The ward rounds start at 6:30 A.M. That’s the good news. The bad news is that the pre-round, when the intern visits all of the patients to prepare for the ward round, starts at 6:00 A.M. I am the intern with one of the trauma surgery teams, at the very bottom of the hospital hierarchy.
It’s the late 1990s. The worst of the local drug-fueled gang wars are coming to an end, but there are still plenty of guns around in Washington, D.C. The city jockeys for position as the murder capital of the United States. Not so long ago, there was an average of one murder a night in the square mile around the White House. This is not how I imagined the nation’s capital.
I work twelve to fourteen hours a day. Every third day, our team is on call. Those days I work from 6:00 A.M. through the night and the following day, thirty-six hours at a time. I have never worked so hard. I stay in an apartment about half a mile from the hospital. I’d imagined that I’d spend my free time getting to know the city, but I’m completely spent by the time the days are over. On the nights that I make it back to the flat, I force myself to stay awake long enough to make a microwave meal and eat it standing at the counter.
As time goes by, I become a little nervous about my neighborhood. The next time I see my resident, Carlo, I mention the shady characters I’ve noticed hanging around.
“Have you seen any shooting yet?” he asks. I misunderstand his question, thinking he’s referring to our caseload in the hospital.
“Sure,” I say. “We see victims of shooting through the trauma rooms every night.”
“No,” he says in a thick Colombian accent, “have you seen, from the window of your house, someone take a gun out of their pocket and shoot somebody else?”
“No,” I tell him.
“Then you don’t live in a bad area.”
—
THE CRASH PAGER GOES OFF. Trauma Call. GSW. ETA 3 mins, flashes the message on the screen. I climb out of the top bunk, trying not to tread on the junior resident in the bed below. GSW is the unit’s standard abbreviation for “gunshot wound.” I hurry along to the trauma room. I’m not sure what time it is or how long I’ve been asleep. We arrive at the same time as the patient. The paramedics spit out a string of jargon: “Eighteen-year-old female, GSW chest, signs of life on scene, arrested in the chopper, no output.”
She is wearing a blue dress with polka dots. Her feet are bare—presumably the shoes are somewhere at the crime scene—but she looks as though she’s been out on the town. A pretty African American girl, her makeup and hair done carefully.
The crew that has just arrived on the helicopter continues with cardiac resuscitation while moving her to the gurney in the trauma bay.
“OK,” says Manish, the senior resident, “let’s crack the chest.” There is no equivocation; there is no time. The surgery must happen here, surgery of the most drastic and invasive kind. They must open the chest, expose the heart and lungs, look for a source of injury—a reason why her heart has stopped—and fix it. It needs to happen now.
A pair of scissors makes light work of her party dress. Another trauma nurse is getting the surgical trays ready. One of the junior residents is covering her torso in iodine solution as a hurried surgical prep.
Manish is taciturn at the best of times. The pace and gravity of the case don’t make him any more verbose.
“Knife,” he says levelly.
The handle of a scalpel is placed in his hand. Manish runs its blade across the skin, making an inch-long incision in the side of her chest, just below her left breast. He pushes forceps into the exposed muscle, separating the fibers and creating a tract. He repeats this exercise on the right side of her chest. If air has become trapped in the pleura, the lining that surrounds the lungs, then its accumulation might be enough to stop the heart from beating. This is what Manish hopes for: that these simple holes in the chest wall might be enough to release trapped air and resuscitate the arrested heart. But tonight there is no such luck. He must proceed.
Manish returns to the right side of the chest and runs the knife along the line of the fifth rib, extending the incision he’s already made until it reaches the breastbone. He divides the muscle between the ribs and then introduces the rib spreader—a gothic-looking piece of stainless-steel hardware with a ratchet system that separates a pair of blunt claws, pulling the chest apart, separating the fifth rib from the sixth, exposing the contents of the chest cavity beneath.
In less time than it has taken you to read this description, I am looking at her stationary heart and lungs.
Manish works quickly, inspecting the pericardium. This baglike structure surrounds the heart like a glove around a hand. If it becomes engorged with blood, it will compress the beating chambers and stop them from pumping. This, too, is relatively easy to remedy, but today it’s not the source of our problems. There is blood everywhere in the chest cavity. A suction tube gurgles away. Manish shells the heart from its protective pericardial sac. He inspects it, hoping that there might be a simple hole, amenable to quick repair. But this is not the case.
He moves farther up into the chest and at last finds the injury. A bullet has torn the great vessels surrounding the heart; her blood has been pumped out into her chest. The emptied ventricle has struggled and then failed to beat. There is no easy fix to this. The team stops resuscitating.
