Montgomery, Alabama, 15 September 1902
It was only a few minutes after midnight and the small, dusty back roads of the city were pitch dark. The horse kicked up the dirt as it cantered along, the buggy jarring violently on unseen rocks and hidden potholes. Physicians of Dr Luther Leonidas Hill's reputation rarely came to this part of town; even during the day, it was easy to get lost. This was the negro area, where few could afford proper medical treatment; doctors usually called here only out of charity. But despite Hill's discomfort and the late hour, this house call was worth it. He might be able to save a life, if he was not too late.
Oil lamps burnt in the windows, and a small group of people had gathered around the door of the small wooden cabin. Several women were sobbing; another was trying to corral a group of bewildered- looking children. The older men hung back in the shadows, chewing on tobacco, mumbling and shaking their heads. A man and a woman stood by the door clasping each other's hands tightly.
Dr Parker and Dr Wilkerson were waiting outside and ushered Hill into the cabin's solitary room. The building was little more than a long shed, sparsely furnished with a table, hard wooden chairs and an iron stove in the corner. Then Hill saw the boy. Thirteen-year-old Henry Myrick was barely alive. He lay on the bed, his skin almost translucent, his breathing imperceptible.
Myrick had been stabbed with a knife at five o'clock that afternoon. The circumstances of the crime were not clear, but Hill found it hard to believe that the boy had been in a fight – his appearance was far too delicate for that. Dr Parker and Dr Wilkerson had been called six hours after the injury. Now, almost eight hours after the stabbing, Hill leant forward to examine the boy.
The knife blade had entered the boy's chest about a quarter of an inch to the right of the left nipple. Hill put his fingers to the wound and could see that it went deep. With every weak beat of the boy's heart, there was a bright red stream of blood, as if someone were squeezing a blood-soaked sponge. The skin was marked with a triangular patch of dullness, a bruise suggesting that most of the blood was being squeezed out inside the boy's chest. The boy's hands, lips and nose were cold. Hill felt for a pulse but could find hardly any sign of it. Even when he bent close, the heartbeat was barely audible.
The boy was slipping in and out of consciousness. Hill shook him gently and asked him how he felt. When the boy spoke, his voice was weak. He was clearly in great pain, but perhaps not beyond help. Hill went outside to consult Henry's parents. The surgeon was offering them a glimmer of hope that their son might survive. They agreed that Hill could operate.
When it came to the heart, Dr Luther Leonidas Hill, MD was one of the best-qualified doctors in the southern United States, if not the world. Obtaining his first medical degree at the age of nineteen, he had studied at medical schools in Alabama, New York and Philadelphia. From September 1883 until March 1884 Hill had even spent six months in London, being instructed by that great father of modern surgery Joseph Lister. Since returning to his native Montgomery, Hill had devised his own medical speciality: the study of heart wounds. Two years previously he had published a report drawing together the known cases of repairing a wounded heart. Hill had studied heart operations: he knew how they should be done and he knew how likely the patients were to survive. However, this was the first time he had seen a wounded heart for himself.
Hill asked for two lamps to be placed near the cabin's single table. The other doctors started to clean the area around it with carbolic as best they could. Hill lifted Henry from his bed and placed him on the hard surface. By now the cabin was becoming crowded with medical men. Hill's brother had arrived, as had a Dr Robinson, who was preparing to administer the chloroform anaesthetic. Hill doused his instruments in carbolic, then laid them out beside the table. Robinson took his dropper bottle, applied the measured amount of chloroform to the mask and held it over the boy's face. At one o'clock in the morning in a battered wooden cabin Dr Luther Hill was about to attempt one of the first operations on a beating human heart.
Hill raises his knife and makes his first cut through the skin to the left of the sternum, the breastbone that runs down the centre of the chest. It is a deep incision. He continues this cut outwards from the sternum along the third rib from the top. He must cut through the skin, the connective tissue beneath and the muscles covering the ribs. He makes a second incision along the sixth rib on the left-hand side, then joins these two lateral incisions together with a further vertical cut. Hill has carved three sides of a rectangle into the boy's flesh, the lines of incision now outlined in red as blood seeps out. This will become Hill's door to the heart.
Hill picks up some bone nippers and begins to cut through the three exposed ribs along the vertical incision in the boy's chest. The cutters go through the bone of each rib cleanly with a brittle snap. Ribs are attached to the sternum by pieces of cartilage, so Hill can lift up the skin where he has cut the bone and use the cartilage as a hinge. He gently pulls up the flap and bends it back, opening a door of skin and severed ribs to expose the heart.
The heart. The size of a large fist, this hollow muscular pump beats around seventy times every minute, 100,000 times a day, 36 million times a year. Over a normal lifetime the human heart will beat more than 2.5 billion times. Every minute it pumps some eight pints of blood around the body through more than 54,000 miles of blood vessels. Stop this circulation of blood for much more than four minutes and the lack of oxygen leads to permanent brain damage. Fail to repair a major wound or cut into the heart and a human can bleed to death within a minute.
Hill looks down at Henry's beating heart. Its protective fibrous sack – the pericardium – is bulging out, filling with blood from the wounded organ. The heart is struggling against the pressure of this blood pushing against it. The pericardium looks as if it could burst, and with every beat the situation is only getting worse. Hill slits the wall of the pericardium, enlarging the original stab wound. Blood pours out, but with the pressure on the heart released, the heartbeat grows stronger. This is a good sign.
Hill asks his brother to reach into the pericardium and pull the heart upwards towards the opening in the boy's chest. Finally, Hill can see where the wound has penetrated. The knife had cut through the thick wall of the left ventricle, one of the two long chambers of the heart. From the left ventricle oxygenated blood leaves the heart at high pressure to circulate through the body.
Hill's brother cups the beating heart in his hand. A jet of blood spurts from the wound with every pulse. It is difficult to keep the organ steady – the blood makes it slippery as it jumps in his palm, but he does his best. Dr Hill reaches for his curved suture needle and some catgut thread and begins to stitch the wound together. As he works, the flow of blood gradually lessens; the gap closes and the blood begins to coagulate.
The heart keeps beating.
His brother gently slips the heart back within the pericardium and Hill pours salt solution over it to both clean the cavity and act as a mild antiseptic. He closes the cartilage hinge and stitches the flap of bone, muscle and skin back in place. Forty-five minutes have elapsed and the operation is over. Hill lifts Henry back to the bed. The boy has a slight fever and is slipping in and out of consciousness, but his heartbeat remains strong.
Three days after the operation, Henry's condition starts to improve. Fifteen days later he is allowed to sit up. Within a few weeks he has fully recovered and can show off his scar with pride. Hill is delighted; he is the first American surgeon to successfully cure a wound to the heart.
When Hill published a report of the case later that year, he included it in a table of similar operations undertaken between 1896 and 1902. For any aspiring heart surgeons the table would make depressing reading. There were wounds from knives, pistol shots and even scissors (in this case the victim had been stabbed a total of six times). Some of the patients received anaesthetic, some did not. Some were operated on immediately, some were not. It was difficult to draw any firm conclusions about the circumstances, given that so many of the operations resulted in death. Patients died of haemorrhages or infection, others bled to death on the operating table. Of the thirty-nine operations Hill had compiled, only fourteen patients survived (including the person stabbed with the scissors). In 1902 the chances were that two out of every three patients who underwent heart surgery would die. The odds were appalling. It was little wonder that most surgeons avoided operating on the heart altogether.
It is not as if the heart is particularly complicated. The organ is divided into two separate halves with a wall along the middle.* Vesalius (see Chapter 1) had accurately described the organ's anatomy in the sixteenth century, but believed blood was absorbed by the body and replaced by blood manufactured in the liver. In 1628 (almost one hundred years after Vesalius) the English physician William Harvey published his essay entitled 'The Movement of the Heart and Blood in Animals', outlining his belief that the blood circulated around the body.
* Galen (see Chapter 1) believed this wall contained tiny holes that allowed the passage of blood from one side of the heart to the other. He was wrong, but before birth there is indeed a hole. This allows blood to bypass the lungs because they are not yet functioning. After birth this hole usually closes, although not in the case of babies born with a 'hole in the heart'.
Harvey described how the heart is divided into two principal parts. The right side of the heart receives blood from the body and pumps it to the lungs; the left side of the heart receives blood from the lungs to pump it around the body. Each side has a smaller upper chamber called an atrium and a long, lower chamber called a ventricle.
Blood arrives at the heart through wide main veins known as the inferior and superior vena cava. This blood, low in oxygen, enters the heart and begins to fill the right atrium – a kind of holding chamber. When the right atrium is full, the muscle contracts to help push the blood through the tricuspid valve into the right ventricle – the pumping chamber. As the right ventricle contracts, blood is pumped out to the lungs to receive oxygen. This oxygenated blood returns to the heart in the left atrium, passes through the mitral (or bicuspid) valve and is pumped away from the heart in the left ventricle. The muscle wall of the left ventricle is thicker than that of the right as much more force is needed to push the blood all the way around the body. In a normal human heart, this whole process works smoothly and rhythmically: valves open and close, blood enters and leaves, muscles contract and relax.
