CHAPTER 14

Heart Disease

Can Dreaded Hardening of Arteries Now Be Cured?

The study of diseases of the heart and blood vessels has received a great impetus in the last year or two. The result has been a noteworthy improvement in the methods of diagnosis, a better understanding of the circulatory system, the invention of many mechanical aids to cardiac therapeutics, and the discovery of a successful remedy for some of the lesions which heretofore have baffled the skill of the medical profession.

In addition, the daring operations on heart, arteries, and veins should not be forgotten; operations which were unheard of a few short years ago, but which have become matters of routine practice. Surgery of the thorax, which includes the heart and the adjacent blood vessels, has assumed such importance that in one hospital at least in this city, the German Hospital, a special operating room has been constructed for this kind of work, so that the air pressure can be regulated to the exigencies of the case.

Prominent among the items of news of a scientific nature recently cabled from Europe was the announcement that Prof. Arthur Keith, the eminent English physician, has been demonstrating at the Royal College of Surgeons, London, some remarkable advances which have been made lately in the knowledge of the structure, functions, and diseases of the heart. One of the most remarkable of these, it is said, is the detection of a small mass of peculiar tissue, which has been named the heart’s “pacemaker,” because apparently within it the beat of the heart has its origin. The announcement probably refers to the localization of a nerve centre.

The structure, it appears, was first recognized five years ago by Prof. Keith and Dr. Martin. Then Prof. Thomas Lewis of University College found that the site of the new structure was also the point at which the heart-beat first appears. Prof. Lewis fixed the localization by means of an electrical device.

Although this point is the chief centre for the activity and regulation of the heart, there are apparently many secondary centres which can take over the initiating of the heart-beat. It is said that the suggestion which led to the discovery of Prof. Keith was made by a Japanese pupil named Towara in Prof. Aschoff’s laboratory.

The most dreaded of all the ills of the cardiac and vascular systems nowadays seems to be arteriosclerosis, or hardening of the arteries. It is an old axiom that a man is as old as his arteries.” This simply means that it is possible for a man of forty to have arteries in a condition which should not be encountered normally in persons under seventy years of age. The hard or hardening artery means increased blood pressure, with a consequent increased strain on the heart.

This may lead to a long train of distressing symptoms, and, of course, ultimate death.

The public is beginning to know a good deal about “hardening of the arteries.” The term figures often—too often—in obituary notices. Heart disease, according to statistics, is carrying off a greater percentage of persons than formerly. This fact cannot be denied, and it is attributed largely to worry, the abnormal rush of the life of to-day, and sometimes to faulty methods of eating and bad nutrition.

Dr. M. Herz of Vienna, an authority on diseases of the heart and blood vessels, commented as follows last Summer on arterio-sclerosis:

“In the United States there is not, so far as we know, any widespread fear of arteriosclerosis. The public recognizes that people are ill from ‘hardening of the arteries,’ and that they often die with, if not from, this condition.

“In Austria, however, there is an exaggerated fear of this condition, which in medical men is amounting to a phobia, and the great frequency or suddenly fatal angina pectoris and cardio-renal (heart and kidney) disease seems largely responsible for this fear. The author [Dr. Herz] thinks arteriosclerosis may have undergone a change of type; and in response to a circular of inquiry addressed to several thousand physicians in reference to possible new causal elements, it appears that psychic trauma (mental injury) and excessive bodily labor are leading factors, and that a combination of the two is especially in evidence.

“All individuals now labor under forced pressure, due, as the author terms it, to conditions having become Americanized. There is a continued succession of psychic traumatism with physical overstrain, and as a matter of fact the cause is practically that of neurasthenia, and the treatment should be mainly psychic in so-called premature cases, the production of a cheerful frame of mind.”

The anxiety and fear concerning arteriosclerosis in Austria may have some bearing on the fact that out of Austria has come a man, Dr. Bruno Fellner Jr., of Franzenbad, near Carlsbad, to tell of what seems to be a fairly successful remedy he discovered for the disease while working in the laboratory with Prof. Franz Müller at Berlin, head of the Physiological Institute there. Dr. Fellner arrived in New York a few days ago, and will demonstrate his treatment in a number of hospitals in this city and throughout the country, and explain it to various medical societies.

Dr. Fellner appeared before the Medical Society of the Greater City of New York last Monday evening and delivered an address on the subject. Here is a part of his paper:

“A number of years have been devoted by the author to the study of blood pressure, in the human body, especially to its abnormal increase (hypertension) as it is found in its most universal and specific representative, arteriosclerosis. These studies were pursued in Vienna at the clinics of Prof. Nothnagel and Prof. von Noorden, and in Munich with Prof. Friedrich Müller.

“For years it has been my aim to find a remedy which would counteract or neutralize or remove the contraction of the peripheral arteries, which is the main factor in the production of increased resistance to the heart’s action and obstruction of free circulation of the blood, both symptoms of increased blood pressure. Such a remedy would be expected to regulate the circulation in two ways: Gradual persistent reduction of pressure and by distinct enlargement of the peripheral vessels.

“All drugs known to be vaso-dilators (dilators of blood vessels) or which exert favorable action on any of the symptoms of arteriosclerosis were subjected to trial without satisfactory results, until Prof. Franz Müller of Berlin and myself decided to utilize the former’s brilliant researches on the vaso-dilatory and pressure-reducing action, of yohimbin, which, derived from the bark of a tree indigenous to Kamerun, in Africa, had hitherto only been known as a drug of doubtful value in another class of ailments.

“Intravenous injections of yohimbin in cats was found to produce a pronounced reduction of blood pressure, dilatation of the peripheral vessels, and increased volume of blood in the extremities and in the brain. This action also occurred in remote arteries, i.e., when heart and brain were excluded, and was, therefore, undoubtedly due to direct irritation of the peripheral vaso-motor nerves and the muscular coats of the vessels.

“The question then occurred to me whether and in what manner the results of these experiments could be applied to cases of hypertension, that is, arteriosclerosis. The hypodermic administration of the drug was found the only method which insured good results. Yohimbin alone, however, was found impractical on account of its injurious action upon the respiratory centres and its irritating action upon the sacral plexus (of nerves).

“Numerous combinations with other drugs were tried with the view of excluding this latter peculiarity without success. Finally, however, it was discovered that the only combination in which it would retain its vaso-dilatory property and lose its irritating action was that of nitrate of yohimbin with uretan. In this new medicament, called vasotonin, the disagreeable properties of yohimbin have been completely neutralized.

“Vasotonin is dispensed in sterile vials of two cubic centimetres, each containing a single dose, and the injection into the arms is painless and can be done without interfering with the patient’s daily work, although it will be wise to administer the first dose at the patient’s home, followed by a rest of one hour. As a rule injections are made every other day, except in cases with very grave symptoms, when they are practiced daily. About twenty injections are necessary. It is very desirable to observe the patient closely, not alone for the improvement of his symptoms, but also of the blood pressure with the aid of proper apparatus.

“Prof. Müller and myself made the first public report of the results of our experiments with this drug at the Congress for Internal Medicine held at Wiesbaden in 1909; later, in the Medical Society of Berlin. Since that time the remedy has been used in numerous hospitals, in clinics, and in private practice, so that up to date the number of cases treated amounts to about 5,000.

“I will now submit to you an impartial, unbiased report of these cases, limiting it to my personal experience and to those published in recent literature by well-known reliable authors. My own cases number 120; 100 of arteriosclerosis, 20 of hypertension from other causes. The increased blood pressure fell considerably in 90 per cent, which result was obtained in from two to six weeks, and lasted from four to fifteen months.

“Increase of circulation in the peripheral blood vessels could be easily demonstrated. Furthermore, it was observed that there was a considerable reduction in the size of the dilated heart, especially of the left ventricle, and also a more or less complete disappearance of various cerebral and nervous symptoms due to the sclerotic process.

“Fifteen cases of angina pectoris remained absolutely free of symptoms for weeks and months. Upon return of that painful condition, a second course of treatment had a favorable influence, lasting from six to twelve months. The precordial pressure, air hunger, vertigo, spasms of vessels, and other sclerotic symptoms disappeared. The patient would regain his courage and take a renewed interest in life.

“Of course, I do not propose to claim a permanent cure of this formidable organic disease, but I do maintain that in 80 per cent of my cases there was a distinct and lasting improvement, 10 per cent were benefited but slightly, and in 10 per cent, while the remedy made no impression upon the disease, there was absolutely no bad effect in any manner.

“The following reports are taken front current literature, especially the German. During a discussion following the reading of a paper by Prof. Müller and myself, Prof. Herz recommended the use of vasotonin, especially in cases of presclerosis and in cases of angina pectoris, but deprecated the reduction of blood pressure à tout prix, although he did not agree with Krehl, who saw absolutely no benefit in arteriosclerosis from pressure-reducing therapy. He extolled the practical results obtained with vasotonin, in which he was joined by Prof. Senator.

“Stachelin of the first medical division of the Charity Hospital of Berlin makes the first extensive and painstaking report. His especial object was to determine whether, when blood pressure was reduced by vasotonin, other symptoms usually accompanying this condition were also favorably influenced, which is denied by Krehl. He declares that with the aid of the sphygmomanometer he was able to demonstrate distinct dilatation of the peripheral vessels, accompanied by considerable diminution of the pressure.

“This reduction varies considerably. The dilatation may be observed in the arm after eight hours. There was also considerable improvement in all subjective symptoms, which would last some time. After fifteen to thirty injections given in the course of four to six weeks, Stachelin saw great relief in cases of angina pectoris, which is afforded by no other known remedy. It is this success in this most grave and painful form of arteriosclerosis which induces Stachelin to consider the immediate use of vasotonin as the foremost indication in the treatment of that affliction.

