FEATURE

he Department of Surgery at the Uni-

Owen Wangensteen versity of is best known served as chair of the for the development of open- Department of Surgery T at the University of surgery, the invention of the pacemaker Minnesota for 37 years, and the emergence of Minnesota’s thriving making it a leader in surgical research and medical device industry known as Medi- facilitating some of the cal Alley. Today, these remarkable events most significant medical triumphs of the 20th are celebrated at the National Museum of century. PHOTO COURTESYPHOTO MINNESOTA OF UNIVERSITY THE American History in Washington D.C. While leading Minnesota figures in —F. John Lewis, C. Walton Lillehei and Earl Bakken, to name a few— have been honored, much of the credit is also attributed to the singular leadership of department chair Owen Harding Wan- gensteen, who served as the department’s charismatic leader from 1930 to 1967.1 Fostering an atmosphere that emphasized the need for surgical science, he encour- aged surgeons to develop active research agendas in the laboratory. The focus on surgical research and its integration into medical education yielded many impor- tant contributions to mid-century surgery beyond cardiology’s impressive results. Wangensteen presided over an active research program that included the devel- opment of nasogastric suction to manage the surgical complications of bowel ob- struction and Henry Buchwald’s work on cholesterol metabolism and development of bariatric surgery. Moreover, during the Wangensteen era, the stage was set for the pioneering organ transplant work that followed under John Najarian’s tenure as chair during the 1970s. Wangensteen also supported the work of surgeons such as William Bernstein and Stanley Goldberg, Beyond cardiac surgery Owen H. Wangensteen and the ’s contributions to mid-century surgical science

BY DAVID KOROSTYSHEVSKY

22 | MINNESOTA MEDICINE | JANUARY/FEBRUARY 2018 FEATURE who played a central role in the transfor- Meanwhile, Wangensteen had im- of pain for the patient. To solve the prob- mation of proctology from a neglected pressed powerful medical men such as lem, Wangensteen devised a simple device corner of general practice into colon and university regent William J. Mayo. The that applied a slight vacuum delivered to rectal surgery, a formal specialization dean of the medical school, Elias Potter the site by a nasogastric tube. His patients within general surgery. Lyon, and the interim leadership commit- improved immediately and the mortality Wangensteen’s rise to prominence did tee of the Department of Surgery decided associated with bowel obstruction dra- not follow an obvious trajectory. As an to offer Wangensteen the post. But first, matically decreased. Thus, the so-called adolescent, he never intended to be a phy- Wangensteen suction device sician, let alone a surgeon. He originally was born. The device, for which wanted to follow in his father’s footsteps Wangensteen won the presti- by becoming a farmer. With his father’s gious Samuel D. Gross Prize in encouragement, however, he finished col- 1935, established him not only lege and entered medical school, where he as an effective administrative quickly acquired an intense interest in sur- leader, but as a notable surgeon- gery. Even though Wangensteen acknowl- scientist.5 edged that he was not the best student The fame of Wangensteen when he matriculated, he graduated at suction grew during World War the top of his medical class.2 Wangensteen II. Intestinal injuries, which re- interned at the University’s Elliot Hospital, quired abdominal surgery, were completed a residency at the Mayo Clinic common on the battlefield. GIs and earned a doctorate from the Univer- with these injuries recovered sity of Minnesota, but then turned down in special wards, which were a lucrative opportunity in private practice, known as Wangensteen Alleys choosing instead the much lower salary of for the rows of devices standing a University of Minnesota research profes- next to the beds. An article on sor. This thoroughly Minnesotan upbring- the cover of a wartime issue of ing and education would become a source Minnesota Morning Tribune’s of local pride for his mentors, colleagues Sunday Magazine, complete and students. with a comic-book drawing The beginning of Wangensteen’s medi- of Wangensteen inventing the cal career took place at a time of turbulent device, celebrated its life-saving institutional change at the medical school they sent him to Switzerland and Ger- contributions to wartime medicine.6 His that followed the publication of Abra- many, countries whose models of scientific associate and friend, physiologist Maurice ham Flexner’s survey of North American research physicians in the Visscher, estimated that by 1944, naso- medical education in 1910. While Flexner esteemed, for a year (1927-1928) to finish gastric suction “had saved some 100,000 had found the medical school’s scientific his training. There he acquired a passion lives.”7 By the 1970s, the device was still facilities to be “[e]xcellent, exceedingly at- for laboratory research and the applica- so well-known that it was mentioned in tractive, and well organized,” he criticized tion of historical perspectives to current an episode of popular television show the school’s small clinical facilities and problems. M*A*S*H.8 dearth of full-time instructors.3 Like the Soon after he returned, Wangensteen Wangensteen’s early research coin- rest of the medical school, the Department assumed the chair of the department, cided with a broader shift in the medical of Surgery became embroiled in a lengthy became the hospital’s surgeon-in-chief, school curriculum. From 1913 to 1936, and contentious transition from part-time and immediately dedicated himself to an Dean Lyon worked hard to implement instruction by community practitioners to active research agenda. In the early 1930s, the recommendations of Flexner’s report. a full-time faculty. At the same time, the abdominal surgery was still difficult and He sought to integrate practical medical 1925 departure of Arthur Strachauer, who risky. Wangensteen turned his attention to education with laboratory research by retired to focus on private practice, left basic research on the problems of bowel promoting graduate degrees in clinical the department chair vacant. The search obstruction, which continued to have a areas. This atmosphere shaped Wangen- committee immediately encountered diffi- high mortality rate. His research revealed steen’s vision of training surgeon scientists culty in attracting suitable candidates. One that what made recovery from bowel ob- to become scholars as well as clinicians. contender, Boston-trained surgeon Francis struction difficult was the buildup of gas While Wangensteen understood that the Newton, remarked, “Well, there isn’t any- and fluid pressure near the wound, which “extra hurdle” of having to do “research thing here, nor will there ever be.”4 impeded healing and caused a great deal and qualify for a graduate degree” was

