ArfiJjcid Orgrins 10(4):263-265. Raven Press, New York 0 1986 International Society for Artificial Organs

Retrospective on Artificial Organs and the Role of the Transactions-American Society for Artificial

Internal Organs

Willem J. Kolff

Departmmts of Medicine, Surgery, and Engineering and Institute for Biomedical Engineering, Division of Artificial Organs, University of Utah, Salt Lake City, Utah, U.S.A.

In 1939 I took a short piece of cellophane tubing, put a little blood in it, added urea in a concentration of 400 mg percent, and shook it in a bath with sa- line. In 5 min nearly all the urea was removed by dialysis. I multiplied everything by 20 and knew that I would have to make an artificial kidney with at least 10 m of cellophane tubing and a very small volume of blood (500 ml), and that both blood and dialyzing fluid should be in continuous movement.

After four trials, we built the rotating-drum artifi- cial kidney with the help of Mr. H. Th. J. Berk in Kampen. In 1943 the first patient was treated in the Municipal Hospital in the small city of Kampen, the Netherlands, during the German occupation ( 1 j. The patient had chronic renal failure and under- went 12 dialyses. The first patient to be saved by dialysis (Maria Schafstadt, patient no. 17) was treated in 1945 after World War I1 ended ( 2 ) .

A rotating-drum artificial kidney was used in Korea just behind the front lines. The patients were dialyzed in a tent. The dialyzing fluid was rice paddy water boiled in an oil drum. All of the United States has become familiar with this scene-thanks to “M.A.S.H.” Dr. George Schreiner, Dr. Paul Teschan, and many others became familiar with di- alysis technique under those circumstances, al- though they had been exposed previously to this type of artificial kidney at the Peter Bent Brigham Hospital in Boston.

In 1955 Dr. Bruno Watschinger and I developed

Received April 1986. Address correspondence and reprint requests to Dr. W. J.

Kolff at Dumke Building, University of Utah, Salt Lake City, UT84112, U.S.A.

the disposable twin-coil kidney (3), which was later marketed by Travenol. This made dialysis possible worldwide.

The value of encouragement by a meeting with people interested in the new concept of artificial organs cannot be overestimated. We drove from Cleveland to Atlantic City for the first meeting of the American Society for Artificial Internal Organs (ASAIO) in my wife’s station wagon because we had no money for any other means of travel. We carried a dozen coil kidneys of the new design in the back of the station wagon. We distributed them among everyone who seemed likely to be willing to try them. After its use, Dr. George Schreiner kept his coil kidney for filtering fertilizer or pesticides in his garden shed, and thereby preserved it for pos- terity.

It was obvious that blue blood entering an artifi- cial kidney became red when it was exposed to the dialyzing fluid, through which we bubbled oxygen with 5% C 0 2 to maintain proper pH. Later we unrolled our coil kidneys, pulled the cellophane tube out, and put in a polyethylene membrane. In so doing, we had a disposable membrane oxygen- ator. We treated 10 puppies with these membrane oxygenators (4). Their hearts were stopped with potassium citrate (5); their right ventricles were opened and closed, and all the puppies survived. Yet, the first human baby died. The second and third babies lived. Stopping the hearts with potas- sium citrate in the early days of open-heart surgery was an enormous advantage, since Drs. Donald B. Effler and Lawrence K. Groves did not have to stitch a moving target, but they could operate in a tissue as still as a wet towel. One obvious disad- vantage was that when the heart was restarted,

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264 W. J . KOLFF

sometimes the bundle of His was damaged and the patient had a heart block.

Obviously, we needed a pacemaker. The head of research refused to buy it because it was clinical. The head of medicine refused to buy it because he said that you never needed a pacemaker; you should treat a heart block with drugs. The head of surgery refused to buy it because it was a medical problem. I asked Rick Olmsted in our laboratory to make a pacemaker and he did (6). The cord for the first electric pacemaker was as long as the distance from the operating room to the intensive care unit, so that the patient could be paced all the way during transportation through the corridors. Rick Olmsted later made a pacemaker that was as small as a cigarette package (6). I wish we had commer- cialized it, but this was against the policies of The Cleveland Clinic.