“Other subjective symptoms, such as vertigo, headache, dyspnoea (shortness of breath), precordial pressure (pressure in front of the heart), and pain were greatly relieved, so that Stachelin advocates the use of vasotonin also in these cases, whether accompanied by hypertension or not. Nephritis (Bright’s disease) furnishes no counter indication.

“These results obtained in hospitals are supported by experience gathered in private practice. Grabi, after observations made upon himself and others who had suffered from this disorder for years, declares that none of the hitherto employed means to reduce pressure showed such a continued action as vasotonin. The most various angio-sclerotic disorders are removed.

“Similar favorable results have been obtained by Schlattenstein in the policlinics at Rosin. Rosendorff of the Jewish Hospital writes of absolute failure to obtain positive results. This is not easily explained, although it is an interesting fact that different observers employing the self-same material occasionally arrive at opposite results. Then we have Bennecke and Lommel of Jena using the same material at that hospital, the former deriving no better results from the use of vasotonin than from the customary hospital treatment, while the latter writes of similar favorable results as obtained by Stachelin and myself.

“Another observation made in my first cases was the favorable influence this remedy had upon sclerotic disturbances in the brain. Experiments upon the animal showed this to be due to a distinct dilatation of the cerebral vessels, and this fact was further beautifully illustrated by Hirschfelder in Liehen’s clinic in a patient who had a considerable loss of substance of the bony vault of the skull. The brain was examined by the plethymograph during the administration of vasotonin. Hirschfelder found after a double dose of vasotonin there was considerable elevation of the plethymogram, showing a great increase in the quantity of blood circulating in the brain.

“This improvement in the cerebral circulation after reduction of hypertension has caused Hirschfelder, Stachelin, and myself to consider it indicated in such cases of cerebral arteriosclerosis, in direct opposition to Tobias.

“Liehen bases his use of vasotonin in cases of depressive melancholia on this very action of vasotonin. His results are to be published in greater detail in the near future. Again, it has been asserted that in cases of apoplectic injury to the brain vasotonin has caused a rapid subsidence of the alarming symptoms and an early disappearance of the accompanying paralysis.

“The blood supply of the sensory organs is also powerfully influenced by this drug. A perceptible dilatation of the retinal vessels has been observed, and researches as to its use in various affections of the eye are now being made.

“Stein and myself at the policlinic of Prof. Alexander in Vienna have tried it in those aural disturbances due to arteriosclerosis of the labyrinth. Such patients often exhibit no other symptoms of arteriosclerosis except those referred to the ear, such as vertigo, ringing of the ears, deafness, and headache. The sphygmomanometer, however, will always show an increased arterial tension.

“A dozen of these cases, in which every other therapeutic measure had failed to give relief, were treated with full doses of vasotonin, which invariably caused a subsidence of these troublesome symptoms as soon as the pressure-reducing action of the blood became evident. Vertigo was always the first to disappear, as shown by the aid of the revolving chair. The deafness was affected in a lesser degree, while the ringing was much improved.

“In bronchial asthma it affords much relief, cutting short the attacks, but the improvement does not endure as in cases due to arteriosclerosis. However, Jacobs of Krause’s clinic, has had very gratifying results in these cases.

“When the tension and pressure in the boiler of a machine are dangerously high, one must open the safety valve as well as other communications to allow the surplus steam to escape. We will, therefore, consider the best remedy, one which will reduce the blood pressure by appealing to vasomotor nerves which govern and regulate the smallest vessels, causing them to open wide, thus increasing their calibre, which will admit of more abundant circulation of blood through them with greater rapidity; the pressure will fall, and the heart and other organs will receive a greater amount of the nourishing fluid.

“At best the treatment of arteriosclerosis is of doubtful success, certainly almost hopeless until this remedy was discovered, which has been shown experimentally and practically to reduce blood pressure, to dilate the blood vessels (accelerating the coursing through them of the blood), to dissolve spasm of the walls of the vessels. It meets the requirements of the theories hitherto accepted of the causation of arteriosclerosis.

“May we not, therefore, hope that this increased flow through the contracted vessels will assist materially by furnishing new nourishment in the recovery of the rigid, degenerated coats of the arteries?”

Dr. Fellner will appear before other medical societies in this city to discuss this new remedy.

The use of the sphygmomanometer has contributed in a large measure to the improvement in methods of diagnosis and in observing the progress of diseases affecting the circulatory system. It is an instrument for measuring the pressure of the blood. It is fastened about the wrist, rather tightly, and the impetus of the pulse is transmitted to mercury in a tube, and the mercury rises proportionately to the blood pressure, which is measured by the marks on the glass, in a manner similar to the registration of temperature by the thermometer.

Another remarkable instrument which is employed now in the diagnosis of cardiac ailments is the electrocardiograph. The impulse of the heart causes tracings to be made, and from these tracings the physician is able to tell whether or not the heart is in a normal condition and position. The accompanying illustrations of electrocardiograms, and X-ray pictures with electrocardiograms, show the difference in tracings resulting from normal positions, malpositions, and pathological conditions of the heart.

These two aids to diagnosis have become well-nigh indispensable to physicians, whether general practitioners, specialists, or insurance examiners.

Dr. J. W. Fisher of Milwaukee says in the insurance department of the Medical Record:

“No practitioner of medicine should be without a sphygmomanometer. He has in this instrument a most valuable aid in diagnosis. The sphygmomanometer is indispensable in life insurance examinations, and the time is not far distant when all progressive life insurance companies will require its use in all examinations of applicants for life insurance.”

A notable feature of surgical work with the blood vessels to-day is the great improvement in the methods of the transfusion of blood. Formerly it was transferred from the donor to the recipient through a glass or metal tube. The operator could never be certain of the value of the procedure, inasmuch as some change was likely to, and often did, occur in the blood while it was passing through the tube, so that it was ineffectual for the purpose for which it was required when it reached the recipient.

This obstacle is now overcome. Direct transfusion is the method of to-day. The artery of the donor is severed and the free end is applied directly to the opened vein of the recipient. The blood flows directly into the vein, and its value is unimpaired in the transmission.

A new method of combating gangrene resulting from arteriosclerosis has been devised. It is a surgical procedure, and consists in a change of circulation by cutting into the affected limb and uniting the main artery with the main vein. It has proved successful in arresting the destructive process in several cases.

A stimulus to thoracic surgery, including necessary operations on the heart and on blood vessels in its vicinity, has been given in this city by the erection at the German Hospital of a new operating pavilion to be devoted solely to operations of this character. It was established as the result of the energy and enthusiasm of Dr. Willy Meyer.

This pavilion has a wonderful air pressure system. In operations where it is necessary to open the chest cavity an air pressure different from the normal is often required, and in the new pavilion any desired pressure can be obtained.

“The German Hospital of New York,” says Dr. Meyer, in a descriptive article written for the Medical Record, “appears thus thoroughly equipped for the performance of thoracic surgery by the transpleural route. It is not limited to the use of the apparatuses which I have provided, but affords facilities for the use of any other thoracic apparatus and the employment of all methods appearing at all promising.

“For, looking broadly at the prospective evolution of thoracic surgery, I expect practice to prove that surgical work in the thorax will have to be done along the general lines of surgical work in other parts of the body.

“There is no one apparatus and no one method covering every contingency. They should all be employed wherever indicated and should be ready for immediate use when required. It is on these comprehensive lines that the new thoracic department of the German Hospital has been conceived and constructed.”

November 26, 1911

Dr. Meltzer Perfects Devices to “Raise the Dead”

Something more than a year ago a group of famous scientists organized to study the effects of electric shock in the hope of lessening the number of casualties resulting from accidents in the industrial world. The immediate object sought was an improved method of resuscitation.

The commission named for this purpose was composed of members of the American Medical Association, the National Electric Light Association, and the American Institute of Electrical Engineers. Prominent among the members of the commission nominated by the American Medical Association was Dr. Samuel J. Meltzer of the Rockefeller Institute for Medical Research. Among this scientist’s well-known achievements was the perfection of the intra-tracheal insufflation method of artificial respiration (in conjunction with Dr. Auer), which is of great value in the administration of general anaesthetics where operations extending over a long period have to be performed. It has also saved the lives of many who were practically dead. There is an instance described by Dr. Meltzer in the article to be quoted from later in which a man took 15 grains of morphine by hypodermic injection (enough to kill fifteen men) and then turned on the gas. To all intents and purposes he was dead when discovered, but he “came to life” again after intra-tracheal insufflation had been practiced for twelve hours. This story was denied when printed exclusively in The Times last Fall, but now it receives official confirmation.

First Experiments

As soon as Dr. Meltzer assumed his responsibilities as a member of the commission he set to work to discover a simple means of artificial respiration by pharyngeal insufflation (the forcing of air into the lungs through the channels of mouth and pharynx) which would be readily available in emergency cases in all kinds of industrial plants. The results of a series of brilliant experiments were announced two months later in the Journal of the American Medical Association on May 11, 1912. In the course of his report Dr. Meltzer made this statement:

“I have made also a few experiments on animals which were killed purposely either by etherization or by illuminating gas. In these cases the pharyngeal insufflation was not instituted until all traces of respiration and heart beats disappeared. So far, only two recoveries can be recorded. No serious attempt, however, has yet been made to study those problems in a proper manner.”