Manish asks the flight paramedics how long she has been down—without a pulse. “More than half an hour” is the reply. He looks at the clock on the wall and calls out the time of death.
The team leaves, Manish first and then the other residents. The most junior member of the team is left with the task of closing the chest. I am that person. A huge curved needle on the end of a wire is handed to me. I am left alone with a girl who perhaps an hour ago was at a party when a man with a gun sprayed rounds into the room. One passed into her chest and through her heart and its surrounding vessels. In an effort to save her life, Manish had searched for that injury, hoping to address it and then restart her heart, racing to restore a fresh supply of blood to her oxygen-starved body and brain. But the mess of ruptured vessels and chambers had proved too complicated to repair in the short time that he had.
In the heat of the moment, during the resuscitation, it is easy to be objective about things, to separate yourself from the horror of the event. Even as a lowly intern, you have a job to do, even if that job is to watch and learn, starting the process of preparation that gets you ready for the time when it might be you wielding the knife and making the decisions.
Alone with her, it’s harder. As a student, the world of medicine appears to be full of patients who are much older than you, who are enduring things that you don’t need to worry about just yet. But she is younger than I am, maybe even a teenager. She belongs back at the party, not lying here on a gurney with her dress cut to pieces.
The surgery she’s undergone, an emergency thoracotomy, is a technique honed for precisely this situation. In skilled hands, in the right circumstances, it gives a victim of otherwise lethal penetrating chest trauma a 10 percent chance of survival. The immediacy with which it is brought to bear is startling. It is in some respects a simple, albeit violent, intervention. And today it wasn’t enough.
Watching that procedure so deftly executed and with such surety, it is tempting to think of cardiac surgery as though it were an ancient art honed over centuries. But learning how to open a chest and confidently operate upon the heart is something that took almost the entire history of medicine to learn.
—
IF YOU PLACE THE PALM of your right hand flat in the middle of your chest, its heel lying in the center of your breastbone and your fingers extended so that your middle digit points at your left nipple, you can gain a good impression of where the heart lies anatomically. And while the beat of its apex is best felt well to the left, where the tips of your fingers resting on your chest now lie, the bulk of its mass is surprisingly central. Neither does the heart lie flat in the cavity of the chest; it is instead slightly rotated, its right side more exposed toward the front of the chest, its left slightly hidden to the rear. The whole arrangement sits protected behind the breastbone and a formidable cage of ribs; an evolutionary nod to the heart’s central importance—and vulnerability.
From the breastbone, the route to the heart is an inch in a straight line, but that trivial distance took medicine more than two thousand years to travel. The twentieth century saw centuries of dogma set aside and cardiac surgery advance in great leaps and bounds. These feats of exploration laid open the continent of the heart to science and medicine just as Scott and Amundsen paved the way to the Antarctic interior.
—
OUR EXPLORATION OF the world’s extremes is in essence an exploration of ourselves and the limits of the human body. It is our physiology and our inability to protect it effectively from the outside world that put the remote corners of the Earth beyond our grasp until well into the twentieth century.
That exploration also saw us turn to the frontiers of medicine, to explore the limits of physiology in health and disease. The same revolutions in science and technology that extended our explorations of the physical world helped to push back the frontiers of medicine and surgery.
There were, at the start of the twentieth century, many facets of human anatomy and physiology that stood largely unprobed—foremost among them the human heart. While nineteenth-century scientists had begun to map the organ’s function and complexity, it remained a territory upon which medicine still feared to trespass. As late as the fifth decade of the twentieth century, as World War II raged, the heart was still a continent as dangerous and unknown in the eyes of surgeons as Antarctica was to explorers of the heroic age.
Physicians saw the heart as largely inviolate, a sacred and complex whole that must remain intact and unaltered, an organ with which surgeons could and should not interfere. This dogma was as old as Aristotle’s teachings and remained unchallenged until the very end of the nineteenth century. Medical textbooks warned against tampering with the heart. In his 1896 text, Surgery of the Chest, esteemed surgeon Stephen Paget made his position clear: “Surgery of the heart,” he famously declared, “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.”
Overcoming the received wisdom of the past, making that leap of surgical faith, was a feat that required the terrible but unique catalyst of war.
—
IT IS WINTER 1917. Somewhere on the Western Front, a British infantryman is marching forward across the frozen earth of no-man’s-land. There is a blizzard in the air and a biting wind sweeping across the battlefield. His clothes are no match for this weather, but the crack of gunfire presents a more immediate threat. From the German trenches, there is the sound of chattering machine guns; the firing positions are perhaps five hundred yards away. At that range, in this visibility, there is a faint hope that their hail can be avoided.