The history of surgery suggests that surgeons have rarely been afraid of trying new, risky and untested procedures. By the 1900s surgeons were quite happy to cut into the body to operate on the internal organs. Appendectomies had become routine, tissue damage could be repaired and complex fractures set. Surgery was clean, relatively pain-free and generally successful. Surgeons were confident, highly respected members of society. But when it came to operating on the heart, they were terrified.
In 1896 the famous British surgeon Sir Stephen Paget declared that heart surgery had 'reached the limits set by nature'. More sobering to most surgeons perhaps were the words of Theodor Billroth, a pioneer of surgery on the digestive system. 'Any surgeon,' he wrote, 'who would attempt an operation on the heart should lose the respect of his colleagues.' And no surgeon wanted that.
Even twenty years later, during the First World War, surgeons would shy away from operating on the heart. Many soldiers had fragments of shrapnel left embedded in their chests, others simply bled to death. Some men survived for many years with bullets lodged in their hearts, the tissue healing around the foreign objects. Distinguished surgeon George Grey Turner summed up the situation when he was operating in a military hospital. He had the chance to remove a shell fragment, but concluded that 'it was beyond human and surgical capacity'. Even if the chances were that a patient would die without surgery, few surgeons were prepared to risk operating.
D-Day, 6 June 1944
Within minutes of the first soldiers landing on the beaches of Normandy, the early casualties were on their way home. The landing craft became ambulances, shuttling backwards and forwards from the beaches to the ships. The ships went from being troop carriers to floating hospitals with makeshift wards and operating theatres. The walking wounded were patched up and returned to the beach to fight another day. As the ships wallowed in the heavy swell, the medics on board made every effort to keep the most severely injured alive. After the beaches had been taken and the Allied Army moved inland, the ships returned to England.
The military operation to evacuate injured soldiers was as well planned as the invasion itself. While hospital ships ploughed back and forth across the Channel, teams of nurses and doctors set up field hospitals to follow the advancing troops. There were flights to repatriate the wounded, fleets of ambulances, and even special hospital trains. Back in England, while the invasion force had been gathering along the south coast, land was being commandeered for new hospitals. The generals could only guess how many casualties were going to need treatment.
At Stowell Park, near Cirencester in Gloucestershire, the 160th United States General Army Hospital had only just been completed. Surrounded by the gently rolling Cotswold hills, lined with dry-stone walls and dotted with woodland, this was a perfect place to convalesce – it truly was England's green and pleasant land. Although the hospital was in countryside to avoid the aerial bombardment suffered by cities, it had good rail connections to London, the ports of Bristol and the south coast. An airfield had been built near by and an extensive network of concrete roads constructed across the site.
The hospital itself consisted of row upon row of Nissen huts – long sheds made of semicircular arcs of corrugated iron on brick bases. Some huts were wards, some were offices, some were operating theatres. There were mess halls and nurses' quarters and an officers' club. There was even a parade ground, not that the patients would be doing much parading. This hospital would receive some of the most serious casualties from the war – those men who would almost certainly have died in any previous conflict. The 160th General Army Hospital was the base for the Fifteenth Thoracic Centre and a daring, confident and ambitious young surgeon: the red-haired, Harvard-trained Major Dwight Harken.
Aged only thirty-four, Harken was held in high regard and was already shaping up to be one of the world's leading chest surgeons. By the time he came to lead the surgical team at Stowell Park, he had perfected new operations to remove cancers, and had worked alongside eminent surgeons in Boston (Massachusetts) and London before the war. He was convinced that no part of the body was off limits to surgeons – particularly the heart. What was the heart anyway but a mechanical pump? He could not understand why so many surgeons shied away from tackling heart injuries, instead allowing foreign bodies to remain lodged there – inhibiting the heart's function, dooming the soldiers to die a slow death from blood poisoning or, worse, triggering a sudden heart attack. Didn't surgeons have a duty to operate on the heart? Harken had lobbied his superiors, including the president of the Royal College of Surgeons, Grey Turner, to be allowed to carry out heart operations should the opportunity arise. Eventually, he was convincing enough to be given the go-ahead.*
* Grey Turner accepted Harken's reasons for wishing to operate, but added one more, telling the young surgeon that he had neglected an important consideration: 'namely, the knowledge of an individual that he harbours an unwelcome visitor in the citadel of his well-being'.
As the first casualties began to arrive at the hospital, the nurses passed along the rows of stretchers, reassuring men that they would receive the best possible care. This was true, although some of the injuries were horrific. Some men were barely able to breathe, their lungs punctured by bullets. Others were coughing up blood or had chests swelling with fluid, their insides peppered with shrapnel.
Dwight Harken began operating around the clock, snatching sleep when he could, his energy and enthusiasm keeping him, and his team, going. Most of the operations involved opening up the chest to remove bullets, shrapnel and other debris – perhaps bits of uniform that had been in the way when the objects penetrated. It was remarkable that these men were still alive. Having entered battle at the peak of physical fitness probably saved them – that and the military effort to get them to hospital.
Harken also had technology on his side. Penicillin was now available, anaesthetics had been improved** and blood banks had been set up to enable transfusions (during the First World War doctors were still 'letting' blood for some injuries). Antiseptic technology had also moved on. The whitewashed operating theatre was kept as clean as possible. Everyone wore gowns and masks, and in addition to thoroughly scrubbing their hands, surgeons usually wore rubber gloves.
** Although in 1944 ether was still often used to induce anaesthesia, other options were now available to doctors, including injections of anaesthetic drugs. During major surgery, once the patient was 'under' a tube could be inserted directly into the trachea (windpipe) to pass air, oxygen or anaesthetic gases directly into the lungs. The mixture was controlled by the anaesthetist. Endotracheal intubation, as it is called, is still used today.
In addition to X-rays, Harken was also able to use a new type of imaging technology called fluoroscopy. This was much like taking a live X-ray image – X-rays were projected through the patient on to a fluorescent screen. Unlike the snapshot conventional X-rays provided, fluoroscopy could show a moving image. So day after day, night after night, images were taken, objects located and chests opened up. Lungs were stitched and reinflated, and infected tissue excised. When the men recovered, Harken presented them with the fragments of metal he had removed from their bodies.
But one day the fluoroscopic screen revealed a much more serious problem. The X-rays showed that the soldier had a bullet in his chest, but on the screen the bullet seemed to be jumping. There was only one conclusion – the bullet was lodged in the soldier's heart. With each beat, the bullet jumped. This was the chance Harken had been waiting for. He decided to operate.
Harken had prepared well. His previous experiments on animals had shown it was definitely possible to conduct delicate surgery on the heart. With each set of operations on dogs he was getting fewer and fewer deaths. He had a closely knit team of experienced doctors and nurses who were trained for this moment but, above all, he had the overwhelming belief that they were not going to fail.
The operating theatre took up half of a Nissen hut and it soon became very cramped. Around the operating table there were trolleys for instruments, the gas apparatus for the anaesthetic and a bulky electrocardiograph machine that drew an image of the patient's heartbeat on rolls of graph paper. Bottles of blood, matched to the patient, were brought in. As well as Harken, there were two other surgeons working as his assistants, an anaesthetist and a further surgeon to monitor the electrocardiograph. Alongside them was the scrub nurse, Shirley van Brackle. Everything was laid out ready; the young soldier was prepared for surgery and put to sleep.
Opening the chest is never something surgeons attempt lightly. There is so much that could go wrong. Soon though, Harken has made a foot-long incision and pulled apart the ribs with a retractor to expose the beating heart. It is obvious that there is a large fragment of foreign material in the right ventricle. Harken places sutures around the site, ready to be sewn together, then he cuts a small hole in the outer layer of muscle. Blood sprays out but the heart keeps beating. Can he stem the massive bleeding before the patient loses too much blood? And can he avoid the heart going into ventricular fibrillation – when the muscle loses its natural rhythm and beats uncontrollably?
Harken's hands are working in a well of blood; everything is bright red. He clamps his forceps firmly over the shrapnel and pulls. It sticks. The fragment of metal is plugging the hole he has cut. The bleeding stops; the heart keeps beating. Then suddenly, like the pop of a champagne cork, the object bursts out of the hole and so does the blood. It gushes in a torrent, a massive haemorrhage. The heart keeps beating, but time is running out. Harken has only seconds to close the hole before blood loss becomes too great. The patient's blood pressure drops but Harken doesn't panic.
As his assistant grasps the sutures in an attempt to tie them together, Harken flings the clamp and shrapnel across the room, narrowly missing Shirley the nurse. He makes another attempt to tie off the sutures, but nothing seems to stop the disastrous flow of blood. In desperation, Harken sticks his finger in the hole. The haemorrhaging stops, the heart keeps beating.
With his finger still in the hole, Harken begins to sew around it – underneath the finger and out the other side, gradually pulling the two sides of the gap together. One of the other surgeons jokes later that it would have been easier to cut Harken's finger off and leave it there, embedded in the heart wall. Harken slowly removes his finger as the sutures are tightened, but when he tries to pull his hand free, it will not come. He realizes he has sewn his glove to the heart wall. With the glove cut free, the blood pressure starts to rise. The soldier makes a complete recovery and Dwight Harken becomes the first surgeon to successfully cut into a beating heart. He is the first true cardiac surgeon.
