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»Listen to this interview in streaming RealAudioThe next in line of a series of interviews is being conducted in Doctor Crafoord’s room at the Brown Palace Hotel, today, the 26th of April, Friday, 1974.
TRS: Doctor Crafoord, welcome to Denver.
CRAFOORD: Thank you.
TRS: Would you tell us a bit about your background and what brought you into the study of medicine?
CRAFOORD: I decided already as a very small boy to be a doctor and to be a surgeon, and I have never been hesitating to follow that decision which was done when I was about 4 or 5 years old at any time.
TRS: During your childhood, were there any obstacles along the way?
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Dr. Clarence Crafoord
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TRS: I see--- very good. And where did you take your medical training?
CRAFOORD: At the Carolinska Institute in Stockholm.
TRS: And when did you finish medical school?
CRAFOORD: I finished medical school in 1924.
TRS: In what area of surgery did you become interested in first?
CRAFOORD: I was interested in general surgery – in the whole field of general surgery – with the exception of eye surgery, which never interested me at all. But I have been acting as assistant – we call it – (you call it, I don’t know, interns) something like that in your country both in ear, nose, and throat departments and in surgical department and in medical department and also in orthopedics one short time. I have been operating all over the human body with the exception in the eyes. I have done radical, radical mastectomies and also the radical operation of septic ears when you take, remove the whole of the inside of the ear and when you incise the sinus and make tamponage of it when the direction is going over on it on that blood vessel.
TRS: When did you first become specifically interested in vascular---cardiovascular?
CRAFOORD: I would say that in 1924-25 I became very much interested in it and that it was probably due to the interest of that field that my chief at that time had.
TRS: Who was that?
CRAFOORD: That was Professor Clutara Yetz and he had studied as a young man down with Sauerbruch in, when he was in, Munich and had watched the overpressure and un, un, and low pressure bringing in that Sauerbruch was using and came to the conclusion that this was the false way to give artificial respiration. So he was doing quite a lot of experimental work with intermittent positive pressure breathing. He wrote an article about that already in 1914-15 and that interested me very much – that work that he had done – and continued on these studies on the best way to give artificial respiration to people under anesthesia.
TRS: What are some of the important developments in this field that enabled you all to do surgery? Some of the important things that developed along this period of time that contributed to success?
CRAFOORD: Yes. It was the friends of mine in the ear, nose and throat department. We were working together on producing a good endotracheal catheter, for instance, with an inflatable balloon and also double barrel catheter that was a friend of mine, Franek. Then there was another one by the name of Carlens – we worked together on that so you could give, at the same time, special determined volumes to each lung so you didn’t have to inflate both lungs at one time. You could go on one lung or on both lungs and so on and during that time in connection with the big, well, the big industries in Sweden the AGA (A-Gas as it is called in our country) they have an experimental department and, well, the engineers there and I made very good friends and he helped very much to develop this Spiropulsator, as we called it, that we had ready at the end of the 1930’s (1937-38) and which I brought over to the United States in 1939 to demonstrate it and in order to give the guest lecture in Los Angeles in 1935 about my opinion about how an open chest operation in what way it should be performed.
TRS: Doctor Beecher was there at that time. What reaction did he have to your presentation?
CRAFOORD: He told me that I was on a very dangerous route in that putting endotracheal catheters was unphysiological and should not be done in any other than emergency cases. And I think that most of us now in the field of thoracic surgery are more in my line than Beecher’s.
TRS: You also met Doctor Cutler on that trip?
CRAFOORD: Yes, yes. I was introduced to him by my surgery chief, Clutara Yetz, who had been a chief professor in his service in, in Boston for I think it was 4 months period or something like that. And they were very good friends at that time and I visited him when I landed and came to Boston.
TRS: I understand that you had some experience in raising pigs at that time. Is that right?
CRAFOORD: Yes. I think that, if I remember correctly, that that was the next time that I came over that we had ……
TRS: It was after the Second World War.
CRAFOORD: Yes. We were chasing pigs in his garden he had during the second world war and he had been breeding pigs for himself and the family and they still had some of those left and they got loose so we – when I came there on a Saturday morning – we had to chase pigs all over the place.
TRS: You’ve also had an interest in anticoagulants.
