A Tribute to Frank F. Allbritten, Jr.

Frank F. Allbritten, Jr., was born on the plains of south central Kansas in 1914. That same year, Germany declared war on Russia, France, and Belgium, igniting World War I. The rich soil that surrounded Frank's hometown of Cunningham produced luscious fields of corn, wheat, and milo. Although not himself a landowner, Frank's father worked at and later purchased a grain elevator in town. As a youngster, Frank excelled in the classroom and graduated from Cunningham High School in 1931 at the age of 16. Four years later, he received a bachelor of arts degree from the University of Kansas. Frank aspired to be a lawyer, but found the coursework too tedious. He settled on becoming a doctor and was accepted into the University of Kansas School of Medicine, where he studied for 2 years. He then transferred to the University of Pennsylvania School of Medicine and graduated with a doctor of medicine degree in 1938. Following a 2-year internship at the University of Pennsylvania Hospital, Allbritten served 3 years as a surgical resident at Pennsylvania Hospital in Philadelphia, where his stipend was $100 per month. During his internship, Frank had met 2 people who changed his life forever. The 1st, Marjorie Clarkson Bately, was a nurse who cared for him while he was briefly hospitalized with a hand infection. Within a few months of their 1st encounter, Frank asked Marjorie to marry him. She accepted. The 2nd person to change Frank's life was a surgical research fellow at the University of Pennsylvania School of Medicine's Harrison Research Laboratory named John H. Gibbon, Jr.

The Gibbon Years

Gibbon was at home in Philadelphia, having been born, reared, and schooled there. Although his undergraduate degree was from Princeton, he had attended high school (Penn Charter) and medical school (Jefferson Medical College) in Philadelphia. After a 2-year internship at Pennsylvania Hospital from 1927 through 1929, Gibbon left for Boston to spend a year as a research fellow at Massachusetts General Hospital, with Dr. Edward D. Churchill. A few months into his fellowship, Gibbon was called to the bedside of a middle-aged, slightly obese female patient who was lethargic, pale, and short of breath. Only moments earlier, the woman had been recovering uneventfully from gall bladder surgery performed 2 weeks prior. Now she exhibited the grave signs of acute, massive pulmonary embolism. Dr. Churchill ordered the woman to be moved to the operating room immediately. Gibbon was assigned the task of recording the woman's pulse, blood pressure, and respirations every 15 minutes. A surgical operation, the Trendelenburg procedure, would be performed to extract the clots only as a last resort. During the night, Gibbon pondered the possibility of removing venous blood from the woman's body, oxygenating it, and then returning it to the systemic circulation. If a machine could temporarily replace the heart and lungs, surely this woman could be saved. Gibbon considered his idea well into the night. At 8 o'clock the next morning, the woman lost consciousness. Dr. Churchill immediately opened her chest and removed several large blood clots from the pulmonary artery. The patient died moments later, despite all efforts to resuscitate her.

As Gibbon's fellowship year in Boston came to a close, his thoughts repeatedly returned to the dead woman, and to the possibility of developing a machine to artificially replace the heart and lungs. Upon returning to Philadelphia in 1931, Gibbon spent 3 years as an assistant surgeon at Pennsylvania Hospital and as a fellow in medicine at the University of Pennsylvania School of Medicine. Few, if any, of his colleagues believed that a machine could ever oxygenate blood outside the body. Gibbon's academic and surgical responsibilities left him little time to pursue research. Therefore, with Dr. Churchill's permission, he returned to Massachusetts General Hospital in early 1934, intent upon fulfilling his dream of building a heart-lung machine. Within a year, he and his wife, Maly, had built a crude device (which included a rotating cylinder-type oxygenator) that successfully supported the circulation of cats for over 2 hours. Recognizing that extracorporeal circulation might indeed be possible, the University of Pennsylvania School of Medicine quickly offered Gibbon a position as surgical research fellow in the Harrison Research Laboratory. Gibbon returned to his hometown of Philadelphia, and over the next several years modified and improved his machine little by little. By 1939, Gibbon was able to report at the American Association for Thoracic Surgery meeting in Los Angeles that he had achieved indefinite survival of cats after they had undergone a brief period of total cardiopulmonary bypass. Frank Allbritten had been introduced to John Gibbon in 1938 during his 1st year as an intern at the University of Pennsylvania Hospital. In the coming years, their relationship would go well beyond a simple acquaintance.

The War Years

From 1939 to 1941, further refinements were made to Gibbon's pump-oxygenator. As the machine's efficiency improved, dogs were used in place of cats as the experimental animal of choice. The war in Europe, however, had reached a state of crisis. Gibbon, like millions of Americans, felt that the United States should intervene. Despite having 4 children ranging in age from 1 to 10, Gibbon volunteered as a reserve officer in the Medical Corps and was sent to the South Pacific in January of 1942. He would be away for 4 years. With a functional heart-lung machine in sight, Gibbon had to put his cherished work on hold.

