The Heart Healers (5 page)

Harken became obsessed by the thought that these young men, still alive with strong, beating hearts, should not be condemned to death by the Hobson’s choice of action or inaction. He was looking at hearts too good to die.

Harken knew well the history of surgery on the heart, what there was of it. The most famous case of survival, reported by German surgeon Ludwig Rehn at the turn of the century, bore some resemblance to his problem. Soon after midnight on the morning of September 7, 1896, a drunken twenty-two-year-old gardener’s assistant named Wilhelm Justus had lurched along the gravel paths of the scenic park bordering the Main River that bisects Frankfurt, Germany. Fleeing a raucous barroom brawl in the red light district, he stumbled and hit the ground. As he rolled to his feet, a massive form loomed above him in the moonlit sky and metal glinted as a knife hit his chest. Just after 3 a.m., a strolling policeman discovered Wilhelm Justus supine behind a park bench, semiconscious and unresponsive, nostrils flaring as he gasped for breath. His right hand was clenched under his jacket. Kneeling to examine Justus further, the policeman immediately ascertained that the hand covered a small slash that slowly oozed onto a blood-drenched shirt.

At Frankfurt City Hospital the night surgeon found an unconscious young man, with cold and clammy skin and a thready, irregular pulse that briefly disappeared with each inspiration. He carefully inserted a probe into the half-inch wound in the space between the fourth and fifth ribs. Deeper and deeper the probe slid into the body, meeting no resistance. Then it halted and began bobbing in and out of the wound with each heartbeat. As dawn broke the surgeon pronounced his grim prognosis: Justus had a wound to the heart for which there was no treatment. Wilhelm was sent to a private room with the reasonable certainty that, like many thousands of injured warriors over mankind’s turbulent history, he would die without regaining consciousness. It was a trivial blessing that unlike so many who preceded him, he would spend his last moments in an environment with a modicum of quiet dignity.

But to Wilhelm Justus was granted the good fortune offered to no one in the prior history of medicine. The chief surgeon at Frankfurt City Hospital was the world-famous Ludwig Rehn. At age forty-seven, Rehn stood as a revolutionary, an innovator who questioned the often tenuous wisdom of his predecessors. When Rehn saw him, Wilhelm was unconscious. Rehn tapped his fingers over the left side of Wilhelm’s chest wall to outline the dull resonance of the heart bordered by the air-filled lungs. Whereas the area of cardiac dullness normally extends to the left nipple, he found it now extended to the armpit. Rehn thought about the policeman’s account and Wilhelm’s symptoms and his physical examination; his fertile imagination visualized what lay unseen within the chest cavity. He knew that in addition to placing the heart behind the bony sternum and ribs, Nature has surrounded and protected it within a tough fibrous sac called the pericardium. Rehn reasoned that when the stiletto slipped between his ribs to enter deep into Justus’s chest, it first punctured a small hole in the pericardium and then penetrated further to barely nick the heart muscle. The nick in the heart muscle caused oozing of some blood, but because the hole in the pericardium was small, the blood was all trapped within the firm fibrous sac. As the blood accumulated within it, the blood-filled sac compressed the heart, just as if a hand was gripping it, restricting the inflow of blood into the heart’s pumping chambers.

Like Harken a half a century later, when Rehn closed his eyes he visualized a heart too good to die. The heart, with just a nick on its surface, could function normally if he could remove the blood from the sac that was compressing it, and close the nick with a stich or two on the heart’s surface to stop further blood accumulation in the sac. Fully aware that many surgeons had failed miserably in similar circumstances he ordered that Justus be taken to the operating room. Opening the chest, Rehn saw the pericardial sac distended with blood to twice its normal size. The heart lay trapped within. He slashed open the sac with his scalpel. Blood gushed from the incision, then within seconds slowed to a tiny trickle. Rehn could now see the heart beating within the sac. Each time the heart filled, blood trickled from a half-inch tear in the wall of the right ventricle. Instinctively, he pressed his left index finger over the cut. The pressure of his finger staunched the bleeding. Justus’s heartbeat continued steady but feeble. With his right hand, each time the heart filled Rehn placed a suture to close the wound. The bleeding stopped. And then the surgeon’s version of exaltation in Beethoven’s Ninth Symphony, the ineffable emotion of snatching a young man’s life back from certain death. A century later we can still marvel at the moment’s stark contrast to the starched science of Rehn’s later description: “bleeding is controlled with finger pressure … suture the heart wound tied in diastole … bleeding diminished remarkably with the third suture … heart rate and respiratory rate decreased and pulse improved.” Rehn closed the chest. Two hours later Wilhelm Justus was awake and resting comfortably, with a normal pulse and blood pressure.

