Interviews With Certain Pioneers in Cardiovascular Surgery - W. Gerald Rainer, M.D.

Dr. Gerard Brom
 
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This is the 21st of April 1976, Denver, Colorado.  This is Gerald Rainer and I have the very pleasant opportunity to talk with Dr. Gerard Brom from Leiden, Netherlands.  Dr. Brom is passing through Denver for a day two visiting with Dr. Henry Swan and Dr. Sadler and me on his way to the American Association for Thoracic Surgery Meeting in Los Angeles.  He has spent the last two days with Dr. John Kirklin and his group in Birmingham.  I have asked Dr. Brom to simply reflect, in a most informal way, some of his thoughts and experiences in the early days of cardiac surgery in his area of the world.  I hope that in doing so he will give us the events of the period that led him to do some of the earliest cardiac surgery in Europe along with some of his distinguished colleagues.  Dr. Brom. 

Dr. Gerard Brom

  • Started cardiac surgery in Leiden, Netherlands 
  • Good insight into cardiac surgery before heart-lung bypass 
  • Fascinating description of personalities of surgeons in early days of cardiac surgery
GB: My interest in cardiac surgery came along 1) because at the clinic where I worked for general surgery, we did a rather good number of lung resections at that time.  And I thoughtthat doing lung resections we should get interested, too, in the field of cardiac surgery even if we didn't know anything about it, if it was worthwhile.  So, I still remember the very day that I really started to be interested - that was in September '47 in London.  There was a meeting there, I believe, for internal medicine. Dr. Blalock was invited to give a speech about "blue babies" and the results of his operation for that.  During his speech, some of the patients operated upon at Guys Hospital were shown.  I was present at that meeting with a man who was doing internal medicine in our hospital, Dr. Vanevenhauser, and that very evening we walked through Regent Park after dinner and we said, "We have to start cardiac surgery in our country".  But I said, "I don’t believe that it is all right to do this without any previous training."  So, the only way to get training was to go to Crafoord in Sweden, who was the only one at that moment in Europe who really did cardiac surgery, because it was Brock who started to do it after the visit of Blalock.  So next day, I spoke with Clarence Crafoord and he was willing to accept me, in January of the next year, as an assistant in his clinic.  I stayed with him for six months and the cardiac surgery that I saw were coarctations, (the first coarctation that I saw was the ninth of Crafoord) and Blalocks and ductuses. That was the only thing done.  When I left Crafoord to go home, I took with me catheters to do heart catheterizations because we didn't have that in Holland.  I took with me syringes where we could do angiograms through the catheters and that is how we started in Utrecht in our hospital with doing catheterizations.  I did it myself because internal medicine man didn't dare to do it.  I did the angios myself and that was in a very special wall, I have to tell you, because we did always with two.  One had a board of wood in front of his chest, holding the syringe, and the other one was hanging around him and holding the syringe and pressing together and pressing the syringe as soon as possible.  It always gave you a bit of dyspnea if you were the one who held the syringe against his chest.   And in that way we did our first investigations.  It was quite interesting but also interesting was the direction of the hospital, which thought it was experimental work on human beings.  So I got an official letter (we call it a letter, what you have to accept) that it was forever forbidden to do heart catheterizations or angiocardiograms in their hospital.  This letter was never withdrawn, and you should know now that in this hospital is the largest cardiac center in our country.  So, I always tell them that they are doing something that is absolutely forbidden by the administration thirty years ago.  That is really some of the things that I should tell about how we started in our country.  At the same time, I started to work with Jongbloed who had developed a very nice heart-lung machine.  The idea about it was a film, a blood film, but was circulating on the surface of the spiral (what was going around) and we did dogs experimentally with that.  I still believe that it is a very good machine.  It never had any clinical results, but that had nothing to do with the development itself. 

WGR: Dr. Brom, once you had that developed and you got on into doing first closed cardiac procedures, what led you to doing open heart procedures, say, with hypothermia?

