19-03-2010, 06:24 PM
(This post was last modified: 19-03-2010, 07:20 PM by James H. Fetzer.)
MORE ABOUT RUBY'S TREATMENT AND DR. EUGENE P. FRENKEL
JUDYTH REMARKS: THIS DOCOR WAS A 'BLOOD CLOT' EXPERT AND KNEW
THAT JACK RUBY SHOULD BE WEARING ELASIC SICKINGS, ETC.
Dr. Eugene Frenkel
Hematology, Hematology & Oncology, Internal Medicine, Medical Oncology,
Pathology - Hematology
"He developed and chaired the Division of Hematology-Oncology at the
University of Texas Southwestern Medical School..."
An Unusual Case of Macroglobulinemia
Turner A. Wood, MD; Eugene P. Frenkel, MD
Arch Intern Med. 1967;119(6):631-637. (a special kind of white bood cell
lymphoma cancer relaed o the immne system)
This article is interesting because it was written soon after Jack Ruby
died of lymphoma.
A pathologist, Dr. George Race, mentions Frenkel when his daughter got
leukemia:
"I also knew that there had never been a survivor of leukemia of that type.
Dr. Eugene Frenkel and all the powers that be in Dallas all looked at her
and said, “What do you want to do?” We decided to treat her as best we
could here. She got sicker and sicker and then died at home in bed. I've
always been sorry that I didn't take her back to see Dr. Farber."
(Frenkel "The Powers that be in Dallas")
http://www.baylorhealth.edu/proceedings/..._race.html
Frenkel was a very important oncologist in Dallas.
DOCTORS CAN'T FIND PRIME RUBY CANCER
$3.95 - New York Times - Dec 16, 1966
Dr. Jay P. Sanford and Dr. Eugene P. Frenkel of the Southwestern Medical
College said the cancer probably is situated in Ruby's lungs or his pancreas.
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http://www.trivia-library.com/c/controve...part-2.htm
Controversy: Was Jack Ruby Murdered? Part 2
About the controversy surrounding the death of Jack Ruby, history and
exploration of whether or not his death was murder.
CONTROVERSIES
WERE THEY MURDERED?
JACK RUBY
![[Image: 2ppe9tu.jpg]](http://i40.tinypic.com/2ppe9tu.jpg)
http://law.jrank.org/pages/3119/Jack-Rub...z0ibzubxIn
His Death: While awaiting retrial, Ruby began complaining of a persistent cough and nausea. On Dec. 9, 1966, he was transferred from the Dallas County Jail to Parkland Hospital, where doctors initially diagnosed his trouble as pneumonia. The next day, however, it was learned that Ruby had terminal cancer. A team of doctors under the direction of Dr. Eugene P. Frenkel reportedly considered the disease so far advanced that they ruled out surgery or radiation treatment as useless and instead injected Ruby regularly with 5-fluorouracil to retard the cancer's progress. Late in the evening of Jan. 2, 1967, doctors suspected that blood clots were forming; they administered oxygen, and by the next morning Ruby seemed in high spirits. Then about 9:00 A.M. he suffered a spasm. Despite emergency procedures, he was dead by 10:30 A.M.
Official Version: After performing an autopsy, Dallas County Medical Examiner Dr. Earl Rose ruled the immediate cause of death to be pulmonary embolism. He said a massive blood clot had formed in the leg, passed through the heart, and lodged in the lungs. He also found evidence of cancer in the right lung, which he listed as a contributing cause of death. But much to the surprise of Ruby's doctors, who believed that the disease had originated in the pancreas, Dr. Rose found the pancreas perfectly normal.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1214561/
The treatment of lesions in the chest besides tuberculosis evolved in the Second World War, as did wider use of blood transfusions. Pulmonary surgery further developed at Barnes Hospital in St. Louis, where the first pneumonectomy was performed by Dr. Evarts Graham. Subsequently, the first lobectomy by individual vessel and bronchus ligation occurred at the Massachusetts General Hospital by Dr. Edward Churchill and Mr. Ronald Belsey, who employed the same technique for segmental resection as well. This innovation allowed the lung to be removed without totally incapacitating the patient. The incidence of bronchogenic carcinoma increased dramatically in the postwar years. The direction of thoracic surgery was changed forever.
Following World War II, Dr. J. Warner Duckett, a general surgeon trained at Johns Hopkins University, began ligating the patent ductus arteriosus—an operation performed first by Dr. Robert Gross in Boston. This advance opened a new thoracic surgical area, which he subsequently expanded to the “blue baby” operation with the Blalock-Taussig anastomosis. It is interesting that Dr. Taussig, a pediatric cardiologist at Johns Hopkins Medical School, traveled on the train to Boston after Dr. Gross had ligated the first patent ductus in 1938. She asked him if he could create ductus, as well as ligate one. Dr. Gross said he could; he had created hundreds in dogs in preparation for the first ligation in humans. Dr. Taussig remarked that the patients with pulmonic stenosis often died when their patent ductus closed. She wondered if such a baby could be saved by creating a ductus. Dr. Gross laughed and said he doubted that it would work. She returned on the train to Baltimore to await Dr. Blalock's coming to Johns Hopkins after World War II, when they developed the Blalock-Taussig shunt for tetralogy of Fallot.
THE BEGINNINGS OF THORACIC SURGERY AT BAYLOR UNIVERSITY HOSPITAL
When Dr. Robert Shaw arrived in Dallas in 1938 after being Dr. John Alexander's seventh resident in thoracic surgery at the University of Michigan, he was the city's first and the state's second thoracic surgeon (Figure (Figure11Figure 1). To set up practice, he requested a loan of $75 from Dr. Alexander to buy his first bronchoscope, which he paid back in the amount of $7.50 a month. To give some perspective, Dr. Shaw began his practice 7 years after the first journal of thoracic surgery appeared and 10 years before the American Board of Thoracic Surgery was established.
Originally, Dr. Shaw intended to become a missionary. He developed tuberculosis and, while being treated, decided to become a physician (and subsequently a medical missionary). He was attracted to thoracic surgery because at that time tuberculosis was the number one killer in the world. Lung cancer was considered a rather exotic medical curiosity.
When Dr. Shaw came to Dallas, Dr. B. Goode and Dr. H. Walton Cochran were performing most of the operations for tuberculosis, drainage of empyema, and related causes. Surgery of the heart was beyond contemplation. Ear, nose, and throat surgeons and thoracic surgeons competed for endoscopy cases, which were primarily done to diagnose and remove foreign bodies of the trachea, bronchus, and esophagus.
World War II erupted, and Dr. Robert Shaw was placed in charge of the thoracic surgery unit at the Frenchay Hospital in Bristol, England. Upon his promotion to the American Hospital in Paris, he was succeeded at Frenchay by Mr. Ronald Belsey, world-renowned thoracic surgeon and frequent visiting consultant to Baylor University Hospital (Figure (Figure22Figure 2). Dr. Donald Paulson, having trained at the Mayo Clinic, was chief of thoracic surgery at Brooke Army Hospital during World War II, where he performed as many as 15 to 20 operations a day, 7 days a week in San Antonio (Figure (Figure33Figure 3).
After the war, Dr. Paulson joined Dr. Shaw in private practice in Dallas, where they shared an office with Dr. John Chapman, an early pulmonologist. Drs. Shaw, Paulson, and Chapman established the first 14-bed ward for tuberculosis at Baylor. This was the initial thoracic unit in Dallas. It was not air-conditioned and was in the wing of the hospital facing House Street. Leslie Sinclair, president of the Dallas Petroleum Club, mounted a massive telephone campaign to air-condition the tuberculosis ward. Mary Beard was a nurse in radiation therapy and took over the management of the tuberculosis unit. Endotracheal anesthesia was not widely available before the war; however, after World War II, Dr. Earl Weir became the chief of anesthesia and markedly expedited the management of thoracic surgical patients, improving the safety of surgery for thoracic disease. Eventually, Drs. John Kee, Harold Urschel, Richard Wood, and Maruf Razzuk joined the partnership of Drs. Shaw and Paulson. Dr. Urschel initially visited to learn about 3 operations popularized by Dr. Shaw and Dr. Paulson that he had not seen over his 10 years of training at Harvard Medical School and the Massachusetts General Hospital: the resections of superior pulmonary sulcus carcinomas, bronchoplastic preservation of lung tissue following the removal of a lung malignancy, and resection of mucoid impaction of the bronchus. These were just a few examples of the innovations and large series of operations performed by the first surgeons in Baylor's thoracic surgery department, which was officially established in 1949 (Table). The department now has 23 active members (Figure (Figure44Figure 4).
