Thursday, April 26, 2012

Robert H. Goetz: The First Coronary Bypass

Great Advances in Science

The chairman of my own department thought that I had "too much work" and suggested that I concentrate on vascular surgery and appointed a cardiac surgeon without consulting me. I tried, but could not convince him to continue in my footsteps.
Robert H. Goetz, 
The Annals of Thoracic Surgery (2000;69:1966-1972)

Robert H. Goetz: On his fishing boat
Credit & Source:

Few persons, including surgeons, know the name of Robert H. Goetz, but millions of persons have benefited from his life-saving surgical technique—the coronary artery bypass, or what many simply call bypass surgery. The first successful heart bypass surgery was performed on a 38-year-old patient at the Bronx Municipal Hospital Center in New York. Igor E. Konstantinov, a physician at the Mayo Clinic, writes  about it extensively in a fascinating article in The Annals of Thoracic Surgery (2000;69:1966-1972):
Robert H. Goetz performed the first successful clinical coronary artery bypass operation on May 2, 1960. He used a nonsuture technique to connect the right internal thoracic artery to the coronary artery by means of a modified Payr’s cannula made of tantalum. The patency of the anastomosis was demonstrated angiographically and the patient remained free of angina pectoris for 1 year. It was an important and brave step forward, a step that was far ahead of its time. Unfortunately, his pioneering work was not appreciated and fell into oblivion.
Such happens at times with certain pioneers, likely more often than we can know for sure. But Goetz's pioneering work is worth remembering, as is the man who helped make life better for the many millions of patients who might take bypass surgery for granted. Science is a series of steps, each an attempt to offer an improvement in the technique or method. Medical science is a noble endeavour since in the best of cases it centres on improving human life.

Goetz's career and pursuit of scientific knowledge took him from his native Germany to Switzerland, then to Scotland and then to South Africa— where one of his students was Dr. Christiaan Barnard, famous for performing the first human heart transplant in 1967— and eventually to New York City. It was there, seven years earlier, where history of a more modest but not less important nature was made.

The Early Years

Robert Hans Goetz was born to Johan Konrad Goetz and Emilie Goetz in Frankfurt, Germany, on April 17, 1910; his father was a sculptor. The young Goetz spent the years of the First World War with his grandparents in a small village in the Black Forest, attending a small one-room schoolhouse. He did well, and after the war was accepted to Helmholtz Ober Real Schule in Franfurt. After he graduated in 1929, Goetz had two career choices before him—architect or physician. "It was the decisiveness of the family physician, who would lance big boils at a wink of an eyelid without anesthesia, which impressed him and made him to choose medicine," Igor E. Konstantinov writes in a biography of Goetz.

Thus, the choice made, he started to study medicine at the University of Frankfurt in 1929, and did well. One of his mentors at the university was Dr Albrecht Bethe, professor of physiology. His son, Hans Bethe, would go on to become a professor at Cornell University and win the  Nobel Prize for Physics in 1967. Goetz was a good student and in September 1934 passed the exam to become a physician "summa cum laude," but he did not get his medical diploma because the Nazi Minister of the Interior declared him "politically unreliable." (The diploma was issued to Goetz in 1997, exactly 62 years later.) As Goetz writes about this dark period in Germany's history:
All students were forced to join the National Socialist Student Organization. As members they were put into uniforms and given a "Book of Duties," in which their compulsory participation in all political rallies, lectures, and demonstrations were officially recorded. The weekends were usually reserved for semimilitary training. More ominously, you were not admitted to the final exam unless you provided proofs in the booklet of your participation in all events of the Organization.
For not going along with the Nazi ideology, Goetz was not granted a license to practice medicine in Germany. He thus left Germany for Bern, Switzerland, where under the care of a former professor, Dr. Hans Bluntschli, Robert Goetz finally received his credentials to practice medicine and the coveted M.D. degree, in 1936, that he had worked assiduously to gain. He then joined the department of pysiology at the University of Edinburgh in Scotland.
I was accepted as a full member of his staff. Using my own methodology, I began investigations into the control of the circulation of the intestine. However, all was not well again. Not being Jewish, I was not considered a "bona fide" refugee by the "Home Office" and got my passport stamped "to stay in Great Britain for one year only" and that I could not accept any remunerative employment. As the year in Edinburgh was coming to an end, I was faced with a big VOID. Just by chance, I saw on the blackboard at the dean’s office an advertisement by the University of Cape Town offering a research fellowship in the Department of Surgery.
In South Africa, Then America

Goetz had married another physician, Verena Bluntschli, who had graduated from the University of Geneva, and both sailed down to Cape Town in October 1937 to start a new life and medical adventure together. At first, Goetz, with his wife acting as his assistant, worked as a researcher at the newly opened Groote Schuur Hospital, and in 1940 at its vascular research lab. Yet, he had no access to patients, since his German and Swiss degrees were not recognized by South African authorities.

In 1944, he passed the exam and finally became a licensed physician; and by 1945, Goetz was in charge of a Unit for Vascular Diseases. After a few years, his reputation in the field of vascular surgery increased so much, that by the 1950s Goetz was considered an internationally recognized authority in blood circulation. It was an opportune time to emigrate to America, where Goetz became Associate Professor of Surgery at the Albert Einstein College of Medicine in 1957 and a full Professor and attending surgeon at Bronx Municipal Hospital in 1961. He held both positions until his retirement in 1982.  Goetz writes:
In 1954, I visited the States with a Carnegie Traveling Professorship. Einstein College was in the throws of assembling its first faculty. Doctor Charles Ripstein had already been appointed Chairman of the Department of Surgery. After he heard my lecture at Georgetown University, he offered me to join his staff as head of cardiovascular surgery and head of the research laboratories. In October 1957, exactly 20 years after I arrived in South Africa from Edinburgh, I joined Einstein and settled with my family in America.

Before really settling down in my job at Einstein, I had to straddle yet another hurdle. I had to pass the American Medical Board Exam. Aged 47, it was not easy, but in 1958, I passed at the first attempt... . After arrival the first task was to get cardiac surgery going.
On May 2, 1960, Dr. Goetz made history when he performed the first successful coronary artery bypass on a human, a 38-year-old cab driver who had such severe angina that he required between 70 and 90 tablets of nitroglycerin daily. Assisting in the surgery were Drs. M. Rohman and J. D. Haller. After the operation, the patient did well, living for a year without angina pain. He died on June 23, 1961. By all accounts, the operation was a success, but few people knew about it. It was the first and last coronary bypass that Goetz performed. This might sound surprising, but it fits with the tenor of the times. The reason, like all innovative procedures, was that it was both controversial and new in a profession that was by all accounts conservative:
You wonder why I did not pursue the subject. The reasons were several. First, with the exception of the attending cardiologist Dr. Jordan, our medical colleagues were violently against the procedure. We even came in for severe criticism from some of our surgical colleagues.
Such is the history of a procedure that is now routinely performed. It would take another decade before the procedure that Goetz pioneered to become more acceptable. By then, others got the credit. This is an attempt to set the record straight to give recognition where it's due.

Robert H. Goetz died of prostrate cancer at his home in Scarsdale, New York on December 15, 2000. He was 90. Dr. Goetz was survived by his wife of 67 years, Dr. Verena Bluntschli Goetz; two daughters, Sylvia Perle-Goetz of Detroit and Angela Goetz of Manhattan; two sons, Lionel Goetz of Fairfield, Conn., and Stephen Goetz of Los Altos, Calif.; eight grandchildren; and a great-grandson.