The German machine-gun crews fire hundreds of rounds a minute, pausing only to clear stoppages, improve accuracy, and prevent their weapons from overheating. Each bullet can travel half a mile in under a second. They spin around their long axes in flight, held stable by the same law of physics that keeps a child’s spinning top upright, making the machine gun accurate over large distances. It is the velocity of the round and the kinetic energy carried with it that makes the bullet so lethal.
The soldier advances, a rifle in his right hand. His left is raised in front of his face to shield his eyes from the heavy drifts of snow. Through that blizzard, a spinning machine-gun round finds him.
The bullet travels through his left arm, just above his elbow, slowed by muscle and flesh. It continues, exiting the arm, piercing first his tunic pocket and then its contents—a notebook and a bundle of letters—before encountering the wall of his chest and finally the substance of his heart.
At the time of World War I, gunshot wounds to the heart were almost invariably fatal, and cardiac surgery was still looked upon dimly. Back in 1883, Christian Albert Theodor Billroth, one of the founding fathers of abdominal surgery, had these words for would-be pioneers: “A surgeon who tries to suture a heart wound deserves to lose the esteem of his colleagues.”
Views such as these continued to hold sway well into the Great War. In 1916, Major George Grey Turner, a doctor in the service of the British Royal Army Medical Corps, addressed an audience of surgeons bound for military duty. Although he had plenty of advice on other topics, he had little to say on injuries to the chest. “These,” Grey Turner told his audience, “are commonly thought to be beyond the scope of surgery, and to merit very little attention. . . .”
Yet the following year, in 1917, Grey Turner received a casualty recently returned from the Western Front, eighteen days after he had been injured by a machine-gun bullet—our infantryman with the bullet holes in his arm and his correspondence.
The soldier was in surprisingly good health and was indeed embarrassed to have been forced to arrive at the hospital on a stretcher. Grey Turner examined him and found evidence of a bullet’s entry at the front of his chest but, ominously, no exit wound.
At the time of World War I, medical X-rays were a novel invention, but their value in locating bullets and shrapnel was rapidly recognized, and they were quickly adopted by military hospitals.
The X-ray tubes at the disposal of hospitals of the time were primitive: a cathode and anode fashioned from metals such as tungsten, separated in an evacuated glass flask and driven by the electricity from an oil-powered generator.
That radiation, passing with ease through soft tissue, attenuated by denser bone and metal fragments, falling finally upon a fluorescent plate, revealed a bullet in the region of the heart’s left ventricle. It was moving synchronously with the heartbeat in a disturbing whirling motion. The bullet appeared to be lodged in the wall of the soldier’s heart, its waist apparently plugging the muscle of the left ventricle, its tip inside the ventricle, wriggling with the flow of blood.
Grey Turner considered his options. If the bullet migrated farther, it could lead to an embolus, showering fragments of clotted blood or infected material into the soldier’s circulation and blocking distant arteries, with unpredictable consequences. Or perhaps its dislodgement might lead to rapid and fatal hemorrhage. Even if it were to remain stable in situ, the presence of the bullet would surely be a source of disastrous infection. In Grey Turner’s eyes, there was little option but to intervene surgically.
The operation proceeded under a primitive anesthetic cocktail of alcohol, chloroform, and ether. Grey Turner made his first incision, shaped like a letter C the size of a man’s palm, in the skin on the left side of the soldier’s chest. Through this he removed the soldier’s sixth rib and then divided the three ribs above it, allowing him to open the chest wall outward like the rear cover of a book. He retracted the lungs, gently pulling them out of the way, and finally gained access to the injured heart. There he carefully opened the pericardium.
—
THE BEATING HEART DOES NOT SIMPLY expand and contract. To witness it in life is to understand surgeons’ traditional reluctance to interfere. There is an element of torsion in the way that it moves—waves spreading across its muscle from base to apex. Even in health, its cadence constantly changes, accelerating and slowing periodically but with a clear, intrinsic, and vital rhythm. It exhibits a physical dynamism like no other organ in the human body, and thus it is inescapably the engine of life, even as it lies on the table before you.
There is anatomical complexity too: Tributary veins flow into the vena cava, the last great vessel of the returning circulation. The point of entry, the atrium of the right side of the heart, is but the first of four chambers. The second, separated from it by a fibrous three-leafed valve, is the right ventricle, thicker walled than the atrium above, able to provide a volume of blood with enough energy to send it through the pulmonary artery, its pulmonary valve, and out to circulate through the blood vessels of the lungs.