Soon Harken would perform the operation again, and again, building up an impressive collection of trophies – shrapnel, bullets, fragments of clothing – all removed from soldiers' hearts. In the end he would operate on a total of 134 patients. There were no deaths. News of the remarkable surgery being undertaken at the 160th General Army Hospital soon spread. Everyone wanted to meet this dynamic young surgeon. There were visits from leading surgeons, generals, the Duchess of Kent, Queen Elizabeth (the future Queen Mother) and even Glenn Miller and his band, who played a few numbers in some of the wards. One of Harken's operations was made into a movie. As he worked, a Hollywood cameraman lay above the table on some makeshift scaffolding to capture the surgery in all its gory detail.
As the operations progressed, Harken gradually came to perfect his technique. New procedures were suggested and tried. At one point it was thought that an electromagnet might be useful to extract the metal fragments. It certainly seemed like a good idea, so a giant electromagnet duly arrived and was suspended over the operating table by a crane arrangement. Unfortunately, the implications of bringing a giant magnet into an operating theatre had not been fully thought through. When the switch was thrown and the magnet energized, the lights dimmed, the electrocardiograph went crazy and every metal surgical instrument in the operating theatre flew at high velocity towards it. Fortunately, there were no injuries but the idea was abandoned.
One of the surgeons who visited Harken was impressed by an operation, but questioned how much use this pioneering surgery would have after the war. What help would it be in peacetime to know how to remove bullets from a soldier's heart? But this visitor missed the point. Harken had done far more than perfect the removal of shrapnel. He had proved that it was possible to cut into a beating heart without killing the patient. The heart was no longer untouchable; it could be operated on safely and successfully.
Before the war intervened, Harken's ambition had been to operate on patients suffering from mitral stenosis. This disease affects the mitral valve, which controls the flow of blood between the left atrium and left ventricle. Mitral stenosis was usually the result of rheumatic fever and caused a narrowing in the opening of the valve. Sufferers from mitral stenosis endured all the usual problems of a weak heart, including poor circulation and breathlessness. The condition could leave them completely incapacitated and virtually guaranteed an early death. A couple of surgeons had attempted to cure the condition in the 1920s, leaving a succession of patients dead on the operating table. With his wartime experience behind him, Harken was ideally positioned to try again, and other surgeons had the same idea.
In 1948 Harken became one of four surgeons to successfully operate on heart valves.* Having proved that cutting into the heart was possible and survivable, the technique was relatively simple. The surgeons would make a small incision in the heart wall before inserting a tiny knife, scissors, or simply their finger to reopen the heart valve. They could not see the area they were operating on and had to feel what they were doing. All this would take place in a pool of blood while the heart was still beating.
* The first of these operations was carried out by Charles Bailey in Philadelphia. Harken carried out his first operation a few days later, but was the first to publish his results.
It was known as 'closed-heart' surgery, although 'smash and grab' heart surgery would have been equally appropriate. As surgeons perfected their techniques, the procedure gradually became safer. Nevertheless, if there were any unforeseen complications, or a new experimental operation went wrong, the patient would usually die. And many patients did. Not only were the surgeons operating blind, they were also operating against the clock. With a hole cut into the heart, blood loss was tremendous. Although blood transfusions were used, surgeons had only around four minutes between cutting into the heart and sewing the hole closed before a fatal amount of blood was lost. Making anything other than a small hole in the heart would cause massive bleeding, and death would be virtually instantaneous. To attempt anything more ambitious, surgeons needed to see what they were doing and, above all, they needed more time.
DR BIGELOW AND THE GROUNDHOGS
Canadian prairie, near Toronto, 1951
Dr John McBirnie was having a miserable day. The prairie was bitterly cold, he was wet and up to his knees in dirt. Despite the fact that every farmer had told him there were groundhogs 'every-bloody-where' and they were a 'bloody menace', he had not seen a single one of the vicious bastards all day.
McBirnie didn't know what he was doing wrong. He had come well prepared for the role of chief groundhog catcher: he set off every morning dressed in waders and armed with a shovel, but his results were pathetic. He had tried digging them out and flushing them out with water. He had sat by their burrows; he had stamped up and down. Frankly, he was running out of ideas.
McBirnie had been assigned the job of catching groundhogs by Wilfred 'Bill' Bigelow, surgeon and director of the Cardiovascular Laboratory at the Banting Research Institute. Bigelow wanted to understand hibernation. In winter, when the prairie was covered in snow, groundhogs curled up in their burrows and hibernated. During hibernation the animals' core temperature cooled down to match their surroundings, their metabolism and circulation slowed, as did their heartbeat, allowing them to withstand temperatures only a few degrees above freezing. Bigelow had the idea of creating a similar state in humans – inducing hibernation to slow down the circulation. If he could reduce the amount of oxygen the body needed, perhaps this would buy surgeons enough time to be able to cut open the heart?
Bigelow had first got interested in studying the effects of cold in 1941, when he was a young surgeon at the Toronto General Hospital. His shift involved having to attend to a patient who had been drinking. The man had got so drunk that he passed out in the snow and when he woke up a few hours later, his hands were badly frostbitten. When he eventually got to the hospital there was not much Bigelow could do other than amputate the poor man's frozen (and now gangrenous) fingers. It was an unpleasant task, but the gruesome experience made the surgeon realize how little doctors knew about frostbite and the effects of cold. It inspired him to study how the body's metabolism reacts to low temperatures. Three years later he had published his first research paper on hypothermia.
After the war (and following a posting as a battle surgeon in the Canadian Army Medical Corps) Bigelow trained as a specialist in vascular and cardiac surgery. When he was working late one night he had a flash of inspiration. He realized that he might be able to apply what he had learnt about the cold to the problems of operating on the heart. He started to experiment on dogs.
The researchers immersed anaesthetized dogs in tanks of icy cold water to induce a state of hypothermia in an attempt to slow down the animals' circulation. The first results were baffling: the dogs were using up more oxygen when they were cooled than when they were at normal temperature. Bigelow realized that the dogs were shivering – even under anaesthetic. The muscle contractions were using up energy, so the muscles required more oxygen. But once the researchers switched to using ether anaesthetic – which also worked as a muscle relaxant – the dogs' temperature could be cooled by several degrees. With the animals' circulation and heartbeat slowed, the organs needed less oxygen. A 7-degree (Celsius) drop in temperature reduced oxygen consumption by half.
Bigelow was a generous man and openly shared his findings and published his results. Some thought he was mad; others thought the studies looked promising. The dog experiments had shown that the animals could be anaesthetized, cooled and their hearts operated on. When the dogs were revived, a good percentage survived and recovered well with no signs of permanent injury. This same technique might work with humans. Other surgeons started to take notice.
Meanwhile, Bigelow had a more ambitious goal in mind: he wanted to go beyond hypothermia to crack the secrets of hibernation. Could the research team find a chemical to slow down the body – a hormone perhaps? He set about collecting groundhogs. Or rather, because he was in charge, he made the (wise) decision to delegate.
Despite McBirnie's initial difficulties, Bigelow's team soon became adept at groundhog capture. They realized that the best way to get the animals out of their burrows was to flush them out with water. Three trucks moved from farm to farm, a line of spectators in their wake, as farmers and other locals came to watch. It seemed that this was the most exciting thing that had happened around these parts for a long time.
The first truck was the scout car; the scout car team was responsible for finding the groundhog burrows. The next vehicle was a tank truck full of water. Bringing up the rear was the truck carrying cages. Once the animals were captured they did everything they could to escape – they chewed through chew-proof cages, they escaped from escape-proof containers, the sharp-toothed little brutes would bite researchers' hands as a matter of course. Some members of the team began to dread the work. All of them came to treat the animals with great respect.
Eventually Bigelow had enough groundhogs to establish the world's first (and only) groundhog farm. A large, fenced-off field, complete with luxury (in groundhog terms) ready-made burrows, was home to some four hundred groundhogs. The burrows consisted of tunnels leading into underground tanks that were built into mounds of earth. From the inside these were ideal groundhog homes. What the animals did not realize was that each mound had a lid on it so that the researchers could reach them while they were hibernating.
Once the groundhogs were settled in for their winter hibernation, the scientists were able to open the lids of the burrows and pick up the tightly curled balls of fur. Unlike when they were awake (and to the great relief of the scientists), the groundhogs did not seem to notice. For the first time, the animals could even be described as cute. The researchers collected extracts of blood, fats, proteins and steroids. They measured, analysed and recorded. The evidence pointed to there being a chemical – some active substance – that let the groundhogs hibernate without coming to harm. All the research team had to do was find it.
But Bill Bigelow was not planning to wait until he had discovered the elusive secret of hibernation. His hypothermia research on dogs had already proved successful, and safe* enough to try on humans. Now the Canadian surgeon just had to wait for the right patient. However, if he had been hoping to make it into the history books, he was about to be beaten to it.
* Well, reasonably safe. Experiments had suggested that cooling the body too much could stop the heart altogether.
OPENING UP THE HEART
University Hospital, Minneapolis, 2 September 1952
The green-tiled operating room was the modern equivalent of an old Victorian operating theatre. Instead of a raked gallery surrounding the operating table, spectators could observe from a room above, through glass portholes in the domed ceiling. And today's operation would certainly be worth watching.
