Vivien Thomas and Canine Surgery

by Donald F. Smith, Cornell University
August 25, 2012

When I lecture on the topic of One Health, I sometimes tell the story of the first surgical repair of the blue baby syndrome to demonstrate how important dogs were in achieving major advances in human medicine. 

Through the first half of the 20th century, dogs were used extensively by physicians in medical schools to help them learn the physiologic and pathologic changes associated with disease in people. Many complex surgical procedures were tested by MDs first on dogs to see if they could be successfully performed in people. Surgical residents developed their technical skills in "dog labs" that were common in medical schools. 

Anna, the experimental dog used 
to develop the corrective surgery 
for blue baby syndrome.
Photo from Johns Hopkins U.

The blue baby story holds special interest to me not just because of its profound impact on human surgery, but also because of the special place of a dog named "Anna" in the folk lore of Johns Hopkins Hospital.  

The term blue baby refers to the bluish-purple appearance of an infant's skin caused by lack of oxygen going to the tissues. A rare but well-known cause of this problem in the early 20th century was  tetralogy of Fallot, in which heart defects during fetal development result in the inability of the heart to pump venous blood into the lungs to be properly oxygenated. Affected babies usually died during the first year of life. 

Vivien Thomas (1910-85), the surgical technician
who developed the technical procedure
for the correction of Tetralogy of Fallot.
Photo from Johns Hopkins U.

In the early 1940s, Alfred Blalock was head of surgery at Johns Hopkins Hospital, and Vivien Thomas was his laboratory technician. A cardiologist named Helen Taussig approached Blalock and Thomas one day in their surgical laboratory and appealed to them to find a way to surgically repair tetralogy of Fallot. Though Taussig did not know it, Blalock and Thomas had years earlier created an experimental model in dogs in which blood to the lungs had been rerouted. The two men devised a variation of that model (in which the left subclavian artery was anastomosed to the pulmonary artery) and developed a plan to test the idea.

Blalock went back to his busy surgical practice and his administrative duties, and Thomas worked in his laboratory to create an experimental model in dogs to mimic the birth defect. Though he had never trained with a veterinarian and had only worked in a human surgical laboratory, he devised a way to surgically produce a condition in dogs similar to the one affecting human babies. Once he could produce the blue baby-like signs in his dog model, he operated on an affected dog to make sure that the type of repair that he and Blalock had devised would correct the blood flow problem that killed the babies. He designed instruments and delicate operative techniques to ensure that the repair could be performed on a tiny child. In his autobiography, Thomas said that he used 200 experimental dogs over a several-month period to accomplish this astounding breakthrough.

Photo from the first successful operation for
correction of tetralogy of Fallot, November 29, 1944
Vivien Thomas is at back left.
Photo from Johns Hopkins U.

The procedure was first performed on a baby girl on November 29th, 1944. Blalock was the surgeon. However, looking over his shoulder and coaching him throughout the procedure, was Vivien Thomas, whose knowledge of every minute detail of the operation was critical to its success. The symbiotic relationship between Blalock and Thomas was complicated by the fact that Thomas, though perhaps the most accomplished canine surgeon of the era, had no formal training in medicine or veterinary medicine. He was a tradesman, a carpenter, whose plans to go to medical school in the late 1920s were thwarted by the Depression.

He was also African-American, working in the segregated environment of Hopkins. His story was beautifully told in "Something the Lord Made" which premiered on HBO in 2004.

In his waning years and with Blalock deceased, Thomas identified what he referred to as the "troika" who developed the procedure to correct the tetralogy of Fallot. Equal with Blalock and himself, he included the dog named Anna. It is a beautiful example of One Health and the impact that physicians had on advancing canine anesthesia and surgery 80 years ago. 

Thomas' expertise continued to be felt for decades as he used dogs to train surgical residents who later progressed to important positions at prestigious medical schools. He occasionally assisted a veterinarian in a nearby animal hospital practice where he used his skills in canine anesthesia and surgery to save lives of dogs with spontaneously-occurring surgical problems.

Dr. Smith invites comments at dfs6@cornell.edu

ONE HEALTH COMES OF AGE

By Donald F. Smith, Cornell University
Posted August 10, 2012

        The AVMA meeting in San Diego this week featured lectures and meetings on One Health, which is the branch of science that unifies human health, animal health and environmental health.
        The One Health concept was the signature initiative of Dr. Roger Mahr when he was president of the AVMA in 2006-07. He challenged the veterinary profession to assert greater involvement in what scientists and regulatory officials were warning was the growing threat of diseases like avian flu and West Nile virus. These infectious diseases, called zoonotic, were erupting with greater frequency and virulence in the U.S. and around the world.