The first closed mitral commissurotomy for mitral stenosis was performed by Drs. Shaw and Paulson in the early 1950s following the lead of Dr. Dwight Harken in Boston and Dr. Charles Bailey in Philadelphia. Dr. Shaw performed over 1000 of these operations in Kabul, Afghanistan, in the early 1960s as a medical missionary. Baylor's thoracic surgeons trained one of his helpers, Dr. Aslami, in cardiac, vascular, and thoracic surgery. Dr. Aslami subsequently became the minister of health for Afghanistan until the Taliban takeover.
Dr. Maurice Adam (Figure (Figure55Figure 5) inserted the first “open chest” pacemaker in the Southwest on July 28, 1960. Drs. J. Judson McNamarra and Harold Urschel from Baylor University Medical Center (BUMC) were the first in Texas to insert a permanent transvenous pacemaker in 1968. Dr. McNamarra trained at the Massachusetts General Hospital, where he learned the technique, and was a thoracic surgical fellow with Drs. Shaw, Paulson, and Urschel.
Other major developments in thoracic surgery at BUMC were the use of the double-lumen endotracheal tube for selective unilateral ventilation, allowing much more expeditious thoracic surgery. This technique was brought from England by Dr. Donovan Campbell of the anesthesia service and reported by Dr. Wood at the Society of Thoracic Surgeons meeting. The technique allowed Dr. Urschel to perform pulmonary resections through a median sternotomy in severely ill pulmonary “crippled” patients, which allowed survival with minimal morbidity because of the lack of pain of the median sternotomy compared with the lateral thoracotomy. New techniques for Poland's syndrome, peripheral atrioventricular fistulae, coronary bypass combined with carbon dioxide gas endarterectomy, and resecting the aortic arch aneurysm were also pioneered by Drs. Urschel, Razzuk, and Campbell. Drs. Razzuk and Urschel developed a posterior reoperation technique for thoracic outlet syndrome and performed more of these cases than anyone else in the world. Dr. Urschel's experience with Paget-Schroetter effort thrombosis in the axillary subclavian vein is also the most extensive, and his technique of initial thrombolytic therapy followed by prompt first rib resection has markedly improved the success in this field.
Dr. Cary Lambert established many new techniques for tissue preservation and pioneered the use of heterografts for valve replacements. Drs. H. H. Shah and Lambert, along with Drs. Urschel and Paulson, developed new techniques for mediastinal biopsy of lymph nodes and staging for lung cancer as well as treatment of malignant pleural effusion with better pleural symphysis techniques.
ONCOLOGIC SURGERY
Dr. Robert Shaw saw a patient in the early 1950s who had a superior pulmonary sulcus carcinoma with pain secondary to a tumor of the lung growing into the lower trunk of the brachial plexus and chest wall. Such patients at that time were being treated with only radiation therapy. The patient developed so much pain after 2 weeks of radiation treatment that he looked elsewhere for relief and talked Dr. Shaw into surgically removing the tumor. The patient subsequently lived for 23 years without evidence of recurrent disease. Dr. Shaw completed a series of cases and popularized the resection of a superior pulmonary sulcus carcinoma following preoperative radiation therapy. In the 1960s he sent a manuscript describing 11 successfully treated patients to the Journal of Thoracic and Cardiovascular Surgery. The manuscript was rejected by the editor as “not having enough cases.” This report comprised the largest series of cases of this type in the world, and all cases were successful. Dr. Paulson subsequently popularized the procedure by writing extensively about lung cancer and particularly superior pulmonary sulcus carcinomas.
Dr. Shaw also envisioned the concept of removing a lung cancer with a sleeve resection of the bronchus, preserving the distal lung that would have ordinarily been sacrificed with a pneumonectomy. These patients did just as well as those with pneumonectomy and had much less morbidity and mortality. Bronchoplastic resection had been used before, but only for benign lesions, not for malignant tumors.
Interestingly, Sir Clement Price-Thomas, after the 1952 meeting in Dallas of the American Association of Thoracic Surgery, returned to England and performed a bronchoplastic procedure for carcinoma successfully. He has often been given credit for the work of Drs. Shaw and Paulson because he published it first. (He was world renowned for having operated on George V, the king of England.)
The radiation therapy department headed by Dr. John Mal-lams was extremely creative and was very helpful in giving preoperative radiation. Radiation treatment was given often based on only a clinical impression because of the difficulty and complications of open-needle biopsy at that time. Diagnostic procedures have become much safer and easier in recent years.
Drs. Shaw, Paulson, Kee, and Urschel treated over 10,000 patients with carcinoma of the lung from 1950 to 1970 (more patients than M. D. Anderson and Sloan Kettering combined). Dr. Urschel administered the chemotherapy (mostly cyclophosphamide) as well. Dr. Eugene P. Frenkel from the University of Texas Southwestern Medical School later served as a consultant in oncology to Drs. Shaw, Paulson, and Urschel and was enticed to send his protégé, Dr. Michael Reese, to BUMC to head up medical oncology. Dr. Reese developed the Texas Oncology practice, which is now one of the largest oncology practice groups in the country.
OPEN HEART SURGERY
The first open heart operation at Baylor was performed by Drs. LeRoy Kleinsasser and Paul Ellis in 1957. Guy Prater was the first perfusionist and also managed the animal research laboratory (Figure (Figure66Figure 6). He was an excellent artist and participated in many of the “firsts” in cardiac surgery at BUMC. Most of the heart surgery performed in the 1950s and early 1960s was limited to closed operations for mitral stenosis and Vineberg internal mammary artery implantations into the left ventricular muscle for coronary artery insufficiency. The first cine coronary angiogram was performed in the late 1950s by Dr. Mason Sones, which opened the field of direct coronary artery surgery. The first open direct coronary artery operation was performed by Drs. Urschel and Razzuk at BUMC on February 6, 1968, transecting the pulmonary artery, anastomosing a vein graft to the aorta from the left anterior descending coronary artery, and then re anastomosing the pulmonary artery. The patient did well initially but subsequently died of bleeding.
Figure 6
Guy Prater, perfusionist.
An open heart surgical procedure was a real strain because of the massive number of blood transfusions. (Fifteen had to be drawn fresh beginning at 2:00 AM the day of surgery. This limited the number of patients who could be operated on and increased the morbidity and bleeding from the procedure.) Dr. Denton Cooley had so many patients that out of necessity he decided to use Ringers lactate solution instead of blood to “prime the pump.” This improved the safety of the procedure while expediting the number of patients who could be treated.
Dr. Paul Ellis died while coming home from the Texas Medical Association meeting in Houston when the plane was struck by lightning and crashed. This tragic event shortened a brilliant career in cardiac surgery.
ESOPHAGEAL SURGERY
The early esophageal operations were confined to large hiatal hernias for benign disease and carcinoma of the esophagus for malignant disease. Esophageal carcinoma had a high mortality rate in the early 1950s; however, the mortality rate markedly improved with experience and the use of various conduits such as the colon, jejunum, and stomach bypasses following resection.
When gastroesophageal reflux was recognized as the major cause of peptic-corrosive disease of the esophagus, the presence of an anatomical hiatal hernia was not necessary to require surgical repair. The simple loss of the “valve” at the top of the stomach led to severe reflux. Dr. Urschel's introduction of the Collis-Belsey procedure to reconstruct the “valve” resulted in over 1200 operations reported in 1966 at the meeting of the American Association of Thoracic Surgery in Vancouver. (This was more cases than Belsey himself reported at the same meeting.) New operations for stricture of the esophagus and for perforation of the esophagus were established by Drs. Urschel, Paulson, and Wood. Esophageal stents for terminal carcinoma and strictures were employed, and subsequently thoracoscopic procedures for esophageal repair that did not require open thoracotomy were introduced. A new technique was introduced by Dr. Urschel of “exclusion and diversion” for esophageal perforations; this technique markedly decreased mortality in the 1960s. The results were presented in 1973 at the meeting of the Southern Surgical Association.
TRACHEAL SURGERY
Over 30 years, Drs. Urschel and Campbell reported on several new procedures for surgery of the trachea: tracheal splints; total replacement of the trachea and lower larynx, including the vocal cords with Silastic stents; and bronchopulmonary lavage for pulmonary alveolar proteinosis. Drs. Shaw and Paulson's experience with mucoid impaction of the bronchus was unique in the USA and represented the largest series in the world. Dr. Urschel presented this experience in 1965 to the Southern Thoracic Surgical Association, and the group of authors received the award for best scientific paper.
