Biographical Sketch: Owen H. Wangensteen, M.D.

Professor Emeritus, University of Minnesota Medical School, Minneapolis, Minnesota.

A.B., M.B., M.D., Fellow, Ph. D. in Surgery, University of Minnesota; L.L.D., Buffalo; Honorary Doctor of Science, University of Chicago, Saint Olaf College, Temple University, Hamline; Honorary Doctor, University of Paris (Sorbonne). Intern, Resident Surgeon, University Instructor and Associate Professor, University Hospital, Minnesota. Assistant at deQuervains' Surgery Clinic, Berne. Switzerland. Associate Professor, Professor, Distinguished Service Professor, Regents' Professor and Emeritus Professor of Surgery, University of Minnesota. Director of the Department of Surgery, University Hospital. Minnesota, June 1930 to June 30, 1967. Assistant to Leon Asher, Physiological Institute, Switzerland.

Grants from U.S. Public Health Service. Erstwhile member, Surgery Section, Heart Council, Research Faculties Council, National Institutes of Health. Recipient of Gross Award, Scott Award, Alvarenza prize from Philadelphia College of Physicians, Passano Award.

Honorary Member, Hellenic Surgical Association, Norwegian Academy of Science, Royal College of Surgeons of England and of Edinburgh, and German and French Surgical Societies.

Award from American Cancer Society and Lannelongue Prize of the French Academy of Surgery.

Fellow, American College of Surgeons and Member American Surgical Associa tion and National Academy of Science.

STATEMENT OF DR. OWEN H. WANGENSTEEN, PROFESSOR EMERITUS OF THE UNIVERSITY OF MINNESOTA MEDICAL SCHOOL, MINNEAPOLIS, MINN.

Dr. WANGENSTEEN. Senator Mondale, Senator Ribicoff, Senator Mundt, ladies and gentlemen:

It is a privilege to be here and to have heard the testimony as well as the evidence which Dr. Barnard presented. There is a difference between testimony and evidence as my distinguished colleague to my left indicated. As Senator Mondale has just said, the field has been illumined a bit by some of my other colleagues, notably C. W. Lillehei who is majorally responsible for making intracardiac surgery possible. Without intracardiac surgery we would not today be on the threshold of heart transplantation.

At the beginning let me make it clear-I am neither a cardiac surgeon nor a transplantation surgeon. My role has been essentially that of a horticulturist, providing the soil, the water, and the sunshine of encouragement. As Senator Mundt has just said, the effort has given many pleasure, including myself.

Now, when Dr. Barnard left Minnesota, he needed a little help, and through the largesse of our good Uncle Sam, and committees operating under your direction, at the NIH it was posible to send him home with $10,000. It was really you gentlemen who gave his work wings. And I do not think so much has ever been accomplished with so little in the history of medicine in modern times. I think, therefore, that you should take some pleasure and satisfaction in this yourselves.

Now, the real question here is the one that has been posed by you— is there a need for such a Federal Commission. The existing broad disparity of views, suggested by people from many walks of life indicates a need for stock-taking and clarification of present guidelines. But let me remind you whereas we have FDA, Federal Drug Admin

istration Act, there are more than 300,000 doctors in the United States who can write prescriptions. At the rate of new medicines becoming available, obviously some type of supervision there is in order.

However, there probably are not above 20 units in our country today where there is expertise in heart surgery, and also interest, knowledge, and available support for research relating to tissue transplantation.

In a few years, as this discussion has suggested, I am certain a large number of medical centers can gear themselves to do thisas has occurred in the field of intracardiac surgery. In the beginning there were just a few such centers, but today, as Dr. Barnard has been at pains to point out, there are many.

Now, my chief objections to a committee or a commission with broad responsibilities would parallel those essentially emphasized by Dr. Barnard. But I would add that in our university and medical school centers there are today, gentlemen, committees functioning under your direction and the NIH. Those of us privileged to have moneys from you for support of our research, involving patients, have to defend such research before a peer judgment committee routinely. Any and all proposed innovative procedures, jeopardizing the health or the welfare of the patient, are always subjected to careful and rigid scrutiny.

Now, Dr. Visscher, my colleague, a regents' professor of physiology at the University of Minnesota and chairman of the Council of the Federation of American Scientists, transmitted to you, I believe recently, Senator Mondale, a letter with a recommendation, which said that the rules now operating under your direction and NIH are satisfactory and adequate to cover the situation.

Senator MONDALE. May I interrupt there. I do have that lettter. I do not think I have submitted it to the committee. And I think we should include it following Dr. Wagensteen's statement, because he does make a very fine argument about the influence of what he calls peer judgment, which is a concept that I think has validity.