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“frequently resented by fellows” in most could come up with ideas… tion of the American Board medical fields, he believed that the student and generally he would tell of Proctology in 1935, Fansler often learned in the process that profes- you to pursue them.” Buch- and J.K. Anderson established sional satisfaction came with the “pursuit wald turned down an invita- a one-day training course in of knowledge to advance his chosen disci- tion to join Wangensteen’s proctology at the University of pline through the agency of research.”9 gastrointestinal physiology Minnesota. Finishing a precep- These values inspired Wangensteen to lab; he was interested in- torship under Fansler, William require most surgical residents to spend stead in researching “cho- Bernstein entered the univer- a year or two in the research labs as part lesterol metabolism” and its sity community and became of their training. Many of them, such as relationship to atherosclero- a friend of Wangensteen. Suc- the now-famous cardiac surgeons, earned sis and heart attacks, which ceeding Fansler as director of PhD’s along the way. Wangensteen’s fa- Wangensteen supported proctology at the department, vorite research field was physiology. In with internal funding until Bernstein established a formal addition to supporting research within the the laboratory secured ex- residency program in proctol- department, he often assigned residents to ternal grants.12 ogy at the University of Minne- work with Maurice Visscher, who joined This research directly sota in the early 1950s.14 the Department of Physiology in 1936. led to the development of Stanley Goldberg, who, like While this combination of clinical training metabolic surgery. Buch- Buchwald, completed a resi- with laboratory research by full-time fac- wald and his team began by dency in the 1960s, succeeded ulty is familiar today, it was a new idea in determining which part of Bernstein as chief of a newly the 1930s. At the time, only the University the gastrointestinal tract was renamed Division of Colon and of Minnesota and Johns Hopkins Univer- responsible for cholesterol Rectal Surgery in 1972. He has sity, whose system inspired Wangensteen, absorption, which made fond memories of Wangen- trained surgeons this way.10 the first gastric bypass operation possible. steen’s influence on his decision to become Wangensteen elevated this vision of sci- Nominated by Wangensteen for this work, a colon and rectal specialist. “It was really entific surgery to the national level. Unlike Buchwald became the second Minnesota Dr. Wangensteen who had the vision,” re- young researchers in biomedical sciences, surgeon to earn the Gross Prize. More im- calls Goldberg, that proctologists “should the residents who trained in Wangensteen’s portantly, early gastric bypass operations be completely trained as a general sur- program during the 1930s did not have to manage cholesterol led to the surgical geon.” In his first year of residency, he met a venue in which to present the results management of obesity and the develop- with Wangensteen for career advice and of their laboratory research. It was then ment of bariatric surgery. discussed his interest in proctology. “So, customary for the American College of Buchwald was also active in biomedical Dr. Wangensteen looked me in the eye,” Surgeons to accept papers by younger sur- engineering research. An active collabora- Goldberg remembers, and said, “I want geons only if they were coauthored with tion between surgeons and engineers led you to change everything.” He “literally an older, established colleague, a practice to the invention of an implantable drug outlined my life for me in five minutes.”15 that Wangensteen despised. Wangensteen pump in 1969. While implantable drug David Rothenberger, who trained under convinced the College in 1940 to establish pumps never became a useful therapeutic Goldberg and would serve as department a forum for young investigators. It became medical device, they inspired the devel- chair from 2013 to 2017, wrote that under a premier site for surgical researchers, opment of infusion portals, implantable Goldberg’s leadership, the practice of colon especially residents, to present their work devices that simplify the delivery of daily and rectal surgery in Minnesota “grew to to the profession. In 1993, the College intravenous medication.13 become the largest such specialty group in changed its original name from the Forum The specialization of proctology into the world.”16 on Fundamental Surgical Problems to the colon and rectal surgery is another signifi- During the Wangensteen era, Minne- Owen H. Wangensteen Surgical Forum in cant achievement of the Wangensteen era. sota surgeons were also at the forefront of honor of its founder.11 During the early 20th century, proctology early . Building on The opportunity to conduct research was a neglected area of medical practice. the success of the cardiac program, which attracted residents like Henry Buchwald, Most physicians were not adequately worked with critically ill patients, Richard who trained under Wangensteen in the trained in the treatment of hemorrhoids, Lillehei—C. Walton Lillehei’s brother— early 1960s before joining the faculty. He fissures, abscesses and fistulas. In re- successfully transplanted dog stomachs wanted to become an “academic surgeon” sponse, Walter Fansler, a and intestines in the laboratory as early who “engaged in basic research” as well practitioner, established the Section of as 1960. Transplants in human patients a “competent clinician” and “technician.” Proctology within the Department of began in 1963, when Richard Varco led the Buchwald recalls, “in that atmosphere, you Surgery in 1917. Soon after the incorpora- first successful human kidney transplant