GB: We started shortly with coarctations and Blalocks and those operations, but then we got the message that the work of Bigelow, Lewis and Swan.  I knew Bigelow and Swan already from some meetings and they became friends of mine.  I knew of all of their work and, a few months after Swan did his first operation, we did the first hypothermia in our country in the same way with a bathtub and ice around it and things like that. 

WGR: Was this an atrial septal defect?

GB: Atrial septal defect. 

WGR: How old was the patient, do you recall?

GB: I don't recall.

WGR: Did he survive?

GB: Yes, the patient survived and we did.  I must say that our results of atrial septal defects with hypothermia were extremely good.

WGR: How did you feel when you did your first one?  This must have been a very exciting moment indeed.

GB: It was very, very exciting because you had a feeling that you were doing something that was experimental, even if you knew that in the United States they had good success with it.  There you were standing alone with, let's say, all your critics of the whole country blowing on your neck and, being rather younger at that time, I must say that I felt very, very nervous.

WGR: When you did your first few straightforward, you know "straightforward", atrial septal defects, did you ever wonder just before you opened the right atrial wall that you might find something different?

GB: I always palpated.

WGR: Did you ever palpate and find something different and then close, if you felt it was a lesion that you had not anticipated?

GB: At that time, I still remember (perhaps it was the fifth or tenth patient) that we found a primum defect.  And I opened it up, but I couldn't, I tried to close it and the patient died; that I remember.  But, after that, we knew how it felt and we never reopened one who we felt was a primum defect.  But we didn't know how to differentiate, at that time, between primum and secundum defects.

WGR: Don't you think that during this particular time period, that innovativeness came along out of necessity?  Many times might you find an anomalous pulmonary vein that you could figure out someway to handle, or treat, so that you really had to do something on the spot that you may not have seen or heard of being done before?

GB: Yes, but if you palpated carefully, as we always did, we took time off before we started to do the operation.  Mostly that meant that we went out of the operating room, had a cup of coffee, discussed it over, and then said what we were going to do.  We just said, "Now, before we open that heart, we must absolutely know how to handle it".  And I still remember the one case where we found that there was a big valve in front of the inferior caval vein and we said, "When we close this defect, we have the inferior caval vein down on the left side", not realizing that the valve had nothing to do with the ASD itself as we know now.  And then we decided that we should go around the wall of the left auricle, as was described later on by Lewis.  I believe Lewis did it before us, but the description came a few weeks or months after we did it, so we came to the same conclusion as Lewis did, to take the wall around it, and that cured the patient.  But it took us about an hour of discussion with coffee.

WGR: Just before we began the formal part of this interview, you were telling me some of the personalities and the driving forces involved.  Would you feel comfortable about tell us, and by "us" I mean, the future, what did you see in the people who were pushing ahead in this era that kept them going?

GB: Now, first of all, I think that there were two types of people.  You had the rather scientific type, a man like Clarence Crafoord, who absolutely was for me a genius in grasping very good ideas, like heparin for instance.  He grasped it.  The moment Crafoord found it, he said, "There is something in it good that we can use".  Crafoord had ideas.  Now, I must say, that Crafoord, as a technician was not such a brilliant surgeon.  If I say so, it's not anything against Crafoord as a personality, but he was a driving force and he drove his younger people to the extremes to find something new that he had really the idea of.  Lets say, the Bjork machine, which later became known as the Kay-Cross extracorporeal machinery oxygenator, but in reality it was developed by Bjork after an idea of Crafoord.  And then, because that didn't give enough oxygenation because the blood level was too low, the only thing that Kay-Cross changed in the whole machine was to bring the blood level higher; therefore, he drove Senning to develop the Senning machine with the drums, who had a very nice oxygenator.  So, I think you have two different types.  And then you have the type of man who just grasped the ideas, had a kind of feeling for technology, and developed techniques themselves, you see, people like Swan.  And, let's say, Potts, not that I don't believe Potts had also very good ideas, but he was technically the man who did it.  And the same with Bailey, for instance, a technical man.  And then another thing was, I think, that the whole group of people who started at that time were young. They were nearly all of the same age.  The other group was about 10 years older.  But, the main group was between 30 and 35 years of age, all of them. 