Senator RIBICOFF. Without objection that will go into the report. following the testimony.

Dr. WAGENSTEEN. Dr. Visscher concluded, expressing the opinion for a very large group of scientists, that the prevailing directives from NIH are adequate to assess and to determine the wisdom, the propriety, the approval or rejection, of any or all therapeutic procedures regarding patients.

Now, you have had within the last few days, from the medical board of the National Academy of Science, through the chairmanship of Walsh McDermott of Cornell University, a similar directive expressing the same attitude of mind, with only this additional suggestion that they recommend a central registry for heart transplantation cases.

We do know this device exists in the kidney transplant area, and I would take it for granted that a means to share information would come immediately into being for heart transplantation too.

My attitude in running a rather large department of surgery over a number of years, in controversial matters has been to take a retrospective rather than too intensive a prospective view.

When you look at things in retrospect, all emotionalism disappears. When you look at the same items in prospect, there oftentimes are

frenzied, frantic, sometimes even a maniacal pitch of reactions. I could cite impressive examples.

A line from "The Courtship of Miles Standish," I think has significance for this discussion. Said Longfellow:

When the heart is so full of emotion it overflows its secret spilt on the ground like water, can never be gathered together.

This admonition has a pertinent lesson for us in too intensive prospective discussion of matters.

Why the the furor over heart transplantation? I am certain everyone in this room has asked himself this question. No one has come up with a satisfying answer.

But if you look into your Bible, you will find that the liver and the kidney receive scant mention. It takes four and a half pages in Crudden's Concordance to list the citations to the heart.

In other words, from antiquity the heart has been associated with the emotion of affection, which we equate with sympathy and sentimental responses. And as you have just said, Senator Ribicoff, we lose some 729,000 patients of heart disease, a larger toll of patients from disease of this organ than from any other. This is probably the primary reason for the furor over heart transplantation.

Surgery has not many significant innovations to cite over these many years. What are its real contributions?

First, hemostasis. When Jean Petit in 1718 invented the tourniquet major amputations could be undertaken. Centuries intervened. We finally got to anesthesia in 1846. There were people in this country, and theologians in Great Britain, debating the morality of giving an anesthetic for a woman to have her child-James Simpson of Edinburgh knew his Bible too, and cited the item from Genesis, where the "Lord cast a deep sleep over Adam" to create Eve.

Then came antisepsis. But the virtues of antisepsis and asepsis too were debated. The nestor of American surgery, Samuel D. Gross, who sat beside Lord Lister when he came to this country in 1876, said that earth and fresh soil poured upon a wound were as important and use

ful as carbolic acid.

I cite these things, gentlemen, only to indicate that the prospective discussions often are very confusing.

Perhaps the most instructive episode is the one referred to by Dr. Barnard Semmelweis, we all know that tragic story. It delayed the coming of antiseptic surgery for 20 years.

When my colleagues Dr. Lillehei, Varco, and others began intracardiac surgery-palliative cardiac surgery was then the order of the day. The surgeons approached the heart in a stealthy way. They first closed wounds of the heart that caused effusions into the pericardium. Then came operations for constrictive pericarditis to liberate the orange-like peel which imprisoned the heart, to free it up so it could function. Then came the operations of Robert Gross of Boston, for such congenital deformities as patent ductus arteriosus and coarctation of the aorta. Then the blue baby operation of Dr. Blalock. It was over this operation that great opposition to intracardiac surgery came about. The keenest exponents of heart surgery of that day said "Dr. Lillehei, your operation is too formidable; we are not ready for it, we must postpone it." Dr. Lillehei very patiently said, "Gentlemen, your operation is palliative. Mine is corrective. Give us a few years and we will equate the disparity."

Last year Dr. Norman Shumway was able to report 81 successive successful intracardiac operations without a death. So what Dr. Barnard has been saying about the progress which will come with development of this field will reduplicate the open heart story. Heart transplantation is a more difficult problem than that of intracardiac surgery-but its germination and growth will certainly duplicate this story exactly. To be sure expensive in the beginning, difficult, and accompanied by some mortality, but surgeons learn through their experience. The time will come perhaps when these operations can be done with a risk approximating that of large intracardiac operations with low and acceptable mortalities.

I do believe we need to be patient, and a bit tolerant over all this. What is the present status of tissue transplantation? I am certain with my successor, Dr. Najarian having been here, you have perhaps been alerted to all the promising possibilities.