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Carnegie Foundation for the Advancement of in Minnesota. The first liver transplant procedure became so negative that some Teaching, 1910: 248. in the state occurred the following year, researchers erased any mention of it from 4 Newton F. Quoted in Wilson LG, Medical 21 Revolution in Minnesota: A History of the University performed by Karel Absolon and Richard their CVs. Although gastric freezing of Minnesota Medical School. Saint Paul: Midewiwin Lillehei. And in 1966, William Kelly and failed as a practical means to take care of Press, 1989: 289. Richard Lillehei performed the world’s ulcers, Delaney explains, the research still 5 Wilson, 307–23. 6 Scholes K. Minnesota Medical ‘Miracle’ Saves first successful clinical pancreas trans- contributed a great deal to basic scien- Thousands of GI’s. Minnesota Morning Tribune plant. And, as is quite well-known, Minne- tific knowledge about gastric physiology, Magazine. September 10, 1944. sota-trained surgeons including the effects of mechanical and 7 Visscher MB. Owen Harding Wangensteen, September 21, 1898-January 13, 1981. In: 22 and Norman Shumway were performing thermal injury to the stomach. Biographical Memoirs of the National Academy of well-publicized heart transplants by the Despite challenges associated with Sciences 60, 1991: 356. 17 8 Good-Bye, Radar: Part 1, Television, M*A*S*H. end of the 1960s. cutting-edge research, Wangensteen’s Columbia Broadcasting System, October 8, 1979. These early efforts were hampered by leadership as department chair facilitated 9 Wangensteen OH. Elias Potter Lyon, Minnesota the problem of rejection; while the opera- the accomplishment of some of the most Dean, Trail Blazer in American Medical Education. In: ed. Wangensteen OH. Elias Potter Lyon: Minnesota’s tions were successful, the outcomes were significant medical triumphs of the 20th Leader in Medical Education. St. Louis: Warren H. unpredictable until the advent of im- century. Indeed, Wangensteen’s legacy has Green, Inc., 1981: 225. 10 Wangensteen. Elias Potter Lyon. munosuppressive drugs in the following become imprinted upon the very geogra- 11 Nahrwold DL, Kernahan PJ. A Century of decade. Nevertheless, these early achieve- phy of the medical campus at the Univer- Surgeons and Surgery: The American College of ments set the stage for major break- sity of Minnesota; dominating the campus Surgeons, 1913-2012. Chicago: American College of Surgeons, 2012: 179–81. throughs, including solutions for manag- skyline, the 11th floor of the Phillips-Wan- 12 Buchwald H. Interview by Korostyshevsky D. April ing tissue rejection, that would follow in gensteen Building remains the physical 12, 2016. the 1970s and ’80s. After Wangensteen home of the Department of Surgery. 13 Buchwald interview. April 12, 2016. 14 Rothenberger DA. A Brief History of the University retired in 1967, John Najarian, a transplant In celebration of the department’s 110th of Minnesota Training Program in Colon and Rectal surgeon and research immunologist from anniversary in 2016, Minnesota governor Surgery. In: Fellowship: The History of Colorectal Surgical Training at the University of Minnesota, California, was attracted to the position Mark Dayton declared Wangensteen’s 2000: 5–6. specifically because of the department’s birthday—Sept. 21—to be Dr. Owen H. 15 Goldberg SM. Interview by Korostyshevsky D. reputation in surgical research.18 Under his Wangensteen Day.23 Wangensteen’s vision April 8, 2016. 