The Person Behind the Inventor of the Heart‐Lung Machine: John H. Gibbon Jr, MD (1903–1973)
2018; Wiley; Volume: 42; Issue: 8 Linguagem: Inglês
10.1111/aor.13280
ISSN1525-1594
AutoresTyler M. Bauer, Vakhtang Tchantchaleishvili,
Tópico(s)Cardiac and Coronary Surgery Techniques
ResumoOn May the 6th, 1953 John H. Gibbon Jr., MD (Dr. Gibbon) became the first surgeon to perform an open cardiotomy during bypass under direct vision in a human, by repairing an interatrial septal defect in an 18-year-old female (Fig. 1) 1. Dr. Gibbon initially became interested in developing the heart-lung machine in 1931, after witnessing a patient with a massive pulmonary embolism 2. The patient was treated with an “off-pump” surgical embolectomy, as described by Dr. Friedrich Trendelenburg, which had a staggeringly high mortality rate, and had never been performed successfully in the USA at that time 2, 3. It is no surprise that this event profoundly affected Dr. Gibbon, as his job was to stay with the patient and take blood pressures every 15 min, for 18 h while she deteriorated. Finally, when a blood pressure was no longer obtainable, surgical treatment was initiated, and the patient ultimately died 4. In Dr. Gibbon's own words, “During that long night, helplessly watching the patient struggle for life, the idea naturally occurred to me that if it were possible to remove continuously some of the blue blood from the patient's distended veins, put oxygen into that blood and allow carbon dioxide to escape from it, and then inject continuously the now red blood back into the patient's arteries, we might have been able to save her life. We would by-pass the obstructing embolus in the pulmonary artery and perform part of the work of the patient's heart and lungs outside of the body” 2. Dr. Gibbon standing with the heart-lung machine almost a decade after his groundbreaking surgery. Thomas Jefferson University Archives, MS-001 Gibbon Collection. Courtesy of Thomas Jefferson University Archives. Making Dr. Gibbon's dream a reality was no small feat. During his 23 years spent in pursuit of developing the heart-lung machine, Dr. Gibbon conducted research at three institutions, finished his residency, got married, had children, took a 4 year hiatus to serve in World War II, and rose to the rank of “Professor of Surgery” at Thomas Jefferson University Hospital 4, 5. Developing the heart-lung machine was the one constant for the majority of Dr. Gibbon's professional life. During this time, Dr. Gibbon's efforts were viewed by his contemporaries as futile, and he was sometimes even described as “crazy” for pursuing such a far-fetched idea 5. When initially discussing his interest in pursuing the development of the heart-lung machine, Dr. Gibbon was dissuaded from doing so by many of his contemporaries, even Dr. Edward D. Churchill, his research supervisor at the time 5. Dr. Gibbon remembers his interactions with Dr. Walter Bauer, a prominent internist working at Massachusetts General Hospital when he first began developing the machine, “…I received a very positive discouragement to pursue the subject of the extracorporeal oxygenation from my friend the late Walter Bauer, who told me that if I wished to remain at Harvard I had better tackle easier subjects which would allow me to publish a large number of articles in the literature” 4. The closest thing to encouragement that Dr. Gibbon received was from a previous mentor, Dr. Eugene M. Landis, who said “…if you think you can do it and if this heart-lung machine would prove useful, [you] should work at it” 2. This was lukewarm encouragement at best, but to Dr. Gibbon, this was enough. It is almost 65 years after the date of the first successful use of Dr. Gibbon's heart-lung machine. Herein we attempt to integrate many of the recounts of Dr. Gibbon's temperament, professional attitudes, nonmedical interests, and family legacy so that scientists, inventors and physicians can better understand the characteristics of the man behind one of the most important surgical inventions of the 21st century. Dr. Gibbon began his journey to create the first heart-lung machine during his first year of fellowship at Massachusetts General Hospital. He began the fellowship in February of 1930, and after eight months of training he witnessed a patient who had died from a pulmonary embolus. Although this event is described as the primary driving force for Dr. Gibbon to pursue the development of the machine, it is clear that he was already conducting research in the area prior to this fateful event 5. Early in his fellowship, Dr. Gibbon began conducting research to determine the physiologic changes that occur in pulmonary emboli. These experiments were conducted in a feline model and showed an inverse relationship between systemic blood pressure and pulmonary artery occlusion, and that at least 81% of the pulmonary artery must be occluded to precipitate cardiac failure 5. These experiments were concluded before Dr. Gibbon's encounter with the patient with a fatal pulmonary