|Year : 2016 | Volume
| Issue : 1 | Page : 2-5
Pioneers of cardiac surgery who just missed being first
Arthur Brown Lee
Department of Surgery, Morehouse School of Medicine, Atlanta, GA, USA
|Date of Web Publication||25-Jul-2016|
Arthur Brown Lee
Department of Surgery, Morehouse School of Medicine, Atlanta, GA
Source of Support: None, Conflict of Interest: None
The gold medal; recognition as "being first" is an icon of western (Post Hellenic) culture. However just behind the victor are concepts and forces that presaged victory, discovery or complete insight.
Keywords: Blacks, cardiac surgery, pioneers
|How to cite this article:|
Lee AB. Pioneers of cardiac surgery who just missed being first. Niger J Cardiovasc Thorac Surg 2016;1:2-5
The reader may ask "why bother with a bunch of losers."
The Nobel Prize has never been awarded to a cardiac surgeon. Considering the marvels, of contemporary cardiac surgery, I find this striking. I can speculate on reasons for this lack of acknowledgment of human collective and individual creativity. Nobel Prize awards are given to individuals or groups of three or less. The edifice that is modern cardiac surgery was created over a period of 100 years, perhaps beginning in 1891 when Daniel Hale Williams dared the fury of the gods when he opened the pericardium of a stab wound victim in Chicago's Provident Hospital.
The heart had been considered a mystical organ since antiquity. Any mortal that dared to mess with it was doomed to celestial punishment and social disgrace. Dr. Dan's decision to invade the kingdom of the heart in 1891 was a modern equivalent of Prometheus stealing fire from the gods. Five years later, Rehn, in Germany repeated Dr. Dan's feat with the addition of a stitch in the heart.
Both patients survived. Credit for priority was divided among observers according to ethnicity. Blacks accorded Dr. Williams priority, Whites preferred to give priority to Rehn, whose procedure took place 5 years later but included a stitch on the heart.
The spell was broken. Within the next 20 or 30 years increasingly bold cardiac adventures took place. In 1922, two surgeons performed closed mitral commissurotomies, one in England and one in the USA.
The mother of one of my playmates in Brooklyn New York, Mrs. Bryant, was a friend of Miss Edna Tuffley, operating room supervisor at New York Hospital, Cornell Medical Center. She got me a job as an operating room technician when I was 15-year-old, the summer before I started college. I made the transition from mopping floors, emptying buckets to replacing instrument nurses for almost the entire repertoire. Cardiac surgery, 1953-1957, at that hospital had not progressed to the use of the heart-lung machine. Closed mitral commisurotomies, Hufnagel valve placements under mild hypothermia were the limits of their repertoire. When I started Medical School at Boston University, I volunteered as a technician in an animal labaratory in Boston city Hospital, run by Dr. Tom Boyd, one of my favorite surgical mentors.
John Strieder had performed a ligation of a patent ductus arteriosus in 1937 in a patient with subacute bacterial endocarditis. The patient died on her 3 rd postoperative day from acute gastric distention. A year later, Robert Gross, at Boston Children's Hospital, did the same operation in a patient that ultimately left the hospital.
Today, everyone has heard of Robert Gross' successful first. But to me, John Strieder's procedure conceptually paved the way. It is very likely that before Dr. Strieder's procedure, the possibilities of such an operation were discussed. For instance in 1922, Alexis Correll discussed and made primitive plans to build a heart-lung machine that would enable repair of aviator Charles Lindbergh's daughter's congenital cardiac defect. Legend has it that in 1939 John Gibbon became emotional while caring for a young patient with recurrent pulmonary emboli at the Massachusetts General Hospital. When she died after the Trendelenburg operation - an attempt to pull clot out of the pulmonary artery without the benefit of cardiopulmonary bypass. John Gibbon and his wife began the decades-long quest to develop a heart-lung machine. He ultimately succeeded in getting his third patient to survive. His efforts followed the attempts by the University of Minnesota's Clarence Dennis, working in Brooklyn's Kings County Hospital, and the cross-circulation open-heart work of Walton Lillehei in Minnesota.
One of John Gibbons biographers describes a couple of episodes of what I call "Nobel Prize fever" triggered by a newspaper reporter referring to one of his assistants in the laboratory as a collaborator. Mrs. Gibbons, who had been inactive in the laboratory for some time took umbrage at this, and that quoted collaborator was fired when it was feared that he would claim or be part of the Nobel Prize. The Nobel Prize that was never awarded, after all.