Some of the brightest, most ambitious and daring cardiac surgeons are working in Minneapolis. Today, F. John Lewis is leading the surgical team. He is assisted by a young surgeon called Walter Lillehei, a man who will come to epitomize the heart surgeon: confident, resilient and, it will later become apparent, something of a showman. Above all, these are men (and they are all men) who are not afraid to fail.
The patient is a thin, frail five-year-old girl named Jacqueline Johnson. She has been diagnosed as suffering from a hole between the two upper chambers (the atria) of her heart. Without surgery she is unlikely to live much longer. Her heart is already swollen and she is becoming weaker by the day. The anaesthetist puts her to sleep (using a muscle relaxant to prevent her shivering) and the surgical team wraps a special blanket threaded with rubber tubes around her. They tie the sides of the blanket together with wide ribbons of cloth and turn on the taps to allow cold water to pass through the tubes.
It is a slow process to gradually cool the girl down – it takes twenty-five minutes before her temperature has dropped just one degree. Eventually, after two hours and fourteen minutes, her body's core temperature is down to 28°C – 9 degrees below normal. And as the girl's temperature falls, so does her heart rate. Jacqueline's heart is now beating at half the normal rate. According to calculations based on Bigelow's research, if surgeons usually had four minutes to operate on the heart to avoid starving the brain of oxygen, they now have six. But is six minutes enough to cut open the girl's heart, repair the defect and sew it back up again? Can those extra two minutes make the difference between failure and success?
The surgeons untie the blankets and Lewis cuts open Jacqueline's chest. Her heart is beating slowly as the surgeon prepares to clamp off the girl's circulation. Lillehei starts his stopwatch.
The six-minute countdown begins.
Lewis works slowly and precisely. Unnecessary haste could be fatal. He tightens tourniquets around the veins entering the heart and the arteries leaving it. The blood stops moving around Jacqueline's body, but her heart keeps beating. Lewis cuts into the right atrium to expose the inside of the heart. Unlike closed-heart operations, where surgeons operate in a river of blood, Jacqueline's heart is practically dry. Lewis can clearly see what he is doing. The defect is exactly as he had expected: a hole between the left and right atrium. He begins to sew.
Two minutes left.
Lewis finishes sewing and pours some saline solution into the heart to test the repair. There is a leak. He puts in another stitch and tries the saline again. The hole is closed.
One minute left.
Lewis starts to suture together the thick muscle of the heart wall. The muscle is still beating but the rhythm is becoming weaker, the beat irregular.
Lewis releases the clamps across the arteries and veins. Blood begins flowing. The surgeon grasps the heart in his hands and begins squeezing to help it back into its natural rhythm.
He closes the girl's chest as quickly as he can and carries her over to a bath of warm water (actually a watering trough ordered from a farm catalogue). Her heartbeat becomes stronger. She is going to be OK. Five-year-old Jacqueline Johnson leaves hospital eleven days later. She will grow up to have two children of her own. It was an incredible surgical advance: open-heart surgery had arrived.
MEANWHILE, BACK AT THE GROUNDHOG FARM
Although Bill Bigelow did not get to perform the first successful open-heart surgery on a human patient, he was undoubtedly pleased that his theory had been proved right. Many patients, particularly young children, would owe their lives to him. Hypothermia bought surgeons valuable extra minutes – enough time to carry out procedures that had previously been impossible. Bigelow continued to work to improve the techniques of cardiac surgery. He developed the first electronic pacemaker. He also continued to study the groundhogs.
Bigelow's team had been collecting groundhogs for almost ten years. The farm was thriving; the little bastards were still biting. Back in the lab the doctors were taking extracts from the animal's brown fat deposits – pads of fat that the researchers decided were the key to hibernation. These samples were analysed and their chemical composition checked. Finally, in December 1961, it appeared that all the research effort had paid off – one of the tests revealed a completely new substance. Could this be the mysterious chemical that allowed the groundhogs to hibernate?
A small amount of the substance was extracted and injected into some guinea pigs. The animals were then cooled down to low temperatures – much lower than they had previously been able to endure. There were no ill effects. This could finally be it. There was great excitement among the team. A vial of the new chemical was personally delivered to the National Research Council in Ottawa for further tests. It was even given a name: Hibernin.*
* Its full chemical name was 1-butyl, 2-butoxy-carbonyl-methyl-phthalate.
The hospital appointed the finest patent lawyer, and Bigelow filed a patent (no Minnesota surgeon was going to get his hands on the product of his research this time). NASA made enquiries – perhaps they could use this substance for astronauts on long-duration space missions? A few journalists got wind that something was going on, but the researchers kept their silence. One of them even delayed a promising job offer so that he could spend more time with groundhogs.
They decided to try out Hibernin on patients. After all, the guinea pigs had survived. The surgeons operated on two people suffering from holes in the heart. The human guinea pigs were hooked up to some tubing to enable Hibernin to be injected. Bigelow found he could cool the patients down to around 18°C – four degrees lower than anything they had achieved before – which bought the surgeons much more time. Both operations were successful. The only peculiar thing they noticed happened after the operation: the patients were sleeping for much longer than usual. They seemed groggy. It was strange, but the nurses in the recovery room said it was almost as if they were drunk.
Now that Hibernin had been proved to work there was immense pressure to publish the results of the trial. Everyone was lined up for a major media event to make the big announcement. This would be a significant achievement for Canadian science. Then Bigelow received a letter from the patent office in Washington DC. The letter said that the chemical had already been patented. 'Hibernin' had been used for some twenty years as a plasticizer – employed to make intravenous plastic tubes pliable. Bigelow was incensed. How annoying that a biological extract from groundhogs turned out to be the same stuff as an industrial chemical. Still, the team had better do one final check as a scientific formality. Some clean plastic tubing was cut up and placed in water. A few hours later the scientists analysed the water. They extracted Hibernin.
Rather than having extracted a miracle substance from groundhog fat, the surgeons had simply flushed out the plasticizer from the tubing used in their research. The plasticizer was a potent form of alcohol. This explained why the patients acted as if they were drunk – they were. It says a lot about Bigelow and his management style that he and his team were able to laugh about it. Ten years of visiting the groundhog farm in the bitter winter. Ten years of groundhog bites. Ten years of hard research work. Thank heavens they had held back on the publication.
They never did find the secret of hibernation. The groundhog farm was shut down and the researchers moved on to other things. Bigelow would often cite the experience as a humbling example of 'intellectual humility'. However, the research did not go completely to waste. It opened up a whole new area of study into the use of alcohol in hypothermia. It turns out that alcohol dilates the blood vessels, allowing smoother cooling and causing less long-term damage. A refinement of Bigelow's hypothermia technique is still being used in operating theatres today.
DR LILLEHEI HAS AN INTERESTING PROPOSAL
'Breakthrough' is one of the most overused words in science and medicine. Most progress is incremental – small changes in procedures or techniques, refinements of treatments and technologies. However, when it came to surgery of the heart, the only way to progress was through daring new breakthroughs: Hill sewed up a wounded heart; Harken cut into a beating heart; now Lewis had performed the first successful open-heart surgery. These surgeons had the courage to try completely new ideas on real living patients.
Hypothermia was undoubtedly a major breakthrough, allowing surgeons genuinely to cure some of the worst heart defects. But hypothermia was severely limited by time. Doctors had only a few minutes to clamp off the heart, open it up, fix the defect, close the heart and restart the circulation. Hypothermia increased the time they had, but it could not stop the clock altogether. And when it came to open-heart surgery, there were so many things that could go wrong. There could be a problem with the anaesthetic, or a difficulty during the cooling of the patient. The surgeon might accidentally sew through a hidden nerve, interrupting the heartbeat or even stopping it altogether (this was known as 'heart-block').
What these pioneering surgeons feared most was a misdiagnosis. Jacqueline Johnson, the first open-heart patient, was suffering from an ASD (atrial septal defect). This was a hole between the upper two chambers of the heart, the atria. Patients could also have holes between the two ventricles – a much more serious condition – or worse. There could be defects in valves, in muscle or nerves. There were some heart defects that many surgeons thought might never be conquered, not least the sinister-sounding tetralogy of Fallot.* This disorder involves not only a hole between the ventricles, but obstructions between the right ventricle and the lungs, a thickening of the right side of the heart and a distortion in the aorta, the main artery from the heart.
* The peculiar name for this congenital condition comes from Etienne-Louis Fallot, a Marseilles surgeon who first described it in 1884.
In the 1950s surgeons had a limited number of tools at their disposal to work out what was wrong. They could X-ray the heart, listen to the heartbeat and study the rhythm on an electrocardiograph. Usually they got the diagnosis right, but sometimes it was wrong. They would open up the heart to find a larger hole than they expected, two holes instead of one, or multiple problems. And however quickly they worked and however brilliant their technique, the surgeons would run out of time. If that happened, the patients – invariably children – died on the operating table.
Hypothermia slowed the clock down, but surgeons now wanted to stop it altogether. To fix some of these more complex problems they needed to be able to isolate the heart completely. They needed some way of clamping off the circulation without jeopardizing the rest of the body by shutting off its blood (and hence oxygen) supply. Back at the University of Minnesota, surgeon, and now associate professor, Walter Lillehei had a brilliantly simple, if somewhat bizarre, idea. Why not keep the patient's blood circulating with someone else's heart?