A brief paragraph will be sufficient to outline the method proposed by Dr. Meltzer at that time. It consisted of the introduction of a catheter into the pharynx, pulling out of the tongue, forcing the back part of the tongue against the roof of the mouth by pressure applied far back under the chin, putting a weight on the abdomen to keep air from being forced into the stomach, connecting the catheter with a bellows, and pumping air into the lungs.

Now, a year later, Dr. Meltzer says (Journal of the American Medical Association, May 10, 1913) that while this method was successful in animals it did not stand the crucial test when applied to human beings. This did not discourage the scientist, however, for he declares in the same paragraph that he has overcome the difficulties met with and obtained the desired end, not by one method alone but by two! The methods are extremely simple and can be used by laymen in factories after a few instructions. Dr. Meltzer’s latest report on this subject is issued from the Department of Physiology and Pharmacology of the Rockefeller Institute for Medical Research, and is entitled “Simple Devices for Effective Artificial Respiration in Emergencies.”

“The method thus described,” says the author, referring to his earlier report of a year ago, “which worked well in four species of animals (dogs, cats, rabbits, and monkeys), has since been tried on living as well as on dead human beings. Here, however, the method failed to work. In human beings, pressure on the suprahyoid region (above the hyoid bone) does not restrict effectively the free escape of air through the mouth; neither is the entrance into the nasopharynx sufficiently blocked by the pressure of the flexible pharyngeal tube. The air insufflated into the pharynx escapes freely through the mouth and nose and enters therefore into the lungs with too little force to overcome the resisting elasticity of the lungs and the thoracic walls and thus to cause an inspiration.

“In other words, the simple arrangement which is so efficient a method of artificial respiration for animals proved to be unsatisfactory when applied to man because of the difference in the anatomic construction.

“I then set out to develop the method further, so as to make it applicable to human beings. I believe that I now have attained that end. In the following I shall describe two methods which have caused effective respiration (that is, effective rhythmic entrance of air into the lungs) even in human cadavers stiff in rigor mortis or frozen stiff. I shall designate the respective methods of artificial respiration as the pharyngeal and the mask device. I shall describe the pharyngeal device first and in greater detail.

“The pharyngeal tube to be used in human beings is made of metal. It measures transversely 38 millimeters and vertically 27, and is about 18 centimeters long. The lower (tongue) side is flat, the upper (palate) side is round. At the pharyngeal end the upper side is longer by about four centimeters than the tongue side; when the tube is inserted through the mouth into the pharynx, the end of the upper side has to reach the posterior wall of the pharynx, while the lower side may end somewhere between the radix (root) of the tongue and the posterior wall of the pharynx.

“For an adult of medium size the dimensions of the tube are sufficient to fill out the entrance into the pharynx so as to prevent the escape of air through the mouth; it also blocks reliably the entrance into the nasopharynx. Of course, tubes of various dimensions may be had at hand, so as to fit the individual sizes. The outer end of the tube carries, in the first place, a hollow neck-like projection to connect the tube with the insufflation apparatus. It has, besides, a round hole, through which a large stomach tube may be introduced into the esophagus and the stomach, when necessary; this hole is usually kept closed by a movable plate.”

The Respiratory Valve

“The outer end of the pharyngeal tube is connected by a short heavy piece of rubber tubing with a little device which I designate as respiratory valve. It is a small tube about 10 centimeters long and 3 centimeters in diameter, which carries a valve inside and a ring outside. By means of that ring the valve may be moved from side to side. When it is moved to the right side, it connects the insufflating apparatus with the pharyngeal tube and air or oxygen is driven into the pharynx and the lungs. When the ring is moved to the left side, the current of air or oxygen is shut off; at the same time an opening is established through which the expired air may now readily escape. The respiratory valve may be conveniently held in the hand and the ring moved from side to side by the thumb. The ring moving the valve is not in the middle, but near one end of that little device, the end which should be connected with the pharyngeal tube.

“The other end of the respiratory valve should be connected by means of strong rubber tubing with glass-blower foot bellows which should be worked so as to give an approximately continuous current of air; or it may be connected with an oxygen tank. Between the respiratory valve and the bellows (or oxygen cylinder) a ‘safety valve’ should be interpolated in order that the air or oxygen should not be driven into the pharynx with too high pressure.

“The safety valve may be of such a simple kind as I described in the recently appeared sixth volume of Keen’s work on surgery for the intratracheal insufflation apparatus. It consists simply of a calibrated tube dipping in mercury. The pressure should be arranged for not less than 20 millimeters mercury, and may be even 25 millimeters; the pharyngeal system of insufflation will always permit an escape of some air through any of the exits.”

How It Works

“Heavy weights to be placed on the abdomen, a broad belt to reinforce the pressure on the abdomen, and a large stomach tube, about 33 French, complete the outfit.

“The pharyngeal insufflation apparatus for artificial respiration consists, then, of a metal pharyngeal tube, the respiratory valve, foot bellows, or an oxygen tank and a safety valve. In addition, there should be on hand a tongue forceps, a stomach tube, heavy weights and a belt. The procedure is as follows:

“After a heavy weight is placed on the abdomen, the tongue should be pulled out by means of an appropriate forceps and the pharyngeal tube inserted into mouth and pharynx as far as it may go. For the sake of being in readiness, the respiratory valve should be kept attached to the pharyngeal tube. The free end of the respiratory valve should now be connected with the foot bellows or the oxygen tank, to either or which a safety valve is attached.

“Now the oxygen tank should be opened, or the foot bellows started working, while the respiratory valve is taken in the right hand and the ring moved by the thumb from side to side, keeping it for two or three seconds at each place. The same man who works the bellows with his foot may work at the same time the respiratory valve with his hand.

“When the ring rests at the right side, the air from the bellows or the oxygen from the tank is insufflated into the pharynx with a force of 20 millimeters of mercury and unavoidably enters the lungs, causing an inspiration. On account of the pressure on the abdomen the inspiration causes essentially distension of the thorax; when the ring is turned to the left the insufflation is cut off and the elastic recoil of the ribs and of the abdominal viscera causes an efficient expiration.

“The rubber tubing connecting the pharyngeal tube with the respiratory valve should be short, in order to cut off the dead space and during expiration eliminate carbon dioxide as much as possible. Rebreathing is surely undesirable. All tubing employed for connections should have thick walls to prevent kinking. The tongue should be kept pulled out in order to keep the epiglottis raised. After the pharyngeal tube is inserted the tongue may be kept in proper position by tying it (not too tight) to the tube; the forceps may be then taken off. The tying of the stretched tongue to the tube may even assist the latter in remaining in position.

“The weight on the abdomen prevents the entrance of air in any considerable quantity into the stomach and the little which gets there escapes again when the insufflation is cut off; it never gets into the intestines. The pressure on the abdomen has still another significance. In patients with completely abolished respiration usually the blood pressure is also very low and most of the blood may be accumulated in the abdominal viscera. The heart is then scantily filled, and not enough arterial blood is sent to peripheral organs. Under such circumstances a good pressure on the abdomen may raise the blood pressure by even as much as 30 millimeters of mercury; the heart is filled more efficiently and sends more blood to the medulla oblongata, arousing there the activities of the respiratory and vasomotor centres. Figure 1 shows the effect of abdominal pressure on the blood pressure.”

In Special Cases

“For this reason I recommend to have a belt on hand to reinforce the pressure. With a belt alone not much success can be obtained. In cases of accidents, when it might happen that no suitable weight is at hand, the individual who handles the respiratory valve may sit down on the abdomen of the victim.

“There might be conditions which do not permit the placing of weights on the abdomen; for instance, when a collapse occurs during a laparotomy. Under this circumstance a stomach tube of a large diameter should be introduced through the esophagus into the stomach. The tube restricts to a sufficient degree the entrance of air into the stomach, and the air which enters there escapes readily through the tube as staged before. In the anterior end of the pharyngeal tube is an opening for that purpose which is usually kept closed by a movable plate.

“A stomach tube of a 33 French diameter fits exactly into this opening. I am of the opinion that it is preferable to have in every instance, even when pressure on the abdomen is exerted, also a tube in the stomach. Since the apparatus may have to be used in some emergency cases by laymen, however, the latter might be loath to handle a stomach tube. And since the experiments have shown that very good results may be had with the pressure alone, I do not feel like insisting on the simultaneous use of the stomach tube in all simple cases.

“Besides the metal pharyngeal tube, I studied also the availability of the use of insufflation with the aid of a well-fitting mask. In this arrangement every other part is the same as in that for the pharyngeal tube, except that instead of introducing a tube into the pharynx, a mask is laid over mouth and nose and by bands tightly applied to the face. The mask has a hollow projection for the connection with the respiratory valve. I tested the mask method on various animals; as was previously found for the pharyngeal tube, it was established that also by means of the mask efficient artificial respiration can be carried on.

“With the aid of the mask method of artificial respiration, completely curarized (and anesthetized) animals were kept in an excellent condition for many hours. By this method, of course, some infectious matter may be driven into the trachea and perhaps cause infection; by this method, further pressure is exerted on the middle ear; neither does the mask method allow the introduction of a stomach tube. However, in dealing with emergency cases, with immediate danger to life, such considerations as the above methods are, comparatively speaking, mere trifles and can be hardly taken into account.

“I have tested also the effectiveness of insufflation through metal pharyngeal tubes on animals; it is even more satisfactory than with elastic rubber tubes. It works promptly; the introduction gives less trouble and the tube remains in position for hours.