16 Rothenberger. A Brief History: 8. leadership, the department would become of medical research and education lives 17 Wilson. Medical Revolution in Minnesota, internationally-known for transplant im- on. Within the Department of Surgery, 537–41. Myers JA. Masters of Medicine: An Historical munology research and a clinical destina- the Division of Basic and Translational Sketch of the College of Medical Sciences University of Minnesota 1888-1966. St. Louis: Warren H. tion for organ transplant patients. Research and Experimental Surgical Ser- Green, Inc., 1968: 411. Najarian JS. The Miracle of Despite the high-profile successes vices exemplify his commitment to surgi- Transplantation: The Unique Odyssey of a Pioneer Transplant Surgeon. Medallion Press, 2009: 66, 85, achieved under Wangensteen’s leadership, cal science. Throughout his 37 years of 93. Tilney NL. Transplant: From Myth to Reality. New Haven: Yale University Press, 2003: 210, 214–15. not all the efforts of scientific surgical re- leadership, Wangensteen never wavered in Hamilton D. A History of Organ Transplantation: search in Minnesota translated into thera- his efforts to integrate scientific research, Ancient Legends to Modern Practice. Pittsburgh: University of Pittsburgh Press, 2012: 290. peutic or clinical applications. As John medical education and history at the Uni- 18 Najarian. The Miracle of Transplantation: 65. Delaney, faculty member who trained versity of Minnesota. MM 19 Delaney JP. Interview by Knatterud ME. February 15, 2016. under Wangensteen in the early 1950s, David Korostyshevsky is a doctoral candidate recalls, one area of research “that didn’t in the History of Science, Technology, and 20 Schmeck HM. Stomach Chilled to Treat Ulcers: Doctors Tell of Arresting Loss of Blood by Cooling turn out too well” was the “cooling” and Medicine at the University of Minnesota. His research ranges from public medical history to with Help of Balloon. New York Times. December 4, “freezing of the stomach” to treat stomach intoxication in the early-modern period. 1958. ulcers, another serious medical problem in 21 Delaney interview, February 15, 2016. 22 Delaney JP. Interview by Tobbell DA. March 27, the mid-20th century. According to Del- REFERENCES 2012, Academic Health Center Oral History Project, aney, the research was both “memorable” University of Minnesota. and “strange.”19 An optimistic article in the 1 Smith MM. Medical Alley (1950s): A Tight-Knit 23 Gov. Mark Dayton. Proclamation: Dr. Owen H. Community of Tinkerers Keeps Ticking. In: Wangensteen Day. State of Minnesota, September New York Times recounted, “In one experi- Molella AP, Karvellas A, ed. Places of Invention: A 16, 2016. ment to develop the technique, a frog” was Companion to the Exhibition at the Smithsonian’s National Museum of American History. Washington “given its own oxygen supply” and placed D.C.; 2015: 86–109. “in the cooled stomach of an anesthetized 2 Doyle R. Emeritus: Interview with Owen Wangensteen. University of Minnesota, October dog for thirty-six hours.” That the frog 24, 1967. Box 5, Collection #2002-0008, University “was alive and apparently unharmed when Media Resource Video Collection, University of Minnesota Archives. brought out again” was meant to demon- 3 Flexner A. Medical Education in the United States 20 strate the procedure’s safety. However, by and Canada: A Report to the Carnegie Foundation the late 1960s, medical opinion about the for the Advancement of Teaching. New York.

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