s clinic in Breslau, because it was too cumbersome. In 1908, Ferdinand Sauerbruch, came to this country as a guest to the AMA meeting, and Carl Beck, who was a surgeon in Chicago, was his host. And Sauerbruch's reaction of this meeting of the AMA was, he said, "Too much cocktail, too much appendicitis." And, on the way back to New York, he met a man with the name of Willie Mayo. You must realize New York was populated with Sinai Hospital and the Lenox Hill Hospital. They were run by a German-born, I mean German surgeons have gone back to Europe, to the European clinics. And, those are very leading figures. Willie Mayo Ellensburg and some others. And on the way back from Chicago to New York, you talk to Willie Mayo and Willie Mayo say, "Well, we'll fix this." And he was building a negative pressure chamber, which looked like this. A nest that is outside, patient inside. Impossible to work in, and he couldn't get it done so they built it in the Rockefeller Institute first. And, it was quickly given up because intermittent positive pressure anesthesia took place at that time. Interestingly enough, Leo Ellis, who only recently died was one of the group. He worked in San Francisco. You remember his name, don't you? Ellis. Well, Leo Ellis was a gnome-like figure, he was a very interesting man. He would just like be thrown in with some of the others, and come back, too, fought in the Spanish Civil War. He fought all the way across China, with Mao Zedong, not that he was a Communist, but he loved liberty and he hated all the others. He was an outstanding fellow. He died at the age of 96 or 97, one or two, three years ago, professor of surgery when he was 24 in San Francisco. Now, opposing all this negative pressure chambers was a man by the name of Rudolf Brauer who realized that intermittent positive pressure would be much better. And this combined with intubation, of course, later on, made modern anesthesia. One thing I'd like to say about Sauerbruch, to come back to him, there's a very interesting book written by Rudolf Nissen, who used to be his pupil, and assistant for a long period of time. It's the only decent thing he and Sauerbruch ever did in his lifetime, he got him out of Germany and got him to Turkey, and then Nissen came back to New York, and then he went back as professor of surgery to Basel, in 1952 or '53. But, anyway, there's a nice booklet, which is called Light Pages, Dark Pages, and it does illustrate this time period. Now, let me go back to ... At that time Rudolf Nissen, everybody thinks that Dr. Graham was the first to do a pneumonectomy. It's not so. Rudolf Nissen did one in 1931, and Cameron Haight did one in 1931. And here's Dr. Howard [Baie 00:23:26], professor of surgery, University of Iowa, following Dr. Rowen, who in 1927 did a pneumonectomy on a tuberculous woman from Oakdale, whom I knew, worked as a telephone operator for 15 years afterwards. Never published it. Now these things are done and that was done by mass ligation technique. Not very fancy, and so on. There was a row of people here after Dr. Baie who were interested in thoracic surgery. Dr. Peterson who became chairman afterwards was less-so, but he had people like Hazel Aines who a man who came from Cincinnati, and there was this big conflict here, which was very interesting. I witnessed it when I was here. This was a [non-Hauster 00:25:01] type of school for surgery. It was a Murphy type school. Rapid cat gut, fairly gross, but very fast. Then the kind of distinction was your Hopkins School. Very slow. Individual self technique, very meticulous, and Dr. Hazel Aines belonged to the Hauster Group, Hopkins Cincinnati lineage, and he didn't last here very long, for that reason. It was not very well accepted. Then there was Dr. Donna Vernon-Peterson, and then I came in later on. But, now the medical peaked sole interest in thoracic surgery. Now let me go back to catheterization a little bit. The French physiologist catheterized large animals and criminals in 1880's, 1890's to get pressure measurements on the right side. The first man whom should surely get credit is W. Forssemann, who in 1929 published in Münchener Medizinische Wochenschrift, a very short line, stating that he passed a catheter through his right antitubercular vein, into the heart, and then he walked upstairs, one flight, injected some dye, and took a film, visualizing right ventricul pulmonary artery. That's 1929, it was pretty much forgotten for a while. He did get a Nobel Prize, later on for it. So many years. This whole things is in the Weekly Medical Journal. 