“Both the pharyngeal and mask methods were tested also on human cadavers. Air entered into the lungs when insufflated by either of these methods, even if the dead bodies were in rigor or frozen stiff. In some cases unmistakable efficient respiratory movements of chest and abdomen were manifestly present. But even when the stiffness interfered with the free movements, auscultation proved conclusively the entrance of air into the lungs. Especially was this the case in a man who died under signs of pulmonary oedema; rales (rattling sounds) could be heard all over the chest.

“The accompanying sketches illustrate these methods better than they can he described. In Figure 2, the pharyngeal tube (P.T.) is shown connected with the respiratory valve (R.V.), the foot bellows (B.) and the safety-valve (S.V.). A stomach tube (S.T.) is pushed through the pharyngeal tube. In Figure 3, the mask (M.) is shown applied to the face. By means of an inflatable ring (Infl.), the mask is made air-tight. There is a weight on the abdomen and a belt around it. The respiratory and safety valves are the same as in Figure 2. The bellows are here replaced by an oxygen cylinder.

“In an emergency case no time should be lost on matters of less importance before starting the main act, and that is: the artificial respiration. When using the mask, for instance, no time should be lost in tying and fixing it properly; it should be pressed over mouth and face by the hand. After the insufflation is well on the way, some one may attend to the tying of the mask, the fixing of the tongue properly and the putting of the belt around the weight over the stomach. Regarding the fixing of the tongue, it may be, as stated before, tied to the pharyngeal tube, when using the same.”

Further Description

“When using the mask, the handle of the tongue forceps may be fixed to the victim’s neck so as to keep the tongue stretched; or the tongue may be tied by means of tape or gauze bandage, pulled out well and the end of the tape or bandage tied around the victim’s neck. It should be kept in mind that the pulling out of the tongue is an essential factor in any procedure for artificial respiration. In completely paralyzed individuals there is a tendency for the tongue to be kept somewhat firmly over the entrance into the larynx, caused, perhaps, by some final attempt at inspiration.

“I may say in passing that the demonstrations made with some machines for artificial respiration, for commercial and advertising purposes, on living and unanesthetized individuals, is entirely misleading and should not be taken as evidence of the efficiency of such machines in cases when individuals are unconscious and the respiratory mechanism paralyzed.

“It will be safer to have on hand a mask as well as a pharyngeal tube. When the latter should prove too small, the escape of the insufflated air alongside the tube may be remedied by tamponading the entrance into the pharynx around the tube with gauze. Besides, as I have indicated above, tubes of various sizes should be on hand.

“The foot bellows need not be large; smaller foot bellows worked a little more rapidly give a sufficiently strong, continuous current of air. The continuous air current is in the arrangement here described preferable to the interrupted current produced by hand bellows; it is difficult to have the rhythm of the bellows coincide properly with the rhythm in the respiration produced by the respiratory valve; it may occur that the bellows are compressed just when the valve is closed, &c., and the result might be an irregular and inefficient artificial respiration.

“It is evident that the methods of artificial respiration by devices here described can be readily combined with the Shäfer method of manual artificial respiration. The individual is then placed on his abdomen and the turning of the ring of the respiratory valve to the left has to coincide in time with the pressure on the lumbar muscles. Inspiration as well as expiration will thus be efficiently reinforced.”

The Emergency Bag

“While on the basis of my extensive experience I have reason to believe that the devices which are here described will answer the purpose satisfactorily in all cases in need of artificial respiration, it is safer to think of methods which are capable of improving the efficiency of the devices. Emergencies may arise of which we are unable to think of now; factors of safety are designated by some students of mechanics as factors of ignorance.

“The emergency bag should contain small foot bellows, the safety-valve, the respiratory valve and the pharyngeal tube all readily connected by rubber tubing. Further, a mask, a tongue forceps, a strong belt or cords, a stomach tube, a roll of tape or one-inch gauze bandages and scissors. Weights might increase too much the weight of the bag. Bricks, stones or pieces of heavy metal, &c., may be had at any place.

“Wherever oxygen can be had it should be used in preference to the air from the bellows. It should be remembered that according to Hill and Macleod, however, prolonged inhalation of oxygen may do harm to the lungs. When, therefore, prolonged artificial respiration is required, the use of air should be alternated with oxygen.

“The devices for artificial respiration here described are certainly simple and inexpensive. Their efficiency has been tested to a much greater extent than any other device I know of. The possibility of keeping up the circulation in a normal condition for hours while the voluntary respiration is completely abolished (by curare) is certainly a rigid test, which has not been applied to any other method of artificial respiration except to that used in experimental laboratories with tracheotomy as a prerequisite, and, as I may add, to the method of intra-tracheal insufflation.

“The last mentioned device, which has now been tested in nearly two thousand cases on human beings, would be, in my opinion, indeed the most ideal method for artificial respiration. It has been used, to my knowledge, in two human cases of severe poisoning (morphine fifteen grains subcutaneously combined with inhalation of gas, and smoking opium for two days with complete absence of respiration) for twelve hours continuously with complete recoveries. But this method requires some training and could never be left to the hands of laymen.

“The handling of the artificial respiration by means of the pharyngeal and mask devices which I describe here is so simple that laymen could well be trusted with its execution. And that was the main object of my endeavor to develop these devices.”

The writer quotes this from a former article:

“There is the possibility that the actual cause of death might be, in one case or another, especially in acute cases, only of a temporary nature, so that efficient artificial respiration might assist in temporizing and thus prove occasionally life-saving indeed. Such possibilities, though they may be realized only once in a thousand times, justify the making of an attempt in each and every instance.”

May 18, 1913

Heart Surgery Made Safer by Invention of Cardioscope

At least one spectacular invention was announced at the recent meeting in Chicago of the American Association of Thoracic Surgeons. Dr. Durff S. Allen of George Washington University, a young surgeon, has the distinction of being the inventor of an instrument which he has named the cardioscope, the purpose of which is to illuminate and magnify the field in operations on the heart.

This implies, of course, the possibility of such operations; it implies, moreover, that the heart is by no means the tender organ that it was formerly considered to be, but is, in fact, a tough muscle so constructed as to be able to withstand the normal strain of a long life. The average rate of the human heartbeat is seventy-two times a minute. Thus in a lifetime of 100 years the heart beats 3,784,320,000 times. An organ that can stand the strain of these myriad pulsations, these alternate expansions and contractions, must be strong indeed; no man-made device can compare with it except the clock or watch, and they have to be wound, whereas the heart is a self-winder.

The cardioscope will facilitate those wonderful heart operations devised ten years ago by Dr. Theodore Tuffier and Dr. Alexis Carrel of the Rockefeller Institute for Medical Research. Inspiration, conviction and resolute daring enabled these two scientists to operate successfully on the valves of the hearts of animals. They widened them by cutting and narrowed them with surgical stitches.

One is led to inquire how a surgeon can cut or sew with safety a beating heart. The answer to that is: The surgeons stilled the heartbeats by applying clamps to the blood vessels leading to and away from the organ, thus relieving it temporarily of its chief functions of propelling blood through the body and drawing it back again. “While the operations were in progress mechanical respiration was maintained by intratracheal insufflation, a method devised by the late Dr. Samuel J. Meltzer, who was also connected with the Rockefeller Institute.

Epochal Operations

The specific operation which the two physicians reported was for enlargement of the pulmonary orifice of the heart to permit the free flow of blood and thus relieve or prevent congestion. Here is what they said about it:

“The operation will be much less dangerous in the future because the details of the technique have now been thoroughly established. These experiments show that it is possible to perform an operation which will increase the circumference of the pulmonary orifice without involving much danger to the life of the animal. It is probable that operations of this type may be employed in the treatment of stenosis (stoppage) of the pulmonary artery in man.”

Bight dogs were subjected to the experiments, which involved patching of the pulmonary arteries. Two of the animals died; the others recovered without shock and six months later were reported to be well.

Dr. Carrel reported other experimental operations on the sigmoid valves of the heart, the organ being rendered quiescent for several minutes by clamps, as in the other cases.

It is in the diagnosis of such conditions as these and in subsequent operations for their relief that Dr. Allen’s cardioscope will prove invaluable. As its name implies, it is an instrument with which to look at the heart. It is described as a small apparatus, in bulk about the size of a pocket flash lamp. It has a strong magnifying lens and is equipped with an electric light. An incision having been made through the tissues over the section of the organ to be observed, the small instrument is introduced so that a magnified view of the diagnostic and possible operative field is obtained. In other words, the surgeon is enabled to obtain visual proof of existing pathological conditions. He can verify or reject a diagnosis which had depended upon symptoms alone, and thus fortify his opinion as to whether surgical interference is warranted.

The possibility of these radical surgical procedures settles the question as to whether or not the heart is a tender or a tough organ; it is unquestionably tough, yet is subject to grievous injury from diseases, from the emotions, from poisons, fatigue and the constant strain of our modern strenuous life.

The First Stethoscope

The art and science of diagnostics, especially in diseases of the heart, have taken a mighty stride between the first primitive stethoscope and the cardioscope. One day in 1813, Laennec, the great French clinician, was on his way on foot to call upon a patient. He saw two boys playing a game at opposite ends of a wooden beam. One tapped on the wood; the other, his ear against the beam, listened. It gave Laennec an idea. Reaching the bedside of his patient, he rolled a sheet of stiff paper into a cylinder, placed one end over the patient’s heart and listened at the other. The heart sounds were heard with much greater distinctness than when the physician applied his ear to the patient’s chest. From this primitive stethoscope the modern instrument of that name was developed.

