Extreme Medicine (10 page)

Blood was supplied in glass bottles. But keeping up with the torrential losses demanded far more than their gravity-driven dribble could provide. To overcome the challenge of delivering blood at speed through narrow tubes, the anesthetist would inject air into the head space of the flasks, increasing the pressure within and thus the rate of flow. Occasionally in the heat of the moment, they would overdo it, and the jars would shatter under the additional pressure, scattering shards of bloody glass throughout the operating room.

Harken meanwhile would be focused upon navigating safe routes to and through the heart. He learned that the simple act of handling the heart was enough to provoke abnormal and potentially fatal disturbances of its rhythm. Like Grey Turner, he came to recognize the peril in removing the heart from its proper position. Harken also devised techniques for incising and entering the heart while exercising at least some control over the resultant hemorrhage. He achieved this by placing sutures on either side of his incisions, leaving a pair of long trailing threads at both edges. His assistant could then hold these taut, keeping control over the opening in the heart as though it were the mouth of a purse. In this way, Harken was able to access bullets and fragments of shrapnel practically wherever they lay.

In the ten fraught months that followed the Allied invasion of Europe, Harken removed no fewer than 134 missiles from the hearts of wounded soldiers. The pace was relentless and the workload exhausting; Harken and his team would often operate around the clock for days on end, sleeping, on improvised cots, only when the lull in casualties would allow. The demand for thoracic surgery outstripped the supply of adequately qualified surgical teams. Harken would sometimes operate by day and then travel by night, with his scrub team, to lend his thoracic expertise to other hospitals. While the accounts of these surgeries were frightening, filled with stories of massive blood loss and tense moments, among the patients upon whose hearts Harken operated there was—incredibly—not a single death.

The effect on Harken of his experiences in Stowell Park was transformative. He had arrived in England optimistic but unsure that cardiac surgery involving the internal structures of the heart might be acceptably performed in humans. He returned to the United States at the end of the war convinced of this fact. And this time the medical profession sat up and took full notice. The documented evidence was unquestionable: The heart was open for conquest. Major Dwight Emary Harken's explorations had proved it so.

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T
HE
S
ECOND
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ORLD
W
AR HAD BEEN
bracketed by two awards for advances in antibiotic therapy. In 1939 the Nobel Prize went to German pathologist and bacteriologist Gerhard Domagk for his work in developing commercially available sulfonamide antibiotics, although the Nazi regime forbade him from accepting it. In 1945, Ernst Boris Chain, Howard Florey, and Alexander Fleming received the prize for the discovery of penicillin. These developments would shape the future of cardiac surgery as much as any surgical technique. Bacterial endocarditis, hitherto an unstoppable disease with a nearly 100 percent mortality rate, was suddenly amenable to treatment by the injection of antibiotic drugs. It was no longer the undefeated foe that Harken had so hoped to slay with surgery. But Harken's wartime experience had taught him that the heart could be opened and the mechanisms within altered and repaired. He turned his attention instead to problems of the mitral valve—at the time, wild territory where respectable surgeons were loath to venture.

The mitral valve, seen from below as it opens into the left ventricle, has the appearance of a gently smiling fish mouth mounted on a ring of tissue around the size of a half-dollar. The delicately engineered mechanism is designed to allow blood to flow in only one direction, from atrium to ventricle. Without its system of valves, the heart is merely a pump that is as likely to push blood backward as it is to push it forward.

The leaflets of the mitral valve are prone to damage from the childhood affliction of rheumatic fever. Something as simple as a throat infection can lead to widespread inflammation and trigger the immune system to attack the body's own tissues. The resulting damage is akin to friendly fire: Your body's own defenses, unable to distinguish foreign invader from self, wreak havoc, attacking the skin, joints, eyes, and the heart.

When this happens, the mitral valve can become narrowed, and the opening through which blood can flow is reduced. As a consequence, pressure builds up in the left atrium and is transmitted back to the fragile circulation of the lungs. There, exposed to this unusually high pressure, the tissue-thin capillaries can rupture, spilling blood and fluid into the air spaces of the alveoli, causing coughing, breathlessness, and the expectoration of bloodstained sputum.