15 lines. That's all. Now, 1933 is interesting to me, and I'll tell you personal experience. At that time, Charles and Scott purified heparin, which was discovered previously. I was, in 1933, I could tell you, give you a personal experience, after early on, my mother died in 1933 of a massive pulmonary embolism, following bout of lower pneumonia. Pneumococcal pneumonia. And her physician was [Venchibar 00:27:04] from Venchibar right there on Blanche Block. And he knew, in 1933, that leeches contained hirudin, which is a heparin type substance. And it was my duty to go to the pharmacy and pick up all kind of leeches, which were applied, and she was heparinized, hirudinized at the time, it didn't do any good. But the people realized that those things were possible in those days. 1933, Dr. Graham did the first pneumonectomy, and I had the privilege of working with him, between 1948 and '49, and between 1930, it'd been '39 to 1940 ... Who is this? Oh, this is Dr. Graham. Everybody knows his face. Between 1938, 1939 and 1940, I was at Hopkins. Renoff had done his first pneumonectomy, 1931, as I mentioned, and he was interested in thoracic surgery. And, I worked for him in the lab, doing innumerable bronchial closures to every possible method available. And it was very interesting. It was in pre-antibiotic area, on a set time, in 1938, the first sulfonamide protocel came out, if you remember [inaudible 00:28:32], which is an antibacterial agent. Penicillin didn't get here until 1945. About that time, people start wondering about angina. Angina was a symptom, and if you talk to angina patients today, many of them don't have angina on the basis of coronary disease. But, a man by the name of O'Shaughnessy, in London, and [inaudible 00:28:58], in Hamburg, they tried to do something about it. They realized that it's something to do with coronary disease, and they thought maybe the possibilities of getting vascular immunization of myocardium from extracardiac supply. And, O'Shaughnessy had some experimental slides with that years and years and years ago. And there's some gas fibers, or asbestos fibers attempting to get some core circulation to myocardium, and this is splenic pulp, which we put in, we thought spleen was good for it. So, all the things I tried. At that time, Claude Beck, in 1935, attempted to revascularize the myocardium with pedicle flaps, omental pedicle flaps, and here's an omental pedicle flap on a dog, which we did at that time. And, here you see you can revascularize, inadequately, the left [inaudible 00:30:06] and the dog feels from in the omental flap. At that time, surgery is changing. All the surgery for the heart was extra-cardiac surgery. It was large vessel surgery. Very little, nothing intracardiac. You can divide time from then on into several phases. Large vessel surgery for cardiac disease, about the heart, closed surgery, intracardiac, and then open surgery, which came a little later, under normal thermic conditions, hypothermic conditions, cross-circulation, and then extracorporal bypass. Now, we get to this in a minute. About that time, Robert Gross, in 1938, ligated the first patent doctors, which was a real impetus to extracardiac graduation surgery. However, the procedure was suggested in 1917 by Monroe. At that time, about the same time Robb and Steinberg in 1938 started to do catheterizations and angiography. And, between 1938 and '40, I was at Hopkins and there were the beginnings of these things. When I was at Hopkins, vascular surgery and cardiac surgery did develop a little bit, and I helped Dr. [inaudible 00:31:40] do an abdominal aneurysm by animal [inaudible 00:31:42], I remember very well on a negro, on a black man, aneurysm, they placated it, and he died the next night, and ruptured posteriorly. I helped renal and [inaudible 00:31:52] closures. I helped Dr. Owen when I was in the fellowship there, put use in coarctations in puppies, to attempt to get collateral circulation. And then, with Mark Ravitch, which was here recently, we attempted to set up the first blood bank. The first two blood bank having been set up by Fantus in this country, 1937. Hopkins was here in 1938. It was nothing like a blood, a few flasks, it was very primitive, but it was celebrated blood because blood available. 