CARDIOPULMONARY TRANSPLANTATION
While cardiac transplantation officially began at BUMC in the 1980s, an experimental transplant was performed at BUMC in the mid 1960s. Following a pneumonectomy, a 39-year-old cattle rancher developed viral pneumonia in his remaining good lung. Gradually, it deteriorated until it was necessary to place him on extracorporeal circulation to support his ventilation until his only remaining lung recovered from viral pneumonia or a human lung donor could be located. Neither of these options materialized, and the patient became worse. At that time, Dr. Watts Webb was chief of thoracic surgery at the University of Texas Southwestern Medical School. Because of his experience in transplantation with Dr. James Hardy and because of Dr. Donovan Campbell's and Maruf Razzuk's experimental work on cardioplegia in calves, the surgeons embarked upon a “last-ditch” effort. A lung transplant was needed for 2 or 3 weeks until the patient's remaining lung recovered, at which time the transplant could be removed; rejection wasn't a concern since the transplant period was short. The surgeons elected to place a calf lung in the empty space of the right chest. The calf was anesthetized in the research laboratory, and Dr. Webb removed the lung. Drs. Urschel and Razzuk then anastomosed it and placed it in the right thoracic cavity. However, every time the pulmonary artery clamp was removed, the heart would dilate and develop right heart failure. Subsequently the lung was removed, and the patient later died. It was noted in retrospect that human erythrocytes would not pass through the capillaries of a calf, goat, or sheep heterograft organ.
Subsequently, cardiac transplantation was carried out successfully in South Africa, and a few heart transplants were performed in Texas. It was obvious that donor procurement was a problem. Because of this, a group of cardiac surgeons, lawyers, and ministers of various faiths lobbied successfully in Austin to have a law passed in Texas to move the “seat of the soul” from the heart to the pineal gland. This effort made it much more attractive to donate your heart after your soul was safely (legislatively) transferred to the brain. Brain transplantation was not imminent. Texas was the only state with such a law.
The cardiac transplant program was initiated in 1986 under the combined directorship of Drs. Ivan Crosby and Peter Alivizatos. During the first year, 3 transplants were successfully completed, and subsequently the average number increased to 15 to 20 per year. In 1991, there were 32 cases, the highest number ever. The first pulmonary transplant was done in 1990. While the average has been 15 per year, in 1997 22 lung transplants were performed. Five heart-lung transplants have been performed over a 15-year period. In 1988, BUMC's cardiac transplant program became the first in Texas to be certified by the United Network for Organ Sharing and to be approved by Texas Medicaid. In that same year, surgeons at BUMC performed the first combined heart-kidney transplant in North Texas, the fifth in the world. In addition, the first “bridge-to-transplantation” procedure in the USA using the Abiomed ventricular assist device was performed. The first heart-lung heart “domino” procedure in Texas was a pioneering operation in a patient with terminal emphysema who received a heart and 2 lungs while another patient with cardiomyopathy received the emphysema patient's good heart. These operations were performed successfully in 1989. In 1990, Medicare approved BUMC's heart transplant program, the first program in North Texas to be approved. A left heart assist device (Thoratec) was implanted in 1999 as a bridge to transplant, and subsequently the DeBakey VAD was approved in 2002 under the direction of Dr. Dan Meyer. Dr. Crosby left the cardiac transplantation program in the late 1980s, and Dr. Steves Ring took it over from Dr. Alivizatos in 1996. Accompanying Dr. Ring from the University of Texas Southwestern Medical School were Drs. Dan Meyer, Michael Jessen, Michael Wait, and Michael DeMaio. Dr. Ring currently operates the heart, lung, and heart-lung transplant service at BUMC along with Dr. John Capehart. Other surgeons historically involved in the program are Drs. Ivan Crosby, Maruf Razzuk, H. H. Shah, Harold Urschel, Richard Wood, Tom Meyers, and Kimble Jett.
ANESTHESIA
Crucial to the development of thoracic and cardiac surgery was anesthesia. The foundation for solid physiological and clinical principles was laid by Dr. Donovan Campbell, who spent most of his time in the thoracic surgery arena. He used new anesthetic agents, developed endotracheal anesthesia devices, and created ingenious methods of managing tracheal discontinuity requiring multiple distal ventilating techniques. Having completed an engineering degree before entering medicine, he was well prepared for his subsequent work of improvising and creating new solutions to difficult thoracic surgery problems. He worked in both the laboratory and the operating room with thoracic surgeons constantly, spending night and day at the hospital improving the basis for clinical care.
In the early 1960s, most thoracic surgery was performed in the prone position on the Naclerio-Overholt table, so that multiple secretions could drain out and so that the patient could breathe without being paralyzed. One disadvantage was that if a cardiac arrest occurred in this position, the operation had to be terminated and the patient turned completely over in the supine position and resuscitated. Dr. Campbell circumvented this problem by bringing the double-lumen tube to America. In addition to pioneering new techniques, Dr. Campbell brought many constructive elements from Europe, not the least of which were 2 subsequent chiefs of anesthesia, Dr. Roy Simpson, who developed the biomedical engineering department and the anesthesia research laboratory; and Dr. Michael Ramsay, who advanced transplantation anesthesia and became the president of Baylor Research Institute.
In July 1959, a nonflammable, volatile, halogenated hydrocarbon was introduced as an anesthetic agent. Two properties that ensured its immediate popularity were its very powerful bronchodilator effect and its failure to excite bronchial and tracheal secretions. Further, it had almost no emetic action and was moderately pleasant to inhale. Thus, halothane diluted only with oxygen was utilized as an induction agent, and the results were remarkable. Patients with bronchospastic disease could be anesthetized and operated on with facility, and as a result of the absence of pulmonary secretions, the postoperative course was easier and shorter. Thoracic surgery was safer, the surgery was surer and quicker, cautery could be employed throughout the procedure, and blood loss was diminished.
In the early 1960s, Baylor established a recovery room and shortly thereafter an intensive care unit. Both were essential for an expanded thoracic surgical horizon and for the development of the relatively new field of cardiac surgery. Implicit in the planning and establishment of these postoperative units was the careful training of the nursing and administrative personnel, without which the units could not have operated.
In conjunction with the advent of cardiopulmonary bypass, a necessity for cardiac surgery, there arose 1) continuous arterial blood pressure monitoring; 2) continuous central venous pressure monitoring; 3) a pulmonary laboratory for almost instantaneous blood gas analyses; 4) very fast laboratory analyses of arterial blood for electrolytes; and 5) continuous electrocardiograms. These proved in later years to have been somewhat crude but moderately safe. Cardiac surgery was off to a start.
In 1970, the first double-lumen endotracheal tube designed specifically for pulmonary and esophageal surgery became available. An English physician studied the anatomy of both male and female adult cadavers of varying height and weight and produced left and right double-lumen tubes in 3 sizes, small, medium, and large. Together with intraarterial pressure monitoring, ready access to arterial blood gas analyses, an anesthetic agent that was nonflammable, and a potent bronchodilator that produced a minimum of secretions, intrathoracic surgery was revolutionized. Further, surgery for resection of lesions in both right and left lungs could be safely and efficiently carried out through a midline sternal incision.
Within 2 years, insertion and use of a pulmonary artery catheter became available for several of the operating rooms. Thus, accumulation of important information, heretofore possible only in a laboratory setting, could now be utilized in an operative setting. This dramatically increased the safety with which complicated thoracic surgical procedures could be done on high-risk patients.
Professor Roy Simpson of the London Hospital was appointed Baylor chief of anesthesia and professor of anesthesia at Southwestern Medical School in 1975. Shortly thereafter, he interviewed and hired Bill Paulson as director of biomedical engineering for BUMC. Bill Paulson tested and evaluated a number of sophisticated monitoring systems and chose one that could be used throughout the hospital's many buildings. The system chosen could show on a screen or screens arterial blood pressure, pulmonary artery pressure, central venous pressure, and a continuous electrocardiogram. When the weight and height of the patient were entered, the system could calculate cardiac output as well as total peripheral resistance. And all these values could be printed out. This information, essential to intelligent preoperative, operative, and postoperative management, vastly improved patient safety and care.
Dr. Michael Ramsay, current chief of anesthesiology at BUMC, is also the president of the Baylor Research Institute. He is a remarkable individual who not only is a world-class clinical anesthesiologist but also operates a superb research facility in collaboration with multiple physicians. He has devised multiple new techniques that significantly improve patient care and leads the anesthesia section with the motto, “Keep the patient first.”
EDUCATION
Thoracic surgery residency
The thoracic surgery residency was initiated immediately after World War II by Drs. Shaw and Paulson at BUMC. Among those trained were Drs. Milton Davis, Ben Mitchel, H. H. Shah, Cary Lambert, Peter Thiele, and Maruf Razzuk, all of whom were subsequent members of the staff at Baylor; Dr. Mitchel later served as chief (Figure (Figure77Figure 7). The residency training program subsequently was transferred to the University of Texas Southwestern Medical School, and the residents rotated to Parkland, BUMC, the Veterans Administration Hospital, and Children's Medical Center. In 1976, the American Board of Thoracic Surgery reduced the total number of surgeons training in thoracic surgery, and the number of thoracic residents in Dallas was reduced from 8 to 4, or 2 a year in a 2-year program. Because of the reduced number of residents, BUMC was used only as the elective part of the rotation. Dr. Steves Ring, who performs the heart and lung transplants at BUMC as well as the medical school, now leads this excellent program.