While rheumatic fever is a disease of childhood, its cardiac consequences are usually seen later in life as the narrowing of the mitral valve progresses. But the physiological demands of pregnancy, which include an increase in the volume of blood pumped out by the heart every minute, can unmask the diseased valve. In Harken's time, it was not uncommon to see young women during their first pregnancy with the symptoms of breathlessness associated with mitral stenosis and heart failure. This condition became Harken's new target for surgical intervention. However, he was not the only ambitious young man determined to conquer this territory, and it proved not to be an endeavor for the fainthearted.

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H
ARKEN'S FIRST FORAYS
into mitral-valve surgery were fraught with complications and loss. Six of his first nine patients died either on the operating table or shortly thereafter. After the sixth fatality, Harken's confidence was badly shaken, and it was only the intervention of his friend and collaborator Dr. Lawrence Brewster Ellis that prevented him from throwing in the towel completely. To complicate matters, Harken had competition on both sides of the Atlantic from the likes of Charles Bailey in Philadelphia, Russell Brock (later Lord Brock of Wimbledon) at Guy's Hospital in London, and Horace Smithy in South Carolina.

Within a year of the end of World War II, techniques in cardiac surgery had begun to advance all over the world. This was more than simple coincidence. Advances in the field of anesthesia, radiology, blood transfusion, and antibiotic therapy combined with the catalyst of war to usher the age of cardiac surgery into existence.

The contribution of these advances is often understated, as though they were not entirely essential to the establishment of elective cardiac surgery. History had not simply waited for a surgeon bold enough to break with convention or one with sufficiently gifted hands. The annals of surgery are, after all, replete with such individuals. It had been waiting instead for a means by which medicine might protect the brittle physiology of those with diseased or injured hearts from the added insult of surgery.

Anesthesia, antibiotics, and transfusion medicine were together a primitive system of life support, a cocoon in which to wrap the patient before the onslaught of the surgeon's knife. Prior to the introduction of more carefully calibrated anesthetic vaporizers and safer anesthetics, it was not unusual for patients to die as a direct result of the unpredictable effect of the anesthetic gases. These mysterious drugs had widespread and often deleterious impacts upon the body. They would cause profound falls in blood pressure but leave the heart overexcitable and prone to arrhythmias; they could precipitate respiratory arrest, cause hepatitis by inflaming the liver, and provoke seizures.

The rapid and massive transfusion of whole blood, which itself had to be managed by a skilled team, replaced volumes lost in hemorrhage, staving off shock and preventing hypotension and eventual cardiac arrest. In the period immediately after the operation, antibiotic drugs would keep infection of those profound surgical wounds at bay.

With a more stable platform from which to launch surgical interventions, the possibility of routine cardiac surgery became apparent to many. In the United States, Harken was thrust into direct competition with Charles Bailey, a surgeon of the same age, based at the Episcopal Hospital in Philadelphia. In the same year that Harken attempted his first mitral valve procedures, so too did Bailey. And he endured the same horrific rate of attrition.

Bailey's first patient, a thirty-seven-year-old man, had been incapacitated for more than ten years with mitral valve disease. His left atrium was, as a result, thin walled and fragile, rupturing during the operation before Bailey got near the valve itself. The patient bled to death in seconds.

During his second attempt at the same procedure, this time as a measure of last resort in a twenty-nine-year-old woman profoundly disabled by her narrowed mitral valve, he was able to access and operate upon the valve. He probed the valve at first with a surgical instrument, but having failed to dilate it sufficiently in this way, he decided to use his finger to increase the size of the opening. The patient died two days later from heart failure.

In the wake of these fatalities, Dr. George Geckeler, chief of cardiology at the Hahnemann University Hospital, wrote to Bailey: “It is my Christian duty not to permit you to perform any more such homicidal operations.” And Bailey's record of failure had not gone unnoticed by colleagues and students. In fact, they began to call him the Butcher.