CRAFOORD: Yes, very much so, in that, we (I) was the first in my country and one of the pioneers in the total pulmonary embolectomies. I made a couple of those with success, already it was ’26 or ’27 – I think it was – and using the same type of artificial respiration but with one of the Sauerbruch’s equipment which I had made some arrangement with I could break it off and let them have free expiration and then pump them into the respiratory gases and the anesthetic gases again in those cases as I did in the few cases that we did at that time with open chest.
TRS: And how about your interest in Heparin? How did that come about?
CRAFOORD: That came about because of my interest in thrombo-embolic complications. When I had the, we had during the late twenties, we had a very decided accumulation of thrombo-embolic complications in cases like cholecystectomies, gastric resections and also abdominal surgery in people over 35-40 years of age and we had (no, we had not) any means to accurately diagnose pre-op, before, embolic episodes came, that a thrombotic lesion was prevalent. And we had no means in making routine prevention of it, but I read at that time the work done by Howell on something that he called “Heparin”, which was a preparation which was not quite clearly defined what it really was and I took that with me to the chemistry department where I had one of my friends and asked him to help me to get this “Heparin” preparation. He told me that it is a very complicated matter and that I couldn’t do that now. But, some years afterwards, he came on the circumscript route to the detection that it was the molecules that contained sulphuric acid and that was very important and he built up the whole chemical formula of Heparin in the beginning of the ‘30’s. It was produced by one of our chemical firms, Vitrum, in Sweden for us. And it was tried first on willing persons in the medical field that put themselves up for the disposing in order to test that it was not poison and that it had no severe after effects, and we got a very pure and good preparation that we decided finally to use in surgical practice as the Salisbury Hospital. At that time, the town authorities were very kind to me because they gave (it was very expensive) and they gave me the means to work with it in the surgical wards and I selected the patients in which I used it and we finally came to the routine that one injection was given intravenously every fourth hour around the clock, of about between 50-150 milligrams of the preparation that we had (I don’t remember what number units that would be equivalent to if you were giving the preparation that they produced in Toronto). They did not give it in milligrams; they gave it in units, so I don’t remember what kind.
TRS: About a 100 to 1 ratio.
CRAFOORD: Yes.
TRS: And then we followed the correlation time of the way and we got a very steep correlation, the depression just a few minutes after the Heparin was given and then it gradually went back and when it was nearly down to normal again then we gave the next one, and that took about, with the quantity that we gave, that took about four hours.
TRS: We really haven’t progressed very much further in our dosage. That is the same way we give it now.
CRAFOORD: Yes, with the exception of those who give it subcutaneously or intramuscularly, which I don’t think is quite as reliable.
TRS: I agree.
CRAFOORD: No, and my secretary that I have now, she came to me at that time as a young girl and she was sleeping on the couch in my room in the hospital and she took the, we went up every fourth hour and draw blood in connection to give you the next injection and make the coagulation determination. So we worked together on that as we are working ever since for more than 34 years now. So that focused my interest on anti-coagulation.
TRS: What stimulated your interest in the surgery of blood vessels? And specifically, now, the thoracic aorta?
CRAFOORD: You know, it was, I had been working in the laboratory on resection of arteries and end-suturing for some time. And I tried different types of end-suturing and had come to the conclusion in the first beginning that if you could just get an anatomical approximation of the two cut surfaces you would get the best healing and the best prerequisites for growing of the vessels. And I had, also, done aortic animal resections and so there came along some cases of coarctation that a friend of mine in the medical side had, and he asked me if I knew if that was working and if I thought it would be advisable to try any of those cases. And I said yes, I think, experimentally it is quite clear that it is possible to do, so I think we could start to do it. And then there came a boy of about 7 or 8 years, something like that, with a coarctation and here we have to try to arterial catheterization and he was practically blocked at the site of the coarctation, couldn’t get up from below anyway, but we had a very big gradient between the aortic arch and the descending aorta. So I explored him and it was an anatomically good case for resection of a rather short segment and end-to-end suture and that went off without any complications at all. And I followed him and that is now more than 30 (no, let me see, it is ’74 now isn’t it?) it will be 30 years, now, next October that the resection was done and I have followed him and his aorta has grown together with him and there has been no resection and I think it is just a matter of exact good anatomical surgical work where that is a prerequisite for the site of resection to grow together with his heart and his heart is growing. I have had cases later on in heart failure which I operated on in the first week of life and their vessels are growing together with the children as well.
TRS: Do you think it makes any difference what type of suture technique that is used?