Figure 7
Dr. Ben Mitchel, chief of thoracic surgery from 1977 to 1986.
Drs. Shaw, Paulson, and Urschel have all been directors and examiners of the American Board of Thoracic Surgery. The Board of Thoracic Surgery was established as a subboard of the American Board of Surgery in 1948 after World War II. It remained that until 1971, when it became an independent board under the chairmanship of Donald Paulson.
Dr. Urschel was a member of the Residency Review Committee for Cardiothoracic Surgery and subsequently became chairman in 1994 for 2 years. This organization oversees the training of all 100 thoracic and cardiac surgery residency programs in the country. Dr. Urschel also sat on the Residency Review Committee for General Surgery and for Vascular Surgery. The Residency Review Committee is unique to the USA. No other country has such a group that evaluates and sets the standard for the training of residents.
Thoracic-cardiovascular fellowship
The first fellowship in thoracic and cardiovascular surgery was initiated in 1964 at BUMC by Drs. Urschel and Paulson. The first fellow was Dr. Andres Morales, a resident who decided to stay on another year with us. He wrote several scientific articles, including one on the implantation of the internal mammary artery into the posterior myocardium. Scientific writing was a prerequisite for subsequent fellows. Relationships were developed with the Massachusetts General Hospital, the Johns Hopkins Hospital, and the Toronto General Hospital, all of which sent residents for additional complementary training because of the extensive num-ber and variety of cases at BUMC. Drs. Razzuk and McNamarra were sent by Dr. Linton to Dr. Urschel as fellows from the Massachusetts General Hospital. Dr. Razzuk stayed for residency training and became a member of the staff. Dr. McNamarra became chairman of the Department of Surgery at the University of Hawaii in Honolulu. Dr. Robert Ginsberg, a fellow from the University of Toronto, introduced formal mediastinoscopy to Texas. He subsequently became chief of thoracic surgery at Memorial Sloan-Kettering Cancer Center in New York and then chairman of the department at the University of Toronto in Canada. Approximately 75 fellows have trained with the Shaw, Paulson, Urschel group and several others with the Davis, Mitchel, Adam, and Lambert group. Dr. Peter Alivizatos was a fellow in this group; he was a cofounder of the cardiopulmonary transplant program and subsequently led it to world-class status. The fellows not only provided improved patient care and contributed significantly to the writing of scientific papers, but also were important in bringing new knowledge from other major thoracic and cardiac centers of the world to BUMC.
Visiting professors
Dr. F. Griffith Pearson, chief of thoracic surgery at the University of Toronto, was a frequent visiting professor at BUMC and would often scrub on subglottic tracheal stenosis cases (Figure (Figure88Figure 8). Dr. Robert Ginsberg also served as a visiting professor multiple times. Other visiting professors included Drs. David Sabiston (Duke), Vincent Dor (Monaco Heart and Lung Center), Don Effler and Tom Rice (Cleveland Clinic), and Ronald Belsey.
Figure 8
Drs. Harold Urschel, Maruf Razzuk, Donovan Campbell, and F. Griffith Pearson performing a subglottic tracheal resection at BUMC.
RESEARCH
The need for many of the new operations that appeared in the 1950s and 1960s was recognized while caring for patients and then developed on calves, goats, sheep, and dogs in the laboratory. Dr. Campbell would put the animals to sleep at 4:00 AM, and the experimental procedures were conducted by Drs. Urschel and Razzuk until 7:30 AM when clinical surgery began. New management of pulmonary alveolar proteinosis with bronchopulmonary lavage, artificial tracheal prostheses from Silastic stents, and improved cardiac oxygenation with hydrogen peroxide were developed in this setting at BUMC.
The cardiovascular and thoracic surgical section at BUMC has had an extremely productive history of scientific presentations and publications since World War II. Originally, research was clinical, prominently in lung cancer and subsequently in cardiovascular as well as thoracic surgery.
More recently, “bench-to-bedside” capability has been added to clinical trials, and the cardiovascular-thoracic surgical service has taken the lead in many new developments, thanks to the efforts and environment created by the current chief of service, Dr. Richard E. Wood (Figure (Figure99Figure 9). He stimulated various members of the service to participate in clinical trials in their areas of interest.
Figure 9
Dr. Richard Wood, chief of thoracic surgery since 1999.
Dr. Baron Hamman has taken the lead in “beating-heart” surgery (off-pump coronary artery bypass grafting), transmyocardial laser revascularization of the ischemic heart, new proximal and distal anastomotic techniques for bypass grafts, and the use of the robot.
Dr. Robert Hebeler has been encouraged to study new types of stentless aortic valves as principal investigator of a clinical trial. He pioneered robotics in Texas as a major investigator in the national study of mitral valve replacement with the robot (Figure (Figure1010Figure 10), participated in the transmyocardial laser revascularization project, and is leading a study to evaluate cerebral malfunction with various types of cardiopulmonary perfusion.
Figure 10
Drs. Richard Wood (left) and Robert Hebeler using a robotic surgery system to perform minimally invasive closed-chest cardiac surgical procedures.
The largest series in the world of endoscopically harvested radial arteries for coronary artery bypass grafts has been accumulated by Dr. Carl Henry. Dr. Harry Kourlis is in the process of evaluating endovascular stents for thoracic thoracoabdominal aortic aneurysms, and Dr. Greg Matter participates in high-volume cardiac surgery study trials.
Dr. Edson Cheung established the Cheung Family Foundation to encourage visiting professorships at BUMC and provide for cardiovascular and thoracic surgical education.
The clinical adult cardiac database is being revitalized. It was originally established in Apollo after several years of hard work by Dr. Maurice Adam. This effort, pioneered at Baylor Hospital, represents one of the more important fundamentals for sound clinical research.
Dr. Thomas Meyers organized and conducted an outstanding course on cutting-edge lung cancer surgery, bringing experts from around the world to BUMC.
The cardiac and pulmonary transplant team, headed by Dr. Steves Ring, has outstanding clinical results and conducts appropriate research. Dr. Dan Meyer directs the left ventricular assist project, including the DeBakey VAD, a miniature assist device developed by engineers at the National Aeronautics and Space Administration. Dr. John Capehart has been an integral part of the cardiopulmonary transplant service since its origin in 1986.
Dr. Wood procured the first robot in Texas. He supported establishing the chair of cardiovascular and thoracic surgical research, education, and clinical excellence, held by Dr. Harold Urschel, and was pivotal in organizing cooperation with the Clinical Cardiovascular Research Center.
In the past year and a half, in large part because of the energy of a general surgical resident, Dr. Amit Patel, a surge in enthusiasm for clinical research has occurred. BUMC medical staff have given more than 30 presentations at regional, national, and international meetings based on cardiovascular and thoracic research; have published more than 20 scientific papers on topics such as cardiac trauma, leukocyte filtration with coronary artery bypass grafts and valves, Syncrus therapy of postoperative arrhythmias, and endoscopic vein and radial artery harvesting; and have given grand rounds at Harvard, Stanford, Cornell, Pittsburgh, and other major medical centers.
NATIONAL AND INTERNATIONAL RECOGNITION OF BUMC THORACIC AND
CARDIOVASCULAR SURGEONS
Dr. Robert Shaw was a founding director and examiner for the American Board of Thoracic Surgery. Dr. Donald L. Paulson was president of the American Association for Thoracic Surgery and chairman of the American Board of Thoracic Surgery. Dr. Harold Urschel was president of the Society of Thoracic Surgeons, the American College of Chest Physicians, and the International Academy of Chest Physicians. The 3 have written over 500 peer-reviewed scientific articles on cardiovascular and thoracic surgery. Dr. Urschel was editor of Atlas of Thoracic Surgery and textbooks on thoracic surgery and esophageal surgery.
Their partnership at Baylor treated the largest series in the USA of lung cancer patients over 20 years (>10,000) and operated on the largest number of patients with superior sulcus carcinoma, thoracic outlet syndrome, Paget-Schroetter syndrome, and Poland's syndrome. Further, they've done the largest number of bronchoplastic procedures, median sternotomies for pulmonary resections, resections of mucoid impaction of bronchi, intraoperative coronary artery balloon angioplasties, and coronary artery bypass grafts with carbon dioxide gas endarterectomy.
BUMC performs over 1500 open heart procedures each year—nearly twice as many as any other hospital in North Texas—with excellent outcomes.