Bailey waited fifteen months to make a third attempt, this time at Memorial Hospital in Wilmington, Delaware, on a thirty-nine-year-old man. Again the operation failed, and massive hemorrhage in the postoperative period was the cause of death.

Bailey chose to perform these later operations in a series of separate community hospitals, partly because he worried that successive failures would not be tolerated by any single center. His fourth fatality, in a thirty-two-year-old man at Philadelphia General Hospital, occurred on the morning of June 10, 1948. The patient's heart became irritable and arrested as Bailey handled it. Despite frantic attempts to massage it back to life, the patient died on the table. Sensing that a moratorium would shortly be called on his procedure if he could not demonstrate something in the way of success, Bailey had already booked a fifth operation for that same afternoon. Leaving Philadelphia General, he drove across town to the Episcopal Hospital for what he must have suspected was his last chance to show that this procedure had value.

At the Episcopal Hospital, Claire Ward was waiting. She knew the outcomes of Charles Bailey's previous operations, as did her family physician, who had advised her not to volunteer herself for the surgery. Claire was a twenty-four-year-old housewife. In childhood she had suffered with rheumatic fever, and over the years, the progressive narrowing of her mitral valve had led to mounting pressure in her left atrium and the symptoms of heart failure. The resulting disease had left her so short of breath that she could no longer look after her young child. If what Charles Bailey had promised was true and the breathlessness and disability that plagued her could be abolished by this operation, then for her the enormous risks were worth it.

By the time Bailey arrived at the operating theater of the Episcopal Hospital, Claire was already on the operating table and being prepared for anesthesia; whether he discussed the earlier events of the day with her is unknown. The anesthetic induction, which had proved perilous in previous cases, went smoothly, and once the patient was stable, the operation proceeded rapidly. The pericardium was opened, the heart was exposed, and sutures were placed in the wall of the left atrium. Bailey incised and opened the heart, using first his finger and then a surgical knife to free the fused leaflets of the mitral valve. Satisfied that these manipulations had achieved the required result, he withdrew and closed the heart. The operation had taken eighty minutes. This time, it worked. Claire Ward left the hospital a week later, much improved. A month later, she no longer had to take digitalis, the cardiac medication upon which she had previously depended. Ward went on to have two more children and lived for another thirty-eight years.

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B
AILEY CARRIED OUT
this first successful closed-heart operation on a mitral valve just four days ahead of his competitor Dwight Harken. Aware of this and not one to be outdone, Harken raced ahead with writing up his own case report, making use of his contacts on the editorial board of the
New England Journal of Medicine
to achieve the much prized priority of publication.

The rivalry between Harken and Bailey became the stuff of lore in the surgical community and provided something in the way of light entertainment for other colleagues. Their interactions were nothing if not ferocious. One resident wrote that the two criticized each other fiercely and openly at surgical conferences and that Harken became “peri-apoplectic.” They were perhaps, at core, too alike in character to be able to tolerate each other. They were men of ambition and confidence who fully recognized the opportunity that lay at hand. Neither followed the dictates of conventional wisdom. They were born in the same year, attempted their first mitral-valve surgeries in the same year, and died in the same year.

The history of this era of surgery, in which the art made rapid progress but during which there were many deaths among patients, makes for difficult reading. It is unthinkable that any new surgical technique being pioneered today would proceed if accompanied by the same horrific rate of mortality. It is tempting to regard Bailey and Harken as being so consumed by ambition and competition that they lost sight of the human cost of their endeavors. But while the pair did indeed race and compete, it is important to understand the complexity of the cases they faced. Physicians of the time had little confidence that the benefits of cardiac surgery outweighed its risks. In general, patients with diseased hearts were referred to Bailey and Harken only as a last-ditch option, when they were already so critically unwell that there was little to lose. In that context, the fact that their failing physiologies often crashed completely when faced with the joint challenges of experimental surgery and primitive anesthesia is perhaps less surprising.