But just let me review the beginnings briefly-as recently as 1932, Dr. Earle Padgett, of the University of Kansas showed for the first time that tissue could be transferred only between identical twins, not between others. This has been confirmed of course in the kidney experience. There has been no mortality in kidney transplantation when kidneys are transferred from an identical twin to the other, showing the problem is not a technical one; it is a rejection phenomenon. And eventually this also will be solved.

As you know, Dr. Thomas Starzl at the University of Colorado has had six patients with liver transplants for either extensive cancer in the liver or for congenital atresia of the bile ducts-when the bile ducts do not fuse; in consequence the children are jaundiced. Some of Starzl's patients are alive at 6 months. As Dr. Barnard said, this is a more difficult operation than transplantation of the heart. But the problem of tissue rejection is the same. And empirically biologists and surgeons are learning how to cope with this.

I believe if we are a bit patient, that some of the questions which you are asking yourselves today will be resolved.

In the beginning the mortality of kidney transplantation was great. Many cases were done other than identical twins without long-time survivors in the beginning. But the same Dr. Tom Starzl whom I have mentioned, of his last 20 cases of kidney transplantation, 19 were still alive at 3 months. That is progress.

In the overall picture of groups doing kidney transplantation, there is probably today a mortality in the first 3 months of about 20 percent. Surgeons are not all Tom Starzls, nor Christiaan Barnards, but a representative of our profession.

So today in kidney transplantation about 20 percent are lost in the first 3 months. At 1 year 50 percent are alive. After 5 years distinctly a lesser number.

It is infection that takes this toll, but we will learn how to deal with it.

My associates, Bill Kelly and Richard Lillehei, transplanted both the kidney and pancreas successfully for an individual at the end of her rope with diabetes completely out of control, and with a renal failure, too. That patient survived 4 months. This is not long ago. In the intervening months it has become perfectly obvious if my associates had not been so anxious to combat the renal rejection phenomenon-the pancreatic rejection phenomenon, the patient might still be alive.

None of us are omniscience; we have to have these experiences to appreciate their significance.

Now, as Dr. Barnard-and as you said, Senator Ribicoff, there are not five but six heart transplants that have been done. Three of those were technical failures-the patient died either on the operating table or in the immediate convalescence. We perhaps could say that those operations were not carefully selected. And not all surgeons are a Christiaan Barnard or a Norman Shumway whose patients did not die of a surgical complication of the heart transplant operation.

So the picture is not as bad as it looks. If there are more patients who come through without a single surgical complication, there will be more surviving patients, like Dr. Blaiberg.

Now, let us look back, Senator Mondale, as I suggested to you in my letter of January 24. I want to allude to a few historical items now. Let me mention smallpox, and how the theologians thundered against this practice.

In Boston, for instance, Zabdiel Boylston was threatened with hanging because he was practicing innoculation in 1721. Alexander Monro in Edinburgh inveighed against smallpox inoculation and begged King George III to set the practice aside by parliamentary action. We know about anesthesia, and those who inveighed against it. This is the centenary of the publication of Wunderlich's marvelous text on thermometry. Yet there are those who said it was unnecessary, that it was an extraordinary expense. Hypodermic needles similarly were objected to. Look how wonderful an aid they are to the doctor today.

In the Massachusetts General Hospital, a very distinguished hospital in Boston, at the turn of the century, Harvey Cushing and George and Crile were proposing to measure blood pressure during surgical operations. A committee-a commission was appointed to adjudicate the suggestion. They came up with a negative proposal, because they could not see any utility in the procedure. I would infer that Harvey Cushing went on and measured the blood pressure during operation anyway. Dr. Barnard outlined very nicely the problem in Vienna over Sennelweis.

The Norwegian Parliament in 1872 was on the verge of invoking legislation to prevent marriage of children of parents afflicted with leprosy. Gerhard Armauer Hansen, a forebear of mine, had studied the situation in Norway, and had observed spontaneous isolated cases of leprosy; by a very narrow margin of votes the proposal in the Norwegian Parliament was defeated. Two years later Hansen discovered the leprosy bacillus, and the contagion of the disease was quite clear, and the issue has never been raised again.

Senator Lister Hill at luncheon today alluded to the skill of his namesake, Joseph Lister, a great benefactor of mankind; I need not review that story. Senator Hill undoubtedly has told it within the hearing of most of you.

But let me also say that a very famous French surgeon, Nélaton, in 1863-64, showed that in his hospital he could do elective, major elective surgery with a very low mortalities: 3 percent in 1863; 7 percent in 1864, with the use of alcohol instead of carbolic acid as a local wound dressing. This was 4 or 5 years before Lord Lister. And what happened? The French Academy of Surgery appointed a commission to adjudicate this. What did the Commission vote? Against it. So the