Dr. Roger K. Mahr, CEO, One Health Commission
President of the AVMA (2006-07)
Photo courtesy of the AVMA    

        One Health or One Medicine was advocated in the 19th century by physicians like William Osler (Johns Hopkins) and veterinarians like James Law (Cornell). However, physicians became less engaged in the potential spread of diseases between animals and people in the last few decades as the development of clinical specialties has changed the focus from the health of populations of people to that of the individual. 
        A One Health Commission was established to promote the understanding, prevention and treatment of zoonotic diseases. This becomes more important as the number and virulence of pathogenic organisms is growing and as the global travel of people, food components, and the movement of animals is increasing. 
        A second component of One Health is the realization that animals get many of the diseases and conditions that affect people. This was considered so important in the early days of veterinary education that at least two veterinary colleges (those at McGill in Montreal and Columbia University in New York) were actually referred to as colleges of comparative medicine. A book called Zoobiquity that provides several interesting examples of comparative medicine has recently received attention in the mainstream media (1).
        The third element of One Health relates to the ways in which pets and other animals actually promote human health. (2) A growing body of research is documenting the improvement of the physical, social, emotional and mental health of people who share their homes and environments with pets. Whether its walking your dog in the morning, riding your horse in the afternoon, or experiencing wild animals in their natural environment, animals improve the human condition. If these benefits to human health can be measured, we have the potential to not just improve the quality of life for both people and animals, but also to reduce the cost of human health care.
        One Health is an example of Back-to-the-Future Medicine, the re-discovery of concepts of medicine from past decades, but critically important in today's world. The leadership of veterinarian Roger Mahr was pivotal to energize a movement whose time had come.

(1) Zoobiquity: What Animals Can Teach Us About Health and the Science of Healing, by Barbara Natterson-Horowitz and Kathryn Bowers (Random House, Inc, 2012).
(2) The role of animals in promoting human health has been termed "zooeyia" by veterinarian Kate Hodgson who works with both physicians and veterinarians. 

Dr. Smith welcomes comments at dfs6@cornell.edu.

Western's College of Veterinary Medicine: An Interview with Two Faculty

By Donald F. Smith, Cornell University

Posted July 31, 2012

This historical blog is in recognition of the 150th anniversary 
of the American Veterinary Medical Association (1863-2013).

Drs. Ana Alcaraz and and Jose (Txema) Peralta left Cornell University in 2007 to join the faculty of the recently-established 28^th veterinary college in the United States. Western University of the Health Sciences had admitted its first class of students four years earlier and the wife-husband Alcaraz-Peralta team have now witnessed five classes of graduates complete their DVM degree requirements.

Drs. Ana Alcaraz and Jose Peralta are faculty at 
Western University of the Health Sciences in Pomona, CA
Photo by the author

‘Western’, as it often called, was established in 1998 as the first veterinary college to open in the U.S. since the early 1980s. Located in Pomona, California, it is one of four veterinary colleges not affiliated with a land-grant university. When Western was accredited fully by the AVMA in 2008, it ushered in a new era of how veterinary colleges can meet national standards for clinical education. That is because Western adopted a model that uses private clinical practices to a significant extent instead of maintaining its own comprehensive veterinary teaching hospital.

Ana and Txema visited Cornell recently, and I asked them to characterize the college’s reputation as they start their tenth year of teaching this fall. “Graduates are our best ambassadors,” Dr. Peralta replied without hesitation, citing their broad distribution in practices throughout the country and their success in attaining competitive internship and residency programs. He gave the example of Dr. Vanessa Rizzo who graduated in 2010, and is now a second-year oncology residency here at Cornell. 

“One of the advantages that our students experience is that they receive much of their clinical education in private practices where they see a broad cross section of routine and primary care cases similar to what they eventually experience in their own practices. This is different than university-based teaching hospitals that rely more heavily on specialty cases. While complex referral cases provide good instruction for residents, the hospital accessions are sometimes less appropriate for third- and fourth-year veterinary students who need to first master more basic material.”

“This allows students to gain a realistic picture of what follows in their careers,” added Dr. Alcaraz, “and the students are more often able to interact directly with the supervising veterinarian because many of the practices do not have the tiered resident-intern-student structure that is the norm in large academic hospitals. Also, these practices do not usually have as many students rotating through a service at a time as in a university setting.”

The distributed nature of the third-year curriculum allows students to spend up to 40 weeks not just in traditional clinical practice, but also in a variety of non practice settings, such as laboratory medicine, wildlife or zoological medicine, and public health centers and facilities. Ana believes this gives students exposure to a more expansive array of career choices in veterinary medicine.

