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September 1998
Volume 62 |
Number 9
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| Unsung Heroes:
The Pediatric Cardiac Anesthesia Story |
Douglas R. Bacon, M.D., Trustee
Wood-Library-Museum of Anesthesiology
Imagine working in a time when there are no antibiotics to combat
bacterial infections. Monitoring is limited to a blood pressure
cuff, stethoscope and a "finger on the pulse." Inhalation agents
are few; ether, nitrous oxide and the "new, revolutionary" cyclopropane,
and calibrated vaporizers are still in the future. The heart and
great vessels are thought to be inviolable, and surgical trespass
will result in death for the patient. Yet, all around the pediatric
wards, children are dying of "simple" diseases such as patent
ductus arteriosus and coarctation of the aorta.
This was the environment in which the first pediatric
cardiac anesthesiologists worked. In 1937, at the Massachusetts
Memorial Hospital in Boston, Massachusetts, John Streider, M.D.,
a thoracic surgeon, ligated a patent ductus arteriosus that had
become infected in a 22-year-old woman. While the details of the
anesthetic remain unknown, the patient died on the fifth postoperative
day. Yet, the case proved that the operation was possible and
the anesthetic survivable. Eighteen months later, Robert Edward
Gross, M.D., ligated the patent ductus of a 7-year-old that was
not infected. She survived!1 Cardiac surgery had begun.
In 1943, during the midst of the second World War, cardiologist
Helen Taussig, M.D., asked thoracic surgeon Alfred Blalock, M.D.,
if he had anything to offer surgically in the correction of pulmonary
stenosis in children. Dr. Blalock quickly described the experimental
work he had been doing in the lab, anastomosing the left subclavian
to the pulmonary artery. On November 29, 1944,1 as
allied troops marched across Hitler's "Fortress Europe," Merel
Harmel, M.D., and Austin Lamont, M.D., used a miniaturized Waters
"to and fro" canister to anesthetize a "blue baby."2
While that first anesthetic has been recorded as ether and oxygen,1
subsequently, cyclopropane was used.2
After the war and the success of the Blalock-Taussig operation,
others began to search for ways to support the circulation of
the child with congenital heart disease while the defects were
repaired. At the University of Minnesota, Ralph T. Knight, M.D.,
and his department had to struggle with two simultaneous anesthetics
as C. Walton Lillehei used the father of a 1-year-old boy as the
surrogate heart while the child underwent ventricular septal defect
repair. In the end, the father survived, but the child died of
pneumonia. This did not deter the surgeons who went forward and
performed eight other cases, with only two deaths. Realizing that
there was the chance of a 200-percent mortality from one operation,
the search for a mechanical heart and lungs intensified.1
In 1955, the University of Minnesota team successfully
used the heart-lung machine with a bubble oxygenator. James H.
Matthews, M.D., Joseph J. Buckley, M.D., and Frederick H. Van
Bergen, M.D., were among the first anesthesiologists to inform
their colleagues of the effects of low flow extracorporeal circulation
on humans.3 The effects of hypothermia were also noted
and applied to these patients. In long-term follow-up of 106 patients
operated on for Tetrology of Fallot, more than 30 percent had
graduated from college, including two who had completed medical
school.1 Working to save these children seems to have
its rewards.
The heart-lung machine revolutionized pediatric cardiac
surgery. For the first time, bloodless operating fields inside
the heart were possible. Surgeons could fix what nature had mistakenly
created. Perhaps most importantly, surgery on the heart could
take place in very young children. There was no need for them
to wait until adulthood for surgery. For the first time in history,
there was real hope for babies born with congenital heart disease.
The heroic struggle of the operating team in congenital
heart surgery has not been fully told. Surgeons have their history
books filled with the technical details of the operations and
who did what first. Anesthesiologists are rarely mentioned. Within
the anesthesiology literature, this story has not been fully told.
How does it feel to lose two out of eight patients operated upon?
What input, if any, did the anesthesiologist have with the surgeon
in these cases? What techniques were fully used? It is the duty
of anesthesiologists everywhere to preserve this history, and
the Wood Library-Museum of Anesthesiology stands ready to support
and preserve our unique history.
References:
- Westaby S. Landmarks in Cardiac Surgery. Oxford: Isis Medical
Media, 1997.
- Harmel M, Lamont A. Anesthesia in the treatment of congenital
pulmonary stenosis. Anesthesiology. 1948; 7:477.
- Matthews JH, Buckley JJ, Van Bergen FH. Acute effects of
low-flow extracorporeal circulation on cerebral circulation.
Anesthesiology. 1957; 18:169.
Douglas R. Bacon, M.D., is the Interim
Vice Chair for Education and Associate Professor of Anesthesiology,
State University of New York at Buffalo, and Chief of Anesthesiology
Service, Veterans Affairs Western New York Healthcare System,
Buffalo, New York.
E-mail the author.
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