Laennec was not the first to conceive the possibilities of auscultation, for Hook wrote in 1703 in his book Method of Improving Natural Philosophy “Who knows but that, as in a watch, we may hear the beating of the balance, and the running of the wheels, and the striking of the hammers, and the grating of the teeth, and multitudes of other noises; who knows, I say, but that it may be possible to discover the motions of the internal parts of bodies, whether animal, vegetable or mineral, by the sound they make; that one may discover the works performed in the several offices and shops of a man’s body, and thereby discover what engine is out of order? I have been able to hear very plainly the beating of a man’s heart.”

Heart Strain in Modern Life

Just before the World War, eminent physicians in Europe and America turned their attention to combating heart disease. Activity in this direction was so marked as to attract worldwide attention. Scientists seemed to be working in concert, as if forewarned of the immediate necessity for action to offset the great strain that was about to be put on the hearts of mankind. Many new diagnostic appliances were brought into use at that time, and many new surgical procedures were developed. The operations on the heart valves mentioned above are examples. And promptly the heart strain came; few escaped it.

What of today? That strain is with us yet, accentuated, moreover, by our present mode of life, by our business methods, by our feverish habits of eating and drinking, and even by the manner in which we take our recreation; in a word, we are living in an age of speed; in an age in which a tremendous strain is daily being put upon our hearts. The result is inevitable; speed will have its toll of death and disability from weakened hearts.

A physician, with this thought in mind, made an automobile tour of Manhattan Island between the hours of 11 p.m. and 1 a.m. a week ago. He touched the limits of the Island in its four cardinal aspects. In avenues and side streets; to the north and south; on the east side and west side; in parks and out of them, the same conditions were found: congestion everywhere of vehicles and persons; evidences of strain on all sides; tense and unavoidable emotionalism that must prevail where the people will not rest. All of this artificiality of life tends to produce functional derangements of the vascular system—weakness of the heart.

Science coldly proves that alcohol, tobacco, coffee and tea are capable of producing heart weakness. Persons who turn midnight into noon for pleasure, after the work of the day is done, habitually consume greater quantities of these four agents than those who do not. There can be no doubt, physicians say, that the night life of the New York of the present is highly conducive to heart strain. What can be done about it? Nothing, unless the doctors can point to a moral and drive it home convincingly enough to actuate the population of the city to go to bed when bedtime comes.

Heart disease and heart strain are two different things. Statistics are variously interpreted. One set of figures has it that 2 per cent of the population, or more than 2,000,000 persons in the United States, suffer from serious heart disease. Others interpret the figures in another light. For instance, a keeper of vital statistics will explain that the term “heart disease” on a death certificate may cover different ailments, such as those of the blood vessels, and that the term is used merely for convenience. It was reported that in 1920 there died from organic heart disease in this country 151,000 persons. On the other hand, Sir James Mackenzie of London, long distinguished as an authority on this subject, says that heart disease is not common.

Preventing Heart Trouble

“Whether common or not, physicians, school clinics and health boards happily have the means of checking it, so that the probabilities are that the future will see less of actual organic heart disease rather than more. For it is a fact that the seeds of heart disease are sown in the young, and science has learned how and where. In many cases the seeds of heart disease are germs that locate in spongy tonsils and adenoids, in bad teeth and in gums. School medical inspection is doing much to clean up these sources of infection. Then we have inflammation of the interior of the heart from rheumatic and other infections, and heart disease may follow diphtheria or scarlet fever.

The germs are swept from tonsil or infected tooth or joint into the blood stream. They reach the heart and may form fungus-like colonies on the heart’s valves. There they cause scars which are in evidence in the form of warped distortions of the edges of the valves so that they no longer fit the orifices they were designed to close tightly. The heart muscle is likewise equipped with blood vessels for its own nourishment, and the wandering germs carried through these find lodgment in the muscle itself, where they produce damaging scars. One of the varieties of germs which frequently reach the heart by the medium of the defective tonsils is the streptococcus viridans, which is the active agent in the so-called septic sore throat, often epidemic and often attributed to a faulty milk supply.

Robert Louis Stevenson strolled in the village of Saranac on a Winter night for purposes of meditation. Later he wrote of his contemplations: “‘Come,’ said I to my engine, ‘let us make a tale.’” The result was The Master of Ballantrae. By his “engine,” he, of course, referred to his brain. Had he mentioned his heart, doubtless, he would have called it his “pump.” It is often spoken of as a pump and sometimes as a power chamber.

The analogy of the pump is a striking one. Many of us have manipulated the handle of a suction-pump. When it was in full working order water gushed from its spout in a smooth, unbroken stream; when it was old, with leaky and patched valves, the water oozed from around the edges of the valves; the stream from the spout was broken and irregular, and the whole action of the apparatus was labored. So it is in the case of valvular heart disease. And it is this condition that advanced surgery, reinforced by the cardioscope, aims to remedy.

What Makes the Heart Beat

We have spoken of the heart as a power chamber; in the light of modern knowledge we can more exactly term it an electrical power chamber. In the course of a long life the heart potentially dies 3,000,000,000 or more times. There is a brief pause after each heartbeat; that infinitesimal hesitation is the potential death of the organ. How is it revived again? Science has learned that it is by self-generated electricity—the never-failing mystery of life. Today physicians speak confidently of the electrical centres of the heart. They are fairly numerous, but their exact distribution is uncertain. “With the expiring movement of the heart one or other of these tiny living batteries springs into action and explodes. For the moment this particular one is the pacemaker; the others follow in rapid succession. This is what we mean when we say that the heart is the self-winder; it is also a self-starter after the initiation of the primary impulse.

If one wishes to get an idea of this mysterious, irregular action of the electric centres of the heart, he has only to visualize a glass jar containing a dozen fireflies. Placed in the dark, the points of light are seen intermittently in different parts of the container as one would see, if they were visible, the discharges of the electric impulses in the heart.

Already science has utilized the conductivity of this heart-generated electricity in the diagnostic field. The electrocardiograph, an instrument attached to the body, receives the different heart impulses and records them by tracings on paper. Dr. Robert H. Halsey used it in the Post-Graduate Hospital in this city more than ten years ago. With these tracings before him the properly trained physician is able to translate them into terms of the cardiac conditions which give rise to them, with the same facility with which he can interpret blood conditions from a report on the analysis of the patient’s blood.

Other diagnostic devices are the polygraph, which records impulses from various blood vessels, and a remarkable instrument which, by the utilization of Einthoven’s string galvanometer, is able to photograph the sounds of the heart. The latter apparatus was used in the laboratory of the College of Physicians and Surgeons of Columbia University a decade ago, and was attached for diagnostic purposes to patients in Roosevelt Hospital on the opposite side of the street.

It should be explained that it is the belief of scientists that the heart’s revivifying electric impulses are generated by the contraction of the organ; and that the five links in the chain of cardiac integrity by which it is able to carry on its work are its functions of rhythmicity, excitability, conductivity, contractility and tonicity.

Other diagnostic inventions are the sphygmomanometer, by which the blood pressure in the arteries is determined, and radiography, by which the size and shape of the heart can be seen by means of the X-ray.

All of these aids to differential diagnosis are of comparatively recent origin. Their use and the concerted campaign against heart disease during the last decade, carried on in this city by the Association for the Prevention and Relief of Heart Disease and several cooperating organizations, have served to bring heart ailments sharply to public attention. It may be that there is no greater amount of organic heart disease than formerly; there seems to be more because of its more general recognition. The amount can unquestionably be reduced by education of the young and beneficent propaganda; also by the concerted efforts of the association for its prevention and relief and the great convalescent work being done in the splendid hospital of the Burke Foundation at White Plains, where so many heart patients are sent from the hospitals in this city. Dr. Frederic Brush presides over this institution, which is the largest and most modern for convalescents in the world. Dr. Brush advocates dancing among other exercises for the cardiac convalescent.

The remedy for modern heart strain lies with the people. There is only one remedy—a return to sane methods of living.

June 10, 1923

Heart-Lung Machine Is Used Successfully for the First Time in a Medical Case

By WALDEMAR KAEMPFFERT

What is said to be the first successful use in this country of a heart-lung machine on a human patient was reported at last week’s meeting of the American Association for Thoracic Surgery. The machine (“dispersion oxygenator” is its technical name) was developed at the Fels Research Institute for the Study of Human Development, Antioch College. It is one of about twenty that have been constructed here and abroad, all alike in principle though widely different in design. The all-glass Fels machine is probably the least expensive of the lot. It cost just $60.

The patient in the case was a former fireman who suffered from fibrosis (scarring) of both lungs. He could breathe only with difficulty, so that he became “blue.” Besides, his heart was unable to meet the demands made upon it. His blood was sent from a leg vein through the Fels machine, enriched with oxygen (normally the function of the lungs), was rid of carbon dioxide, and returned to the body through a vein in the arm. The machine was primed with three pints of blood. A little heparin prevented it from clotting.

In this case the blood was oxygenated for seventy-five minutes. The patient’s color changed from blue to a near-normal pink. Since the machine served as a lung he did not have to strain himself by breathing in short gasps. No anesthetic was necessary. After the machine had done its work the man slept soundly for the first time in weeks.

Experiments

All this was the successful outcome of a project in which the Fels Institute was joined by the University of Cincinnati’s Medical School. Not until a year’s experience had been gained with dogs was the machine tried in a human case.

There was no surgical operation. The ex-fireman did not have his chest opened to expose the heart, which is what happens to experimental dogs that survive the operation and that run about days later as if nothing had happened to them. The fireman’s lungs and his heart were still functioning. The machine did most of their work.

