Stanton B. Miller is proud to have followed in the footsteps of his father, Bernard J. Miller, as a surgeon. He graduated from the Jefferson Medical College in 1980 and trained in general surgery at Jefferson from 1980 to 1986. After the completion of his training in 1986, he joined his father in practice, where they worked together for the first 10 years of his career as an attending surgeon. He stills considers that to be one of the most special times of his professional career. (His father will always remain one of the few surgeons upon whom he would bestow the term master surgeon.) At midcareer as a surgeon, he developed a fascination with public health and received his master’s degree in public health from the Johns Hopkins University in 2002, at which time his career in healthcare became more and more oriented in that direction. Presently, he is the founding executive director of the Jefferson Center for Injury Research and Prevention, which is a formal research center in the acute care surgery/trauma division of Thomas Jefferson University and Jefferson Health.
Q: Dr. Miller, can you talk a little about how your father met Dr. Gibbon?
A: The quiet force behind my father was my mother, who he began to date at the beginning of medical school. Every
year, one senior at the Jefferson Medical College was eligible to receive the Sheehan medal in surgery, a prize awarded to those who excelled in surgery. But in order to be eligible for the award, he had to write an essay, which he only wrote after prompting and encouragement from my mother (Figure 1). He ultimately ended up winning the Sheehan medal for the class of 1943.
Back then, being selected for a residency was an entirely different process than now. My father actually planned on going into pathology. He was all set to take a residency in Cleveland, Ohio under Dr. Karsner, who was one of the most famous pathologists at that time and had his own textbook, “Karsner’s Textbook of Pathology.” However, one day, he received a letter from the chairman at Jefferson, Dr. George P. Muller inviting him to be his resident. Residency training at that time was very similar to an apprenticeship: you did residency with one person, unlike the current system where you match at a hospital and rotate with all the different surgeons. Back then, you had to be invited by an attending to do your residency with them, and you were their apprentice and did all your operating with them. So my father began his residency in 1943 at Jefferson Hospital with Dr. Muller. But there was something else going on in the world at that time: World War II. The US armed forces needed young men and they certainly needed doctors, so my father was able to complete his internship from 43′ to 44′ but was then drafted into the army.
My father was assigned to Fort Bragg, North Carolina, where he became an army surgeon. Although World War II ended in 1945, he served from 44′ to 48′. Then he was honorably discharged and returned to Philadelphia. By then Dr. Muller had passed away and a new chairman of surgery had arrived, and his name was John Gibbon Jr.
My father didn’t know Dr. Gibbon and Dr. Gibbon certainly didn’t know my father. Back then surgery residencies were 4 years long, and he had finished 1 of 4 years, and like a lot of young men back then, he returned to finish his education. My father showed up to meet Dr. Gibbon and after some initial difficulties, was given his residency back, provided he spent a year in Dr. Gibbon’s research laboratory.
FIGURE 1 Picture of Bernard J. Miller and his wife Ethel. Ethel was truly an inspiration for Dr. Miller. Photograph was taken in the 1950s, right around the time when Dr. Miller worked on the heart–lung machine.
Q: How did that lead to working on the heart–lung machine?
A: Dr. Gibbon told my father about this vision he had about this machine that would enable you to operate inside of the heart. Of course, Dr. Gibbon had been tinkering around with the idea of a heart–lung machine since the early 1930s. That was building upon the vision of a French surgeon Alexis Carrel in the 1800s and was one of those outrageous ideas that you really couldn’t take anywhere. And Gibbon, as a young surgeon in the 30s, became intrigued with that idea and he spent a year or two tinkering around in the laboratory at the Massachusetts General Hospital and was able to bypass the heart and lungs in cats, but following this, no significant progress was really made.
After also serving in World War II, Gibbon then returned to Philadelphia, where he grew up, where his father, John Gibbon Sr. had also been a surgeon at Jefferson in the 1910s–1920s. When he came back, in 1946, he started his own laboratory wanting to tackle this idea in a more serious way. When my father arrived in 1948, Gibbon had already established a laboratory with the idea of this incredible kind of machine. So, my father was tasked with working on this idea, particularly the problem of “blood volume changes in surgical patients undergoing major thoracic operations” and ultimately made incredible strides. Gibbon recognized this and made my father the director of the lab in 1950.
Q: With all these innovations to your father’s name, what was his engineering background?
A: The eventual development of the heart–lung machine was one of the greatest biomedical engineering feats of the 20th century, but it happened long before the term biomedical engineering was coined. Long before any sorts of schools even had programs in biomedical engineering. The field didn’t exist. Gibbon began developing this machine, and he had engineers from IBM come down from New York to help, but they were 100% engineers and didn’t know anything about medicine. They weren’t able to make the connection between what needed to be done from an engineering point of view and what needed to be done from a clinical surgery point of view. They were engineers through and through. Quite frankly, my father comes along, and my father is in his early 30s, but objectively speaking he was brilliant. He had never taken one engineering course in his life, but he was very mechanically inclined and was completely self-taught. He even had an electronics laboratory in our basement where he would refine aspects of the heart–lung machine after working all day at Jefferson and experiment with new ideas.