Txema also noted that because the college is private and does not rely on public funding, they have been spared some of the economic challenges of institutions that rely on substantial levels of state support. “Everybody has financial challenges these days, but as long as we have a competitive curriculum, Western will continue to flourish. As I said earlier, our graduates are our best ambassadors and prospective veterinary students often choose to apply here through word of mouth.”

I shall present the introductory lecture on the history of veterinary education at the AVMA meeting in San Diego this weekend. During these remarks I shall pay tribute to Western for having created a new paradigm in the dynamic world of veterinary education. 

Dr. Smith welcomes comments at dfs6@cornell.edu

Veterinarians working with Physicians

By Donald F. Smith, Cornell University
Posted July 15, 2012


         A 200-page report on the Workforce Needs in Veterinary Medicine was recently released. Five years in the making, the authors (mostly veterinarians and several of whom I know well) assessed the current and anticipated needs of veterinarians. They paid special attention to agricultural animals, global food security, industry, public service and biomedical research.  However, the role of practicing veterinarians in promoting the role of pets to enhance human health and well-being within the family was not given a high priority compared to other critical-need areas.
         I recently authored the following op-ed on the question, "What can physicians learn from veterinarians?" It presents a more expansive view of how veterinary medicine can enhance human health by considering our pets an integral part of a healthy family structure.  


Reprinted from Zocalo Public Square, June 17, 2012
How to work together
         "When my daughter was a first-year Yale medical student in 2006, I told her that family medicine practices would someday offer services for both people and puppies. They would enter the same door and be seen by the appropriate member(s) of a team of healthcare professionals that included physicians, veterinarians, clinical psychologists, and veterinary behaviorists for annual checkups; nutrition, exercise, and disorder counseling; noninvasive imaging; and family planning.
         "There was a time when physicians and veterinarians worked together, and when Harvard and New York University’s medical and veterinary students learned side-by-side. But the replacement of the horse by the automobile led to the closure of almost all of the large urban veterinary colleges by the mid 1920s, and the medical disciplines drifted apart. However, the modern resurgence of comparative medicine has given the once-accepted concept of one medicine, one health new hope as more physicians recognize what they have in common with veterinarians.
         "As a veterinarian, I dream of a day when cancer wards of hospitals, assisted living homes for the aged, and hospice centers for the dying welcome pets to provide comfort, reduce pain and suffering, relieve anxiety, and smooth the transition from machine-living to compassionate-passing. I dream of a day when we consider substituting pets for prescriptions, and when we can modulate high blood pressure and cholesterol levels by more dog-walking and less pill-popping.
         "I long for the day when the NIH funds research that examines the positive role that pets can have on children with mental disorders, on returning veterans with PTSD, and on prisoners as they return to society.
         "I am ever hopeful for the day when physicians partner with veterinarians—with their education in comparative medicine and their sensitivity to the human-animal bond—to advance human health and reduce the cost of healthcare."


Dr. Smith invites comments at dfs6@cornell.edu      

Minimizing a Dog's Reliance on Anti-Stress Medication

By Donald F. Smith, Cornell University
Posted July 8, 2012

         My wife and I recently met Jodie Yim, an MBA graduate on the Island of O'ahu who turned her dog's health challenges into a thriving and personally-rewarding business. She explains on her website that she was several years on the road to a corporate career in advertising and marketing when God led her down a different pathway and she became a handmade paper artist. 
         A short while later, a Black Labrador Retriever puppy "with anxiety and noise phobias" joined her, and her life changed again. Not wanting to use anti-stress drugs, she learned enough about semi-precious gemstones to make her first piece of jewelry, a 'calming collar' for Pono. 
         As her skills with creating jewelry expanded, she was able to work from her home with Pono, often with him literally at her feet. With the exception of an "occasional dose of Rescue Remedy® and wearing a Thundershirt® during especially stressful times," Pono is entirely free of medications. The name of Jodie's company, 'Ponoma' [Pono-Ma] reflects her special relationship with her dog.

Jodie Yim and Pono wearing a colorful  Christmas lei

   

 Pono's original "calming collar"
Photos providing by Jodie Yim

       
Jodie's experience reminds us not just of the pleasure and comfort we can derive from healthy relationships with our pets, but she also exemplifies what it means to be a responsible pet owner. In her case, that responsibility included finding creative ways to spare Pono the use of behavior-modifying drugs.  
      