So far a heart-lung machine has not been used when it was necessary to open the chest and to by-pass heart and lungs completely. Dr. A. M. Dogliotti, Professor of Surgery of the University of Turin, Italy, came the nearest to this last year. He reported at the fourteenth congress of the International Society of Surgeons that in August, 1951, he had used a heart-lung machine on a 50-year-old man who was dying because a tumor was interfering with the heart’s action. Dr. Dogliotti opened the man’s chest, connected the heart-lung machine and cut out the tumor. When last heard from the patient was alive and well. Dr. Dogliotti made it plain that he used the machine only as a partial substitute for the heart. A 6-year-old child was operated on in this country last year with the aid of a heart-lung machine, but died because the case was hopeless.

Bubble Danger

In all heart-lung machines the formation of bubbles must be avoided as oxygen is introduced into the blood. Bubbles mean death. To prevent them from forming, a turbulence is created in the blood reservoirs of some machines, just as some of us stir up a Scotch and soda to make it “fizz” more. In the Fels machine oxygenated blood is broken up and with it larger bubbles by passing it upward through beads coated with silicone. In addition there is a bubble trap.

The all-glass oxygenator of the machine was invented by Dr. C. Clark Jr. He and Dr. James Helmsworth of the University of Cincinnati worked together on the fireman.

May 11, 1952

A Balloon Device Averts Surgery for Coronary Disorders

By LAWRENCE K. ALTMAN

To spare many patients painful and costly surgery, doctors are turning to a technique that involves inflating a balloon in arteries clogged by fatty deposits from arteriosclerosis.

The balloon, inflated after being introduced into the damaged area of a blood vessel, compresses obstructions and allows more oxygen-rich blood to flow to an organ. In some instances, the technique is relieving cramps and saving legs by removing obstructions to the blood supply to the lower limbs. In others, it relieves the obstructions that produce the chest discomfort called angina and might also lead to heart attacks.

In addition, this method (known technically as percutaneous transluminal angioplasty) is treating, and even curing, some cases of a type of high blood pressure that results from blockage of an artery feeding the kidneys. Although such blockages cause only a small percentage of all cases of high blood pressure, the therapy can be dramatically successful, freeing the patient entirely from drug therapy.

Until four years ago, radiologists who were experienced in using angioplasty for several ailments were unable to flatten obstructions in the coronary arteries, which are the ones that nourish the heart. Heart attacks can result when coronary arteries are blocked by fatty substances.

Now this technique, in addition to all its other applications, is becoming more commonly used to compress obstructions in coronary arteries. Although coronary angioplasty generally is still considered experimental, it is becoming a standard practice at a few hospitals.

Three doctors who have compressed obstructions in the coronary arteries of more than 1,100 patients have the longest experience with the technique. They are Dr. Andreas Gruntzig, who devised the technique at the University of Zurich and now works at Emory University in Atlanta; Dr. Simon H. Stertzer at Lenox Hill Hospital in New York; and Dr. Richard K. Myler at St. Mary’s Hospital in San Francisco.

A few doctors at other hospitals have done about 100 cases, and many more are learning the technique by attending tutorial courses and by observing their more experienced colleagues. Beyond learning the actual procedure, the doctor must also learn how to deal with the variety of life-threatening complications that can develop at any step, particularly in the coronary arteries.

Because of those potential complications, wherever coronary angioplasty is used, there must be a back-up team ready on an instant’s notice to do open-heart surgery.

Angioplasty removes the blockage caused by atherosclerotic plaques, or the accumulation of fatty substances on the inside wall of an artery. Precisely what happens to the compressed plaque and extruded material remains a mystery, but early fears that extruded plaque material might produce some new problem somewhere else have not been realized.

The chief practical problem now with this procedure is that the blood supply in an artery can stop suddenly for any of several reasons—an arterial spasm, a blood clot—threatening a heart attack or sudden death unless the problem is relieved by emergency open-heart surgery.

Until recently, use of the balloon in coronary arteries was limited to removing single obstructions, and for that reason, only about 10 percent of the estimated 100,000 patients eligible for coronary by-pass operations each year in this country were expected to benefit from the balloon technique.

However, the sausage-shaped balloon devices are being made longer and stronger. A few doctors are testing them to compress more than one obstruction in a single coronary artery or single obstructions in more than one artery. Future modifications in the equipment may allow doctors to compress, as they cannot yet, obstructions that have become hardened from natural calcification.

Further, some doctors are doing angioplasty in patients who have had coronary by-pass operations and then developed further obstructions in the veins that were grafted in the by-pass operation.

As the technology and experience improve, the number of patients who may benefit from the technique could become much larger. And whether there is a potential limit to the number of obstructions that can be removed is not known.

In about four of five patients, the balloon technique removes the obstruction and immediately relieves the symptoms. And about 84 percent of such patients will maintain their success after three years, according to data collected in a registry at the National Institutes of Health and reported at a meeting of the American Heart Association in Dallas two weeks ago.

However, the blockage may recur and close down the artery in about 16 percent of patients. Such recurrences usually happen within the first six months following angioplasty. A second angioplasty, or a by-pass operation, or both, may be needed in these cases.

According to the most recent report, emergency surgery is performed on 6.9 percent of coronary angioplasty patients. The death rate among all coronary angioplasty patients as a result of the procedure is 0.8 percent, about the same as for coronary by-pass operations done by experienced surgeons.

The angioplasty technique was devised in 1964 by Dr. Charles T. Dotter and Dr. Melvin P. Judkins at the University of Oregon, where they used it to relieve leg cramps and other problems that had resulted from arteriosclerotic plaques that blocked the arteries that nourish the pelvis and legs in nine patients. Last year, Dr. Dotter reported that the artery in one of those patients was still open without further surgery 14 years later.

The Oregon technique gained wider acceptance in European than American hospitals for compressing plaques in the arteries that supply blood to the legs. But it was not until 1977 that Dr. Gruntzig, working with engineers in Switzerland, succeeded in developing miniaturized tubes, small enough to compress an obstruction in a coronary artery. About 15,000 angioplasties have been done to date in all arteries throughout the world.

The technique, simple as it may sound, involves plenty of medical technology, including the use of a fluoroscope, at least two sets of coronary angiogram X-rays (before and after the balloon does its work), injection of several drugs during the procedure, and Teflon-coated tubes.

At Lenox Hill Hospital last Wednesday, Dr. Stertzer successfully compressed a plaque in a coronary artery of a 57-year-old-man. A few days earlier, coronary angiograms showed that his angina pain was due to an obstruction measuring less than one inch in length in a major coronary artery.

As Dr. Stertzer scrubbed his arms before beginning the procedure, he told a visiting physician: “In anyone’s first 75 cases, the complication rate is on the high side and the success rate on the low side. Now my complication rate is decreasing and my success rate increasing.”

Dr. Stertzer, a cardiologist, was aided by four attendants, including a heart surgeon, Dr. Eugene Wallsh, who stood by in case a complication might arise during the procedure, which lasted a little more than one hour.

Dr. Stertzer began by injecting a local anesthetic into the patient’s right elbow crease and used a scalpel to cut to the artery. He injected heparin, a blood-thinning drug, into the artery to help prevent the formation of potentially dangerous clots.

Then he pierced the artery with a long thin tube. At the tip was a guide wire. Two passages ran the length of the tube. One was to collect blood to record data such as the pressure within the artery as well as to allow injection of radio-opaque substances to outline the anatomy of the heart’s blood vessels. Through the second passage, an assistant would later use a hand device to inflate the balloon with fluid to crush the plaque.

Before Dr. Stertzer could align the balloon with the plaque in the left anterior descending coronary artery, he had to push the tube through the arteries in the upper arm, shoulder and into the aorta, the main artery leading from the heart.

Among the limiting factors of the technique are the tortuosity and angulation of the blood vessels as well as the nooks and crannies of the anatomy, which vary according to the individual and the degree of damage produced by arteriosclerosis.

Dr. Stertzer injected a dose of nitroglycerine to help prevent a potentially dangerous spasm of the coronary arteries. When he wanted to outline the arteries, he squirted a small amount of radio-opaque dye through the tube and observed the pattern on a fluoroscopic screen directly in front of him.

Dr. Stertzer worked patiently, but in a moment of frustration, he commented that the balloon tube “almost always goes where you don’t want it to go.”

From time to time, Dr. Stertzer removed the tube from the patient’s heart to reshape the tip of the guide wire so that he could more easily follow the anatomy of the coronary arteries. At one point, he left the room to check the location of the blockage on an angiogram.

Shortly thereafter, he passed the balloon through the obstructed portion of the artery. A technician rapidly inflated the balloon for a few seconds, then deflated it. They repeated the step three times. Each time, they increased the pressure in the balloon, thereby decreasing the amount of pressure gradient.

Then, the doctors took another series of X-rays and removed the tubes. As Dr. Stertzer sutured the incision in the elbow crease, he told the patient that he would rest in his hospital room overnight, go home to have Thanksgiving dinner with his family, and return to have exercise testing as an outpatient.

Meanwhile, the patient’s angina pain is gone, and so is his need for medication—at least for now—all without a coronary by-pass operation and at about one-fifth of the $15,000 a by-pass operation costs.

December 1, 1981

Dentist, Close to Death, Receives First Permanent Artificial Heart

By LAWRENCE K. ALTMAN

SAlt Lake City—For the first time in history, surgeons early today implanted a permanent artificial heart to replace a dying human heart.

The operation, which lasted seven and a half hours, was performed at the University of Utah Medical Center here by a team headed by Dr. William C. DeVries.

The patient was Dr. Barney B. Clark, a 61-year-old retired dentist from the Seattle area. Dr. Clark, who was described as bedridden and on the verge of death from heart failure just before the operation, was reported in critical but stable condition tonight. If he recovers, he is destined to spend the rest of his life tethered to 6-foot-long hoses connected to an air compressor that powers the artificial heart. The compressor sits in what his doctors call “a grocery cart.”