The theory went like this: as well as the patient, a healthy person would be brought into the operating theatre. Arterial blood from the healthy person's body would be pumped across to the patient. This oxygenated blood would be passed directly into the patient's arteries to circulate around his body. Then, instead of returning the blood to the patient's heart, deoxygenated blood would be returned to the donor. The concept became known as cross-circulation and held enormous promise. During the period the two people were connected, their blood mingling together, surgeons would be free to open up the patient's heart. They then had plenty of time to fix any major defect.
The healthy donor would obviously need to have a matching blood group. But as the donor would usually be a close family member – ideally a parent – this would not be a problem. And what parent wouldn't do all they could to help their dying child? Yes, OK, it was risky taking a perfectly healthy adult into an operating theatre, sedating them and hooking them up to someone else, but wasn't it a risk worth taking? What could possibly go wrong?
Lillehei was not one to shy away from risk – particularly when the reward was so great. If this worked, he would be able to save any number of children from an early death. He began experimenting on animals to refine the technique. He acquired a pump – normally used in the dairy industry to move milk – and some plastic tubing designed for beer taps. He had to work out the layout of the operating theatre, the staffing and procedures for two patients. Above all, he had to make sure that the system he devised to connect the two patients was airtight. Any foaming from the pump, in fact just one tiny bubble, was enough to induce a stroke. It could leave the patient or the donor with permanent brain damage. If something went awry during the operation, one or both of them could be killed. Lillehei had invented the first surgical procedure with the potential for 200 per cent mortality.
SO MUCH FOR THE THEORY
University Hospital, Minneapolis, 31 August 1954
Howard Holtz was an ordinary man with an ordinary job. He spent most of his working life outside, maintaining the Minnesota highways. The twenty-nine-year-old was married with three perfectly healthy children, and another on the way. There was nothing particularly unusual about Howard Holtz. Except his blood. He had AB negative blood – the rarest of blood groups, found in only 1 per cent of the population. The blood was on a donor register. Of course, it's one thing to donate blood, quite another to donate your entire circulation, but this is precisely what Howard was asked to do when he was approached to act as a donor for one of Lillehei's operations.
Lillehei had been performing cross-circulation operations since March, and the procedure was reasonably well established, even though the risk was still considerable. The first operation on a sickly one-year-old baby boy had been successful. The patient and donor were connected for some nineteen minutes. Unfortunately, the boy died eleven days later from another complication.
In April the surgeon had operated on a three-year-old boy and four-year-old girl. Both operations were successful – successes that the proud showman Lillehei revealed to a press conference a week or so later. He even wheeled out the cute little girl so that she could be photographed with her parents, and her father, the donor, could be questioned by the pressmen. They were told how close the poor girl was to dying, the pneumonia she suffered from, and the oxygen tent she once had to live in. Now she could grow up to lead a normal and healthy life (and she would).
The papers described cross-circulation variously as 'miraculous', 'daring' or even 'impossible'. Some patients died, but those cases didn't get reported. There were no official mortality figures. In 1954 cross-circulation was the best chance many extremely sick children had of surviving into adulthood. Whether to go ahead with the operation was an awful decision for parents to make, but, after careful consideration, most decided it was their child's best hope. As Minneapolis was the only place in the world where this operation was being performed, most parents considered themselves lucky even to have the opportunity.
For Mike Shaw's parents, Lillehei offered the chance of a miracle cure. Ten-year-old Mike was seriously ill. He had been diagnosed as suffering from tetralogy of Fallot and had been in and out of hospital since birth. You could tell he was sick just by looking at him. The boy was thin and pale, his skin so tinged with blue that he was practically translucent. His ears stuck out from his wan face, giving him an emaciated appearance. Mike could walk only a few paces before becoming breathless. Without surgery he had only months to live. Lillehei might be able to save his life.
Mike's parents agreed that Lillehei should go ahead with a cross-circulation operation. They were aware of the risks, but trusted the surgeon, who was at least honest about their son's chances (although as this was the first attempt to correct tetralogy of Fallot, no one really knew for sure). The boy's blood was tested so that they could decide which family member would make the best donor, but then they hit the snag. With AB negative blood, neither Mike's parents, nor seemingly any other relatives, matched. Would a complete stranger be prepared to help?
When Lillehei explained the situation to Howard Holtz, the highway worker agreed to lend his body to the procedure. A complete stranger to Mike Shaw, Howard figured that if his own kids were sick, someone would do the same thing for him. A child's life was at stake, and Howard realized that a 'no' from him amounted to a death sentence for Mike. As far as the safety of the operation was concerned, none of the previous donors appeared to have suffered any ill effects. Any risks (and Lillehei had explained clearly that there were risks) were surely worth taking. Howard met Mike and the boy's family. The operation was scheduled.
Because cross-circulation involved two patients, it required two teams of surgeons. It is incredible that so many could fit into the small operating theatre. The room seems to be teeming with people, with little space between them. Everyone is gowned and masked, all slightly anxious. On the left lies the heart patient. At his head the anaesthetist and his assistant. They need to keep the patient's lungs replenished with air until the cross-circulation is connected; after that they are unusually powerless. A low curtain separates the anaesthetist from Lillehei and his assistants.
Even with his hat and mask on, it is easy to spot Lillehei. A long scar runs down his neck and disappears beneath his gown. The scar is evidence of major surgery to remove a tumour, and gives his head a lopsided appearance. Above the table a set of lights is angled downwards, but Lillehei also wears a head lamp on his forehead so that he can see clearly into the bloody hole in the boy's chest. The lamp, which is plugged into a socket in the floor, looks like it has been cobbled together from an old desk light, and becomes uncomfortably hot above the surgeon's face.
To the right of the main operating table lies Howard. He has also been put to sleep. This is not strictly necessary for the operation, but avoids any distress (or even boredom) on the donor's part. It is important to keep the anaesthetic as light as possible – any drug circulating in Howard's body will also circulate in Mike's. The anaesthetist also makes sure the donor's breathing is regular. As long as the two patients are connected, Howard is breathing for two. A surgeon has made an incision in Howard's right leg (left as you look at him) and inserted a tube into his femoral artery. Another tube enters the main vein in the leg – the great saphenous vein.
Between the two operating tables snake the beer tubes full of blood. Brightly coloured oxygenated blood flows one way across the operating theatre and darker venous blood flows back the other. The blood passes through the dairy pumps to regulate the pressure and make sure the boy's fragile circulation is not overloaded. The pumps make a smooth, rhythmic sound as a line of small mechanical fingers press the blood along the tubes. Nurses move between the two patients, a surgeon monitors the flow of blood, Lillehei cuts away at Mike Shaw's heart.
For those observing through the windows of the gallery above – even the most experienced of surgeons – this is a remarkable operation to witness. Probably the most daring, ambitious and perhaps downright foolhardy they have ever seen undertaken. As Lillehei cuts and sews slowly, methodically beneath them, some of those watching are mentally calculating the odds on Mike Shaw and Howard Holtz both coming out of the operating theatre alive.
The pump is switched off. Mike's heart takes up the strain. Howard is disconnected. The donor leaves hospital after a few days. Not long after, so does Mike Shaw – he is cured. It is another miracle for Lillehei's revolutionary and 'impossible' surgery.
The operation had transformed Mike Shaw from a sickly patient to a healthy, active boy. At the time of writing, Mike and Howard are still very much alive. Mike grew up to become a musician – a bass guitarist – and, thanks to Lillehei's operation, has lived life to the full. At eighty-two, Howard is also fit and healthy, and regularly goes line dancing. Several years after leaving hospital, Mike's mother complained to Lillehei that her son was now playing in a band, staying out late at night and dating a lot of girls. Before the operation she had been worried that he couldn't do anything; now she worried he was doing too much!
Lillehei was a hero to the patients he saved, but unfortunately not every case was so successful. Later that year he had a series of failures – complications arose or a misplaced stitch resulted in heart-block. Sitting with parents telling them the worst news possible is something few surgeons get used to but, unlike some, rather than delegate the responsibility Lillehei made it his job to talk to the parents himself. Despite his self-belief and bravado, Lillehei shared their grief. But somehow he was able to recover, ready to attempt another operation the following day. At one point he was close to abandoning the procedure altogether, until persuaded by his boss to keep going. In the end he performed cross-circulation operations on a total of forty-five sick children. Twenty-eight survived surgery and most went on to lead normal, healthy lives.
It was the welfare of donors that finally brought an end to the operations. On 5 October 1954 Geraldine Thompson was hooked up to her daughter and the pump between them switched on. Lillehei began to operate, concentrating on the girl's heart. However, someone else in the operating theatre was not doing his job properly. A bubble of air had got into the system. The operation was halted, but it was too late. Mrs Thompson was left severely brain damaged. The observation that this was an operation with the potential for 200 per cent mortality had almost come true.*
* Lillehei told Mr Thompson that the failure of the operation was due to an error. He clearly felt terrible about it and, as he held liability insurance, suggested that he sue on his wife's behalf for a reasonable amount. Unfortunately, once the lawyers got involved, a reasonable amount became millions of dollars, and the case ended up in court. The court ruled that Mrs Thompson had been fully aware of the risks, so the family ended up with nothing.