In his presidential address to the ASAIO in 1957 (7), Dr. Peter Salisbury described a totally implant- able artificial kidney with which he had experi- mented in a dog. He also talked about a totally im- plantable artificial heart. No other Society would have listened, and no editor other than Dr. George Schreiner would have published it.

The total artificial implantable kidney still has not materialized, but artificial hearts, although still driven by compressed air from the outside, have now been applied in human patients (8).

As editor- of the Transactions-ASAIO, Dr. George Schreiner has been open to new ideas and to statistically unproven concepts as long as the statements had a sound conceptual basis. We shall always be grateful for that. Also, the turnover from concept to presentation to publication in the Trans- actions was very short. Rapid publication was especially important in the area of artificial organs where developments were quick and diverse. The aim for a deadline is a necessary impulse for many people in the laboratory.

Therefore, the Transactions greatly helped to ac- celerate the development of artificial organs. Without them, it would have been extremely diffi- cult to find out where the concept originated and who were the true inventors. It was also occasion- ally the forum for review of the developments in the field of artificial internal organs. In the case of the artificial heart, I was asked to put the contributions of many of my co-workers into perspective (9).

At the yearly banquets of the Society, George Schreiner would add luster and humor to the occa- sions as a raconteur. If the United States had adopted his proposal of introducing two kinds of money, green money for services and blue money

for material goods, our society would have been much different and probably much better.

When I think back to that time, I remember a phrase I have not heard for years, namely, “false hope.” It was used by the enemies of artificial organs! Artificial organs would create “false hope” in patients for whom basically nothing could be done. Talking to a patient about an artificial kidney would be to create “false hope” because life with the artificial kidney would not be worthwhile. Talking to a patient about a pacemaker would be to create “false hope” because the pacemaker would probably not last. Talking to a patient about coro- nary artery surgery and bypass grafts would be to create “false hope” because the grafts would thrombose. Talking to a patient about an artificial heart would be to create “false hope” because no one would want such a life. Talking to a patient about an artificial eye would be to create “false hope” because it would not be available for many years. In reality, the thought that an artificial eye might be possible brought numerous blind volun- teers to us who wanted to make themselves avail- able to prove whether or not stimulation of the brain would result in a visual perception, perhaps comparable to what we see on a scoreboard, which, nevertheless, might be very useful for someone otherwise living in the dark.

One day in 1960, when I came into m)’ laboratory at The Cleveland Clinic, Dr. Spyros Moulopoulos and Steve Topaz had inserted a balloon in a poly- vinyl tube and demonstrated the concept of the intra-aortic balloon pump (10). I take credit for not having killed the idea, but the time was not right. We were even given the opportunity to attempt treatment of a patient at The Cleveland Clinic, but he was dead by the time the balloon was inserted into his aorta. Since the patient was onl an image amplifier, we demonstrated that even in a dead pa- tient you could get perfusion of the coronary ar- teries by pumping the balloon.

The concept of blowing either air, CO,. or helium in and out of the balloon in the aorta was so strange that it just was not acceptable. That widespread at- titude earned more credit for Dr. Adrian Kantro- witz who was admirably persistent and applied bal- loon pumping in a series of patients ( I l) . Publica- tion about the intra-aortic balloon was very difficult before Dr. Kantrowitz’s work, but it was published in George Schreiner’s Transactions (101.

It is always very difficult to obtain attention for a concept before it has been applied in humans. The step from experimental animals to human investi- gation is a quantum leap. Before this leap occurs,

Artif Organs, Vol. 10, No. 4. 1986

RETROSPECTIVE ON TRANSACTIONS-ASAIO 265

most medical and surgical publications are closed for reports about mechanical devices. Also, strangely enough, whereas chemical trickery is quite acceptable and even admired, very clever me- chanical solutions to a medical problem are hardly considered to be science. If one person at the Na- tional Institutes of Health Study Section uses the word “gadget,” you have lost your grant. Yet, me- chanical devices can open entirely new fields of medicine and scientific inquiry. The artificial kidney is purely a mechanical device that applies dialysis in a practical manner. The early version did not even have any electronics. Yet, this mechanical device provided potential for research work not otherwise possible. To give two examples, i t be- came possible to reduce the potassium content of the blood at will and study the resultant electrocar- diographic changes and it also became possible to remove all kinds of poisons and drugs from the blood rapidly and at will. Georgetown University became the international center for dialysis of poisons. The Editor of the Transactions, Dr. George Schreiner, never said, “It is a gadget.”