CRAFOORD: Yes, I think it does. I think that one has to use the type of technique that gives us the less fibrous reaction as possible. I tried to use isolated tissue as much as possible only a short stretch on the back side is easier to do continuous and then stretch those two ends and then go on with the isolated sutures afterwards, but also in the area where you have continuous suturing when the child is growing I think that then I have seen one case that we had a post-mortem on quite a long time after he died from quite another cause that the part of the continuous suture made had broken down and was just as a foreign body incorporated in the area of the suture and I don’t know – I think if you do a continuous all around it is not, it is more difficult, for the growth. It is not the same good situation for growing afterwards.
TRS: Did you encounter cases where you thought you might have to use some other material? A graft?
CRAFOORD: I have tried to avoid that as much as possible because I have always been an opponent to incorporating foreign bodies in the human being if it is possible to avoid it. But I have had to use grafts in full grownups where the quality of the wall of the aorta had been so bad so the sutures will try to get a little tension and I have used Dacron-- Dacron grafts-- later on.
TRS: When were you first aware that Dr. Gross was working on this problem at the same time?
CRAFOORD: I was not aware of that before I came over to the United States first time after the war. I met him and saw him do experimental work on producing and closing patent ductuses already in 1939. And I did my first ductuses after I came back home after having seen his work in that field. But we had Dr. Walter Bauer, whom you know was at the Massachusetts General as a guest during the war, and he saw (I think it was) my coarctation number 2 or 3 at the beginning of 1945. He was in my operating room and he saw me perform one and he went back and told about it in Boston. But I don’t think that Gross ever realized he had seen me do it because he didn’t mention it in his first publication at all.
TRS: Dr. Blalock was working on this problem about the same time.
CRAFOORD: Yes, but he was taking down the subclavian artery and tried to make an anastomosis between the cut end of the subclavian artery to the aorta, a modification that did not attract me at all. You couldn’t get the same good, wide anastomosis.
TRS: One of the problems that he had was ischemia of the cord. Did you-- have you-- run into this problem in your early work?
CRAFOORD: No, I have not run into troubles with that at all.
TRS: And don’t feel that it is particularly necessary to protect the cord at all?
CRAFOORD: No. You know when I was reasoning like this – when you can see clinical that if you have a coarctation that is practically a 100 percent, then you have so good developed collateral circulation so the cord wouldn’t be hit by it when you cross clamp and you don’t do the coarctations, (we didn’t do the coarctations) in the beginning if that was not a very definite gradient between below and above; and where there is a high gradient there must be a quite well-developed collateral circulation. I only been having a complication of spinal cord one time and that was because of a great heavy bleeding. I had to cross clamp the aorta in the case of patent ductus and I had it clamped for about 20 minutes and that changed it a lot, some spinal cord disturbances, afterwards.
TRS: What do you think about the role of the high intercostal arteries below the level of the coarc? Do you worry about taking one or two of those?
CRAFOORD: No, not at all. I try to avoid it naturally but if I have to do a dissection long enough to get the aortic stumps together, I have to free so much in direction and caudal direction in order to get it together, I never hesitated to take one or two intercostal arteries. They are very big and they, naturally, have some importance for the collateral circulation but when you are doing the arteriograms preoperatively, you see they are very large and big mammary arteries which also gives a lot of the arterial circulation down to the lower part of the body.
TRS: In your experience, up to the time area that we are talking about, are there any amusing incidents or anecdotal episodes that occur to you right now?
CRAFOORD: Yes. When I was over here for the first time after the war, I met Jack Gibbon. Our relationship developed into a very close friendship between us, the two of us, and our families (telephone rings: “that must be for you not for me”). I was just telling you that I was meeting Jack Gibbon in Philadelphia and saw his experimental work on the heart-lung machine and when I came back home we started to work on that as well. The same engineer that had made the Spiropulsator and I , we started to work on that and I had at that time Dr. Bjork, who is now my successor, working with me and he was taking part in that as well and made his thesis for the medical doctor examination on that and we produced a disc oxygenator. It was mainly the engineer was doing most of the construction work, you see, and we started out with only perfusing the brain as we knew that the brain does not stand more than three or four minutes of complete ischemia. And then we operated on dogs for 20 minutes-half an hour with only brain perfusion and then we cut it off again and could show that brain perfusion was quite adequate to prevent brain damage. And so we did continuously better and better technical equipment and then Ẩke Senning came with me and he and I and another engineer from the same company were trying the roller equipment and we did our first complete open heart operation already in the summer of 1954. Jack Gibbon had made one in 1953. If I remember, ours was the second that was done and that was a case of a big left ventricular aneurysm that we resected under open heart and that man, he lived for about a five-year period afterwards and died from coronary disease finally. And then we started out with not the very best cases because we were interested in the tetralogy of Fallot. So we started out to do them open but they were not suitable for it as this aneurysm and also this big tumor that we did quite a short time after that aneurysm, one of the big tumors of the left auricle. We opened up and made that open with good success and then we gradually came into refining the open heart surgery techniques and we could also get the tetralogies and things like that.