No other surgeon in the world dared to attempt cross-circulation, although some tried ideas that seem even more absurd. At the Hospital for Sick Children in Toronto, surgeon William T. Mustard was experimenting with monkey lungs. Just before the operation, he would anaesthetize and kill several monkeys, remove their lungs and clean out the disembodied organs with antibiotics. The lungs would then be suspended in jars of pure oxygen and connected to the patient. During a series of operations on twenty-one children, only three of Mustard's patients survived.
Another surgeon and researcher, Gilbert Campbell, tried a similar experiment with the lungs of a dog. After a successful trial during a routine operation (not on the heart) he recruited Lillehei as lead surgeon to give it a go during a tetralogy of Fallot case. The patient died shortly after the operation, but later attempts were more successful, most famously in an operation on Calvin Richmond, a thirteen-year-old Afro-American boy from Arkansas who had been badly injured in a road accident and was seriously ill. Doctors concluded that he was suffering from a hole in the heart, but there was little they could do. His only hope lay in the miracle surgery being conducted by Walter Lillehei at University Hospital, Minneapolis.
A fund-raising campaign involving a Little Rock newspaper and TV station raised enough money to send Calvin to Minnesota for treatment and he was flown north courtesy of the Arkansas Air National Guard. However, on learning of cross-circulation, the boy's mother declined to participate in the operation. A volunteer was sought from the local prison instead. When none came forward – for fear of their 'white' blood and Calvin's 'black' blood mixing – Lillehei decided to use the dog-lung method. The operation went without a hitch, the animal lung oxygenated Calvin's blood while the boy's damaged heart was repaired. The success was widely reported, although most correspondents skated over the bit about the lungs from the dead dog.
If cross-circulation had its faults – and its potential to leave both participants dead was a downright terrifying one – then employing monkey and dog lungs was hardly any better. Lillehei used the dog-lung technique a few times more, but concluded that it was far from ideal. At least Lillehei knew when to stop. As for the monkey lungs, you can only have great sympathy for the desperate parents who put their trust in William T. Mustard. Something better was needed. And while the surgeons in Minneapolis were using other humans or animals to oxygenate the blood, surgeons elsewhere were turning to machines.
DR GIBBON'S REMARKABLE INVENTION
Philadelphia Jefferson Hospital, 6 May 1953
The operation was going well. Eighteen-year-old Cecelia Bavolek lay on the table, her chest cut open to expose her beating heart. Dr John H. Gibbon Jr was relieved that the diagnosis had proved correct – Cecelia was suffering from an atrial septal defect – a hole in the heart between the two atria. His blood-splattered hands began to stitch the two sides of the one-inch hole together. For Gibbon this was a well-practised procedure, though all his previous successes had been on cats and dogs. His first, and until now only, attempt on a human patient had ended in death on the operating table.
Gibbon worked slowly, methodically and precisely. As usual, the operating theatre was crowded. There were other surgeons huddled around the table, plus assistants and scrub nurses to pass instruments. The anaesthetist monitored the girl's blood pressure; an assistant passed the surgeon some scissors. Gibbon was not relying on hypothermia to cool his patient; neither was he using cross-circulation or some other animal's lungs to pump and oxygenate the girl's blood. He was trying out the latest version of his great invention – the heart-lung machine – which was gurgling, humming and clunking beside him.
Gibbon's heart-lung machine looked (and sounded) like something out of a 1950s B movie, where the unhinged scientist meddles with forces he doesn't fully understand. But, on the face of it, there was nothing even slightly eccentric about Gibbon. He had a reputation for calm professionalism; he was well respected by his colleagues and, remarkably for a heart surgeon, was shy and selfeffacing. Colleagues described him as a 'perfect gentleman', kind and considerate. If there was anything eccentric about Gibbon, it was his obsession with developing a machine to keep a human being alive during major surgery.
Gibbon had been working on the project since the 1930s. The early attempts were crude mechanical affairs, the size of a grand piano. Visitors invited to his lab to see the machine in action were issued with wellington boots. The giant machine needed buckets of blood to get it started, but once under way could sustain the life of a very small cat. Pretty soon the visitors would notice that the floor was getting wet and that they were walking around in blood. 'Uh oh,' said Gibbon, as pints of cats' blood sloshed across the floor. 'We've got a leak again this morning.'
Emulating the human heart and lungs within a machine proved to be a tough challenge. Replacing the heart itself was relatively simple: this could be done with a pump. As long as the circuit had some pressure controls and there was a safeguard against air getting into the system, an artificial heart pump could employ off-the-shelf technology (such as the dairy pump Lillehei used for his crosscirculation operations). The problem was the lungs.
Human lungs consist of a branched network of tubes, where gases are exchanged between the air and the blood. Oxygen from the air passes into the blood, and carbon dioxide passes from the blood into the air. The total surface area available for this exchange is an astounding 84 square yards – about the same area as a tennis court. Any machine needed either to include a similarly massive surface area (much bigger than your average operating theatre) or find some other way of getting oxygen into the blood. The obvious way was to bubble the oxygen into the liquid, but this was fraught with difficulties. If even the slightest single tiny bubble remained and was allowed to pass back into the patient's bloodstream, it could kill them. Gibbon favoured pumping the blood over a flat surface – a plate or screen – to expose a film of blood to oxygen. As long as he could keep the blood flowing, this method seemed to work. The trouble came when the blood started to clot.
Over the years Gibbon's heart-lung machine became more refined. After the war the International Business Machine Corporation (IBM) offered its support and an engineer. Electronics were introduced to control the flow of blood and monitor the pressure and oxygenation process. The experimental animals got bigger and bigger, while the machine became smaller and more efficient. Even so, the heart-lung machine was still bulky and incredibly complex. Around the size and shape of two large top-loading washing machines bolted together, the contraption was so big that when it arrived at the hospital it had to be winched in through a window. But with IBM's help, it no longer resembled a crude Heath Robinson affair. Now it looked more like cutting-edge technology.
The machine was covered in switches, pipes and dials. Dials to measure acidity and pressure; electronics to monitor and control the flow of blood; even a back-up battery should there be a power failure. The top was a mass of plastic tubing, the sides hung with glass bottles. Rising from the upper surface was a rack of screens down which the film of blood would cascade to be exposed to oxygen. Snaking from it were two tubes – an input tube that would take blood from the patient's veins, and an output tube that would return oxygenated blood to the patient's body. Once it was hooked up, the machine would take the place of the patient's heart and lungs.
It is twenty-six minutes into the operation and Cecelia Bavolek is doing well. Blood that would normally pass through her heart and lungs is being diverted into the machine. It is being oxygenated and returned to her body. But something has gone wrong. The blood on the oxygenator screens is no longer running freely. It has started to clot. The pumps keep working and the pressure in the machine starts to build. On the operating table Cecelia is no longer receiving enough oxygen. The machine begins to foam. It is going to explode.
Vic Greco is responsible for the machine.* He has been working in the research lab with Gibbon and guesses what has gone wrong. Before it is hooked up to the patient the machine has to be 'primed' with blood. When they had done this earlier in the day, they had probably not added enough of the blood-thinning chemical heparin. But there is no time to analyse why it has gone wrong. They have to solve what is rapidly turning into a very messy crisis. Unless they can fix the machine, Cecelia Bavolek is going to die.
* The machine was usually the responsibility of Jo-Anne Corothers, but it had been decided that it would be 'better for the historical record' if a doctor ran the machine that day.
At the operating table Gibbon tries his best not to get too distracted. He works as quickly as he can, but the foaming is getting worse. The blood is beginning to back up around Cecelia's body, and her circulation is coming to a halt. Greco climbs up a stepladder to hold down the lid of the oxygenator to prevent Cecelia's blood from spraying around the room. Then Bernard Miller, who has been intimately involved in the technical development of the machine, starts rerouting the pipes. He figures that the only chance they have is to bypass the now useless oxygenating screens and turn the heart-lung machine into just a heart machine. This will at least get the blood moving and restart Cecelia's circulation.
The blood starts to flow again, only this time it is not getting any oxygen. This is circulation of sorts, but what hope does Cecelia have without any means of getting oxygen into her system? Gibbon carries on anyway. Cecelia's heart loses its rhythm and goes into fibrillation. Gibbon begins to stitch together the incision he has made. He uses an electric shock to get her heart beating again and it goes into a normal rhythm. She could yet live. At least nothing else can go wrong. But it isn't Gibbon's day. As the surgeon continues to work, Cecelia starts to come round from the anaesthetic. She struggles on the operating table. Gibbon closes her chest and puts the final stitches in her skin. Remarkably, her heart continues to beat; her breathing is normal. Within a fortnight, Cecelia Bavolek is discharged from hospital, the hole in her heart successfully closed.
The operation had lasted forty-five minutes. For twenty-six of those minutes her life had been sustained by a machine. It was proclaimed an 'historic operation'; the twenty-six minutes 'the most significant in the history of surgery'. Gibbon shied away from the publicity the operation generated, shunned the press and only grudgingly gave a few quotes to Time magazine (although he declined to be photographed with the machine). As far as Gibbon was concerned, the successful operation was the result of more than twenty years of research, and he had proved that a heart-lung machine could work.