Indicates He Is Not in Pain

Doctors at a news conference late today said Dr. Clark was able to recognize his wife, signal yes or no in response to questions and move his arms and legs. His doctors said he had indicated to them that he was not in pain.

He was also said to have given a note to a nurse asking for a drink of water, which he cannot have yet. He cannot speak because his breathing is being maintained for now by an artificial respirator that is connected to a tube in his windpipe.

Dr. DeVries declared the operation “a success” and expressed cautious optimism about Dr. Clark’s prognosis. “He looks like any other patient coming out of open-heart surgery,” Dr. DeVries said. His recovery, he added, “is not over yet; it’s just beginning.”

The surgeon said that “last night, all the doctors on the team believed he would be dead” without the operation, “and he isn’t.” The operation was described as a dazzling technical achievement. But its value in the treatment of the estimated 50,000 Americans each year who might need it will depend partly on how long and how well Dr. Clark and other recipients live. Moreover, if the procedure proves successful, it will raise difficult questions about who should receive the hearts and the nation’s willingness to pay the price. The device itself cost $16,450.

The doctors frequently adjusted the rate of Dr. Clark’s artificial heartbeat after the operation ended shortly after 7 a.m. today. It was beating at 116 times each minute at latest report. The heartbeat for healthy people varies considerably but is usually within the range of 65 to 80 beats a minute. The doctors do not know what the appropriate rate for Dr. Clark will ultimately be.

In the complex recovery process, Dr. Clark faces many potential complications, including pneumonia, other infections, collapsed lungs and blood clots. But the possibility of rejection, which has been the bane of human heart transplantation, does not exist in this case because there is no foreign tissue to set off the body’s attack mechanism.

Dr. Clark was described as an ideal candidate to be the first recipient of the experimental heart because he was psychologically well-adjusted and had excellent support from his family. Moreover, as a medical professional, he understood that doctors could do nothing else for him and that he had no other option but death.

The artificial heart, made largely of molded polyurethane, is called the Jarvik-7 after its developer, Dr. Robert K. Jarvik, who is a member of the surgical team. The device is somewhat larger than a human heart but weighs about the same. Powered by the compressor, it makes a soft clicking sound that is audible through Dr. Clark’s chest wall.

Dr. Chase N. Peterson, vice president of health affairs for the University of Utah, described Dr. Clark and the surgical team as “on the threshold of something that is as exciting and thrilling as has ever been accomplished in medicine.”

“Striking Out for New Territory”

“This man is no different than Columbus,” he said. “He is striking out for new territory.” For the last three years, Dr. Clark has suffered from a condition of unknown cause called idiopathic cardiomyopathy, which is a primary disease of the heart muscle. It resulted in congestive heart failure, in which an insufficient supply of blood is circulated through the body.

There were anxious moments in the operation, although they were not considered life-threatening. One part of the mechanical heart was defective and had to be replaced by a spare part. Another difficulty was that Dr. DeVries had to work with heart tissue that was paper-thin because of earlier steroid therapy.

Dr. DeVries expressed hope that Dr. Clark could leave the hospital in a few weeks. He would then live with his family in a specially equipped house in Salt Lake City.

Dr. DeVries made it clear that he would not proceed with another similar operation until the results of this one were clear.

Was No Definitive Treatment

Until the recent licensing of a drug called captopril, there has been no definitive treatment for the condition Dr. Clark suffered from. In addition, many other drugs are part of the standard medical regimen for heart failure. Coronary bypass and other operations are of no value in remedying Dr. Clark’s condition.

Dr. Clark’s physicians in Seattle and here had treated him with steroids because they suspected he might have a condition called myocarditis that resulted from a viral infection.

At the time of the operation, his diseased heart was no longer responding to the standard drugs. Dr. Clark was selected as the first recipient of an artificial heart largely because he was born in Utah and commuted here from Seattle to visit members of his family. His cardiologists, Dr. Terence A. Block in Seattle and Dr. Jeffrey L. Anderson here, worked as a team and eventually referred him to the Utah medical center as a possible candidate for the operation.

As Dr. Clark’s condition deteriorated, his physical activity was increasingly curtailed. In recent weeks he was confined to bed as the heart failure approached its terminal stages.

Operation Was Put Off

He was reported to have put off the operation until now partly because he wanted to put his affairs in order. He was not eligible as a candidate for a heart transplant at Stanford Medical Center because doctors there have decided not to do the operation on people older than 50.

Dr. Clark’s condition worsened last weekend. More fluid accumulated in his legs and abdomen because his dying heart could not pump enough blood. His breathing became more difficult because fluid accumulated in the lungs.

Had Dr. Clark not been a candidate for the artificial heart, Dr. DeVries said, he probably would have died at home. Instead, he was admitted to the hospital Monday afternoon. Shortly thereafter, he signed a so-called informed consent form permitting the experimental operation. He signed it again 24 hours later in accordance with regulations of the Federal Food and Drug Administration, which regulates devices such as the artificial heart.

In the intervening 50 or so hours, the doctors prescribed even larger doses of the drugs he was taking to prepare him for the operation. The doctors also worked to correct abnormalities in his blood clotting system and other bodily functions resulting from the heart failure. Tests of his critically important kidney function were reported within normal limits. The other worrisome conditions responded well enough for the doctors to proceed.

The operation had been scheduled to begin at 8 a.m. today, but it was advanced to late last night because the doctors felt they could wait no longer.

His cardiac output, a critical test of heart function, was one liter instead of the customary five liters, Dr. Peterson said.

There were several urgent concerns. One was that Dr. Clark would suffer a stroke or serious brain damage overnight, thereby making the operation worthless. Another was that with further deterioration the hazards of surgery would have been even greater than they generally are for an experimental operation.

In the operation, about two-thirds of the heart was removed. The surgeons removed the bottom two chambers, the left and right ventricles. But they left the top two chambers, the left and right atria, as an anchor for the artificial heart.

December 3, 1982

Race Is On to Develop Nonsurgical Ways to Unclog Arteries

By SANDRA BLAKESLEE

As millions of Americans cope with the pain and danger of clogged arteries, physicians are striving to develop improved nonsurgical techniques for cleaning out the arteries safely and permanently.

In experiments at hospitals all over the country, patients are having their arteries reamed out with hot lasers that boil away the clogs, or blasted out with “cold” lasers. Others are having their arteries cleaned with mechanical devices that shave or gouge away the clogging material, called plaque. Some patients are having mesh-like wires implanted into their freshly cleaned arteries to prevent new obstructions from forming.

Doctors say many patients, lured by the notion that lasers perform miracles and by hospital advertising, are specifically requesting such procedures instead of today’s conventional nonsurgical treatment, balloon angioplasty.

Some Experts Are Worried

This worries some experts. While some new methods may prove helpful in saving lives, some proponents are making unsubstantiated claims about their experimental systems and especially about lasers, said Dr. George Abela, a cardiologist at the University of Florida School of Medicine in Gainesville who is a pioneer in the field. “Unfortunately, if these claims are not borne out, both the public and the scientific community will be put off the technology.”

Dr. Tom Robertson, chief of the cardiac disease branch of the National Heart, Lung and Blood Institute in Bethesda, Md., said: “The public should consider these techniques to be experimental. We do not yet have enough information to know if the benefits outweigh the risks.”

Experts said the lure of huge profits was driving the boom in improved methods for cleaning arteries, especially clogged coronary arteries that can lead to heart attack.

Until a decade ago, the only treatment for blocked arteries was bypass surgery. In a long operation, blood is detoured around the blocked section of an artery with a section of vein taken from the leg or with a nonessential artery from the chest.

In the late 1970s a nonsurgical technique, balloon angioplasty, was introduced in which an ultra-thin guidewire is inserted into a major leg artery and threaded through the circulatory system to an obstruction. Only a minor incision is required.

Doctors track the wire on a special screen with an image similar to an X-ray. Dye is injected into the patient’s arteries so they are highlighted on the screen. Next, a long thin tube called a catheter, with a deflated balloon on one end, is passed along the guidewire to the obstruction. When the tip of the catheter reaches the blockage, the balloon is inflated, pressing plaque against the arterial walls and opening a channel through which blood can flow more freely.

The major drawback is that 30 percent of all coronary arteries and 40 to 50 percent of leg arteries develop new obstructions within six months of the balloon treatment, doctors say.

Surgeons are not surprised by the high recurrence rate, said Dr. Nicholas Kouchoukos, a cardiologist at Washington University in St. Louis. “When you take plaque and mash it up against the wall of an artery, you split layers of the vessel itself,” he said. “That trauma invites problems.”

Doctors say the balloon often leaves a jagged edge, with flaps of tissue hanging loose from the artery’s inner lining. Most balloon angioplasties are done with a surgical team standing by so that if an artery clogs soon after the balloon is removed, an emergency bypass operation can be performed. Another drawback is that totally blocked arteries and arteries with many obstructions are not amenable to the technique.

Given these problems and the vast market, dozens of companies are developing techniques to improve conventional balloon angioplasty.

The sexiest systems from a marketing standpoint use lasers to vaporize or destroy plaque. Lasers are devices in which atoms or subatomic particles are jostled to generate highly concentrated energy beams. The three being developed for use in arteries are based on different ways of exciting the atoms of a variety of gases or matter. These include argon, a synthetic garnet crystal and a mixture of reactive gases. Each operates at different energy levels.