Gibbon had my father do some work in this early lab and quickly realized he had a really bright guy in his laboratory. He was a natural -he had both engineering and clinical genius. And it was my father who was able to bridge the missing connections between engineering and clinical surgery that enabled the really critical developments in the machine that finally made it work. These developments include the servo flow mechanisms, the left ventricular vent, a modified oxygenator for the heart–lung machine, and the Jefferson ventilator.
For example, dogs were the models for the early prototypes and my father realized in the dog lab that when they were doing the operations, the dogs were getting cerebral air emboli. He made the connection that the reason they were doing this was when the heart stopped, air was flowing up into the apex of the left ventricle. When the heart was restarted, these air emboli were forced out of the left ventricle into the brain. Seeing this, my father envisioned what is now the LV vent: the little simple tube that at the beginning of the operation the cardiac surgeon puts in the apex of the left ventricle. Again, it was the fact that he understood both surgery and engineering that allowed him to make that connection. Ultimately, he was recognized for his engineering talent and in 1996, he received the Holley Medal from the American Society of Mechanical Engineers for the servo flow mechanism (Figure 2).
FIGURE 2 Bernard J. Miller receiving the Holley Medal from the American Society of Mechanical Engineers in 1996.
Q: What was Gibbon’s leadership style for his lab?
A: When it came to the laboratory, Gibbon really gave my father free reign, without much guidance. By 1950, he had officially made my father director of the laboratory developing the heart–lung machine. He saw this unique engineering and clinical genius in my father. In that regard, Gibbon afforded my father a lot of autonomy. Clinically, Gibbon ran a pretty tight ship with regards to the surgery service he ran, so that was a pretty big contrast.
Q: What was the transition like from testing in dogs to making a model fit for humans?
A: Ultimately, Cecilia Bavolek was the bravest person in the world on May 6, 1953. She was 18 years old. Not John Gibbon, not my father, but Cecilia Bavolek. My father never spoke about why they chose her specifically. I think they felt they were ready. My father worked tirelessly on the heart–lung machine. I think they felt they had done everything, tested it multiple times on dogs, and were ready to go. Here was this 18-year-old girl who was referred from Wilkes-Barre, PA, which is a few hours from Philadelphia, and she had an atrial septal defect and was having significant respiratory issues. For her it was a matter of life or death. They felt like they were as fine-tuned as they were going to be, that this was a young girl, and that if they didn’t do the operation, she was not going to survive. She and her family wanted the operation, so the team decided they were going to go for it. It was a courageous decision on the part of the surgery team, but an even more courageous decision on the part of Cecilia Bavolek.
Q: What was your father’s involvement on the actual day of the first successful case and in the cases to follow?
A: My father participated and had critical contribution to the famous case, the very first one, on May 6, 1953. I think it’s never been a well-known fact that the machine actually clotted, and my dad, because of his thorough knowledge of the machine, hand-cranked the pumps the rest of the day during the surgery to ultimately get the patient successfully off of the bypass. That had been because the blood bank had not prepared the heparin concentration properly to prime the machine. He broke scrub to hand crank it the rest of the way. When it was evolving that that was what was happening, Gibbon’s exact words per Dr. Victor Greco, a surgical resident present in the case, were, “BJ, do something.” After that, there was a significant hiatus before Dr. Gibbon eventually tried again. My father was only part of the first operation because he had been so involved in the engineering development of that machine. He had stepped away from clinical duties for months prior to May 6, 1953, to dedicate himself to the engineering of that machine. After its success, in the two cases afterward that my father was not a part of, the patients died and Dr. Gibbon put a moratorium on doing any further cardiac surgery. With this in mind and the knowledge that Dr. Gibbon did not plan on doing this operation again soon, my father resumed his clinical surgical practice. As much as my father loved engineering development, he also loved clinical surgery and he missed it.
Q: How did your father balance a prolific research career with clinical practice?
A: My father loved scholarship. I worked with my father for the first 10 years of my career up until his retirement. I scrubbed with him on hundreds of cases over a 10-year period (Figure 3) so I feel like I have a pretty objective view. My father was the greatest surgeon I have ever operated with. He also had a second faculty appointment at Jefferson teaching anatomy, and he taught medical students, residents and senior house staff anatomy for over 35 years. Just like he excelled as a self-taught biomedical engineer, he excelled at gross anatomy, but it was applied anatomy: anatomy as applied to surgery. He operated in many ways differently than every other surgeon I know. Every operation was essentially a formal anatomic dissection. The research and clinical practice were two different passions that fueled each other. As a busy clinician, he would see issues that he realized needed to be researched, so he would go into the laboratory and research those issues and his research would then inform and change his own clinical practice. It was natural for him to be interested in both and do both because the passions fueled each other. It was a beautiful fit for him. My father, as accomplished as he was as a surgeon, he excelled even more as a father and family man (Figure 4). I always think of him firstly about our time on sailboats in the Chesapeake Bay (Figure 5). That’s also an incredibly important lesson, juggling a successful career as a surgeon and as a family man, because it can be done (Figure 6).