That outflow divides and fragments into a plethora of smaller and smaller vessels, until finally they form the many millions of fine capillaries, vessels sometimes smaller in diameter than the red blood cells that must traverse them.
Here those red blood cells, the all-essential vehicles of oxygen delivery, must distort as they squeeze through the capillaries, snaking around the alveolar air sacs, grabbing oxygen and giving up carbon dioxide as they go.
Then there’s the return journey. Capillaries become venules, venules become veins until they merge to comprise the pulmonary vein, returning the circulating blood once more to the heart. Here a third chamber, the left atrium, receives blood from the pulmonary vein, freshly laden with oxygen from its voyage through the lungs.
The left atrium provides just enough impetus to push the blood through a valve shaped like a bishop’s miter—the mitral valve—whereupon it enters a fourth and final chamber: the left ventricle. This structure, with its muscular wall, must develop enough force to accelerate the blood of a single heartbeat out through the aorta and past the aortic valve to circulate throughout the body.
Through this network of vessels, into these chambers, over these surfaces, blood must flow endlessly, never faltering, never forming eddies or clotting, from moment to moment across the entire span of a human life. And in 1917, somewhere in this complex mass of mobile, twisting tissue lies a bullet that Major George Grey Turner must find.
—
GREY TURNER BEGINS HIS SEARCH. He finds a scar covering an entry wound in the wall of the left ventricle. There is no doubt that the bullet lies within. He carefully cups the heart in his hands, trying to feel for the missile. The heart, he notes, develops the hardness of a stone while contracting, making it impossible to feel anything within. In the cycle of each heartbeat he has less than a second when the muscle is relaxed enough for him to locate the bullet. But even this proves impossible; the bullet is too deeply seated. Instead, he punctures the heart carefully but repeatedly in the area around the scar, remarking upon how solid its substance feels and noting that these needle wounds bleed but stop quickly of their own accord. In his written record of the operation, Grey Turner narrates his exploration like a mountaineer describing a new route. These are discoveries, territories uncharted. But the bullet remains elusive.
Unwilling to give up, Grey Turner pares the rib stumps back to give himself more room. He rotates the heart to examine its posterior aspect, whereupon—to his horror—it stops. Grey Turner massages the now flaccid heart, squeezing it in his hands, hoping in some way to resuscitate it back to life. He rotates it back to its proper position, continuing to squeeze it in his hands, and finally it begins to beat again. But the bullet is still nowhere to be found.
After an hour and a half of searching in vain, Grey Turner decides to fall back upon the most fundamental of the general principles in surgery: primum non nocere, “first, do no harm.” To any practitioner of medicine, knowing when to stop is at least as important as having the courage to proceed. Admitting defeat, he withdraws and closes the chest, leaving the bullet lodged in the officer’s beating heart.
Grey Turner’s instincts to withdraw were correct. The projectile was left in place, and the patient duly recovered from his surgery. In fact, the soldier in question recovered fully and was even sought out and found by Grey Turner twenty-three years after that abortive operation, in 1940, alive and well. His only complaint was of occasional fatigue, but that, Grey Turner explained, the patient had attributed to his exertions in “the current war.”
—
GREY TURNER was not the only surgeon of the Great War to attempt cardiac surgery. Elsewhere there were reports of surgeries to remove missiles from hearts—some successful—but these were few and far between and not enough to convince the wider surgical fraternity that the heart could be reliably interfered with. The received wisdom of the time stood. The heart was perceived as all but inoperable.
But World War II saw the further mechanization of combat; the practice of war became still more efficient, and the specter of wounded hearts returned. Shell fragments and bullets found their way into chests in greater numbers, and casualties with wounded hearts once more began to arrive at military hospitals.
Dwight Harken had visited London as a civilian and had worked alongside the renowned British surgeon Arthur Tudor Edwards. In 1942, Harken returned as a thirty-three-year-old U.S. Army captain and an aspiring thoracic surgeon, assigned to a post in Brigadier General Paul Hawley’s office in Grosvenor Square, tasked with assisting the U.S. Army in organizing and coordinating medical logistics.