1941 Dr. [inaudible 00:32:34] came from France and he started cardiac catheterization. I'd started catheterizations only in this country, in New York, and when I came back from the war in 1945, I went by Hopkins and there was Dr. Bing, Richard Bing, who by the way was a brother of Rudolf Bing, who was then the director of New York Opera ... not of a metropolitan. There he was doing right-sided catheterizations, it was doing a Blalock era. And, at that time, the catheterization unassisted of an old end of a [inaudible 00:33:20] with the string at one entire wall, washed white, this legs on it for pressures, and this old [inaudible 00:33:29] string, after he got the catheter in the heart, used to move past if negative inflection there on in this way. There were no computers, nothing flickered, nothing lit up. But, they did catheterizations, right sided catheterizations. In 1944, Crafoord was the first one resected the coarctation, which was a real accident. He wanted to do a patent ductus, but then the patient found it was a coarc and he asked me about it, I said, "Well, it was there, so we took it out." And he actually was the first one who did the first coarctation resection. Crafoord is the man who trained Åke Senning and Viking Bjork, one of them retired, and then Åke Senning is professor in Zurich, now. They're close friends of mine. They're nice people. You must realize that in 1914, the Russians did cardiac transplants, not into the cardiac position, but into the neck, things of this sort, and the men who ... It was not, but, the credit is given to Alexis Carrel, who worked at the Rockefeller Institute, was a Frenchman. As a person, probably quite a son-of-a-bitch, I hate to say that. Don't ... But, very unpleasant person. He went to Montreal, rapidly left Montreal, ended up in the hospital in New York, then rapidly changed to the Rockefeller Institute. He was a genius in many ways. He was the first one with two vascular sutures. Lindbergh worked with him. Charles Lindbergh, which is important. And one of the important things you see, perfected the Lindbergh apparatus, which was a forerunner of extracorporal bypass, that shows [inaudible 00:35:32]. And other men who should be mentioned, is Ernst [Jego 00:35:38]. Very well, not known in this country. He is a Viennese, Austrian, who was, in 1909, in Carrell's laboratory for about 9 months. But, gets stimulated and then left and went to Mikulicz’s clinic in Breslau. At that time, this man started experimentation on the outer pulmonary anastomosis, it's so called blalock anastomosis. So, Taussig-Blalock were not the first ones who did it. He did it on animals long before the idea was there. He made attempts at extrapulmonary ventilation, and he finally died as a prisoner in a Siberian war camp in 1915. And, just before he died, he had the opportunity to reimplant an arm, rolled it up and smuggled this thing out. So, the first reimplantation goes to Jego. These things are not well known in the literature. Now let's go to Alfred Blalock. Well, first at surgery at Hopkins. An interesting thing, a little anecdote I want to tell you, in 1944, he did many, many Blalock-Taussig shunts. And here is Taussig. Whether it just depends if you are an internist or a pediatrician, it's Blalock-Taussig, or Taussig-Blalock, but the procedure is the same. And there is a little anecdote I want to tell you. Blalock had tuberculosis. A Dr. Alexander had tuberculosis, who was professor of thoracic surgery of Michigan. And the man is name of [Bethoun 00:37:21], who you probably don't know. Bethoun was a Canadian who is revered like a God in China today, who also doing a Chinese revolution, fought in the Mao side, and he was a Communist. But, a very brilliant guy. And, he's buried in China. And they all had tuberculosis. And, they all went to China [inaudible 00:37:47] tuberculosis sanitarium, into the sanitarium at one time, and the same pavilion where they lived, and there was some wooden boards, and they inscribed their name and the date, and they thought it was their name and the date that they were going to die. None of them died of tuberculosis, except Dr. Alexander many years afterwards of a little tuberculosis. Two of them had thoracoplastis, one of them had [inaudible 00:38:17], but anyway, this little panel was found and Herb Sloan found it, and he brought it back to the University of Michigan where it is now, and they dismantled those little houses in Saranac Lake. Well, there's another man the name of Potts. Willis Potts, Northwester University, pediatric surgeon, who in 1946 devised a different type of pulmonary artery aortic shunt, but his main contribution, you must realize, there was no decent industry for anything, there was no equipment. I think the biggest contribution of this man was to produce the first decent vascular clamps, Potts-Smith clamps. Smith was a physician, a drunk, a flier, disappeared as a bum in Chicago someplace, but he is the man who designed these instruments. And Potts and Smith. Potts died a few years ago. Sir Russell Brock. The first one who attempted to devise instruments for intracardiac blind manipulation. He is another character. He also describes [inaudible 00:39:43] anatomy. And he was very ... At that time we started doing some hypothermia experiments. And I remember meeting at the test meeting when we presented our results of surface hyperthermia on [inaudible 00:40:00] intracardiac