TRS: What type of protective devices did you use to prevent air in the left side of the heart during your operations on the aneurysm and the mitral?
CRAFOORD: We closed, at that time, manually the mitral orifice, during the time that we had it open, and we also had the aorta clamped, during the time that the auricle was open. And we did not have at that time any embolic, in the first case, we didn’t have any embolic complications.
TRS: Have you had any experiences or early experiences in the field of hypothermia?
CRAFOORD: Oh, yes. We combined from very early in our combination (with the heart-lung machine) – we combined and we continued to combine that with moderate hypothermia down to something about 26-27 degrees of the esophageal and brain temperature. But we had some complications when we tried with the deep hypothermia as well. And we had with the deep hypothermia some brain disturbances in the encephalograms and also from the patients waking up. They were not quite the same to talk to as they were before when we had to go down to 15 centigrade. We tried that sometimes and we consider that deep hypothermia on full, grown-up people might be dangerous. And we stopped it then.
TRS: You have had a great and distinguished career to look back upon. Could I pick your brains for what you think the future has to hold for this particular field?
CRAFOORD: I think that the development towards being able to prevent the blood that you take out and oxygenate, to prevent this blood to get into contact directly with the atmosphere is an important factor. You can’t prevent all the blood that you may take back to the machine to get into contact, but the less contact the more that you can do with oxygenation similar to the one that is done in the lungs, I think is something to strive at and quite a number of people do that now.
TRS: Do you think that the membrane oxygenator may be an answer to this question?
CRAFOORD: Yes, I think that some sort of that type might be the answer. It might be possible that it has been tried to use different types of animal, and also human, lungs to oxygenate and I don’t know something might come out of that in connection to transplantation and developments of transplantation.
TRS: What do you think about the operation that is sweeping the world at the present time – the bypass procedure for coronary artery disease?
CRAFOORD: I think it can be considered already proven and that for a short time periods (I count 3 or 5 year survival as a short time), it might be have some benefit. But I think that what one must do is try to find how to prevent coronary atherosclerosis to appear. I think that is the main thing and to do a one, two, three, four or five bypass graft, I think is not the route to try to make us as the route that we should follow for the future. I think that prevention there is the only answer to question, but as long as we can’t do that we will have to do the next best thing.
TRS: I understand that you are acquainted with Dr. Swan, as we are, and that you took a trip to Athens with him at one time. And I wonder if you would mind relating some of your experiences there?
CRAFOORD: I think that the experience that I had in his room with the lung fishes swimming in his bathtub I think was the most exciting of all the experiences and I know he was able to get all these animals through the customs and through the authorities in Egypt, in Greece, in France, in England, and finally he brought them to Denver, Colorado and made some interesting experiments in order to try to elucidate why hibernation is taking place both for cold and for heat.
TRS: Reminiscing again, are there any people in our discussion so far that we may have left out that you think contributed greatly to cardio-vascular surgery in its infancy?
CRAFOORD: Yes. I think that a man like Sauerbruch contributed. I think that old Matas from New Orleans contributed quite a lot; he was a very early one positive to more normal conditions during artificial ventilation than any of the other ones on this side of the ocean, and I think that then when The Society of Thoracic Surgeons started, you had people in New York and in this country during the date period between 1918-1919, beginning of the 20’s, who were working on the intermittent positive pressure breathing as well but not with the same well-developed machines and with the intratracheal air tightening intubation which came much later here when the very sensitive hand of the anesthetist on the pressure bag was the only thing to produce artificial ventilation.
TRS: Dr. Crafoord, thank you very much for taking the time to be with us today and we hope that you have a pleasant stay in Colorado and a nice trip back home. Thank you so much.
CRAFOORD: Thank you. Thank you for your kindness to approach me and for what you have done for me.
TRS: Thank you.
