The date is June 22, 1973. We are in Toronto, this is Gerald Rainer and I have the distinct privilege of interviewing Dr. Bill Bigelow. We've had a pleasant dinner to sort of re-hash the content of what he might say, but what he might say really is quite informal and is to bring to us some of the historical memories that he has that led him to play the vital role that he did play in the beginning of cardiac surgery. I'm going to ask Dr. Bigelow to start off by going back to the very beginning and recounting the things that prompted him to get in to the experimentation of the effects of hypothermia on the body, and especially the heart, and to take it from there, Dr. Bigelow.
WB: Dr. Rainer, I suppose most people are interested in what prompts someone to delve into an area of research or study that may be new and I don't think it was anything particularly dramatic; it just seemed to evolve and I would think that my interest in cold probably started as a resident in about 1940 before joining the army. I remember presenting a case of frostbite to Dr. W.E. Galley, who was Chairman of the Department of Surgery at that time and a very wonderful person, a very stimulating person. I had read the literature part of my case presentation on rounds and found that it was very little known in the English-speaking language and I brought this out on rounds. I said I was very disturbed that we as Canadians should know so little about frostbite. He called me over at coffee that morning and said, "Why don't you pursue this?" which I did, and it really didn't require much but a word from him was a stimulus. I reviewed the foreign literature and also found a marked limitation in the knowledge of the pathogenesis and treatment of frostbite. Dr. Galley further, when he realized that he'd kindled some interest in me, asked me to interview a man by the name of Craberg, who was in a Norwegian establishment here in Toronto during the war.|
Dr. Wilfred Bigelow
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WGR: Now, didn't your work then lead you to present a paper - what was it, in the late '40s - at the American Surgical that got other people to thinking that soft of caused some other seeds to land on prepared soil?
WB: Yes, I think that is a fair assessment from what I have learned from speaking to others subsequently. We studied the principle of hypothermia and I suppose that it is interesting to realize that, when I came back and looked up the literature, I was a bit dismayed to find that the current experimental work at that, up to that time, indicated that cooling an intact animal actually increased the oxygen consumption. I couldn't find an article that supported my theory although, in fact, the oxygen consumption did fall after the animal became stuporous and anesthetic from the cold. So we worked with this and found that if we totally controlled all the shivering and rigors in the muscle that we could, in fact, get a fairly straight-line relationship. And I suppose that was a contribution. It was encouraging to find that we could reduce the temperature, but we were frustrated to find that in all experimental animals that we worked on, there was a ventricular fibrillation or cardiac standstill which occurred in the adult animal around 20 degrees centigrade, which didn't give us as much time inside the heart as we had hoped. We had hoped to get lower temperatures. But, anyway, we were prompted to report, as you have mentioned, report our work as it stood at that time, cooling dogs to 20 degrees and opening the heart for 20 minutes, and we took a moving picture of the inside of the right atrium and the right ventricle, which I guess was probably unique. It was thrilling to see. As a matter of fact, we have lost that movie. I don't know where it is now. But several people, as you have mentioned, have told me that this seemed to stimulate their thinking and obviously it had fallen on rich soil, Lillehei, Henry Swan, and John Lewis. So that was thrilling to think that we had stimulated thought elsewhere.
WGR: What can you think of - what do you recall - was your first application of hypothermia to the clinical person? The first time that you opened the heart of a human being to do something and what were your thoughts and approach at the time?
WB: Well, I guess that some of the drama was removed because I couldn't (uh, we couldn't) come by a case of atrial septal defect, which was the obvious thing to start on, for awhile, and so we took some very poor risk patients that ordinarily we would not operate on and we cooled them and did mitral split on a patient in chronic failure in an orthopneic condition and, actually, I'm sure we seemed to get by with surgery in those that would perhaps have been a higher risk otherwise. So that when we came to cool the patient for open heart surgery, we had already been through the initial stages. I remember the first time we cooled a patient. I think there must have been 28 people in the operating room and there was a great big fan (blowing air) over two large blocks of ice to keep the operating room cool. And it was great! Great excitement! But that just evolved into doing atrial septal defects and, of course, John Lewis, to him goes the credit of doing the first open heart procedure. And we followed shortly afterwards, as every one else did. He broke the ice and he gave us full credit for having developed the concept and gave us credit for devising, or at least recommending, the technique of vena caval occlusion.