Rehn immediately understood the implication of his success. He imagined that his report would galvanize a new surgical era. His lofty aspiration to be a father of cardiac surgery, however, was not to be. Although Rehn’s scalpel had laid bare the folly of centuries-old dogma that the heart was off-limits for surgery, his report became an anecdote rather than a breakthrough. In medicine, as we shall see throughout our chronicle, credit goes to the person who convinces the world, not to the one with the first idea. Harken succeeded where Rehn failed because Rehn operated on one man, whereas Harken would operate on another 133 soldiers with shrapnel in their chest cavity, some embedded directly in the heart.

For the half century after Rehn, few dared to operate directly on the human heart, and the few who tried failed. The twin fears of condemnation by colleagues and killing patients outright stayed the hand of even the most adventuresome surgeons. And woe to the surgeon who chose to challenge entrenched authority. The voice of the great Viennese surgeon Theodor Billroth still boomed paternalistically through the decades: “A surgeon who tries to suture a heart wound deserves to lose the esteem of his colleagues.” Billroth’s eminent English contemporary Stephen Paget pronounced the final, never-to-be challenged, eternal verdict: “Surgery of the heart has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart.”

After World War I, Harvard’s pioneering surgeon Elliot Cutler attempted to treat severe narrowing of the mitral valve, the valve between the left atrium and the left ventricle, that limits entry of blood into the heart’s main pumping chamber. His idea was to make a tiny incision in the heart wall, insert a cutting device through the incision, cut out a piece of the narrowed valve. Cutler’s reasoning was only partly correct. Although removing a portion of the valve improved forward flow across the valve, it also allowed torrential backflow when the heart contracted. All but one of seven patients in whom he cut out a portion of the narrowed valve died. Deeply discouraged by so many deaths, Cutler abandoned the procedure. One of the great ironies of research, however, is that we learn more from our failures than from our successes, more from unexpected results than from those we anticipate. Destiny decreed that Elliot Cutler would be Dwight Harken’s mentor. Harken learned the details of Cutler’s failed technique. Now he would use that knowledge to piece together the shards of Cutler’s shattered dream, transforming his failure into an initial baby step on the road to success.

In London’s battlefield hospital, Harken devised a plan of action. His idea was simple enough. It was Rehn’s finger-in-the-dike strategy. Of course if the hole was bigger than his finger, if his finger slipped off the slick surface of the bleeding heart, if he couldn’t completely close the hole with sutures, if the taut silk sutures tore a little further through the heart muscle with each contraction, he would fail. So many ways to fail, so few to succeed. If he failed, his would be the image of a man holding a squirming, writhing, ruptured fire hose gushing five quarts of blood a minute throughout the room for a minute or two, followed by devastating, demoralizing, humiliating, condemning, awesome silence. Death on the table.

When is it ethical to take an action that might kill a patient immediately, particularly if no one had ever done it before? Harken was confronting nothing less than a confrontation with medicine’s most hallowed three words: primum non nocere—“First do no harm”—a principle as enduring and as sacrosanct as the Hippocratic Oath. In our story we will encounter this conundrum repeatedly: medical research pits two laudable principles against each other. Medical breakthrough versus benevolence. Progress versus compassion. Harken argued that his conscience was clear: “You have to have a diagnosis that is absolute, a condition that is incurable and, then, if you have any rational concept of how you might attack it, you have the right to try,” he said.