embolus, but it is here where he developed the prototypes of many of the laboratory tools that would be used for animal experimentation, such as the apparatus that he used to occlude the pulmonary artery. While Dr. Gibbon had set his mind on developing the heart-lung machine during this fellowship year, he did not start directed experiments until much later. Dr. Gibbon accepted the position of “Assistant Professor of Surgery” at the University of Pennsylvania Hospital in 1931, and while he continued research during these years, he did not pursue research related to the development of the heart-lung apparatus 5. During these years, Dr. Gibbon conducted research under the direction of Dr. Eugene H Landis and attributes his painstaking approach to conducting research to Dr. Landis 5. In 1934, Dr. Gibbon requested an additional year of research from Dr. Churchill at Massachusetts General Hospital, with the sole purpose of developing the heart-lung machine. Dr. Churchill was not very enthusiastic about the prospects of pursuing the project, but nevertheless offered the position to Dr. Gibbon, doubting that he would ever achieve his goal. It was during this year that Dr. Gibbon developed the prototypes of many of the key components of the heart-lung machine, including the oxygenator, the venous reservoir, and the arterial pump 5. The most essential component of the heart-lung machine that was developed at this time was the flow oxygenator. Early on, Dr. Gibbon realized that this would be the main challenge of constructing the machine, and while there were many different approaches to oxygenating blood at the time, all had their drawbacks. Settling on film oxygenation (as opposed to bubble oxygenation), Dr. Gibbon initially constructed a vertical revolving cylinder oxygenator (Fig. 2) 5 As he remembers the first prototype, “I bought an air pump in a second-hand shop in East Boston for a few dollars…Valves were made from solid rubber corks with the small end cut transversely three quarters through to form a flap 2mm thick…a cork borer was passed through the center of the stopper, thus creating a small channel for the stream of blood.” and “This assemblage of metal, glass, electric motors, water baths, electrical switches, electromagnets, ect. looked for all the world like some ridiculous Rube Goldberg apparatus.” (Rube Goldberg was a prominent cartoonist best known for his zany invention cartoons) (Fig. 3) 4. This prototype proved sufficient and was used on all of the animal research, but this design would have to be scaled to unimaginable proportions to support an animal larger than a small dog 5, 6 A prototype of the prototype vertical cylindrical flow oxygenator. Thomas Jefferson University Archives, MS-001 Gibbon Collection. Courtesy of Thomas Jefferson University Archives. Dr. Gibbon compared complexity of the early heart-lung apparatus to drawings of Rube Goldberg, such as this one “Pencil Sharpener.” The description reads, The Professor gets his think-tank working and evolves the simplified pencil sharpener. Open window (A) and fly kite (B). String (C) lifts small door (D), allowing moths (E) to escape and eat red flannel shirt (F). As weight of shirt becomes less, shoe (G) steps on switch (H) which heats electric iron (I) and burns hole in pants (J). Smoke (K) enters hole in tree (L), smoking out opossum (M) which jumps into basket (N), pulling rope (O) and lifting cage (P), allowing woodpecker (Q) to chew wood from pencil (R), exposing lead. Emergency knife (S) is always handy in case opossum or the woodpecker gets sick and cannot work. Figure and description reprinted with permission from Rube Goldberg, Inc. (http://whoisrubegoldberg.com/). It was in 1935, that Dr. Gibbon demonstrated artificial circulation could maintain life in cats for up to 2 h and 51 min, and also that normal circulation could be re-established after artificial circulation was used 7. As Dr. Gibbon recounts the first time he successfully maintained oxygenation after complete occlusion of the pulmonary artery, “Although it gives me great satisfaction to know that open heart operations are being performed daily around the world nothing in my life has duplicated the joy of that dance around the laboratory…” 4. After this incredible success, in 1935, he returned to Philadelphia to continue his research. The next few years were spent balancing clinical practice and conducting research in Philadelphia. In 1939, Dr. Gibbon published his research that had been conducted in the Harrison Research Laboratory at Pennsylvania Hospital. The major goal of these experiments was to decrease the hemodilution seen in the previous experiments, and to track long term success (previous experiments sacrificed the animals after the immediate postoperative period). In his series of 39 animals, 13 survived more than 24 h. While Dr. Gibbon continued to make advancements on the heart-lung machine, he quickly entered active service in World War II. Prior to volunteering to join the war effort, Dr. Gibbon was able