Acknowledgments
The Cardiothoracic Surgery Section of Baylor University Medical Center wishes to thank Mrs. Rachel Montano for her dedication and commitment to the research and completion of this history.
JUDYTH REMARKS: THIS DOCOR WAS A 'BLOOD CLOT' EXPERT AND KNEW
THAT JACK RUBY SHOULD BE WEARING ELASIC SICKINGS, ETC.
Dr. Eugene Frenkel
Hematology, Hematology & Oncology, Internal Medicine, Medical Oncology,
Pathology - Hematology
"He developed and chaired the Division of Hematology-Oncology at the
University of Texas Southwestern Medical School..."
An Unusual Case of Macroglobulinemia
Turner A. Wood, MD; Eugene P. Frenkel, MD
Arch Intern Med. 1967;119(6):631-637. (a special kind of white bood cell
lymphoma cancer relaed o the immne system)
This article is interesting because it was written soon after Jack Ruby
died of lymphoma.
A pathologist, Dr. George Race, mentions Frenkel when his daughter got
leukemia:
"I also knew that there had never been a survivor of leukemia of that type.
Dr. Eugene Frenkel and all the powers that be in Dallas all looked at her
and said, “What do you want to do?” We decided to treat her as best we
could here. She got sicker and sicker and then died at home in bed. I've
always been sorry that I didn't take her back to see Dr. Farber."
(Frenkel "The Powers that be in Dallas")
http://www.baylorhealth.edu/proceedings/..._race.html
Frenkel was a very important oncologist in Dallas.
DOCTORS CAN'T FIND PRIME RUBY CANCER
$3.95 - New York Times - Dec 16, 1966
Dr. Jay P. Sanford and Dr. Eugene P. Frenkel of the Southwestern Medical
College said the cancer probably is situated in Ruby's lungs or his pancreas.
----------
http://www.trivia-library.com/c/controve...part-2.htm
Controversy: Was Jack Ruby Murdered? Part 2
About the controversy surrounding the death of Jack Ruby, history and
exploration of whether or not his death was murder.
CONTROVERSIES
WERE THEY MURDERED?
JACK RUBY
http://law.jrank.org/pages/3119/Jack-Rub...z0ibzubxIn
His Death: While awaiting retrial, Ruby began complaining of a persistent cough and nausea. On Dec. 9, 1966, he was transferred from the Dallas County Jail to Parkland Hospital, where doctors initially diagnosed his trouble as pneumonia. The next day, however, it was learned that Ruby had terminal cancer. A team of doctors under the direction of Dr. Eugene P. Frenkel reportedly considered the disease so far advanced that they ruled out surgery or radiation treatment as useless and instead injected Ruby regularly with 5-fluorouracil to retard the cancer's progress. Late in the evening of Jan. 2, 1967, doctors suspected that blood clots were forming; they administered oxygen, and by the next morning Ruby seemed in high spirits. Then about 9:00 A.M. he suffered a spasm. Despite emergency procedures, he was dead by 10:30 A.M.
Official Version: After performing an autopsy, Dallas County Medical Examiner Dr. Earl Rose ruled the immediate cause of death to be pulmonary embolism. He said a massive blood clot had formed in the leg, passed through the heart, and lodged in the lungs. He also found evidence of cancer in the right lung, which he listed as a contributing cause of death. But much to the surprise of Ruby's doctors, who believed that the disease had originated in the pancreas, Dr. Rose found the pancreas perfectly normal.
------------
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1214561/
The treatment of lesions in the chest besides tuberculosis evolved in the Second World War, as did wider use of blood transfusions. Pulmonary surgery further developed at Barnes Hospital in St. Louis, where the first pneumonectomy was performed by Dr. Evarts Graham. Subsequently, the first lobectomy by individual vessel and bronchus ligation occurred at the Massachusetts General Hospital by Dr. Edward Churchill and Mr. Ronald Belsey, who employed the same technique for segmental resection as well. This innovation allowed the lung to be removed without totally incapacitating the patient. The incidence of bronchogenic carcinoma increased dramatically in the postwar years. The direction of thoracic surgery was changed forever.
Following World War II, Dr. J. Warner Duckett, a general surgeon trained at Johns Hopkins University, began ligating the patent ductus arteriosus—an operation performed first by Dr. Robert Gross in Boston. This advance opened a new thoracic surgical area, which he subsequently expanded to the “blue baby” operation with the Blalock-Taussig anastomosis. It is interesting that Dr. Taussig, a pediatric cardiologist at Johns Hopkins Medical School, traveled on the train to Boston after Dr. Gross had ligated the first patent ductus in 1938. She asked him if he could create ductus, as well as ligate one. Dr. Gross said he could; he had created hundreds in dogs in preparation for the first ligation in humans. Dr. Taussig remarked that the patients with pulmonic stenosis often died when their patent ductus closed. She wondered if such a baby could be saved by creating a ductus. Dr. Gross laughed and said he doubted that it would work. She returned on the train to Baltimore to await Dr. Blalock's coming to Johns Hopkins after World War II, when they developed the Blalock-Taussig shunt for tetralogy of Fallot.
THE BEGINNINGS OF THORACIC SURGERY AT BAYLOR UNIVERSITY HOSPITAL
When Dr. Robert Shaw arrived in Dallas in 1938 after being Dr. John Alexander's seventh resident in thoracic surgery at the University of Michigan, he was the city's first and the state's second thoracic surgeon (Figure (Figure11Figure 1). To set up practice, he requested a loan of $75 from Dr. Alexander to buy his first bronchoscope, which he paid back in the amount of $7.50 a month. To give some perspective, Dr. Shaw began his practice 7 years after the first journal of thoracic surgery appeared and 10 years before the American Board of Thoracic Surgery was established.
Originally, Dr. Shaw intended to become a missionary. He developed tuberculosis and, while being treated, decided to become a physician (and subsequently a medical missionary). He was attracted to thoracic surgery because at that time tuberculosis was the number one killer in the world. Lung cancer was considered a rather exotic medical curiosity.
When Dr. Shaw came to Dallas, Dr. B. Goode and Dr. H. Walton Cochran were performing most of the operations for tuberculosis, drainage of empyema, and related causes. Surgery of the heart was beyond contemplation. Ear, nose, and throat surgeons and thoracic surgeons competed for endoscopy cases, which were primarily done to diagnose and remove foreign bodies of the trachea, bronchus, and esophagus.
World War II erupted, and Dr. Robert Shaw was placed in charge of the thoracic surgery unit at the Frenchay Hospital in Bristol, England. Upon his promotion to the American Hospital in Paris, he was succeeded at Frenchay by Mr. Ronald Belsey, world-renowned thoracic surgeon and frequent visiting consultant to Baylor University Hospital (Figure (Figure22Figure 2). Dr. Donald Paulson, having trained at the Mayo Clinic, was chief of thoracic surgery at Brooke Army Hospital during World War II, where he performed as many as 15 to 20 operations a day, 7 days a week in San Antonio (Figure (Figure33Figure 3).
After the war, Dr. Paulson joined Dr. Shaw in private practice in Dallas, where they shared an office with Dr. John Chapman, an early pulmonologist. Drs. Shaw, Paulson, and Chapman established the first 14-bed ward for tuberculosis at Baylor. This was the initial thoracic unit in Dallas. It was not air-conditioned and was in the wing of the hospital facing House Street. Leslie Sinclair, president of the Dallas Petroleum Club, mounted a massive telephone campaign to air-condition the tuberculosis ward. Mary Beard was a nurse in radiation therapy and took over the management of the tuberculosis unit. Endotracheal anesthesia was not widely available before the war; however, after World War II, Dr. Earl Weir became the chief of anesthesia and markedly expedited the management of thoracic surgical patients, improving the safety of surgery for thoracic disease. Eventually, Drs. John Kee, Harold Urschel, Richard Wood, and Maruf Razzuk joined the partnership of Drs. Shaw and Paulson. Dr. Urschel initially visited to learn about 3 operations popularized by Dr. Shaw and Dr. Paulson that he had not seen over his 10 years of training at Harvard Medical School and the Massachusetts General Hospital: the resections of superior pulmonary sulcus carcinomas, bronchoplastic preservation of lung tissue following the removal of a lung malignancy, and resection of mucoid impaction of the bronchus. These were just a few examples of the innovations and large series of operations performed by the first surgeons in Baylor's thoracic surgery department, which was officially established in 1949 (Table). The department now has 23 active members (Figure (Figure44Figure 4).
The first closed mitral commissurotomy for mitral stenosis was performed by Drs. Shaw and Paulson in the early 1950s following the lead of Dr. Dwight Harken in Boston and Dr. Charles Bailey in Philadelphia. Dr. Shaw performed over 1000 of these operations in Kabul, Afghanistan, in the early 1960s as a medical missionary. Baylor's thoracic surgeons trained one of his helpers, Dr. Aslami, in cardiac, vascular, and thoracic surgery. Dr. Aslami subsequently became the minister of health for Afghanistan until the Taliban takeover.