Nevertheless, Cecelia's operation was a close-run thing – she was lucky to be alive. Just how lucky would soon become clear. Gibbon attempted two more operations using the heart-lung machine. Both operations were carried out on five-year-old girls. Each of them died in the operating theatre. Gibbon had had enough. He did not have the resilience of some of his colleagues to carry on regardless. Three of his four patients had died while connected to the machine. The surgeon decided not to operate with his machine again, and ordered a year-long moratorium on its use. Gibbon never returned to cardiac surgery.
But others believed that Gibbon was on to something. At the Mayo Clinic in Rochester, less than an hour and a half's drive away from where Lillehei was developing cross-circulation, another surgeon began work on refining Gibbon's machine. After two years of research, on 22 March 1955, John W. Kirklin was ready to operate. He decided to test the machine on eight patients – no more, no less. During the first operation on a five-year-old girl, the machine practically exploded. There was blood everywhere, but the patient survived. By May Kirklin had operated on his target of eight patients. Four survived. The odds were improving, although patients still had only a fifty-fifty chance of coming out of the operating theatre alive.
DR LILLEHEI RISES TO THE CHALLENGE
Back in Minneapolis, Walter Lillehei was also working on a heartlung machine, only his was a good deal simpler. Lillehei decided to try just the sort of system that everyone else had warned against – one that bubbled oxygen into the blood. He assigned the task of designing the new machine to Dick DeWall, a young doctor who had come to Lillehei with a design for an artificial heart valve – something DeWall had been working on in the evenings at home (as you do). Lillehei decided not to mention to DeWall that everyone else believed that a 'bubble oxygenator' was impossible, if not downright dangerous. But then they had said the same about cross-circulation.
Bubbling oxygen into the blood is relatively easy. The problem comes with getting the bubbles out again. DeWall set to work with a couple of pumps (the same sort of dairy pumps that were being used for cross-circulation) and some plastic tubing, all held together with a few bits of tape and some metal hose-clips. The resulting machine looked too simple to be effective, but that simplicity was the beauty of the system. The blood from the patient's veins was pumped into a mixing chamber, where oxygen was bubbled through a large rubber stopper with hypodermic needles sticking out of it. The newly oxygenated bright red blood then passed through what DeWall termed a 'de-bubbler tube' – a diagonal piece of pipe filled with an anti-foam chemical to break up the surface of any bubbles. It was the same chemical used in factories to make mayonnaise. Finally, the blood flowed down a helical spiral. This was probably the cleverest bit and was designed to defeat any lingering bubbles. The heavier blood that was free of bubbles rolled downwards with gravity, while the lighter blood, containing bubbles of air, was forced back to the top. Finally, the blood flowed out of the helix through another dairy pump and back into the patient's arteries. The whole arrangement of pumps, bottles and tubes sat on a trolley beside the operating table. When the operation was finished the plastic tubes could be thrown away – no need for the complicated cleaning or difficult preparation of the Gibbon machine.
The Lillehei-DeWall bubble oxygenator was first put to the test on 13 May 1955. Unfortunately, the patient later died, but this did not appear to be down to any fault in the machine. There were so many other things that could go wrong with this pioneering surgery. By December one hundred operations had been performed using the machine. Most of the patients survived. The odds of open-heart surgery were improving. The machine was refined, improved and commercialized. Soon any hospital in the world could purchase one.
With the heart-lung machine, surgeons were able to operate on an open heart free of blood. They could take their time and see exactly what they were doing. However, one last problem remained: even with the heart-lung machine connected, the patient's heart kept beating. Placing precise stitches into a beating heart was difficult, and the slightest slip could end in disaster. What surgeons needed was some way to stop the heart beating altogether. Of course, the other thing surgeons had to be able to do was start it up again.
The answer came from a British surgeon, Denis Melrose,* who published his research in the Lancet in 1955. He devised an injection of potassium citrate. He later changed this to potassium chloride, a compound that disrupts the electrical signals in the heart. It's the same chemical that forms the basis of the 'lethal injection' used to administer the death penalty in some US states. When it was first tried out in Britain on a patient at Hammersmith Hospital in London, they had to consult a coroner and church leaders because technically, for the duration of the operation, the patient was dead. As for starting the heart again, this was done with electricity applied directly to the heart muscle.
* Melrose was a remarkable surgeon. As well as his work on stopping the heart, he also developed a heart-lung machine, which was adopted by hospitals all over the world.
Within the space of a few years, cardiac surgery had been transformed. From Harken's first quick incision into a beating human heart to remove a bullet, surgeons such as Melrose and Lillehei were stopping hearts altogether to open them up and correct major defects. With the ability to stop the heart came even more daring and intricate procedures. Patches were stitched across large holes; artificial heart valves were grafted on; arteries were replaced with synthetic tubing. Every year more and more patients were undergoing openheart surgery, and every year more and more were surviving.
In 1958 the personable young Melrose made history by conducting open-heart surgery live on Californian television. The broadcast started at 7 p.m. when Melrose began operating on 'Tommy', the seven-year-old son of an American war veteran. For over four hours viewers were glued to their small black and white TVs as Melrose cut open the boy's heart. It was the highest-rated programme that night – real life drama with the genuine risk that the boy might die on live television. Tommy survived, but his heart was repairable. What about those hearts that were so badly damaged that no amount of surgery could fix them? Could the heart – the centre of the soul, the very core of the body – be replaced with another one?
THE NIGHT OF THE PIGS
National Heart Hospital, London, 1969
It was a desperate, last-ditch attempt to save a life. An experimental procedure to keep a dying patient alive.
One of the UK's leading cardiac surgeons, Donald Longmore, had put in the call. The farmer assured him that the pigs were on their way. He would deliver them himself in his Land Rover. It wouldn't take long. Everything else was ready.
In the operating theatre the male patient lay on the operating table, his chest open and tubes snaking across to the bulky heartlung machine. Dark red blood flowed one way, bright crimson blood flowed back. The machine's regular beating rhythm was keeping the man alive. The anaesthetist, sitting beside a complex rack of gas canisters, calmly monitored the patient. A nurse placed some freshly sterilized instruments on the trolley; another kept an eye on the machine. All the lights and dials seemed to be indicating everything was OK. There was little else for the surgeons to do than wait. For the pigs.
They had decided to call this the 'piggyback' operation. The surgeons' plan was to graft a pig's heart and lungs into a patient so that the animal's organs would help keep the man alive. The operation had been conceived to help someone with serious heart disease. The pig's heart and lungs would work – or piggyback – alongside the patient's own heart and lungs to relieve some of the strain. At the very least it might keep this seriously ill man going for a few more months before the heart transplants pioneered in 1967 and 1968 were perfected and a suitable donor found. It might last even longer. It could even be another 'miracle breakthrough' the newspapers were so fond of reporting. As usual, the procedure had been tried on other animals and it seemed to work. The patient was seriously ill, his heart ailing. This experimental operation offered the only chance of survival.
Everyone waited for the pigs.
The farmer pulled up to the mews at the back of the hospital. The first inkling Longmore had that it was going to be a long night was when Thompson, the head porter, called him. 'Mr Longmore, is that pig in a Land Rover in the mews anything to do with you?'
'Yes, it is.'
'Well, it has just got out and turned left along Wimpole Street.'
Reluctant to make its own valuable contribution to medical progress, the pig had escaped. It is surprising how fast a pig can run, especially when its life is at stake. Still dressed in their operating theatre gowns, caps, masks and boots, the entire surgical team gave chase.
The pig ran as fast as its little legs could carry it, but was no match for London's finest heart surgeons, who eventually caught it halfway up the road. The pig squealed in protest, but Longmore herded it back towards the hospital. It was five o'clock in the evening and people were heading home from work, so the street was relatively busy. Most passers-by paid little attention to the odd group in the road. Only one gentleman seemed a little perturbed. Raising his bowler hat, he said, 'Excuse me, sir. You are going the wrong way along a one-way street.'
Back in the operating theatre, the anaesthetized patient lay on the table. The heart-lung machine pumped and breathed on his behalf. The nurses and surgeons stood around. The clock ticked. Where was the pig?
The pig was with Longmore in the lift. He wasn't going to let it get away this time. There were also a few hospital visitors in the lift, but no, they didn't mind if the lift went straight to the top floor marked 'mortuary'. What business was it of theirs if the surgeon fancied having pork for his supper?
Arriving at the mortuary, Longmore had arranged for an anaesthetist to put the pig to sleep so that it could be killed and its organs removed. When the anaesthetist assigned to the task showed up, he turned out to be Jewish. He refused to kill the pig. Another anaesthetist was found, but by now Longmore was beginning to wonder if all this grief was going to be worth it.
In the operating theatre, the heart-lung machine continued to pump. The surgeons and nurses waited.
The heart and lungs were eventually removed from the pig, but now there was another problem: the patient was also Jewish. What were the chances? The patient himself was in no position to reassess the merits of the operation, so rather than panic (or pray), Longmore did the next best thing – he rang a rabbi.
When Longmore explained what they were trying to do, the rabbi went very quiet. The surgeon apologized for putting him in such a difficult position and understood if he didn't want to get involved. There was another long, somewhat muffled silence. Finally, the rabbi could hold back no longer. 'Sorry,' he said. 'I was trying to stop laughing.' The rabbi told Longmore that if this was a genuine attempt to save the man's life, then certainly he should go ahead. First the escaping pig, then the Jewish anaesthetist, now this. Another obstacle overcome. At last the surgeons could get on with the operation.