Over the many years-1957-1985-that we worked on artificial hearts, at meetings with a regis- tration of up to 3,000, we have often spoken in a small section to an audience of 8-20 people. If the Transactions had not existed, where could we have published our papers that in their preliminary steps were of interest to only a few scientists? Moreover, the plenary sessions of the ASAIO have given us an opportunity to reach on occasions a larger audi- ence.

I recall the presentation of the first electrohy- draulic heart made for me by S. Harry Norton from Thompson Products. Dr. Tet Akutsu and others worked on it in our laboratory. I showed it in a film at the ASAIO meeting around 1960 (12). It demon- strated that a bolus of contrast medium injected into the right atrium could be followed through to the right ventricle, to the pulmonary artery, to the pulmonary veins, to the left atrium, to the left ven- tricle, and out into the aorta. I do not like to go over my alloted time; and when I noticed that I might go over, I asked the chairperson of the ses- sion if he wanted me to stop. According to someone in the audience, the chairperson would have been shot dead if he had stopped me.

Such interest in a new concept wanes quickly when it is not applied in patients within 3 years. However, over all these years, the Transactions has given us the opportunity to publish. What would we have done without it?

By his tireless efforts as Editor of the Transac- tions-ASAZO, Dr. George Schreiner has given nu- merous young authors an opportunity to get their work in print, thereby setting them off on their sci- entific careers. Hundreds of young artificial or- ganists are grateful for it. As one of the oldest living artificial organists, I fully recognize my personal debt of gratitude toward Dr. George Schreiner, an old and trusted friend.

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Kolff WJ, Berk HTHJ, Welle M, van der Ley AJW, van Dijk EC, van Noordwijk J. The artificial kidney: a dialyser with a great area. Acta Med Scand 1944;117:121-34. Kolff WJ. New ways of treating uraemia; the artificial kidney, peritoneal lavage, intestinal lavage. London: J & A Churchill Ltd., 1947: 112. Watschinger B, Kolff WJ. Further development of the artifi- cial kidney of Inouye and Engelberg. Trans A m Soc Artif Intern Organs 1955; 1 : 37-8. Kolff WJ, Watschinger B. Further development of a coil kidney. J Lab Clin Med 1956;47:969-77. Kolff WJ, Effler DB. Disposable membrane oxygenator (heart-lung machine) and its use in experimental and clin- ical surgery while the heart is arrested with potassium ci- trate according to Melrose technic. Trans A m Soc ArtifIn- fern Organs 1956;2:13-7. Olmsted F. Remarks on the transistor electronic pacemaker. Trans A m Soc Artiflntern Organs 1959;5:304-6. Salisbury PF. Implantation of physiological machines into the mammalian organism. Identification of problems con- nected with the implantation of artificial hearts and of artifi- cial kidneys. Experimental results to date. Trans A m Soc Artiflntern Organs 1957;3:37-42. Joyce LD, DeVries WC, Hastings WL, Olsen DV, Jarvick RK, Kolff WJ. Response of the human body to the first per- manent implant of the JARVIK-7 total artificial heart. Trans A m Sac Artiflntern Organs 1983;29:81-7. Kolff WJ. Artificial organs-forty years and beyond. Trans A m Soc Artiflntern Organs 1983;29:6-24. Moulopoulos SD, Topaz SR, Kolff WJ. Extracorporeal as- sistance to the circulation and intra-aortic balloon pumping. Trans Am Soc Artiflntern Organs 1962;8:85-8. Kantrowitz A, Tjonneland S, Krakauer J , Butner AN, Phillips SJ , Yahr WZ, Shapiro M , Freed PS, Jaron D , Sherman JL Jr. Clinical experience with cardiac assistance by means of intra-aortic phase-shift balloon pumping. Trans A m Soc Artiflntern Organs 1968;14:344-8. Kolff WJ, Akutsu T, Dreyer B, Norton H. Artificial heart in the chest and use of polyurethane for making hearts, valves and aortas. Trans A m Soc Artiflntern Organs 1959;5:298- 300.

ArtifOrgans, Voi. 10, N O . 4, 1986