To Orwell Today,

cont'd from ORWELL'S DOC O'SHAUGHNESSY'S GRAVE & ORWELL DOC O'SHAUGHNESSY LETTER

Dear Jackie,

Please link below to the recently published paper in which I have used the info you provided. Feel free to use it as you see fit.

From Galen to Gross and beyond, Abstract/References: A brief history of the enigmatic patent ductus arteriosus, Full Article, by Tonse N. K. Raju, Journal of Perinatology (2019)

...But, was Gross the first to perform cardiac surgery? There is at least one credible and another possible contender for this fame. The first is the brilliant British surgeon Laurence O'Shaughnessey (1900-1940). In a letter dated March 7, 1939 (Fig 3) he congratulated Gross and urged him to publish the case report. In the letter shown in Figure 3 he states that on 2nd September 1938 (date notation as per the British convention of wirting date/month/year) he had operated on a 25-year-old "cardiac cripple" and found that the ductus had been "obliterated". He ligated it and performed "decompression" measures that helped the patient. He concludes that "...an exploration of the heart need not be disturbing". This was one week after Gross's successful ligation of PDA on August 26, 1938. Tragically, O'Shaughnessey was killed in action in World War II at Dunkirk. His body was never recovered and records on the date of his death have varied. However, thanks to a webpage [24] dedicated to the memory of the famous British writer George Orwell (O'Shaughnessey's brother-in-law) we know O'Shaughnessy was killed on 27th May 1940...

Above I cut and pasted the text on page 3 extending onto page 4 about Dr. O in my paper.

Thanks,
Tonse N.K. Raju, MD, DCH

Greetings Tonse,

Congratulations on the publication of your paper and thank you for citing ORWELL TODAY in your sources so other aspects of O'Shaughnessy's life can be learned by your readers.

It was helpful of you to isolate the passages where you tie in O'Shaughnessy's influence on your work for the benefit of my readers who may not read your entire article. I did, however, read it in its entirey.

It's fascinating that you work to help unborn and preterm infants who, in our society, are often considered non-persons until they emerge, fully formed, at birth.

All the best,
Jackie Jura, October 2019

To Orwell Today,

Dear Jackie,

Thanks for your guidance. Of course I would cite your Orwell Today page -- author's ethics!

Thanks for your sentiments about my work. It is a great field that brings much satisfaction.

Best,
Tonse Raju, October 2019

Greetings again Tonse,

I have just now re-read your paper on the history of the heart procedure known as PDA ligation, about which Orwell's brother-in-law, Dr O'Shaughnessy, in London, was the first to perform almost siumltaneously (one week later) with Dr Gross, in Boston, who is credited with being the first -- and which Dr O' so graciously acknowledged in his famous letter about which we solved some questions.

Here are excerpts from pages 4 and 5 of your paper that give the history of heart surgery performed on preterm infants, including those pre-born (figuratively unborn) at 24-weeks gestation:

The period between the 1920s through the 1940s was the golden age of fetal physiology, with Sir Joseph Barcroft (1872-1947) as its supreme priest. After four decades of research on high-altitude pulmonary physiology, Barcroft started studying fetal physiology in 1932. He and his colleagues adapted the exteriorized fetal sheep model developed by Huggett to study fetal-placental gas exchange; placental blood volume; fetal cardiovascular reflexes; cardiac output and distribution; the nutrient functions of oxygen, glucose, fat, proteins, and amino acids; and the physiology of fetal growth restriction. Barcroft and colleagues were the first to demonstrate ductal blood flow in fetal lambs using cineangiography. Barcroft also studied the factors responsible for ductal closure postnatally, and corrected numerous erroneous assumptions concerning fetal circulatory physiology...

The years from the late 1950s through the 1980s can be considered as an era when modern neonatal intensive care evolved. This is the period when assisted ventilation of newborn became a routine part of neonatal care rather than a curiosity. Other advances during this era include: the discovery of surfactant deficiiency as the cause of hyaline membrane disease (1959); the introduction of the terms "neonatology and neonatologist" (1960); the introduction of continuous positive airway pressure (1971); antenatal steroids to enhance fetal lung maturation (1972); and research on exogenous surfactants and their availability (late 1970s through the early 1990s).

The immediate effect of successful neonatal ventilation (before the availability of exogenous surfactants) was increasing rates of survival for premature infants. Paradoxically, the longer survival also led to a greater recognition of the diseases manifesting later in the first week of life and beyond -- necrotizing enterocolitis, intracranial hemorrhage, sepsis, failure to thrive, bronchopulmonary dysplasia, and retinopathy of prematurity...

The questions facing clinicians during the early years of neonatal intensive care (before the introduction of surfactant) were: what is the role of a significant PDA in causing the morbidities noted above? How to assess a hemodynamically "signicant" PDA? And, should one treat it by the only known approach -- surgical ligation (until the mid-1970s), and if so will "curing" a PDA improve outcomes. Thus, before long, PDA became the focus of investigation and target for interventions. It appears that the surgeons from Australia were the first to successfully ligate PDA in preterm infants. On August 7, 1962 Mostyn Powell presented a report of six pre-term infants presenting with signs of cardiac failure due to PDA, in five of whom the PDA closed spontaneously between six weeks and five months of age...

New issues have emerged during the current era of increasing rates of survival of infants as premature as 24 weeks of gestational age. There is a refined definition of "new" BPD. Yet, the question remains the same: does a PDA increase the risk for the adverse events mentioned above in extremely immature infants? In many trials on PDA therapy, the incidence of major morbidities have not improved, leading experts to question the role of PDA treatment on improving outcomes.

The final twist in the history of PDA therapy is the evolution of transcatheter ablation of the PDA technique and the approval of Amplatzer Piccolo by the United States Food and Drug Administration on January 11, 2019, that has enabled intervention cardiologists to occlude the PDA even in the tiniest of premature infants.

The current dilemma is: should one consider this procedure for occluding a PDA in preterm infants? If so, what severity of PDA qualifies for the ligation and what are the risks and benefits? What are the costs of surgery versus benefits? Are there reductions in morbidity rates and shorter durations of hospital stay? And finally, what meaningful outcomes should be considered in those infants recommended for transcatheter ligation of PDA. These issues are the topics of ongoing reseach and other papers in this issue of the Journal...

Your study of O'Shaughnessy's field of expertise -- cardiac surgery -- and in particular your focus on saving and curing unborn and premature infants -- has further connections to Dr O's brother-in-law. George Orwell had a true understanding of the development of the unborn (not as great as yours of course) as described in his 1936 book KEEP THE ASPIDISTRA FLYING.

Once again, I thank you -- as no doubt so would O'Shaughnessy and Orwell -- for your contributions and ongoing study of how to care for the tiniest hearts in our tiniest human beings.

All the best,
Jackie Jura, October 2019

ORWELL AGAINST ABORTION (...He looked up and saw that he was passing a public library. A thought struck him. That baby. What did it mean, anyway, having a baby? What was it that was actually happening to Rosemary at this moment? He had only vague and general ideas of what pregnancy meant. No doubt they would have books in there that would tell him about it. He went in. The lending library was on the left. It was there that you had to ask for works of reference... He opened one of the books and searched inexpertly through it. There were acres of close-printed text full of Latin words. That was no use. He wanted something simple - pictures.. How long had this thing been going on? Six weeks - nine weeks, perhaps. Ah! This must be it.... His baby had seemed real to him from the moment when Rosemary spoke of abortion; Its future, its continued existence perhaps, depended on him. Besides, it was a bit of himself - it was himself. Dare one dodge such a responsibility as that?...)