defects. He got up, and so did others. Swan was there, and some of the others. He got up and very quietly went to the stage and says, "In England we prefer to take our bath in warm water in the privacy of our home." And sat down. You know? Different. But, anyway, this is the first attempt of intracardiac surgery blind with instrumentation. At that time Gordon Murray, in Canada, attempted to put fascia on and close a ventricular septal, in ventricular septal defects; and an interesting man by the name of Weinberg in Montreal, again got interested in angina, and started implanting internal memory arteries into the myocardium. By that time there was no coronary angiography. The doses were made clinically or done EKGs possibly, and so on, the history. So, there was no angiography, no proof that people had coronary disease. But [inaudible 00:41:11], in 1898, suggested that mitral stenosis is a surgical disease. Sir Lauder Brunton in 1902 suggested the same. Cutler, Levine, and Beck produced some valvulotomes between 1923 and 1928. They blindly tried to pass it through the mitral valve and excise a piece of it to release mitral stenosis. It already didn't work. But Henry Souttar, Sir Henry Souttar, in 1925, did operate a 19 year old girl. [inaudible 00:41:53] opened up the mitral valve. 1925. She lived 5 years. The credit does not go to Souttar, but it goes to Bailey and Harken. It seems, in 1948, Dr. Bailey beat Dr. Harken by 10 days to do a closed mitralplasty and they had a fight every time they met each other, and they hate each other, and they fought. They really fought at the meetings. Both of them started traveling all over the country looking for patients. They came to Iowa, like a bunch of locusts. Interestingly enough, Dwight Harken is not from Boston. He is from Osceola Iowa, where his father was a long-time physician and surgeon. And all this took place in June of 1948. Charles Bailey, who was apparently the first one, was a very interesting man. He was super aggressive. Initially he was a neurosurgeon. Now he is a lawyer, trying to help collect money for physicians. He's 75. He was a brilliant, aggressive, and absolutely ruthless person. He still is. I saw him a few days ago, talked to him. Nobody wants to talk to the guy, really. And it's wrong. I think he contributed a great deal. He was the first one who did all kind of other maneuvers, extracardiac maneuvers for intracardiac disease and so on. From 1948 to '49 I went to Saint Louis, Dr. [Womack's 00:43:37] suggestion, with Dr. Graham and Beaufort. At that time there was a man by the name of [inaudible 00:43:43]. And Dr. Graham, who in this picture, I showed you this, couldn't stand still. There was cardiac surgery to be done. The man was a very poor surgeon, technically, but it was my job, in the lab, to get to the mitral valve, and they designed a gas cone with a sliding knife on the side, and we did it on ... I helped him do it in the lab, and we tried to slide this cone down to the mitral valve, along the wall in the dark, and tried to cut the mitral valve. It didn't work, [inaudible 00:44:21], so I light it, the gas rod. It didn't work very well. But attempts were made. Also, the thing that shows of interest, the oximetry, which is coming back to phenol oximetry, goes back to that period of time. There was a man by the name of Dr. Gauer, who was a German scientist/physiologist, who was one of the people who were captured in 1945, when we caught a bunch of them, and the Russians caught a bunch of them. They were captive scientists, usually attached to the air force, some of them loaned out. He was in Saint Louis, in the physiology lab with Dr. [inaudible 00:45:06], and we tried to build the first oximeters, when they were ear oximeters. They're much more refined now. At that time, at University of Iowa, when they came back with the constrictive experiments, constrictive perichondritis, cardiac resuscitation, coronary revascularization, and then in 1950, after it took Dr. Jeno a year and a half, and me, to convince Dr. Womack that a mitralplasty could be possible. Do you remember those days? He wouldn't listen. He couldn't understand cardiac surgery. We finally were able to do our first mitralplasty in June of 1950. Early March of 1950. Now, then the area of open-heart surgery started. Oh, here's Harken, and this is Bailey, oh, they look lots older now. Here's a mitral valvular plasty. Now, there's some other close procedures that you used to do, for instance. The Vern technique for closing atreol or septal defects. Or making a donut and suturing it down. There were all kind of schemes for different things. Let's give you some examples. However, then a period came when hypothermia came in and Bigelow, Swan, Lewis, ourselves here in Iowa City, did a lot of experimentation on surface hypothermia, and Dr. Faulk would remember these periods. And, as you can see, you can lower a body temperature and then open up a heart, the inflow and outflow occlusion, and gain access to the inside of the heart for short periods of time. At the same time, Walton Lillehei, in 1954 and 1955, started core circulation, attaching a mother to the baby. This fell away because there was a lot of complications. 