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Beyond Cardiac Surgery Owen H FEATURE he Department of Surgery at the Uni- Owen Wangensteen versity of Minnesota is best known served as chair of the for the development of open-heart 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 OF MINNESOTA THE UNIVERSITY American History in Washington D.C. While leading Minnesota figures in cardiac surgery—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 University of Minnesota’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 United States 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 JANUARY/FEBRUARY 2018 | MINNESOTA MEDICINE | 23 FEATURE “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
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