to report that he had achieved indefinite survival of good condition in felines and had begun experimenting on canines. Additionally, he had completed his development of a new apparatus, which was ready for testing, but his research on the heart-lung machine was put on hold until he returned from the Medical Corps. Dr. Gibbon returned to his clinical practice at Pennsylvania Hospital in 1945, only to be offered the position of Professor of Surgery and Director of Surgical Research from Dr. Tomas Shallow at Jefferson Medical College (now Sidney Kimmel Medical College at Thomas Jefferson University) within a few months. It was at this institution, that he would complete his goal of developing a functioning heart-lung machine. By sheer luck, one of the medical students at Jefferson had connections to Mr. Thomas Watson, chairman of the board of directors of International Business Corporation (IBM) 4. Through this student, a meeting was arranged, and a fruitful professional relationship for the next 7 years began. This association led to seemingly inexhaustible resources 6. Long gone were the days of air pumps bought from second-hand stores, or makeshift valves. All parts of the machine were constructed using the finest materials, which manifested in incredible results 6. The list of deficiencies in the heart-lung machine were rapidly dwindling after IBM became involved in 1947. Dr. Gibbon's blueprints were followed and a formal prototype, known as the “Model I,” was shipped to Thomas Jefferson University for testing. This machine was tested extensively in canines, and the results of this machine were published in 1950 8. The main deficits that were noted in the Model I were: (i) the oxygenator was inadequate and could not support an animal larger than a small dog, (ii) the arterial pump frequently caused air emboli, (iii) there was a large amount of hemolysis, incompatible with surgery, (iv) the amount of respiratory acidosis that developed from the thoracotomy was incompatible with surgery, and (v) foam formed within the left ventricle if a cardiac defect exposed the left ventricle to atmospheric air 6. These problems were addressed over the following years, resulting in many inventions that were not only crucial for the development of the heart-lung machine but also useful to surgery in their own right. The flow oxygenator was optimized by introducing turbulence into the stream, which vastly increased the oxygenation. Furthermore, the cylindrical design was exchanged for a design that included six steel screens suspended from weirs 5, 6. The respiratory acidosis was corrected by the development of the first positive-negative intratracheal ventilator, known in the literature as the “Jefferson Ventilator” 5, 6. This ventilator was used in surgeries in the USA as well as abroad 6. A fluid control servo system, which made the flow of the machine completely automatic, safeguarded against embolization was an engineering feat in its own right 6. Another significant device that was produced at this phase was the left ventricle vent, which managed the buildup of foam into the left ventricle (Fig. 4) 5, 6, 9, 10. The left ventricular vent was constructed to decrease the foam from building up in the left ventricle. This foam would occur when atmospheric air would enter the left ventricle, in the case of a cardiac defect. The vent was originally developed as a necessity in experiments in which the surgeon would create and close an atrial septal defect in canine hearts, as depicted in the image. The first of these experiments failed due to foam buildup in the heart. Thomas Jefferson University Archives, MS-001 Gibbon Collection. Courtesy of Thomas Jefferson University Archives. After the implementation of all the changes, IBM constructed a new machine, known as the “Model II.” The mortality rate in canines were decreased from 80 to 12% from 1949 to 1952 4, 5. After testing, it was confirmed that this model was suitable for use in humans. There was one unsuccessful attempt of the use of the heart-lung machine in a 15-month-old female. Preoperatively, all of the cardiologists agreed that the patient had a large septal defect, which was not visualized in surgery. While the surgeons searched for the defect the child died on the table. A large patent ductus arteriosis was found on autopsy 5. In this patient, cardiac catheterization was forgone because the patient was too small, and this is a mistake that would not be made in the future 5, 6. On May 6, 1953, Dr. Gibbon successfully completed the first surgery using heart and lung bypass to repair a large interatrial septal defect in an 18-year-old female. After two more unsuccessful uses of the Model II heart-lung machine, Dr. Gibbon ordered a year's moratorium on the use of the heart-lung machine, and delegated cardiac surgery at Jefferson to his assistant from the first successful case, Dr. John Y. Templeton. During the years leading up to his successful surgery, Dr. Gibbon had been sharing his blueprints and experiences with