If you liked this blog, you may also enjoy the posting of April 14, 2011, entitled:
A Letter to Sasha and Malia Obama on the Second Anniversary of Bo's Arrival

Dr. Smith invites comments at dfs6@cornell.edu

Veterinarians in New York State

By Donald F. Smith, Cornell University
Posted July 3, 2012

         When animal owners seek veterinary care in New York State, their dog, cat, horse or herd of cattle could be treated by a graduate of any number of colleges across the U.S. or throughout the world. Though Cornell has over 3,100 alumni dispersed around the country, fewer than 1,300 are here in New York. Graduates from other colleges in the region, especially Penn, Tufts, Michigan State and the Ohio State, add another 530.
         The largest change in the profile of New York's veterinarians in the last decade, however, has been in the substantial growth in graduates of foreign colleges, in particular, Ross and St. George's universities in the Caribbean, and the University of Prince Edward Island in Canada. These are relatively new schools and many of their American graduates practice in the northeast.  
         The following graph shows how the addition of graduates from a greater number of colleges is changing the profile of veterinarians in New York. When you consider N.Y. veterinarians of all ages, 35% are Cornell graduates. However, Cornell alumni make up only 22% when we look at the younger veterinarians, specifically, those who graduated in the ten-year period between 1997 and 2006. (I have not included data from the most recent six years because there is a more year-to-year movement in the first few years after graduation that is often associated with internship and residency positions.)
         The spectrum of institutions represented among the state's veterinarians also means that a New York student wanting to become a veterinarian can find graduates from a variety of schools to provide information on the institution they might be considering. 

Colleges from which Veterinarians in New York State received their DVM degrees
 in the 10-year period between 1997 and 2006.
(AVMA membership record, 2012) 

         New York has 3,630 veterinarians registered as members of the national veterinary association (AVMA). That is about one veterinarian for every 6,000 people in the state. Looking at the numbers from a national perspective, there appears to be an inverse proportion of  veterinarians to population density. For example, states like Iowa, Colorado and Wyoming, have one veterinarian for every 2,300 people, over twice that of New York, New Jersey or California.

Number of Veterinarians per 1,000 Population for the Twelve Largest States
(AVMA membership records, 2012)

         The preceding graph shows that New York ranks near the bottom in number of veterinarians per 1,000 people for the twelve most populous states. However, unlike a few years ago before the economic slowdown, many New York veterinarians will tell you that there not a shortage of DVMs in the state.

Note: All veterinary data in this blog are from the American Veterinary Medical Association. 

If you liked this blog, you might also like to read a blog posted on May 29, 2012, entitled "Employment Opportunities for Veterinarians"  

Dr. Smith invites comments at dfs6@cornell.edu.

Veterinary Medicine in the Post Land-Grant Era

By Donald F. Smith DVM, Cornell University

Posted June 25, 2012

I seldom use this blog as a forum to share personal opinions. This posting is an exception, however, and does not necessarily reflect the views or policies of Cornell University or the AVMA. Comments are welcome on this blog or by writing me at dfs6@cornell.edu

         A century ago, there were three types of veterinary colleges. The majority were for-profit schools of varying quality, located in major cities with their focus on horses. These schools could not be sustained past the 1920s because of decreased enrollment when the horse lost its dominance to the internal combustion engine. An additional factor in their demise was the increased scrutiny given private, for profit medical and veterinary schools as the professions improved their regulatory standards. 

         A small handful of veterinary programs were affiliated with their respective medical schools, for example, those at Harvard, the University of Pennsylvania, NYU and George Washington University. Only Penn survived. 

         The third type of veterinary college was part of the land-grant initiative. Established in response to the Morrill Act of 1862, land-grant institutions (one per state or territory and mostly located in towns or small cities) were designed to provide practical education for rural youth in agriculture, engineering and the sciences. Starting with Cornell University in 1868, veterinary programs developed at nine land grant universities in the next few decades. Iowa State University became the first public-funded (land-grant) veterinary college in 1879. 

         Another cluster of land-grant veterinary colleges was established in the post World War II era, and a final cluster in the 1970s. Like the early veterinary schools, most of these later colleges were also located in smaller communities apart from major medical schools. In some states, the colleges were located in towns without major transportation hubs. The agricultural lobby was often the dominant political force in justifying the new veterinary college and all but four of the current 28 veterinary colleges are located at land-grant universities. There is also an imbalance favoring locations of colleges in the Midwest and southern states compared to the most populous areas of the country.  Unlike major medical schools which are most prevalent in large metropolitan areas, only two veterinary colleges (Penn and the Ohio State) are located in the 40 most populous U.S. cities.

         In the early 20th century, it could be said that the land-grant system saved veterinary medicine. Without the emphasis on livestock and food production, as well as having state governments providing core financial support, veterinary medicine might otherwise have floundered as the horse lost its central role in transportation and industry. 