WGR: Did you sense in that group a compelling desire to be "number 1" or first about other things that they did besides their surgery?

GB: I must say that if you look at a "hypothermia group", as I call them, that’s the one - Swan, Bigelow, and Senning - they were also competing in a quite different field, and that was "dancing".  They, all three, and I want to include myself, too, but I am not in the same class of dancer as the other ones, but I enjoy dancing, too, but there was really a high competition between them.  Even so, as I just told you the story that Henry Swan, after one of his accidents with a plane crash, came into the nightclub in Brussels where Ake Senning was just giving a show of how to dance, and he looked around, and he was just out of the plaster cast, and he picked up a girl and he started to compete with Senning in the dancing.  The end result was an edema that his leg was about three sizes too much, three times bigger, and I must say, by far, Senning was the best.  Swan was a good one, then Bigelow, and then we came. 

WGR: This was soft of a reflection in their personality in everything they did, wasn't it?

GB: Yes.

WGR: Dr. Brom, you mentioned the use of the bathtub in the hypothermia in the closure of atrial septal defects.  Before you got into using extracorporeal circulation, did you attempt more complicated repairs such as ventricular septal defects using hypothermia and inflow occlusion?

GB: No, never.  We never did.  Besides atrial septal defects, we did a few pulmonary stenosis, but I must say that pulmonary stenosis, when you cooled them down, we got more ventricular fibrillation. So, we rather very early went to inflow occlusion and pulmonary valvulotomy at normal temp.  A method that we still use up to this very day.

WGR: Is that right?

GB: We still do it without extracorporeal circulation.

WGR: So, if you had a patient with straightforward isolated pulmonary valvular stenosis, you would still use inflow occlusion and normothermia?

GB: Yes, I think that is a marvelous operation.

WGR: What is your usual duration of occlusion to do pulmonic valvulotomy?

GB: One and half and two minutes.  It is very easy to do.  And I was very pleased that Castaneda in Boston does it, too, still.  I was amazed to see it even.

WGR: Well, sir, we really appreciate your being willing to talk with us.  I personally think that this is absolutely superb because so many of us did not ever get the personal grasp of the development of surgery during this era, and it is only people such as you that could feel in such a way that is so hard to describe.

GB: There is one thing that I really appreciate from that period, is that during the four years that I was working at the hospital in Utrecht only, all the catheterizations, all the cineangiograms, were made by us, by the surgeons, my friend and me.  And because the bad internal medicine man didn't dare to do it, so I still have the feeling that if I see catheterizations done, I say, "Now, if you turn the catheter that direction or that direction, you will get there".

WGR: That gives you also a broader perspective of things, doesn't it?  Do you recall the contrast medium that you used in those days?  Was it Diatrast or Urokon?  At least, that's what we call them?

GB: Diatrast.  I believe it was Diatrast.

WGR: Did you every recall any problems with the contrast agents then?  Did you have more fibrillation?  Did you have any problems that you could ascribe to the agent?

GB: No, we have lost one patient on heart catheterization; I still remember that child.  He was a very severe Fallot and I was so proud that I was in the pulmonary artery that I kept the catheter very long in the pulmonary artery and took pressure readings and oxygen saturation.  And, the oxygen saturation got lower and lower and we lost the patient by blocking of the pulmonary artery.  That is one of the experiences that I keep in my life-long memory from; it shouldn't be done; but I am sorry that is what I did.

WGR: That is another aspect that you can appreciate that the surgeons nowadays just have no contact with and cannot appreciate.  I must have been one of the last surgeons to do some heart catheterizations myself.  You know, coming along as late as I did, we still had a few that did this before it was commonplace for the cardiologist.