After completion of his surgical residency at Pennsylvania Hospital in 1943, Allbritten too entered the United States Army Medical Corps, and quickly rose in rank to lieutenant colonel. Like Gibbon, Frank said goodbye to a wife and children while he fulfilled what he considered to be his patriotic duty.

Gibbon returned to Philadelphia in December of 1945 and resumed his position as assistant professor of surgery at the University of Pennsylvania Hospital. A month later, he was offered the position of professor of surgery and director of surgical research at Jefferson Medical College. At last, Gibbon felt he had secured an appointment that would enable him to dedicate all of his time to his heart-lung machine. His 1st order of business, however, was to fill vacancies in the surgical residency program that he helped oversee. Second, he desperately needed an assistant to carry out his various departmental duties, so that he could focus on his research. As coincidence would have it, Allbritten was on his way home to Philadelphia, having served 3 years in the Army. When Gibbon learned of Allbritten's availability, he immediately hired him as an assistant surgeon. Within a year, Allbritten was promoted to chief of surgery at Jefferson Medical College. He also served as director of surgery at Jefferson College Hospital's Barton Memorial Division. A few years later, Jefferson Medical College promoted Allbritten to associate professor of surgery. While most of the surgical residents who worked alongside Gibbon in the research lab stayed a year, perhaps 2 at the most, Allbritten remained on staff from 1946 to 1954 (Fig. 1). Indeed, he became the “go-to” guy within the Department of Surgery. He operated. He lectured. He published. He oversaw the various units and wards where surgical patients convalesced. While Allbritten so capably carried out the day-to-day duties and responsibilities of the Department of Surgery, Gibbon concentrated on perfecting his heart-lung machine in the research lab. Gibbon trusted Allbritten. Accordingly, it was Allbritten who was called upon one day to solve one of the more baffling problems associated with open-chamber cardiac procedures.

Fig. 1 Allbritten (left) at a surgical conference in Quebec in 1952 with fellow Philadelphia surgeons Bernard J. Miller (center) and John Y. Templeton III (right).

(From: Romaine-Davis A. John Gibbon and his heart-lung machine. Philadelphia: University of Pennsylvania Press; 1991. Copyright ©1991 Ada Romaine Davis. Reprinted with permission of the University of Pennsylvania Press.)

Deadly Air Bubbles

Over the years, Gibbon and his team identified and solved many problems associated with the heart-lung machine. Blood clotting, low oxygenation, hemolysis, and all sorts of equipment failures were but a few of the obstacles that had to be overcome. One particular problem that arose time and time again was the presence of air in the dog's coronary and cerebral circulation at the time of autopsy. Were these deadly air bubbles being passed into the animal's bloodstream by the heart-lung machine itself? Further observation and study revealed that the air was in fact being trapped beneath the leaflets of the mitral valve during open-chamber experiments (for example, during the closure of interatrial or interventricular defects). This air would then escape slowly into the animal's aorta, coronary arteries, and cerebral circulation during the postoperative period, resulting in certain death. Gibbon's residents suggested various approaches to solving the problem (flooding the operative field with carbon dioxide, filling the cardiac chambers with saline just before closure, and so forth) but nothing seemed to work consistently or reliably. Frustrated, Gibbon invited Allbritten to join the effort. After observing several experiments and gathering input from the residents, Frank retreated to his office to devise a solution. When he emerged several days later, he shared his idea, complete with drawings, with Gibbon and the team. His proposed remedy was to create a vent by which the air could be evacuated during the surgical procedure. Specifically, a small tube would be placed in the left ventricle by means of a stab wound in the heart's apex (Fig. 2). Gentle suction would be applied to the vent tube throughout the course of the operation. Air that inadvertently collected in the heart's left atrium or left ventricle could now be “vented” safely to the outside. Gibbon, a true researcher and scientist, held his excitement in reserve until further experimentation could prove Allbritten's ventricular vent a success. In a series of 17 dogs operated on for interatrial or interventricular defects before the use of Allbritten's vent, 5 had succumbed to air emboli present in the coronary or cerebral circulation. In contrast, none of 27 consecutive dogs operated on with the vent tube in place exhibited the devastating signs or symptoms of air embolism. Furthermore, no air could be found in any of these animals during postmortem examination. Frank's ventricular vent worked.

Fig. 2 Drawing depicts venous cannulation and Allbritten's vent (bottom right), which is placed in the left ventricle through a stab wound in the heart's apex.

(From: Romaine-Davis A. John Gibbon and his heart-lung machine. Philadelphia: University of Pennsylvania Press; 1991. Copyright ©1991 Ada Romaine Davis. Reprinted with permission of the University of Pennsylvania Press.)

By early 1953, Gibbon felt the time had come to use his machine in human beings. His success rate using medium-sized dogs had risen markedly, due in large part to Allbritten's ingenious ventricular vent. Furthermore, his confidence in his heart-lung machine and his surgical team was at an all-time high. Gibbon's dream was about to be reached.