         However, in today's world, I believe that the dominance of the land grant system in veterinary education represents a serious challenge for our profession's sustainability. Starting in the years following the Great Depression, migration from rural to urban and suburban areas was accompanied by a massive growth in numbers of household pets and other companion animals. Meanwhile, livestock production was concentrated on larger agricultural units requiring veterinarians.  Today, fewer than 10% of veterinarians work with livestock or the food production systems. About 80% of veterinarians in private practice work with household pets. Another 10% work with horses, zoo animals, wildlife and laboratory animals. 

Beau is an important member of our family.
 Good nutrition, twice-daily scheduled exercise without fail, 
and quality veterinary medical care have given him health and mobility in his 16th year of life.
Photo by the author in 2007.

         Despite the dramatic expansion of the mission of veterinary medicine, state support for veterinary colleges is still largely defined based upon the needs for livestock and safe food production. While these remain a fundamental responsibility of veterinarians, they do not address adequately the larger and more diverse missions of veterinary medicine, especially the role of healthy and well-adjusted pets in supporting human health and well-being.

         To assure sustainability of veterinary colleges in the present era, we need to embrace enthusiastically the role that veterinarians play in an expanded family profile that often includes pets. In responding to this opportunity, we must adapt a bold new approach for public funding that emphasizes the role of veterinarians as critical members of the medical health community. This includes the veterinarians' role in public health and the prevention and control of diseases that are transmitted from animals to people. But it also needs to acknowledge the role of household pets and other companion animals in promoting both physical and emotional health of people at all stages of life. 

         In practical terms, the public funding of veterinary colleges should be broadened and not remain solely the provenance of departments of agriculture.

Dr. Smith invites comments at dfs6@cornell.edu

Veterinary Education and the G.I. Bill

By Donald F. Smith, Cornell University
Posted June 22, 2012
Honoring the GI Bill, signed 68 years ago today.

This historical blog is in recognition of the 150th anniversary 
of the American Veterinary Medical Association (1863-2013).

As World War II was drawing to a close, hundreds of thousands of battle-weary veterans returned home. Eager to resume their lives, the G.I. Bill of Rights (signed by President Roosevelt on June 22, 1944) eased the transition of some of them back into society by providing access to university and postgraduate education. Students who started veterinary college between 1946 and 1948 were mostly veterans, many of whom were already in their mid- to late 20s with spouses and small children. It is sometimes quipped that Cornell's 1950 graduating DVM class photo had 50 graduates and 50 children, most still in diapers. 


With only ten veterinary colleges in the United States in the early 1940s (1), available slots for veterinary students were very limited. The situation was especially acute in the agriculturally-rich midwest and southern states, and in California. Responding to this need, seven new colleges were established in the four-year period starting in 1944. Six were at land-grant universities; the other was at Tuskegee Institute, a member of the Historic Black college system.

Location of  Veterinary Colleges established
before 1920 (red) and between 1944 and 1948 (blue). 
Colleges are identified in footnote (2).

Members of the first graduating class of the new college at the University of Minnesota were all men, one of whom was Dr. Glen Nelson:  "Most of us were veterans. We had a B17 pilot who was shot down over France and escaped back to England with the French Underground. We had a B29 pilot [who] flew over Nagasaki the day after THE Bomb. I was a tank officer under Patton in North Africa and Italy. We had a prisoner of war in our class, an ex-POW, and another who was shot up pretty bad (sic) on Saipan. Going to the student center was like sitting around the American Legion Club."


Of the 17 veterinary colleges in 1948, all but two (University of Pennsylvania and Tuskegee Institute, later University) were at land-grant institutions. Most of these were located in rural areas of the country in towns or small cities such as College Station, TX; Ithaca, NY and Athens, GA. An 18th veterinary college was added at Purdue University a decade later, but no more were established until the 1970s.


(1) Middlesex University in Massachusetts operated a veterinary college  in the late 1930s and early 1940s.
(2) Veterinary colleges established between 1868 and 1920 were at: Auburn, Colorado St, Cornell, Iowa St, Kansas St, Michigan St, Ohio St, Texas A&M, U of Pennsylvania, and Washington St. Those established between 1944 and 1948 were at: Oklahoma St, Tuskegee, UC-Davis, U Georgia, U Minnesota, U Illinois, and U Missouri.


Some material for this blog first appeared in an article by Dr. Smith in the Journal of Veterinary Medical Education (JVME, 38[1], pages 84-99, 2011).
Dr. Smith invites comments at dfs6@cornell.edu.