Dr. John Kirklin at The Mayo Clinic. Eventually, the Mayo Clinic built the “Model III” based on the proposed changes from Dr. Gibbon's lab which led to several successful surgeries there. In other words, we can say that while Dr. Gibbon's lab proved that cardiac surgery with heart and lung bypass could be performed, The Mayo Clinic went on to show that it could be done safely 5, 11 Some of the most fascinating aspects of Dr. Gibbon were his interests outside of medicine. Dr. Gibbon had an intense interest in many nonmedical areas prior to attending medical school. Due to the all-consuming nature of his professional aspirations, Dr. Gibbon had to suppress his interests in these areas for the vast majority of his surgical career, but he returned to these interests following retirement. As a young boy, Dr. Gibbon wanted to be a poet and a writer 12. His mother, Marjorie Gibbon was the primary influence for him pursuing liberal arts studies 13. During his time at Penn Charter School, Dr. Gibbon was incredibly involved in nonscientific interests. He participated actively in many theater presentations, on one occasion playing a female role 4. During his time at the charter school, he was also an assistant editor on a student led magazine 4. At the young age of 16, Dr. Gibbon enrolled in Princeton University to study philosophy and religion 5, 14. While Dr. Gibbon was incredibly well read for his age, he struggled to connect with the other students and their world views, and spent most of his time in his room reading. As he stated later in life “It was the worst year of my life, I was simply too young” 4. During a summer trip to France to visit his sister, he delved deeply into the study of philosophy and its interplay with religion, to the point where he impressed his sister and persuaded her to think critically about religion 5, 15. During this trip he also spent time studying medicine, which is the first time that he spent any time considering medicine as a field 4. It was at Princeton that Dr. Gibbon first began painting, later remarking that he was “…smitten with painting” during his collegiate experience 4. He graduated Princeton at the age of 19, and began his medical schooling at Jefferson Medical College. Dr. Gibbon's early years were marked by a regret in not pursuing his interests in literature and poetry 13. Even after completing his first year of medical school at Jefferson Medical College, he seriously considered quitting to pursue poetry but was talked out of this by his father 5, 13. The first year of medical school was especially difficult for Dr. Gibbon, later remarking, “The first year of medical school was, frankly, boring as hell – all needless memorization” 4. Years later, after the successful use of the heart-lung machine, Dr. Gibbon implored other medical educators, “Teaching the minutia of medical and surgical specialties to undergraduate medical students should be thrown out” 16. Dr. Gibbon confided in a close friend that he felt that his father pushed him into medical school, often stating that “[Dr. Gibbon] wouldn't write less well for having a medical degree” 12. Although Dr. Gibbon did not pursue a career in writing, per se, his interest in the subject and natural eloquence certainly lent itself to his prolific involvement in research literature and excellent legacy as a visiting professor. One of his former colleagues noted that “Mastery of words was one of his great attributes,” and another attributed his success as the editor-in-chief of Annals of Surgery to his incredible command of the English language 12, 17. Dr. Gibbon had a love of nature that was cultivated from a young age, and persisted his entire life. In 1912, his father bought Lynnfield Farm, a 150 acre farm in Media, on the outskirts of Philadelphia. Dr. Gibbon was expected to complete yard work and care for the animals during his summers at the farm 5. It was at the farm that he began to develop his athletic interests, such as horse riding, and a life-long love of tennis 5. Dr. Gibbon often spent time climbing various parts of the structures of the property, swimming and challenging is his younger brother, Sam, in many of these activities 4. It is clear that Dr. Gibbon had a strong connection to the farm, and after the death of his parents in 1956, he bought his brother's and sister's shares in the property 5. On retirement, he moved to the farm permanently 5. Even in his old age, Dr. Gibbon continued to contribute to maintaining his farm, including building a pool and doing yard work, and often entertained world renowned physicians and scientists there (Fig. 5) 12. Dr. Gibbon and Maly at the Jefferson class reunion, which was held at Dr. Gibbon's house, Lynnfield Farms in Media, PA in 1967. Dr. Gibbon painted the portrait of Maly pictured to their right. Thomas Jefferson University Archives, MS-001 Gibbon Collection. Courtesy of Thomas Jefferson University Archives. Having lived 68 years I don't know I am, why I am, or where I am. I only know that here I am Now, this instant of time, This no-dimensional dot In the geometry of the universe. 