WGR: But, in spite of the fact that you weren't the first to do the clinical application of your concept clinically, it still must have been a tremendous thrill when you did your first atrial septal defect?
WB: Oh, I think so. I mean, there were so many things going on and we were in the microcirculation at the time and were developing the pacemaker at that same time and, whether we got credit for doing the first human case didn't seem to make much difference. It seemed to be more, to many more things on the horizon and life was so full of a number of wonderful things that…
WGR: At the time that you did your first clinical case, how much time did you judge that you had to do whatever you had to do inside the heart to close the defect?
WB: I think we were about…. I think we allowed about seven minutes. Actually the time that we assessed and the safe level of cooling that we assessed didn't change very much over the years.
WGR: Seven minutes.
WB: Um huh, and we thought the 28-29 degrees was safe and that never changed over the years.
WGR: Would you commonly reocclude for a few moments, restore circulation, and then go back for a final act?
WB: Dr. Rainer, we did everything in those days. We reoccluded; we kept it clamped off for too long, oh goodness.
WGR: What is the most time of occlusion and rest and go back that you can recall?
WB: Oh I don't recall really, I suppose maybe two or three times - I don't think, I can't think of any excessive number of reclampings. I'll never forget encountering a myxoma in the atrium a matter of a month or so after Crafoord had reported the first removal. I bumped into it doing a mitral, so I backed out and I thought we will cool him in four or five days and do it properly and do it under open heart technique and he died the next day because his tumor went down and occluded the valve. And, interesting enough about three months later, doing a routine mitral, I encountered another myxoma and I thought, "Well, we can't leave this fellow", so we got some cold saline and poured cold saline into his open chest for what seemed to be hours until he was cooled down to 30 degrees. I think the water was about two inches deep in the operating room, but we cooled him down, interrupted the circulation, took the myxoma out, and the fellow did fine. It was the second myxoma ever to be removed and the first one under hypothermia.
WGR: Fantastic!
WB: Reported in an article it sounds neat and tidy, but I tell you it was far from that in the operating room.
WGR: Were you in the left chest at that time?
WB: Uh huh.
WGR: And how did you reach across to close?
WB: I think we cut across the sternum.
WGR: Go across?
WB: Uh huh.
WGR: Very good. Now I have two final things to ask you to sum up. First, one has to do with your concept of where stand today in our clinical application to open heart surgery as you might have envisioned it, what - 20 years ago? And the second, what are your elaborations on your thoughts of tenacity that you mentioned to me earlier, which obviously must involve your philosophic concepts of research and pushing ahead in medicine?
WB: Umm, your first question was?
WGR: Had to do with your concept of where we stand today…
WB: You mean the overall picture?
WGR: As how you might have envisioned it 20 years ago. Have we gone ahead at the speed you would have guessed, more or less? Did you envision when you started your first open heart surgery clinically that we would be doing the things that we do today?