1953 and '54 Dr. Gibbon built the first extracorporal circuit in Philadelphia. And closed an ASD with a child, however died. Clarence Dennis in 1955 devised a machine and the period of extracorporal circuit came in. In Hypothermia, this is what it used to look like. See the first-rate equipment we used to have? An old EKG machine, an old rectal thermometer which give us the temperature drops. This is Jack [Morris 00:47:53] in the back, 1985, news. This was entire equipment, and we did many, many patients this way. Okay? We used to call it Sherbert surgery. The patient was put warmed up, naked in a tub of warm water. Here's a procedure which is carried out. The total occlusion time was 8 minutes. It's an open heart. It's a long time to do things in the heart, you be prepared. We did many, many patients. Pulmonic stenosis, ASDs, some ventricular septal defects, all kind of things. Okay. But, we ran into some problems. With the advent of pump oxygenators, and there were bubble oxygenators. We ran into the difficult severe complications. The severe complications in simple effects was hypothermia were less than they were with extracorporal bypass. And we had to select our patients, of course. Best we could. At that time, there was no left-sided cardiac catheterization, it was all right-sided. We had a large reservoir of patients. Many of them looking like this. I can't tell you if it's a tetrad or whatever, right to left shunt, it was? I can't tell you. But, you wanted two tetrads a day was fine. We were limited by several things. We were limited by blood supply, the blood bank. We were able to do one patient a week, initially, usually children. The reason was, the blood could not be supplied. We had to go to the prisons, Fort Madison, or some other prison where we had a captive audience and picked up the blood today, or surgery, to prime the pumps. All those things have changed. Now, let me go through a few things. I show you some of the early pumps. This is a scheme. This is actually a pump on the dog. This is 1954, '55. The early experiments. These are the pumps which we used to use. They came from the milk industry. The industrial pumps. This is the clinical set up which used, initially. They improved it by encasing it in aluminum so it looks well. This is all our own build, I want to tell you that. In those days there was no industry. All those things are put together by hand, by technicians. For every case, there was nothing you could unwrap sterilely and just put up. These are improvements. This is a disk oxygenator, a different one. Still the same old set up. It's better pumps. And this is about what it looks like today. Not quite, but just similar to this. I have to go on. And here, at that time, we then started combining hypothermia with extracorporal circuits, total arrests, and there were many changes of course. Potassium arrests. All those things are old. There is nothing new about this. Now, let me go a little bit of valve replacements. The first valve which was inserted was in the descending aorta by [Euff Nadal 00:52:09] for aortic insufficiency. And this is it. That was in September 1952. All kind of gadgets were developed after we were able to open up the heart to bolster leaflets, keep them from being insufficient, or there are enumerable schemes. This is a very early aortic valve for implantation in sub-coronary position. Won't believe it, we use some of those. This was made a trileaflet valve there, they lasted for about a year, and then they were calcific, or they got SBE, all kind of things happen. This is a valve, the first trileaflet plastic valve, the [inaudible 00:52:59] valve. The old time Starr-Edwards, which is still being used, 1260 series. The govern valve, self-sealing. There are hundreds of different valves. Want to see some more? And this is the first tissue valve. A Hancock. [inaudible 00:53:25] sterilization and preservation. At that time, more complex cardiac problems could be attacked, of course, as a profusion became better, and as we were able to devolve replacements. In 1968, prematurely Christian Bernard, [Denken Cauley 00:53:55], and Adam Kantrowitz, who also was responsible for left-assisted devices, left-sided cardiac assist devices, did the first cardiac transplants. That died down again until now. Coronary