5 Dr. Gibbon Painting at his house at Lynnfield farms in Media, PA, USA during retirement. Thomas Jefferson University Archives, MS-001 Gibbon Collection. Thomas Jefferson University Archives, MS-001 Gibbon Collection. Courtesy of Thomas Jefferson University Archives. [Color figure can be viewed at wileyonlinelibrary.com] His father-in-law, Charles Hopkinson was a renowned portrait painter and landscape watercolorist 19, 20. Hopkinson's influence on Dr. Gibbon's painting endeavors are apparent, although Dr. Gibbon shied away from the more “realistic” portrait styles used by his father-in-law, and instead produced more abstract works. Finally, Dr. Gibbon would often invite friends and colleagues to the farm to play doubles in tennis. He was described as a fierce competitor. Dr. Gibbon was an extremely complex man. Many of the recounts of Dr. Gibbon's personality are somewhat contradictory. One of his colleagues depicted him as aloof and uncaring, but acknowledged that this was a façade that he intended to keep during his time as chief 19. To his peers and close friends, Dr. Gibbon was known to be talkative, animated, and friendly 19. Perhaps one of the most flattering comments on Dr. Gibbon's personality is as follows, “Some men are crushed by the mantle of greatness. Some find it so heavy that they must stand tall, erect, and arrogant. Jack wore his with easy grace, with no undue pride, but with a pleasant, somewhat surprised satisfaction” 12. While Dr. Gibbon's personality has been described as everything from sympathetic to narcissistic, there are some personality traits that were universally reported by his close colleagues 5. One aspect of Dr. Gibbon's personality that is not debated among any of his friends or contemporaries is his undying persistence. The most obvious example of his persistence is through the long and arduous 22-year process of developing the heart-lung machine. There are, however, other anecdotes that display his persistence. A resident once had a dispute with Dr. Gibbon about whether or not “cc” or “c.c.” was the correct abbreviation of cubic centimeters 19. This debate came at a time in which the manuscript was due the following day, after the presentation of the findings at a national conference. After calling multiple editors that Dr. Gibbon knew personally, he decided that “c.c.” was the correct abbreviation 5. After the article was retyped (prior to the advent of word processors), and submitted, the journal replied that they believed “cc” was the correct abbreviation 5. On notification of the abbreviation decision, Dr. Gibbon called another editor and the journal itself to voice his opinion that “c.c.” was the correct abbreviation. On hearing that the journal would be publishing “cc,” Dr. Gibbon seriously contemplated retracting the manuscript, much to the resident's dismay as the research was critical to his career, but ultimately Dr. Gibbon allowed the manuscript to be printed. Dr. Gibbon did not relinquish his preference, and later claimed that “the editors are illiterate” 19. Dr. Gibbon's persistence was also demonstrated when he had suspected that he had lung carcinoma. A former resident and friend recalled, “For example he was a heavy smoker and developed a chronic dry cough. He suddenly decided to quit smoking, cold turkey. A few months later the cough remained and one day he confided in me that he had carcinoma of the lung. Of course I was shocked and asked when he had discovered this disaster. He said that he had not yet proved it but knew that he was right. My response was ‘Let's go get a chest roentgenogram.’ He said that was not possible now because he was in the midst of editing his book ‘Surgery of the Chest’, and if his diagnosis was confirmed he would be obligated to follow through and couldn't meet the deadline for completion of the book imposed by the publisher” 19. It is clear that when Dr. Gibbon had committed to a task, he would not let anything derail its completion, even his own health. In somewhat of the same vein, Dr. Gibbon was known to have an incredible attention to detail. It was known among his residents that a surgical topic written with other faculty members would take half the time compared to Dr. Gibbon, although the quality of work was often higher with Dr. Gibbon 5. During his time as the editor-in-chief of Annals of Surgery, Dr. Gibbon was noted to be “fussy about statistics” and was “driven to fury” about the presentation of any statistic as a percentage that was based on less than 100 cases 17. During his presidential address to the American Surgical Association in 1955, Dr. Gibbon took time in his speech to highlight the importance of providing reference values in research, the adequate use of significant figures, and the critical evaluation of measurements as being necessary for surgeons, or “…he will be buffeted on the seas of surgical opinion” 16. His attention to detail was paired with a natural decisiveness, and he was never