Dr. Maurice Adam (Figure (Figure55Figure 5) inserted the first “open chest” pacemaker in the Southwest on July 28, 1960. Drs. J. Judson McNamarra and Harold Urschel from Baylor University Medical Center (BUMC) were the first in Texas to insert a permanent transvenous pacemaker in 1968. Dr. McNamarra trained at the Massachusetts General Hospital, where he learned the technique, and was a thoracic surgical fellow with Drs. Shaw, Paulson, and Urschel.
Other major developments in thoracic surgery at BUMC were the use of the double-lumen endotracheal tube for selective unilateral ventilation, allowing much more expeditious thoracic surgery. This technique was brought from England by Dr. Donovan Campbell of the anesthesia service and reported by Dr. Wood at the Society of Thoracic Surgeons meeting. The technique allowed Dr. Urschel to perform pulmonary resections through a median sternotomy in severely ill pulmonary “crippled” patients, which allowed survival with minimal morbidity because of the lack of pain of the median sternotomy compared with the lateral thoracotomy. New techniques for Poland's syndrome, peripheral atrioventricular fistulae, coronary bypass combined with carbon dioxide gas endarterectomy, and resecting the aortic arch aneurysm were also pioneered by Drs. Urschel, Razzuk, and Campbell. Drs. Razzuk and Urschel developed a posterior reoperation technique for thoracic outlet syndrome and performed more of these cases than anyone else in the world. Dr. Urschel's experience with Paget-Schroetter effort thrombosis in the axillary subclavian vein is also the most extensive, and his technique of initial thrombolytic therapy followed by prompt first rib resection has markedly improved the success in this field.
Dr. Cary Lambert established many new techniques for tissue preservation and pioneered the use of heterografts for valve replacements. Drs. H. H. Shah and Lambert, along with Drs. Urschel and Paulson, developed new techniques for mediastinal biopsy of lymph nodes and staging for lung cancer as well as treatment of malignant pleural effusion with better pleural symphysis techniques.
ONCOLOGIC SURGERY
Dr. Robert Shaw saw a patient in the early 1950s who had a superior pulmonary sulcus carcinoma with pain secondary to a tumor of the lung growing into the lower trunk of the brachial plexus and chest wall. Such patients at that time were being treated with only radiation therapy. The patient developed so much pain after 2 weeks of radiation treatment that he looked elsewhere for relief and talked Dr. Shaw into surgically removing the tumor. The patient subsequently lived for 23 years without evidence of recurrent disease. Dr. Shaw completed a series of cases and popularized the resection of a superior pulmonary sulcus carcinoma following preoperative radiation therapy. In the 1960s he sent a manuscript describing 11 successfully treated patients to the Journal of Thoracic and Cardiovascular Surgery. The manuscript was rejected by the editor as “not having enough cases.” This report comprised the largest series of cases of this type in the world, and all cases were successful. Dr. Paulson subsequently popularized the procedure by writing extensively about lung cancer and particularly superior pulmonary sulcus carcinomas.
Dr. Shaw also envisioned the concept of removing a lung cancer with a sleeve resection of the bronchus, preserving the distal lung that would have ordinarily been sacrificed with a pneumonectomy. These patients did just as well as those with pneumonectomy and had much less morbidity and mortality. Bronchoplastic resection had been used before, but only for benign lesions, not for malignant tumors.
Interestingly, Sir Clement Price-Thomas, after the 1952 meeting in Dallas of the American Association of Thoracic Surgery, returned to England and performed a bronchoplastic procedure for carcinoma successfully. He has often been given credit for the work of Drs. Shaw and Paulson because he published it first. (He was world renowned for having operated on George V, the king of England.)
The radiation therapy department headed by Dr. John Mal-lams was extremely creative and was very helpful in giving preoperative radiation. Radiation treatment was given often based on only a clinical impression because of the difficulty and complications of open-needle biopsy at that time. Diagnostic procedures have become much safer and easier in recent years.
Drs. Shaw, Paulson, Kee, and Urschel treated over 10,000 patients with carcinoma of the lung from 1950 to 1970 (more patients than M. D. Anderson and Sloan Kettering combined). Dr. Urschel administered the chemotherapy (mostly cyclophosphamide) as well. Dr. Eugene P. Frenkel from the University of Texas Southwestern Medical School later served as a consultant in oncology to Drs. Shaw, Paulson, and Urschel and was enticed to send his protégé, Dr. Michael Reese, to BUMC to head up medical oncology. Dr. Reese developed the Texas Oncology practice, which is now one of the largest oncology practice groups in the country.
OPEN HEART SURGERY
The first open heart operation at Baylor was performed by Drs. LeRoy Kleinsasser and Paul Ellis in 1957. Guy Prater was the first perfusionist and also managed the animal research laboratory (Figure (Figure66Figure 6). He was an excellent artist and participated in many of the “firsts” in cardiac surgery at BUMC. Most of the heart surgery performed in the 1950s and early 1960s was limited to closed operations for mitral stenosis and Vineberg internal mammary artery implantations into the left ventricular muscle for coronary artery insufficiency. The first cine coronary angiogram was performed in the late 1950s by Dr. Mason Sones, which opened the field of direct coronary artery surgery. The first open direct coronary artery operation was performed by Drs. Urschel and Razzuk at BUMC on February 6, 1968, transecting the pulmonary artery, anastomosing a vein graft to the aorta from the left anterior descending coronary artery, and then re anastomosing the pulmonary artery. The patient did well initially but subsequently died of bleeding.
Figure 6
Guy Prater, perfusionist.
An open heart surgical procedure was a real strain because of the massive number of blood transfusions. (Fifteen had to be drawn fresh beginning at 2:00 AM the day of surgery. This limited the number of patients who could be operated on and increased the morbidity and bleeding from the procedure.) Dr. Denton Cooley had so many patients that out of necessity he decided to use Ringers lactate solution instead of blood to “prime the pump.” This improved the safety of the procedure while expediting the number of patients who could be treated.
Dr. Paul Ellis died while coming home from the Texas Medical Association meeting in Houston when the plane was struck by lightning and crashed. This tragic event shortened a brilliant career in cardiac surgery.
ESOPHAGEAL SURGERY
The early esophageal operations were confined to large hiatal hernias for benign disease and carcinoma of the esophagus for malignant disease. Esophageal carcinoma had a high mortality rate in the early 1950s; however, the mortality rate markedly improved with experience and the use of various conduits such as the colon, jejunum, and stomach bypasses following resection.
When gastroesophageal reflux was recognized as the major cause of peptic-corrosive disease of the esophagus, the presence of an anatomical hiatal hernia was not necessary to require surgical repair. The simple loss of the “valve” at the top of the stomach led to severe reflux. Dr. Urschel's introduction of the Collis-Belsey procedure to reconstruct the “valve” resulted in over 1200 operations reported in 1966 at the meeting of the American Association of Thoracic Surgery in Vancouver. (This was more cases than Belsey himself reported at the same meeting.) New operations for stricture of the esophagus and for perforation of the esophagus were established by Drs. Urschel, Paulson, and Wood. Esophageal stents for terminal carcinoma and strictures were employed, and subsequently thoracoscopic procedures for esophageal repair that did not require open thoracotomy were introduced. A new technique was introduced by Dr. Urschel of “exclusion and diversion” for esophageal perforations; this technique markedly decreased mortality in the 1960s. The results were presented in 1973 at the meeting of the Southern Surgical Association.
TRACHEAL SURGERY
Over 30 years, Drs. Urschel and Campbell reported on several new procedures for surgery of the trachea: tracheal splints; total replacement of the trachea and lower larynx, including the vocal cords with Silastic stents; and bronchopulmonary lavage for pulmonary alveolar proteinosis. Drs. Shaw and Paulson's experience with mucoid impaction of the bronchus was unique in the USA and represented the largest series in the world. Dr. Urschel presented this experience in 1965 to the Southern Thoracic Surgical Association, and the group of authors received the award for best scientific paper.