WB: Well, I did, but I didn't think it would be with a heart-lung pump. I was fearful of all the gadgets and pumping blood through tubes because we had studied the microcirculation and I was terribly impressed with the effect of trauma on the blood. Even squeezing or cold or any form of trauma. I thought at that time my microcirculatory studies discouraged the concept of being able to do what we can do with a bypass. But I really didn't think that we would (or we could) solve the hypothermia thing and I visualized being able to clamp off circulation for two hours. You can do it with hibernating animals - we soon found that out. And we also found out that a newborn or a premature human is almost identical with a hibernator. He has an unstable thermo-regulating mechanism. He is a poikolotherm really. He doesn't sludge as an adult does, and a hibernator doesn't sludge when you cool, and I thought "We have all the qualities in an infant or a premature that there is in a hibernator: therefore, if we can just reverse this endocrine process, we can re-establish what was here already." In other words, we weren't creating something new. So, I had great dreams of what we could do with hypothermia really. But that led us into…. Well, to finish your question, 20 years, yes I thought that we would be doing this 20 years hence but I thought it would be with hypothermia and not with the pump. And, in a search for the secret to safe deep hypothermia, we studied hibernation for about 15 years. We never learned the secret. We learned a lot about hibernation and about metabolism, but the hibernators still go down the holes every winter and their secret is still with them. It is a wonderful secret and they are just incredible animals; it is an amazing quality they have and they have a built-in alarm clock - if they cool too far they automatically arouse. It's amazing. And we talk about tenacity, I think that is a key quality in a researcher - to be able to stay at a subject long enough to get the most of it, but not to hang on for so long that you are wasting your time and the time of your staff. I hung on for too long on hibernation. We thought at one time we had the secret and I think we can all think of examples where we left a subject too soon. I think one of the spin-offs on hypothermia was the pacemaker, which we reported in 1951 as the first proof that you could stimulate a heart and produce expulsive beats. It might have been fun to develop that as a transistor.
WGR: What prompted you to think of that to begin with? The principle of the pacemaker for external stimulus?
WB: Well, just observing an exposed cold heart and cooling the animal with the heart exposed and observing it. And when it went into a standstill, giving a mechanical stimulus, we found that the heart responded with an expulsive beat. So, we thought that the problem in hypothermia and the inability to cool adult animals to lower temperatures was perhaps the neurogenic one that the pacemaker mechanism wasn't working, so we developed the pacemaker to see if we could overcome that. But the historic experiment when we had the pacemaker and cooled the animal to the point of standstill turned on the pacemaker and it only cooled another 2 degrees was a little disappointing.
WGR: Dr. Bigelow, I really can't express our appreciation adequately, I don't think, for simply being able to capture your thoughts in this fashion. I would ask you to cover any final thoughts that you might have just about the broad subject of cardiac surgery or medicine or philosophy of life or just what might turn you on.
WB: Well, Dr. Rainer, you are putting this question to me without any prior consideration as to an answer. I guess that I might have two thoughts off the top of my head. One is that in my association with research, I think the new idea is not as dramatic an episode as we often would like to make it. Historically, I think probably it's created into a more of a dramatic episode than it really was. And any work in hypothermia, of course, is built upon work that was done by a prior research team. We just built on what had already been known and techniques that had been tried - oxygen consumption studies, all these tests were worked out by other people. We made use of them, just fitted them together a little differently. So, it's really not all that dramatic and we probably don't get as much credit as we do. The other thing, I have used the word "we" in this little discussion we've had and it's certainly far from a one-man effort. Actually, there has been an interdisciplinary team right from the word "go" from 1947. And these men have done most of the work and they have come up with many of the ideas that we have explored, and you just heard of very often they act as a little bit of a catalyst and get far more credit for what you do than you should get. I can't think of any great philosophical thoughts at the moment other than that. I think probably we are very research-oriented in both exact sciences and in the biological sciences. I think that biological scientists try to behave like exact scientists and they like to make use of numbers and statistical significance. And that has always bothered me because I realized from the first that if you are dealing with dogs you have got about a twenty percent variation from one dog to another. The idea of getting a burette so that its correct to the third decimal point when you are using dogs with that degree of variation immediately impressed me that there is no way in which biological sciences can duplicate the exact science research. And when we start applying the same rules to both types of research, it's the cause for just as much misrepresentation of values as it is a cause of accuracy. I still think that there is a very great place for impressions and intuition in biological research. When you are dealing with such a nebula of variables, you can't sell it to the public without some statistical evidence - some evidence that conforms to the standards set down by the basic scientists.
WGR: Well, Dr. Bigelow, again thank you very much. It has been delightful and I am sure that it might be a great deal more inspiring than you might dare realize. Thank you.
WB: Thank you. Very interesting to talk to you.