Dr. Aubrey Maynard was the chief of surgery at New York City's Harlem Hospital. The large volume of penetrating trauma led to the publication of the landmark article describing a series of cardiac stab wounds treated without mortality. Their success exceeded that of more famous and prestigious institutions and was probably due to their blanket approach of exploring all precordial stab wounds. These were the days before emergency room echocardiography. When Dr. Martin Luther King was stabbed by a female in a department store on 125 th street, he was taken to Harlem Hospital were a team of four surgeons ultimately operated on him. As chief of surgery Dr. Maynard, as described in his autobiography led the approach to the problem. The four surgeons were Dr. Maynard, Dr. John Vincent Cordice, Dr. Emile Naclerio, and Dr. Farrow Allen. As described in his book, Dr. Maynard directed the approach to the ice pick which had been shown by across table lateral X-ray to be perilously close to the ascending aorta. This was in the days before computerized axial tomography scans. An anterolateral interspace incision was used, and a bit of the sternum was rongeured away and under direct vision, the ice pick was pulled out of the sternum. This pulling of the ice pick out of the sternum, a technically trivial procedure was apparently performed by Dr. John Cordice when Dr. Maynard, who had torn one of his gloves, stepped out of the operating field and allowed the rest of the team to continue without him. As Dr. King's fame grew, the operation began to assume historic importance. Cordice later claimed credit for saving Dr. King. Later in 1984, as a new Chairman of Surgery at Morehouse School of Medicine in Atlanta, I sought to make a connection to the politically powerful civil rights community. I initiated a lecture series called the Maynard Lecture series and was able to obtain as my second invited lecturer Dr. Charles DuBost of Paris' l'hopital Broussais. Dr. DuBost was instrumental in contributing to the training of Dr. Maynard and Dr. Cordice in Cardiac Surgery at a time when Blacks could not obtain that training in the USA.
After Dr. Cordice completed his training with Dr. DuBost, he returned to the USA and worked with Dr. Clarence Dennis at Brooklyn's King's County Hospital. Dr. Dennis's main research interest was the heart-lung machine, surprisingly, Dr. Dennis was not a thoracic surgeon. This might have provided Dr. Cordice with an opportunity to achieve fame if he had been successful working with Dr. Dennis in developing a clinical series of patients treated with the pump oxygenator. Dr. Cordice now dead and I don't know what happened but after two failed attempts to secure a survivor marred by an error in preoperative diagnosis in one (the patient had an undiagnosed patent ductus) and an anesthesia error in which air was pumped under pressure by anesthesia in the second patient, the project was abandoned. Dr. Cordice with the concurrence of his wife, who needed help raising their children left investigative cardiac surgery and devoted himself to thoracic surgery and general surgery in the borough of Queens and occasionally as a visiting's thoracic surgeon at Harlem Hospital. Financial necessity was probably a consideration here.
For reasons which I don't fully understand Dr. Maynard and Dr. Cordice became distanced or at least had little good to say about each other. I asked both of them about this since I was fond of them both, in 1970 or thereabouts, and Dr. Cordice was reluctant to say much. Dr. Maynard said that Dr. Cordice was the great black hope in cardiac surgery, and he abandoned this heroic quest to take care of his wife and children. I think this needs to be taken with a grain of salt since it is well known that Maynard did not like to share the spotlight. Dr. Maynard lived a relatively monastic life as a bachelor until past middle age. Surgery at Harlem Hospital was his life. He walked to the hospital daily from his home on Convent Avenue, near City College of NY Campus.
So, now we have seven (if we count the entire four-member team that operated on Dr. King) pioneers of cardiac surgery whom narrowly missed being first. What is it about claiming priority that drives people crazy?
Creativity seems to be a function of all life. The emergence of antibiotic resistance in bacteria can be seen as evidence of creativity. In 1954, George Wald published results of an experiment in which ammonia, methane, and water were put together in an apparatus with an electric spark and after a while simple amino acids, alanine, and glycine emerged. Even simple organic molecules come up with "brilliant" breakthrough innovations. When colonies of bacteria develop antibiotic resistance is it ever possible to recognize the first bacterium to develop resistance? As the zeitgeist of resistance development progresses in the colony of Escherichia coli, say, is it possible to identify the first bacterium, or as Friedrich Hegel would say, "the world historic hero" or at least the colony historic hero - the individual bacterium that first developed the enzymes to deactivate the antibiotic. A Nobel Prize has yet to be proposed for a team of E. coli.
One of my biology heroes, Alfred Russell Wallace, co-author of "origin of species" with Charles Darwin and is musings on evolution and natural selection takes care not only to mention the work of Darwin but also a couple of others who were conversant with the ideas of natural selection at the time.
Russian mathematician, Grigori Perlman, who advanced the odd ideas of Ricci flow of Professor Hamilton at Columbia University in solving the last bits of the Poincare conundrum (in algebraic topology) and therefore would have received the Field Prize in mathematics was so much against the process of identifying a Messiah in mathematics so that he took great pains to self-publish on the internet avoiding thereby some of the mischief that can come from publishing in a refereed journal. Politically aggressive science journal editors can do great mischief. Stephen Hawking at the end of his book on a "Brief history of Time" takes pains to excoriate Sir Isaac Newton, Editor of Philosophical Transactions for his use of that journal to fraudulently establish priority over Leibnitz in the "discovery" of the calculus.