The main risk of using lasers is perforation. Coronary arteries are notoriously difficult to work with. Small and fragile, they move with each heart beat and take tortuous turns. The sac around the heart will fill up with blood a minute after a vessel is broken, stopping the heart. Lasers can also burn arterial walls, causing them to shrink and lose water.

Most laser angioplasty systems today are being tested in long, straight leg arteries. Only a few are being tested in the coronary arteries.

One leading system, the hot tip, makes use of a laser to heat a bullet-shaped metal or sapphire cap at the end of a catheter. The tip, 750 degrees Fahrenheit, is moved back and forth through the blockage. After the tissue swells up from the heat injury, a balloon widens the vessel.

Another system employs a hot laser to destroy tissue, then relies on conventional balloon angioplasty to further open the artery. In June, a team at the St. Francis Hospital in Evanston, Ill., was first to open a totally blocked coronary artery using laser-assisted balloon angioplasty.

Researchers are also working on a “cold,” or excimer, laser, which operates at ultraviolet wavelengths with extremely high energy levels. Molecules are driven apart by light rather than heat. The excimer cuts precisely, leaving a smooth unburned surface. Balloon angioplasty may not be needed as a follow-up.

Another experimental procedure uses two types of laser. After a catheter reaches a blockage, a low-power laser is used to identify the type of tissue in the target. Then a high-powered laser blasts away the tissue.

Laser-Balloon Techniques

Perhaps the newest technique is balloon-laser welding. An artery is first widened by conventional balloon angioplasty. On the last balloon inflation a laser is turned on, heating the surrounding tissue. The temperature is not hot enough to destroy tissue, but the artery walls are stretched and welded into a smooth surface. Because the procedure is painful, patients are briefly anesthetized.

Some doctors are testing new mechanical devices. An artherectomy catheter shaves plaque out of an artery. Other devices suction the plaque or gouge it out. In addition, mesh-like metallic devices called stents are being placed in arteries to hold them open after balloon angioplasty.

Dr. Abela and others say that each new system for cleaning arteries may eventually find its own niche.

“We need to learn which device works best under which circumstances,” he said.

July 28, 1988

New Heart Studies Question the Value of Opening Arteries

By GINA KOLATA

A new and emerging understanding of how heart attacks occur indicates that increasingly popular aggressive treatments may be doing little or nothing to prevent them.

The artery-opening methods, like bypass surgery and stents, the widely used wire cages that hold plaque against an artery wall, can alleviate crushing chest pain. Stents can also rescue someone in the midst of a heart attack by destroying an obstruction and holding the closed artery open.

But the new model of heart disease shows that the vast majority of heart attacks do not originate with obstructions that narrow arteries.

Instead, recent and continuing studies show that a more powerful way to prevent heart attacks in patients at high risk is to adhere rigorously to what can seem like boring old advice—giving up smoking, for example, and taking drugs to get blood pressure under control, drive cholesterol levels down and prevent blood clotting.

Researchers estimate that just one of those tactics, lowering cholesterol to what guidelines suggest, can reduce the risk of heart attack by a third but is followed by only 20 percent of heart patients.

“It’s amazing and it’s completely backwards in terms of prioritization,” said Dr. David Brown, an interventional cardiologist at Beth Israel Medical Center in New York.

Heart experts say they understand why the disconnect occurred: they, too, at first found it hard to believe what research was telling them. For years, they were wedded to the wrong model of heart disease.

“There has been a culture in cardiology that the narrowings were the problem and that if you fix them the patient does better,” said Dr. David Waters, a cardiologist at the University of California at San Francisco.

The old idea was this: Coronary disease is akin to sludge building up in a pipe. Plaque accumulates slowly, over decades, and once it is there it is pretty much there for good. Every year, the narrowing grows more severe until one day no blood can get through and the patient has a heart attack. Bypass surgery or angioplasty—opening arteries by pushing plaque back with a tiny balloon and then, often, holding it there with a stent—can open up a narrowed artery before it closes completely. And so, it was assumed, heart attacks could be averted.

But, researchers say, most heart attacks do not occur because an artery is narrowed by plaque. Instead, they say, heart attacks occur when an area of plaque bursts, a clot forms over the area and blood flow is abruptly blocked. In 75 to 80 percent of cases, the plaque that erupts was not obstructing an artery and would not be stented or bypassed. The dangerous plaque is soft and fragile, produces no symptoms and would not be seen as an obstruction to blood flow.

That is why, heart experts say, so many heart attacks are unexpected—a person will be out jogging one day, feeling fine, and struck with a heart attack the next. If a narrowed artery were the culprit, exercise would have caused severe chest pain.

Heart patients may have hundreds of vulnerable plaques, so preventing heart attacks means going after all their arteries, not one narrowed section, by attacking the disease itself. That is what happens when patients take drugs to aggressively lower their cholesterol levels, to get their blood pressure under control and to prevent blood clots.

Yet, researchers say, old notions persist.

“There is just this embedded belief that fixing an artery is a good thing,” said Dr. Eric Topol, an interventional cardiologist at the Cleveland Clinic in Ohio.

In particular, Dr. Topol said, more and more people with no symptoms are now getting stents. According to an analysis by Merrill Lynch, based on sales figures, there will be more than a million stent operations this year, nearly double the number performed five years ago.

Some doctors still adhere to the old model. Others say that they know it no longer holds but that they sometimes end up opening blocked arteries anyway, even when patients have no symptoms.

Dr. David Hillis, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas, explained: “If you’re an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them they don’t need the procedure, pretty soon Joe Smith doesn’t send patients anymore. Sometimes you can talk yourself into doing it even though in your heart of hearts you don’t think it’s right.”

Dr. Topol said a patient typically goes to a cardiologist with a vague complaint like indigestion or shortness of breath, or because a scan of the heart indicated calcium deposits—a sign of atherosclerosis, or buildup of plaque. The cardiologist puts the patient in the cardiac catheterization room, examining the arteries with an angiogram. Since most people who are middle-aged and older have atherosclerosis, the angiogram will more often than not show a narrowing. Inevitably, the patient gets a stent.

“It’s this train where you can’t get off at any station along the way,” Dr. Topol said. “Once you get on the train, you’re getting the stents. Once you get in the cath lab, it’s pretty likely that something will get done.”

One reason for the enthusiastic opening of blocked arteries is that it feels like the right thing to do, Dr. Hillis said. “I think it is ingrained in the American psyche that the worth of medical care is directly related to how aggressive it is,” he said. “Americans want a full-court press.”

Dr. Hillis said he tried to explain the evidence to patients, to little avail. “You end up reaching a level of frustration,” he said. “I think they have talked to someone along the line who convinced them that this procedure will save their life. They are told if you don’t have it done you are, quote, a walking time bomb.”

Researchers are also finding that plaque, and heart attack risk, can change very quickly—within a month, according to a recent study—by something as simple as intense cholesterol lowering.

“The results are now snowballing,” said Dr. Peter Libby of Harvard Medical School. “The disease is more mutable than we had thought.”

The changing picture of what works to prevent heart attacks, and why, emerged only after years of research that was initially met with disbelief.

Early attempts to show that opening a narrowed artery saves lives or prevents heart attacks were unsuccessful. The only exception was bypass surgery, which was found to extend the lives of some patients with severe illness but not to prevent heart attacks. It is unclear why those patients lived longer; some think the treatment prevented their heart rhythms from going awry, while others say that the detour created by a bypass might be giving blood an alternate route when a clot formed somewhere else in the artery.

Some early studies indicated what was really happening, but were widely dismissed. As long ago as 1986, Dr. Greg Brown of the University of Washington at Seattle published a paper showing that heart attacks occurred in areas of coronary arteries where there was too little plaque to be stented or bypassed. Many cardiologists derided him.

Around the same time, Dr. Steven Nissen of the Cleveland Clinic started looking directly at patients’ coronary arteries with a miniature ultrasound camera that he threaded into blood vessels. He found that the arteries were riddled with plaque, but almost none of it was obstructing blood vessels. Soon he began proposing that the problem was not the plaque that produced narrowings but the hundreds of other areas that were ready to burst. Cardiologists were skeptical.

In 1999, Dr. Waters of the University of California got a similar reaction to his study of patients who had been referred for angioplasty, although they did not have severe symptoms like chest pain. The patients were randomly assigned to angioplasty followed by a doctor’s usual care, or to aggressive cholesterol-lowering drugs but no angioplasty. The patients whose cholesterol was aggressively lowered had fewer heart attacks and fewer hospitalizations for sudden onset of chest pain.

The study “caused an uproar,” Dr. Waters said. “We were saying that atherosclerosis is a systemic disease. It occurs throughout all the coronary arteries. If you fix one segment, a year later it will be another segment that pops and gives you a heart attack, so systemic therapy, with statins or antiplatelet drugs, has the potential to do a lot more.” But, he added, “there is a tradition in cardiology that doesn’t want to hear that.”

Even more disquieting, Dr. Topol said, is that stenting can actually cause minor heart attacks in about 4 percent of patients. That can add up to a lot of people suffering heart damage from a procedure meant to prevent it.

“It has not been a welcome thought,” Dr. Topol said.

Stent makers say they do not mislead doctors or patients. Their new stents, coated with drugs to prevent scar tissue from growing back in the immediate area, are increasingly popular among cardiologists, and sales are exploding. But there is not yet any evidence that they change the course of heart disease.

“It’s really not about preventing heart attacks per se,” said Paul LaViolette, a senior vice president at Boston Scientific, a stent manufacturer. “The obvious purpose of the procedure is palliation and symptom relief. It’s a quality-of-life gain.”

March 21, 2004