The Day Comes

Cecelia Bavolek, an 18-year-old college freshman, entered Jefferson College Hospital on 19 January 1953, complaining of fatigue, shortness of breath, and an irregular heartbeat. Physical examination, including roentgenography, revealed cardiac enlargement and a loud systolic murmur. Not entirely sure of the diagnosis, the attending cardiologists treated her for rheumatic heart disease. At her initial discharge, she was scheduled to return in 2 months for further evaluation. Readmitted on 29 March, she displayed symptoms that had worsened to include fever, chills, and hemoptysis. A cardiac catheterization revealed an atrial septal defect with a large left-to-right shunt. Her surgery date was scheduled for 6 May. Gibbon and his team had just over a month to prepare.

On the morning of surgery, a mixture of excitement and nervousness filled the air at Jefferson College Hospital. The heart-lung machine, roughly the size of a grand piano, was primed with heparinized blood obtained from donors the night before. Allbritten, whose efforts and dedication over the years had helped bring Gibbon and his team to this point, was first assistant during the procedure (Fig. 3). According to operative records, it was Allbritten who inserted the left ventricular vent, his left ventricular vent, which almost certainly prevented air from reaching Cecelia's brain and killing her postoperatively. According to operative records, it was Allbritten, the boy from Kansas, who suggested to Gibbon that a primary closure of the septal defect would be faster than closure with a pericardial patch, yet equally effective. Finally, it was Allbritten, the son of a grain elevator worker, who in the coming years stood up repeatedly to the numerous critics who attacked Gibbon's work as fruitless.

Fig. 3 Gibbon (right center) and Allbritten (left center) during 1st successful open-heart surgery with cardiopulmonary bypass, in Philadelphia on 6 May 1953.

(From: Romaine-Davis A. John Gibbon and his heart-lung machine. Philadelphia: University of Pennsylvania Press; 1991. Copyright ©1991 Ada Romaine Davis. Reprinted with permission of the University of Pennsylvania Press.)

Cecelia was discharged from the hospital on 19 May. A cardiac catheterization performed 2 months later revealed that no residual shunt or septal defect existed.

Afterword

In 1954, Allbritten was duly appointed professor of surgery at the University of Kansas School of Medicine and chairman of the Department of Surgery at the University of Kansas Medical Center. Although his departure from Philadelphia was sad, his position at KU allowed him the opportunity to pursue his true interest diseases of the lung and chest. Between 1954 and 1971, Allbritten published over 100 scientific articles on thoracic, pulmonary, and esophageal disorders. In 1962, he co-authored a chapter on lung diseases for Gibbon's classic textbook Surgery of the Chest. In 1972, Frank retired from KU and quietly returned home to Cunningham (Fig. 4). He now lives in the very house in which he was born 87 years ago.

Fig. 4 Allbritten at home in Cunningham, Kansas, in 1999.

(Used by permission.)

My drive from Hays to Cunningham took about 2 hours. When I arrived, Frank was busy in his yard pruning bushes and raking pine needles that had fallen during the winter months. He grinned when I introduced myself and told him that I operated the heart-lung machine for a living. In his day, the term perfusionist didn't exist, although he thought it had a nice ring to it. He offered me a seat in his study while he washed up. The walls were adorned with framed letters, black-and-white photos, and numerous plaques and other accolades. Gibbon's picture was there. So were Cooley's and DeBakey's, and Dennis's and Lillehei's. I felt an inch tall. Although nearly 50 years had passed, Frank Allbritten seemed delighted to tell me about his idea for the left ventricular vent. He admitted to not being able to sleep that night in the spring of 1953 before Gibbon and he and their associates performed the 1st successful open-heart surgery using a heart-lung machine. He spoke of his regret for the many patients who had died waiting for extracorporeal circulation to be perfected. I could barely breathe when he told me about the fear that he himself had felt in undergoing coronary artery bypass surgery at the age of 80.

My drive back to Hays was a quiet one. Frank F. Allbritten, Jr.—the once tall, handsome surgeon who had served his country during war, the man who had worked so diligently alongside Gibbon for more than 8 years, the man who had devised a vent catheter to rid the heart of air—was now wrinkled, bent, and hard of hearing. That got to me just a little bit. As a Kansan, I perhaps owed him more than just an occasional visit or telephone call. As a perfusionist, I saw that my profession as a whole owed him something. After all, the left ventricular vent, his vent, is still used today by most cardiac surgeons and perfusionists to keep the heart decompressed and free of air. Furthermore, Frank is a direct, living link to that incredible day in Philadelphia in May of 1953 when the heart-lung machine was born and true history was made. Only a handful of these remarkable individuals are left. Whoever and wherever they are, we ought to seek them out and listen to their stories. I'm lucky to have met Frank at all; but whatever amount of time I spend with him, it simply won't be enough.