Historians have shown many of the revelations of Moses, Jesus, Mohammed, were being talked about and in air at the time of their revelations. Since I live in the Bible Belt, I consider it dangerous for me to pursue this line of discussion further creation without Creator. There's actually quite an ample literature on it which includes Freud's "Moses and Monotheism" among other interesting works.
I must say a few words about my former mentor and colleague John C Norman M.D. I met Jack Norman when he was doing studies on perfusing porcine livers with the blood of comatose patients in hepatic failure at Boston City Hospital's Harvard Service, Sears Research Lab. Several of these patients woke up. It was a fascinating look at the future possibilities of Xenotransplantation. Dr. Norman went on to great things at the Texas Heart Institute where he was Director of Research and Founder of the Journal of the Texas Heart Institute. His research was on the development of the artificial heart, nuclear power supply for the artificial heart, and left ventricular assist devices. John and I shared the pleasure and the pain of shuttling back-and-forth between two warring societies. The white academic world of research and the black world of medicine in the ghetto. Indeed, medicine in the ghetto was the title of one of his books. He wrote one of the first texts on cardiac surgery, and he was a Prolific Publisher of journal articles approaching 300 total. He deserves a biography. He died 2 years ago.
Vivian Thomas of the "Thomas - Taussig - Blalock shunt," as I like to tell the story to black medical students, was a great cardiac surgeon. He never attended medical school nor did Mikele Ghebrihewot of East Africa who trained himself in vascular surgery and cardiothoracic trauma after Civil War broke out during his 3 rd year of medical school. Given the social limitations on education of Blacks in colonized countries, I have decided in my analysis to waive the requirement of attending medical school and certainly of being a Diplomate of the American Board of thoracic surgeons since these institutions often exclude pigmented people.
Marule Lucas Mohlala, a graduate of the University of Natal and a classmate of Steve Biko, was trained in Cardiothoracic Surgery by Ben Leroux, and he was appointed as Professor and Chairperson of the Division of Cardiac Surgery at Medusa (Medical University of Southern Africa) and Ga-Rankuwa Hospital in "bop" (Boputhatswana). I visited him during the first few weeks starting his new department, and we did a large number of cases. Over 40 of these pump cases (161 as I recall). I lost 10 pounds during that time partly because we left home before stores were open and got back after they had closed. After 2 weeks, we were reduced to eating strange South African snacks such as biltong and Mopani worms.
Ga RanKua serves patients from Pretoria up to the Mozambique border. Over 1 million patients as I recall, it is a 2000 bed hospital, underfunded and busy in every category. Prosthetic valves are to be avoided in rural Africa when possible. Moreover, because of this Lucas had become a master of mitral valve repair. Rheumatic heart disease is quite common in African school children. In East Africa in 1989, Dr. Ghebrehiwot had done a survey, and as I recall 30-40% of eighth graders had evidence of rheumatic valvular heart disease. I believe the incidence in South Africa was similar. The ability to bear children is critical to young village women. Anticoagulation for a mechanical heart valve is a major risk for pregnancy.
I visited Trinidad for Carnival in January 1964. I decided to pay a visit to the local cardiothoracic surgeon and at Port of Spain General Hospital, I met brothers Dunstan and Halsey Macshine, general surgeons extraordinaire. I had never before seen a black cardiac surgeon in an operating room, and they invited me to return the next day and visit. The operating lists that day included a couple of inguinal hernias, and esophageal resection, a prostatectomy, and a mitral commissurotomy. In 1964, they had performed pulmonic valvotomy using mild hypothermia and inflow occlusion successfully. After training I had either at Boston University, Columbia-Presbyterian, New York University, my only pigmented skin mentors were at Harlem Hospital 1963-1964.
| Conclusion|| |
These unsung heroes were my role models. Nobel Prize winner Joseph Murray (of the Peter Bent Brigham Renal Transplant Team, Circa 1960) once helped me do cervical node dissection at the Boston Veterans Administration Hospital. I was with Professor Stuart Sullivan enjoying a luncheon when Dr. Erwin Chargaff of the purine-pyrimidine stoichiometry came in for lunch and started his frequent rant on how Watson and Crick stole the Nobel Prize. It made a big impression on me.
As Eric Kandel's work with Aplysia suggests to me; at a molecular level, the process of discovery in humans and bacteria is the same.
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Conflicts of interest
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Forrestor J. The Heart Healers: The Misfits, Mavericks, and Rebels who created the greatest medical breakthrough of our lives. St. Martin Press; 2015.