It was a relief to return to the operating theatre. Once he had changed and scrubbed, Longmore was ready to begin. The heartlung machine continued to pump. The dark red blood flowed in; the bright red blood flowed out. The patient was still alive, the pig heart was ready. The operation could get under way.
The operation itself seems to be going surprisingly well. The heart is stitched into the patient's circulation ready to help keep him alive. The final part of the procedure involves a simple injection of calcium to the pig's heart. In humans calcium is used to increase muscle strength. However, as Longmore now discovers, it has a different effect altogether in pigs. The pig's heart sets like a stone. It is useless, and after all that effort the operation fails and the patient dies. It is little consolation to the surgeons that he would have died anyway, but at least they have learnt from the experience.
The story became known as the 'night of the pigs', and to cap it all, the feared hospital matron had been woken up by pig squeals and was furious. A member of the surgical team sent her pork chops for breakfast, which hardly helped.
FRAGILE HEARTS, FRAGILE EGOS
Groote Schuur Hospital, Cape Town, 3 December 1967
Compared to bullet wounds, hibernating groundhogs, crosscirculation and porcine predicaments, heart transplantation itself is a relative anticlimax. In 1967 the race was on to be the first surgeon to transplant a human heart. There was no knowing who would get there first, and although many surgeons talked of sharing their results and cooperating with their rivals, secretly most of them would admit that they wanted to be the one to get the credit and possibly a little bit of glory.
Many believed the first would be Norman Shumway, a surgeon at Stanford in California, who had been working for almost ten years on perfecting the heart transplant technique in animals. Shumway had presented his first heart transplant results on dogs in 1961, and was now ready to try it on humans. He had developed new combinations of drugs to prevent the heart from being rejected by the body (see Chapter 3). He even went on to suggest that transplanting a heart should be a relatively straightforward surgical procedure, and less likely to end in rejection than, say, a skin or kidney transplant.
Elsewhere in the United States, down in Mississippi, James Hardy was waiting for a human donor for a terminally ill heart patient. With no suitable transplant available, he tried transplanting the heart of a chimpanzee, but this proved unsuccessful. Meanwhile, many European surgeons were keen to steal a march on the Americans – there was national, as well as personal, pride at stake. So far, most of the cardiac 'firsts' had been by Americans. In France, hospitals were said to be ready, and in London Donald Longmore at the National Heart Hospital was waiting for the right combination of patient and donor, having spent the previous few months battling with a bunch of 'oily' bureaucrats from the Department of Health.
They were all beaten to it by a relatively unknown, although hardly unqualified, South African surgeon. Christiaan Barnard had been trained by Walter Lillehei in Minneapolis and had a good, if inconspicuous, surgical pedigree. His record for complicated openheart surgery was remarkable. The chances of surviving a Barnard operation were extremely good. Like many of the most successful heart surgeons, he thought of the organ as merely a 'primitive pump' – one that demanded respect, but commanded no great mystical power, no soul.
Barnard had been studying the problems of heart transplants for some time, although much of what he learnt was from other surgeons rather than his own experiments. He travelled to see Shumway at Stanford, and visited Longmore in London to witness his heart-lung transplants on dogs. Barnard was personable, antiapartheid and had something of a reputation – the handsome young man's interest in affairs of the heart extended beyond pure technical interest. While in London, he also attempted to seduce one of Longmore's nurses (with some success apparently).
Barnard had learnt from the greats, and in an obscure South African hospital, undisturbed by the authorities, he decided the time was right to put his knowledge to the test. On 3 December 1967 he removed the beating heart of a twenty-five-year-old female car crash victim, pronounced dead by a neurosurgeon. The recipient of this fresh young heart was lying ready in an adjacent operating theatre. Fifty-three-year-old diabetic Louis Washkansky had already suffered several heart attacks and, quite frankly, did not have long to live. The operation took two hours. Washkansky's new heart started beating and kept beating. A day later he was awake and talking. A few days later he was out of bed. Eighteen days later he was dead.
Washkansky died of pneumonia. The drugs used to suppress his immune system to prevent the heart being rejected had also left him open to infection. But no one remembers Washkansky. Christiaan Barnard was the hero of the day – an instant celebrity. Barnard would be received by the pope, entertained by presidents and prime ministers. He became the world's most eligible bachelor, dating a string of beautiful and famous women.
Some of Barnard's rivals expressed more bitterness than others. Longmore was pleased for him. Others muttered that they had done all the work only for Barnard to take the glory. And what glory. Who cared about the second man to fly across the Atlantic (Bert Hinkler), to run the four-minute mile (John Landy) or to climb Mount Everest (a matter of some debate)? Christiaan Barnard would be the man in the history books.
But while Barnard had won the main prize, there was still a degree of national pride at stake. If South Africa could do it, why not the United States, Great Britain or France? The same bureaucrats who had been so reluctant for Longmore's London hospital to carry out a heart transplant were now asking what he was waiting for. In January 1968 the second heart transplant was performed by Adrian Kantrowitz in Brooklyn, so Shumway – the surgeon who had spent so long developing heart transplant techniques – didn't even get that honour. Shumway's operation was the fourth, and by the time he came to operate later that month, Barnard had already performed a second heart transplant.
The first British heart transplant (the world's tenth) took place on 3 May 1968. The surgeon was Donald Ross (also a South African). Longmore's role was to collect and deliver the donor heart. For some reason this required a police escort through the streets of London. In fact, the whole affair became a major public event, with a large crowd of spectators, reporters and photographers gathered around the door of the National Heart Hospital. It was, of course, a great national achievement of a proud nation, etc., etc. However, the patient, Frederick West, died of an 'overwhelming infection' forty-six days later. And that was the problem: while the surgeons were getting the glory, none of their patients were lasting very long. In the first few years of heart transplant surgery, patients survived on average just twenty-nine days. Despite all the euphoria, the awful truth was that heart transplants were difficult, dangerous and complicated.
There are few surgeons as well known as the pioneers of heart surgery. Heart surgeons were courageous, daring and bold. Heart surgeons stood apart from the rest, almost every operation a matter of life or death. When they succeeded, they saved lives. When they failed, they had to be prepared to come back the next day and try again. Many of them had personalities to match their abilities. Some were self-confident, others were egotistical or arrogant. A few were foolhardy or seemingly oblivious to risk. Most heart surgeons were revered by their patients; many became national or international celebrities – household names courted by the media, their faces on the front page of Timemagazine. Few people could name one of today's heart surgeons, but then, thanks to pioneers such as Harken, Bigelow, Lillehei,*Gibbon, Melrose and Barnard, major open-heart surgery has finally become routine.
* There is a curious footnote to Lillehei's career. In 1973 he was found guilty of tax evasion. Although he was undoubtedly at fault, his crime was more one of carelessness than deliberate evasion. He had always been bad at keeping financial records, and had performed many operations for free. He carried out his last operation in 1973, but was to maintain a keen interest in heart surgery until his death. At Lillehei's eightieth birthday party in 1998 many ofthose invited to celebrate owed their lives to his expertise. He died a few months later, but a great many of his patients live on.
A photograph taken in 1848 of an operation to be carried out under anaesthetic at the Boston General Hospital, Massachusetts. Judging from the sprawled position of the unconscious patient, it looks as if he is about to lose a leg, although it is curious that he is wearing socks.
This photograph, taken in 1883 to demonstrate Lister's antiseptic operating technique, appears to be somewhat staged. The carbolic spray is being operated by the man on the right.
Galen attends to a wounded gladiator as the crowds bay for more blood.
Simpson's butler walks in to find the surgeon collapsed on the floor – another successful experiment on the properties of anaesthetics.
A 'muscleman' illustration from Vesalius' De Humani Corporis Fabrica (1543) alludes to his foray into body snatching.
Robert Liston: 'sharp features, sharp temper'.
The man of wounds. Suggesting most of these were curable seems wildly optimistic.
You can sense the intensity in the operating theatre as Walter Lillehei performs open heart surgery using crosscirculation. The first of these operations took place in 1954.
Walter Lillehei operating on a beating human heart.
One of the few pictures ever taken of John Gibbon with his fearsome looking heart-lung machine. At the top left of the machine is the screen where the blood was oxygenated.
Christiaan Barnard with the world's first heart transplant patient, Louis Washkansky, in 1967. The plastic sheet was used to help protect Washkansky from infection.
The dramatic assassination of President Sadi Carnot on 25 June 1894. The murderer is being grabbed by the crowd as he attempts to make his escape.
The weird and wonderful world of Alexis Carrel in an illustration taken from a French periodical. It's difficult to tell whether they were proud of their countryman.
Another experiment in the laboratories of Alexis Carrel. Heaven knows what is going on behind the sheet. This picture is undated, but was probably taken in the 1930s.
Alexis Carrel and Charles Lindbergh make the cover of Time magazine in June 1938. Not long afterwards, their reputations would go into freefall.
The appalling result of Vladimir Demikhov's 1959 operation to transplant the head of a puppy onto the head of another dog.
Richard Herrick is wheeled out of hospital by his identical twin brother, Ronald, on 19 January 1955.
Clint Hallam enjoying the use of his recently transplanted hand in 1998. Even before Hallam's body started to reject the transplant, its appearance was disconcerting.