FIGURE 3 Drs. Stanton B. Miller (right) and Bernard J. Miller (center) operating together at Germantown Hospital in Germantown, PA, in 1995.
FIGURE 4 Bernard J. Miller (right) with his sons Stanton (left) and Lawrence (center), 1990s. Dr. Stanton Miller is a Clinical Associate Professor of Surgery, Emergency Medicine, and Population Health and directs the Jefferson Center for Injury Research and Prevention. Dr. Lawrence Miller recently retired as the Chair of Orthopedic Surgery at Cooper University Hospital in Camden, NJ.
FIGURE 5 Bernard J. Miller with his grandson Matthew, taken at the Cheasepeake Bay outside of Chestertown, MD, ca. 1998. The name of the boat is “Ethel M” after Dr. Miller’s wife. Matthew is now a radiology resident at the Massachusetts General Hospital in Boston, MA.
FIGURE 6 Bernard J. Miller with his two oldest grandchildren, 1988. According to his children and grandchildren, he was a wonderful family man.
Q: What were some research lessons that your father passed on?
A: I would say that the strongest lesson my father passed on is always wanting to follow the scholarship (Figure 7). My father would always tell me, just follow the scholarship. He would tell me, no matter what type of research you are conducting, follow the scholarship and do what you’re most passionate about, because if you’re passionate about something, you’ll work tirelessly at it and you’ll do it well.
Q: What were your father’s thoughts on the state of modern cardiac surgery?
A: He was incredibly proud of his contribution and that he had been recognized for that work. I don’t think he was ever surprised that the heart–lung machine would go on to become even more perfected and that cardiac surgery grew into the field that it did. He realized the seminal contribution of that original machine and in retrospect the incredible medical/surgical history that was made on May 6, 1953. That operation made everything possible. That operation proved that everything could be done, so that the DeBakeys and Cooleys could follow. In his later years, he actually developed a correspondence with Dr. Cooley because Dr. Cooley became intrigued with the history of the machine, so they sent letters back and forth between each other.
FIGURE 7 Forever an inquisitive mind, Bernard J. Miller continued to innovate and invent even after his retirement, as demonstrated by these two most recent patents awarded in 1997 (A) and 1999 (B).
Q: Did your father have any regrets following the success of the heart–lung machine?
A: My father was never surprised that the field evolved the way it did, he knew that was going to happen. I think his regret was that after that operation, the team fell apart due to the failure of the two subsequent cases. My father’s one regret was that he felt the surgical team at Jefferson could have kept on going. But he wasn’t the chairman, Dr. Gibbon was, and cardiac surgery really wasn’t done in a very substantive matter at Jefferson for several years after.
While my father felt like maybe that wasn’t the greatest administrative decision, in the end they were the ones that did it first. I equate it to the first successful moon landing. That moon landing made everything else possible because it showed that it could’ve been done and it was up to others to perfect it afterwards and turn cardiac surgery into the field it is today. While my father didn’t end up doing much cardiac surgery, I think his patients were also better served because of it. My father was a true old-school general surgeon and he operated on everything outside of the brain. He even did orthopedics: general surgeons of the World War II era would even set hips. In the end, his practice had a great variety that allowed him to serve a greater number of patients (Figure 8).
FIGURE 8 Bernard J. Miller in the operating room (center). Dr. Miller loved operating. He operated until 74. He loved the entire breadth and spectrum of surgery, and could operate on anything “from the neck to the toes.” In this photograph, taken in the 1970s, he is performing an abdominal surgery, likely a Whipple procedure (Dr. Miller had performed many Whipple procedures during his career).
Q: How do you feel about the legacy that was left by your father?
A: It is certainly my opinion that the operation of May 6, 1953, is arguably one of the most historic operations of the 20th century. Even as a child, I realized that there was something very special about my father that pertained to his career as a surgeon and scientist. His seminal contribution to the engineering success of that machine will forever be a source of great pride to me and my entire family. What I am most proud of is that his contribution to the development of that machine has subsequently saved millions of lives globally. On any given day, I can only imagine that thousands of people around the world are being placed on this machine. So, in an interesting way, the worlds that I now live in of clinical surgery and public health totally mirror my father’s career in which he united the incredible privilege of care of the individual patient with a development that saves millions of lives.
Joshua R. Chen
Vakhtang Tchantchaleishvili
Division of Cardiac Surgery, Department of Surgery,
Thomas Jefferson University Hospital,
Philadelphia, Pennsylvania, USA
ORCID
Joshua R. Chen https://orcid.org/0009-0005-6550-7448
Vakhtang Tchantchaleishvili https://orcid.org/0000-0002-4357-3533