Harken argued his case at U.S. Army Corps headquarters. His superiors pointed to the common surgical wisdom of centuries. They buttressed their argument with recent reports that surgeons in the French theater had failed in attempts to extract shrapnel from the heart. Harken countered that since his surgical approach was unique and untested, it deserved to be tried in these dying young men. The balance tipped in his favor when the president of the British Royal College of Surgeons unexpectedly agreed with Harken that at least his proposal was logical, that no one could say with certainty that it wouldn’t work. A tepid endorsement, indeed.

In June 1944 Dwight Harken was brought a dying soldier with a gaping injury to his sternum and ribs. The heart’s right ventricle lies directly behind the sternum, Nature’s impenetrable bony shield. Ancients saw Nature’s logic. The word
sternum
descends from the Greek word
sternon,
meaning a soldier’s breastplate. As his assistants used retractors to widen Harken’s field of view within the chest cavity, he saw shrapnel had penetrated the right ventricle.

For days and weeks leading up to this moment Harken had imagined his every move. First, he placed sutures in a complete circle around the point of shrapnel entry. Harken tried to grasp the end of the protruding fragment of shrapnel, with a clamp (called a hemostat). The ragged sliver of gunmetal bobbed back and forth continuously with each heartbeat, insolently waving at him, a metronome counting down the solder’s remaining hours, death by bleeding or by infection. When Harken succeeded in clamping on to the evasive shard, the two men were linked by the soldier’s only possible bridge to survival, Harken’s hemostat. I can only imagine myself with my own hand on Harken’s clamp.

That night Harken described the terrifying sequence of what happened next in a letter to his wife: “For a moment I stood with a clamp on the fragment that was inside the heart, and the heart was not bleeding.” Harken steeled himself to commit to the act he had only imagined. He yanked. “Then suddenly with a pop, as if a champagne cork had been drawn, the fragment jumped out of the ventricle, forced by the pressure within the chamber … blood poured out in a torrent.” He tightened the sutures around the wound. But still the bleeding continued. His patient was bleeding to death on the table. “I told the first and second assistants to cross the sutures and I put my finger over the awful leak. The torrent slowed, stopped, and with my finger in situ [in place over the wound], I took large needles swedged with silk and began passing them through the heart muscle wall, under my finger, and out the other side. With four of these in, I slowly removed my finger as one after the other was tied.… Blood pressure did drop, but the only moment of panic was when we discovered that one suture had gone through the glove on the finger that had stemmed the flood. I was sutured to the wall of the heart! We cut the glove and I got loose…” Years later, in the macabre humor that characterizes doctors in close encounters with death, we joked (Did I mention, behind his back?) that Harken could have done just as well if he had cut off his finger and left it there.

Emotions surged through Dwight Harken. Exhilaration. He had saved a young man who otherwise would have died. Relief. He had overcome a moment of panic. Vindication. He had proven his skeptics wrong. If he allowed his imagination to roam more broadly, he might even imagine that he had created a brand-new phrase for Webster’s dictionary: “cardiac surgeon.”

Yet as he stripped off his surgical gloves, even Harken could hardly have imagined how history would revere this day. It was the day of the largest amphibious invasion in world history, when 195,700 Allied personnel in over 5,000 ships landed on a fifty-mile stretch along the beaches of the Normandy coast. It was D-day. Like twins, the turning point of World War II and cardiac surgery would have the same birth date. The world could resist the Nazi army, but not the idea whose time had come. As Walter Cronkite, the great newscaster of the outset of this era, liked to remark: “What sort of a day was it? A day like all days, filled with those events that alter and illuminate our times.”

Harken had discovered an unprecedented, lifesaving strategy. In retrospect, I have wondered if he succeeded where others failed because of his instantaneous decision to use two strategies to prevent his sutures from cutting through the muscle with each heartbeat. First, he used “swedges,” tiny cloth rolls wedged between the silk sutures and the heart muscle that prevented the sutures from cutting. Second Harken deliberately tied his sutures, as Ludwig Rehn had, during the split second when the heart relaxed and reached its largest volume, so that the heart’s alternating expansion and contraction did not place extra stress on the sutures.

Harken, like Rehn half a century before him, understood the implications of his success. Unlike Rehn, however, he took the next step. Over the ensuing months he removed shrapnel from the hearts of sixteen soldiers. Not a single soldier died.