CARDIOPULMONARY TRANSPLANTATION
While cardiac transplantation officially began at BUMC in the 1980s, an experimental transplant was performed at BUMC in the mid 1960s. Following a pneumonectomy, a 39-year-old cattle rancher developed viral pneumonia in his remaining good lung. Gradually, it deteriorated until it was necessary to place him on extracorporeal circulation to support his ventilation until his only remaining lung recovered from viral pneumonia or a human lung donor could be located. Neither of these options materialized, and the patient became worse. At that time, Dr. Watts Webb was chief of thoracic surgery at the University of Texas Southwestern Medical School. Because of his experience in transplantation with Dr. James Hardy and because of Dr. Donovan Campbell's and Maruf Razzuk's experimental work on cardioplegia in calves, the surgeons embarked upon a “last-ditch” effort. A lung transplant was needed for 2 or 3 weeks until the patient's remaining lung recovered, at which time the transplant could be removed; rejection wasn't a concern since the transplant period was short. The surgeons elected to place a calf lung in the empty space of the right chest. The calf was anesthetized in the research laboratory, and Dr. Webb removed the lung. Drs. Urschel and Razzuk then anastomosed it and placed it in the right thoracic cavity. However, every time the pulmonary artery clamp was removed, the heart would dilate and develop right heart failure. Subsequently the lung was removed, and the patient later died. It was noted in retrospect that human erythrocytes would not pass through the capillaries of a calf, goat, or sheep heterograft organ.
Subsequently, cardiac transplantation was carried out successfully in South Africa, and a few heart transplants were performed in Texas. It was obvious that donor procurement was a problem. Because of this, a group of cardiac surgeons, lawyers, and ministers of various faiths lobbied successfully in Austin to have a law passed in Texas to move the “seat of the soul” from the heart to the pineal gland. This effort made it much more attractive to donate your heart after your soul was safely (legislatively) transferred to the brain. Brain transplantation was not imminent. Texas was the only state with such a law.
The cardiac transplant program was initiated in 1986 under the combined directorship of Drs. Ivan Crosby and Peter Alivizatos. During the first year, 3 transplants were successfully completed, and subsequently the average number increased to 15 to 20 per year. In 1991, there were 32 cases, the highest number ever. The first pulmonary transplant was done in 1990. While the average has been 15 per year, in 1997 22 lung transplants were performed. Five heart-lung transplants have been performed over a 15-year period. In 1988, BUMC's cardiac transplant program became the first in Texas to be certified by the United Network for Organ Sharing and to be approved by Texas Medicaid. In that same year, surgeons at BUMC performed the first combined heart-kidney transplant in North Texas, the fifth in the world. In addition, the first “bridge-to-transplantation” procedure in the USA using the Abiomed ventricular assist device was performed. The first heart-lung heart “domino” procedure in Texas was a pioneering operation in a patient with terminal emphysema who received a heart and 2 lungs while another patient with cardiomyopathy received the emphysema patient's good heart. These operations were performed successfully in 1989. In 1990, Medicare approved BUMC's heart transplant program, the first program in North Texas to be approved. A left heart assist device (Thoratec) was implanted in 1999 as a bridge to transplant, and subsequently the DeBakey VAD was approved in 2002 under the direction of Dr. Dan Meyer. Dr. Crosby left the cardiac transplantation program in the late 1980s, and Dr. Steves Ring took it over from Dr. Alivizatos in 1996. Accompanying Dr. Ring from the University of Texas Southwestern Medical School were Drs. Dan Meyer, Michael Jessen, Michael Wait, and Michael DeMaio. Dr. Ring currently operates the heart, lung, and heart-lung transplant service at BUMC along with Dr. John Capehart. Other surgeons historically involved in the program are Drs. Ivan Crosby, Maruf Razzuk, H. H. Shah, Harold Urschel, Richard Wood, Tom Meyers, and Kimble Jett.
ANESTHESIA
Crucial to the development of thoracic and cardiac surgery was anesthesia. The foundation for solid physiological and clinical principles was laid by Dr. Donovan Campbell, who spent most of his time in the thoracic surgery arena. He used new anesthetic agents, developed endotracheal anesthesia devices, and created ingenious methods of managing tracheal discontinuity requiring multiple distal ventilating techniques. Having completed an engineering degree before entering medicine, he was well prepared for his subsequent work of improvising and creating new solutions to difficult thoracic surgery problems. He worked in both the laboratory and the operating room with thoracic surgeons constantly, spending night and day at the hospital improving the basis for clinical care.
In the early 1960s, most thoracic surgery was performed in the prone position on the Naclerio-Overholt table, so that multiple secretions could drain out and so that the patient could breathe without being paralyzed. One disadvantage was that if a cardiac arrest occurred in this position, the operation had to be terminated and the patient turned completely over in the supine position and resuscitated. Dr. Campbell circumvented this problem by bringing the double-lumen tube to America. In addition to pioneering new techniques, Dr. Campbell brought many constructive elements from Europe, not the least of which were 2 subsequent chiefs of anesthesia, Dr. Roy Simpson, who developed the biomedical engineering department and the anesthesia research laboratory; and Dr. Michael Ramsay, who advanced transplantation anesthesia and became the president of Baylor Research Institute.
In July 1959, a nonflammable, volatile, halogenated hydrocarbon was introduced as an anesthetic agent. Two properties that ensured its immediate popularity were its very powerful bronchodilator effect and its failure to excite bronchial and tracheal secretions. Further, it had almost no emetic action and was moderately pleasant to inhale. Thus, halothane diluted only with oxygen was utilized as an induction agent, and the results were remarkable. Patients with bronchospastic disease could be anesthetized and operated on with facility, and as a result of the absence of pulmonary secretions, the postoperative course was easier and shorter. Thoracic surgery was safer, the surgery was surer and quicker, cautery could be employed throughout the procedure, and blood loss was diminished.
In the early 1960s, Baylor established a recovery room and shortly thereafter an intensive care unit. Both were essential for an expanded thoracic surgical horizon and for the development of the relatively new field of cardiac surgery. Implicit in the planning and establishment of these postoperative units was the careful training of the nursing and administrative personnel, without which the units could not have operated.
In conjunction with the advent of cardiopulmonary bypass, a necessity for cardiac surgery, there arose 1) continuous arterial blood pressure monitoring; 2) continuous central venous pressure monitoring; 3) a pulmonary laboratory for almost instantaneous blood gas analyses; 4) very fast laboratory analyses of arterial blood for electrolytes; and 5) continuous electrocardiograms. These proved in later years to have been somewhat crude but moderately safe. Cardiac surgery was off to a start.
In 1970, the first double-lumen endotracheal tube designed specifically for pulmonary and esophageal surgery became available. An English physician studied the anatomy of both male and female adult cadavers of varying height and weight and produced left and right double-lumen tubes in 3 sizes, small, medium, and large. Together with intraarterial pressure monitoring, ready access to arterial blood gas analyses, an anesthetic agent that was nonflammable, and a potent bronchodilator that produced a minimum of secretions, intrathoracic surgery was revolutionized. Further, surgery for resection of lesions in both right and left lungs could be safely and efficiently carried out through a midline sternal incision.
Within 2 years, insertion and use of a pulmonary artery catheter became available for several of the operating rooms. Thus, accumulation of important information, heretofore possible only in a laboratory setting, could now be utilized in an operative setting. This dramatically increased the safety with which complicated thoracic surgical procedures could be done on high-risk patients.
Professor Roy Simpson of the London Hospital was appointed Baylor chief of anesthesia and professor of anesthesia at Southwestern Medical School in 1975. Shortly thereafter, he interviewed and hired Bill Paulson as director of biomedical engineering for BUMC. Bill Paulson tested and evaluated a number of sophisticated monitoring systems and chose one that could be used throughout the hospital's many buildings. The system chosen could show on a screen or screens arterial blood pressure, pulmonary artery pressure, central venous pressure, and a continuous electrocardiogram. When the weight and height of the patient were entered, the system could calculate cardiac output as well as total peripheral resistance. And all these values could be printed out. This information, essential to intelligent preoperative, operative, and postoperative management, vastly improved patient safety and care.
Dr. Michael Ramsay, current chief of anesthesiology at BUMC, is also the president of the Baylor Research Institute. He is a remarkable individual who not only is a world-class clinical anesthesiologist but also operates a superb research facility in collaboration with multiple physicians. He has devised multiple new techniques that significantly improve patient care and leads the anesthesia section with the motto, “Keep the patient first.”
EDUCATION
Thoracic surgery residency
The thoracic surgery residency was initiated immediately after World War II by Drs. Shaw and Paulson at BUMC. Among those trained were Drs. Milton Davis, Ben Mitchel, H. H. Shah, Cary Lambert, Peter Thiele, and Maruf Razzuk, all of whom were subsequent members of the staff at Baylor; Dr. Mitchel later served as chief (Figure (Figure77Figure 7). The residency training program subsequently was transferred to the University of Texas Southwestern Medical School, and the residents rotated to Parkland, BUMC, the Veterans Administration Hospital, and Children's Medical Center. In 1976, the American Board of Thoracic Surgery reduced the total number of surgeons training in thoracic surgery, and the number of thoracic residents in Dallas was reduced from 8 to 4, or 2 a year in a 2-year program. Because of the reduced number of residents, BUMC was used only as the elective part of the rotation. Dr. Steves Ring, who performs the heart and lung transplants at BUMC as well as the medical school, now leads this excellent program.