surgery, after we were able to have extracorporal bypass endometrectomy. They were done by Bailey, the one I mentioned, they be long mile, in 1957, only this all prior to the time before we had coronary oculogram. Mason Sones started coronary photography in 1958. And Weinberg rose his head again. In 1965 there was coronary visualization possibly Weinberg did many, many; we did some of them. Rejuvenated the Weinberg procedure. Implantation of intramammary vessels, into the myocardium. And I want to show you that it works. This is a dog heart with a left coronary anti-descending ligated in the blood supply, coming through an intramammary implant. And, in 1968 [Favalon Efflo 00:55:12] started to record the coronary surgery, and the bypass graft. As you can see, what happened to cardiac surgery, and thoracic surgery, was good and bad. It destroyed thoracic services, teaching services to some extent. Here you have the advent of valve replacements, the valve is out, a coronary surgery, '69, '71, shot up to the extent where they are doing 180,000, to 200,000 a year. It has decreased now, something that's percutaneous angioplasties. Lebovics angiography are another thing. We needed to do some peripheral arteriography, and this is the first arteriography Dr. [Tabo 00:57:35] and I put together in 1949 or '50. And this is it. We did the lumbar arteriogram, when we had three plates, which is shot through and exposed. Left-sided angiography for cooptations was done by cut-downs into the carotid vessel. Patient moved to the edge of the x-ray room and injected, and then took them back up and closed the carotids. He is one with a cooptation in the PD and pulmonary arterial hypertension. Left-sided catheterization did not come on until quite later, in 1963. Peripheral vascular substitutes, Avalon. We made our own peripheral vessels. Which is a plastic which had to be compressed. Then we tried to harvest. We wanted something on the shelf to take down and use. We did the lyophilization and had it in storage in tubes for implantations in patients. They're all stop-gaps. And then the making of other materials instead of human grafts. This is a home-made one. Actually we made it here. Mrs. Tabo sewed it together, and we implanted it into a patient. It lasted for a while. And then of course the commercial ones became available. 1962, the first pacemakers. First left ventricular assist devices, a sinus pump with [inaudible 00:57:57] corporation. Good idea, wrong concept in this patient. But we tried to use it. Just like the intra-aortic balloons. Didn't work. Of course, and then with the advent, recently, with immunology, and the new area opened up, I can't go into this in any detail, with cardiac transplantation, and transplantation of other organs. And then the continued search for cardiac substitutes, which is explosive, very controversial. Names like Kloff and Jarvik and Devries. You see? This is what you're living with today. Now, I'd like to give some tribute to some people in Iowa, particularly Dr. [Jandway 00:58:46], [Theolin 00:58:47], [Empky 00:58:48], [Neunon 00:58:48], Dr. [Vlad 00:58:52], Dr. [Echstein 00:58:50], [Kolbertson 00:58:53] and [Kurtz 00:58:53], the Catheterization Lab, Dr. [Lanips 00:58:56] and [Moyes 00:58:57] and two people who are dead, Dr. Wilson and Dr. Fisher. I have tried in part to show you some revolution in this particular specialty. It is impossible to include to include all the ramifications. Where are we now and where do we go from here? The contemplative approach to the art of medicine has been replaced by highly technically, very costly diagnostic and therapeutic measures, under continued ethically financial and philosophic pressures, and above all in the public eye. There has been an escalating expansion that seems to be leveling off now. Especially of new innovative ideas. The technical progress, partly driven by industry will continue but will be applicable to a smaller number of specific conditions in patients. It is transplants. It's a minute need for it. The public pressure and the idea of health being a right and not a privilege, which is prevalent today, will continue to cloud the rational approach to what would be sociologically and economically best, to give the care to the least risk, giving your best results for the longest period of time. At present, rehabilitation, productivity and overall worth to society are not the primary factors being considered today. Placing undo financial burden, anxiety, and insecurity on the public. It is a question of whether our financial commitments in the future will come to even sharper conflict with our presently prevailing ethics. A solution will have to be found, which I fear has slipped out of the hands of the medical profession.