hesitant to take an unpopular stand if he believed he was correct. One specific instance of this was when he alone went to the public press to gain support to continue maintaining the American College of Physicians Medical Library 21. Another example of this is when he co-authored a list of demands to the Board of Trustees of Jefferson Medical College listing grievances pertaining to the way that the surgical internship was being managed, as well as the dismissal of hospital faculty 22. Surprisingly, this article was authored a year prior to him being offered the chair of the department position in 1956. Appropriately, Dr. Gibbon was described as being “incisive in speech, in thought, and in action” 23. It is clear that this triad of persistence, attention to detail, and decisiveness were all critical to his success as a researcher and surgeon, especially in light of the fact that he had such little support from his peers when embarking on assembling the heart-lung machine. Dr. Gibbon was noted to have an “explosive” temper at a young age, often leading to altercations with his younger brother, Sam 4. As Dr. Gibbon progressed through grade school, his temper vanished, giving way to his unshakable and peaceful persona that was noted throughout his professional career 4. Dr. Gibbon is remembered as being soft spoken, and never having to raise his voice in a professional setting to make a point. Dr. Gibbon was also known for his humility, and while he did not actively shy away from the publicity that was brought to him for his achievements, he did not actively seek them out either. Indeed, Dr. Gibbon never received any monetary profit from his work on the heart-lung machine, nor did he ever attempt to 5, 24. One of his previous pupils and eventual colleagues remembers an event where Dr. Gibbon chastised him for bringing undue publicity to Dr. Gibbon in an instance where a radio advertisement was broadcasted asking for blood donations for a life saving cardiac case that Dr. Gibbon was about to perform 24. Dr. Gibbon had a strong belief in applying to a position based solely on one's merit separate from family and associated professional staff. Residents were often upset that Dr. Gibbon would not “call upon” his peers and connections to help their placements with jobs, residencies, or fellowships 5. While this was frustrating for those that worked under him, it cannot be denied that Dr. Gibbon embodied this attitude when it came to developing his own career, as he was never known to call on his father for professional opportunities, who was a prominent surgeon in the Philadelphia area 5, 19. Despite a his resistance to calling in favors for placement of surgical residents, Dr. Gibbon managed to serve as an excellent mentor to many young surgeons during his time at Jefferson University Hospital. His influence altered the lives of medical students, residents, and even faculty members at the time, and many went on to receive prestigious awards and highly sought positions 18, 19, 24. Dr. Gibbon spent much of his time as an educator at Jefferson Medical College. As he stated in his presidential address, “As the best charity lies in helping people to help themselves, so I believe the best education lies in helping the student to educate himself…[education] is a lifelong process” 16. Dr. Gibbon thought that a medical student that did not learn to self-educate would be destined to be a poor physician 16. He thought that curiosity about the unknown was necessary for teachers and students alike, saying that at least 10 min of every hour of lecture should be set aside to acknowledge current gaps of knowledge in the subject matter 16. Just as his interest in liberal arts was vast and varied, Dr. Gibbon displayed an incredible understanding of many areas of surgery, including urology and orthopedics 17. He held weekly grand rounds with the senior medical school class and frequently took this opportunity to educate the students on his vast understanding of the different surgical subspecialties and physiology 17. His approach to education shows that Dr. Gibbon shared the mentality of his long-time mentor, Dr. Churchill, that surgery is a single discipline, rather than multiple subspecialties 17. With respect to developing an equally broad understanding of surgery in his trainees, Dr. Gibbon was noted to strongly encourage all surgical residents to spend at least a year in the laboratory, to build their understanding of physiology and ability to review surgical literature 13. Furthermore, he stated that all surgeons should pursue a second year of surgical research in a laboratory after the conclusion of their residency, to increase proficiency in bench research 13. It is clear that these views are consistent with Dr. Gibbon's commitment to his own broad understanding of surgery, as he himself had taken extended dedicated time spent developing the heart-lung apparatus. Dr. Gibbon was not interested in the technical aspect of surge
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