Figure 7
Dr. Ben Mitchel, chief of thoracic surgery from 1977 to 1986.
Drs. Shaw, Paulson, and Urschel have all been directors and examiners of the American Board of Thoracic Surgery. The Board of Thoracic Surgery was established as a subboard of the American Board of Surgery in 1948 after World War II. It remained that until 1971, when it became an independent board under the chairmanship of Donald Paulson.
Dr. Urschel was a member of the Residency Review Committee for Cardiothoracic Surgery and subsequently became chairman in 1994 for 2 years. This organization oversees the training of all 100 thoracic and cardiac surgery residency programs in the country. Dr. Urschel also sat on the Residency Review Committee for General Surgery and for Vascular Surgery. The Residency Review Committee is unique to the USA. No other country has such a group that evaluates and sets the standard for the training of residents.
Thoracic-cardiovascular fellowship
The first fellowship in thoracic and cardiovascular surgery was initiated in 1964 at BUMC by Drs. Urschel and Paulson. The first fellow was Dr. Andres Morales, a resident who decided to stay on another year with us. He wrote several scientific articles, including one on the implantation of the internal mammary artery into the posterior myocardium. Scientific writing was a prerequisite for subsequent fellows. Relationships were developed with the Massachusetts General Hospital, the Johns Hopkins Hospital, and the Toronto General Hospital, all of which sent residents for additional complementary training because of the extensive num-ber and variety of cases at BUMC. Drs. Razzuk and McNamarra were sent by Dr. Linton to Dr. Urschel as fellows from the Massachusetts General Hospital. Dr. Razzuk stayed for residency training and became a member of the staff. Dr. McNamarra became chairman of the Department of Surgery at the University of Hawaii in Honolulu. Dr. Robert Ginsberg, a fellow from the University of Toronto, introduced formal mediastinoscopy to Texas. He subsequently became chief of thoracic surgery at Memorial Sloan-Kettering Cancer Center in New York and then chairman of the department at the University of Toronto in Canada. Approximately 75 fellows have trained with the Shaw, Paulson, Urschel group and several others with the Davis, Mitchel, Adam, and Lambert group. Dr. Peter Alivizatos was a fellow in this group; he was a cofounder of the cardiopulmonary transplant program and subsequently led it to world-class status. The fellows not only provided improved patient care and contributed significantly to the writing of scientific papers, but also were important in bringing new knowledge from other major thoracic and cardiac centers of the world to BUMC.
Visiting professors
Dr. F. Griffith Pearson, chief of thoracic surgery at the University of Toronto, was a frequent visiting professor at BUMC and would often scrub on subglottic tracheal stenosis cases (Figure (Figure88Figure 8). Dr. Robert Ginsberg also served as a visiting professor multiple times. Other visiting professors included Drs. David Sabiston (Duke), Vincent Dor (Monaco Heart and Lung Center), Don Effler and Tom Rice (Cleveland Clinic), and Ronald Belsey.
Figure 8
Drs. Harold Urschel, Maruf Razzuk, Donovan Campbell, and F. Griffith Pearson performing a subglottic tracheal resection at BUMC.
RESEARCH
The need for many of the new operations that appeared in the 1950s and 1960s was recognized while caring for patients and then developed on calves, goats, sheep, and dogs in the laboratory. Dr. Campbell would put the animals to sleep at 4:00 AM, and the experimental procedures were conducted by Drs. Urschel and Razzuk until 7:30 AM when clinical surgery began. New management of pulmonary alveolar proteinosis with bronchopulmonary lavage, artificial tracheal prostheses from Silastic stents, and improved cardiac oxygenation with hydrogen peroxide were developed in this setting at BUMC.
The cardiovascular and thoracic surgical section at BUMC has had an extremely productive history of scientific presentations and publications since World War II. Originally, research was clinical, prominently in lung cancer and subsequently in cardiovascular as well as thoracic surgery.
More recently, “bench-to-bedside” capability has been added to clinical trials, and the cardiovascular-thoracic surgical service has taken the lead in many new developments, thanks to the efforts and environment created by the current chief of service, Dr. Richard E. Wood (Figure (Figure99Figure 9). He stimulated various members of the service to participate in clinical trials in their areas of interest.
Figure 9
Dr. Richard Wood, chief of thoracic surgery since 1999.
Dr. Baron Hamman has taken the lead in “beating-heart” surgery (off-pump coronary artery bypass grafting), transmyocardial laser revascularization of the ischemic heart, new proximal and distal anastomotic techniques for bypass grafts, and the use of the robot.
Dr. Robert Hebeler has been encouraged to study new types of stentless aortic valves as principal investigator of a clinical trial. He pioneered robotics in Texas as a major investigator in the national study of mitral valve replacement with the robot (Figure (Figure1010Figure 10), participated in the transmyocardial laser revascularization project, and is leading a study to evaluate cerebral malfunction with various types of cardiopulmonary perfusion.
Figure 10
Drs. Richard Wood (left) and Robert Hebeler using a robotic surgery system to perform minimally invasive closed-chest cardiac surgical procedures.
The largest series in the world of endoscopically harvested radial arteries for coronary artery bypass grafts has been accumulated by Dr. Carl Henry. Dr. Harry Kourlis is in the process of evaluating endovascular stents for thoracic thoracoabdominal aortic aneurysms, and Dr. Greg Matter participates in high-volume cardiac surgery study trials.
Dr. Edson Cheung established the Cheung Family Foundation to encourage visiting professorships at BUMC and provide for cardiovascular and thoracic surgical education.
The clinical adult cardiac database is being revitalized. It was originally established in Apollo after several years of hard work by Dr. Maurice Adam. This effort, pioneered at Baylor Hospital, represents one of the more important fundamentals for sound clinical research.
Dr. Thomas Meyers organized and conducted an outstanding course on cutting-edge lung cancer surgery, bringing experts from around the world to BUMC.
The cardiac and pulmonary transplant team, headed by Dr. Steves Ring, has outstanding clinical results and conducts appropriate research. Dr. Dan Meyer directs the left ventricular assist project, including the DeBakey VAD, a miniature assist device developed by engineers at the National Aeronautics and Space Administration. Dr. John Capehart has been an integral part of the cardiopulmonary transplant service since its origin in 1986.
Dr. Wood procured the first robot in Texas. He supported establishing the chair of cardiovascular and thoracic surgical research, education, and clinical excellence, held by Dr. Harold Urschel, and was pivotal in organizing cooperation with the Clinical Cardiovascular Research Center.
In the past year and a half, in large part because of the energy of a general surgical resident, Dr. Amit Patel, a surge in enthusiasm for clinical research has occurred. BUMC medical staff have given more than 30 presentations at regional, national, and international meetings based on cardiovascular and thoracic research; have published more than 20 scientific papers on topics such as cardiac trauma, leukocyte filtration with coronary artery bypass grafts and valves, Syncrus therapy of postoperative arrhythmias, and endoscopic vein and radial artery harvesting; and have given grand rounds at Harvard, Stanford, Cornell, Pittsburgh, and other major medical centers.
NATIONAL AND INTERNATIONAL RECOGNITION OF BUMC THORACIC AND
CARDIOVASCULAR SURGEONS
Dr. Robert Shaw was a founding director and examiner for the American Board of Thoracic Surgery. Dr. Donald L. Paulson was president of the American Association for Thoracic Surgery and chairman of the American Board of Thoracic Surgery. Dr. Harold Urschel was president of the Society of Thoracic Surgeons, the American College of Chest Physicians, and the International Academy of Chest Physicians. The 3 have written over 500 peer-reviewed scientific articles on cardiovascular and thoracic surgery. Dr. Urschel was editor of Atlas of Thoracic Surgery and textbooks on thoracic surgery and esophageal surgery.
Their partnership at Baylor treated the largest series in the USA of lung cancer patients over 20 years (>10,000) and operated on the largest number of patients with superior sulcus carcinoma, thoracic outlet syndrome, Paget-Schroetter syndrome, and Poland's syndrome. Further, they've done the largest number of bronchoplastic procedures, median sternotomies for pulmonary resections, resections of mucoid impaction of bronchi, intraoperative coronary artery balloon angioplasties, and coronary artery bypass grafts with carbon dioxide gas endarterectomy.
BUMC performs over 1500 open heart procedures each year—nearly twice as many as any other hospital in North Texas—with excellent outcomes.
Acknowledgments
The Cardiothoracic Surgery Section of Baylor University Medical Center wishes to thank Mrs. Rachel Montano for her dedication and commitment to the research and completion of this history.