Harken hailed from the small town of Osceola in Iowa. Graduating near the top of his class, he won the opportunity to attend Harvard Medical School. Harken remained at Harvard as a graduate, spending part of his surgical residency in Boston and later New York before winning a grant from the New York Academy of Medicine to develop his interests abroad in a location and specialty of his choosing. Ambitious but not wishing to compete with the likes of Allen Whipple, Edward Delos Churchill, and Elliott Carr Cutler—titans of general surgery—Harken decided to take a gamble and specialize in the newly emerging field of thoracic surgery. This was a bold move in an era that valued the gifted generalist more highly than the narrowly skilled specialist. Nevertheless, Harken chose to travel to England and take up a visiting fellow’s post at the Royal Brompton Hospital with Arthur Tudor Edwards.
Tudor Edwards was one of the few thoracic surgeons, if not the only one, in the world at the time of Harken’s secondment. His caseload was principally concerned with the treatment of tuberculosis. Assisting in the operating room, Harken marveled at Tudor Edwards’s skills as a technician, watching keenly as he carefully explored the contents of his patients’ chests and pared back tuberculous tumors, liberating blood vessels and elements of the branching bronchial tree from their encasement.
Yet Harken couldn’t help but wonder why, when confronted with the diseased heart, which was in his eyes a mechanical entity, Tudor Edwards and his colleagues remained reluctant to operate, despite the pioneering work of Grey Turner’s generation. So when the outbreak of the Second World War interrupted his apprenticeship with Tudor Edwards, Harken returned to Boston to begin his own experimentation.
—
BACTERIAL ENDOCARDITIS, AN INFECTION of the inner surfaces of the heart and its valves, was an almost invariably fatal affliction in Harken’s time. In the absence of antibiotic therapy, the bacterial infection would disintegrate the heart’s internal structures. Worse, the pumping action of the heart would seed infection and emboli throughout the body. Harken sought to combat this formidable enemy. In theory, surgical removal of the focus of infection would arrest the process and give the afflicted patient the opportunity to survive. But at a time when the world remained reluctant to enter the cavities of the heart, Harken’s hypothesis needed the support of hard evidence before he could attempt it in human patients.
He began by working on dogs. He operated on canine hearts and attached metal clips to the surface of their mitral valves. He found that this intrusion always led to infection and the onset of bacterial endocarditis. This approach provided a model of the disease he sought to treat, allowing him to simulate naturally occurring bacterial endocarditis in dogs, and it also gave Harken confidence that the cavities of the living, beating mammalian heart could be entered and repaired without immediate fatality.
However, Harken’s work was once again interrupted by the events of war, as he was returned to England in 1943 and posted at Grosvenor Square under the command of General Paul R. Hawley, chief surgeon in the European theater of war. Here, anticipating a flood of casualties with penetrating chest wounds, he and Tudor Edwards campaigned successfully for the establishment of specialist thoracic units.
In the first half of 1944, presumably in preparation for the imminent Allied invasion of Europe, several specialist thoracic units were set up throughout England. In May 1944, Dwight Harken was released from his office post in Grosvenor Square and, to his delight, made director of the 15th Thoracic Center at the 160th U.S. General Hospital in Cirencester—a thousand-bed facility complete with a nearby runway to receive casualties from the battlefront. For Harken, this was a happy release from the burden of his administrative role at Grosvenor Square, letting him return to the operating room and resume his passion for surgery.
—
THE U.S. ARMY HOSPITAL WAS BUILT on the grounds of Stowell Park in Northleach, England. It amounted to little more than a cluster of corrugated-steel Nissen huts housing patient wards and surgical teams.
The month of May 1944 failed to provide much in the way of casualties to occupy Harken and his team. He spent the time productively nevertheless, preparing and training his clinical staff in the new art of thoracic surgery.
They would not have long to wait to put theory into full practice; June 6, 1944—D-Day—was suddenly upon them. The hospital received a tidal wave of casualties, delivered by air from the European theater, first from the invasion and then a later surge after the Battle of the Bulge. Confronted by casualties arriving with missiles lodged in their hearts, Harken consulted George Grey Turner for guidance on whether or not to attempt their removal. Grey Turner gave Harken his blessing, stating that there were many good clinical reasons to remove such foreign bodies but that the neuroses that might result from a patient’s knowledge that he “harbors an unwelcome visitor in one of the citadels of his well-being” might give cause enough. The challenge that Harken had so meticulously prepared for had finally arrived.
—
ONE OF HARKEN’S GREAT SKILLS LAY in understanding that the technical ability of the surgeon had to be matched with an equally capable operating team. These surgeries, particularly those involving foreign bodies in the cavities of the heart, often demanded considerable intraoperative resuscitation. While Harken navigated his way through the anatomy, his anesthetist would be responsible for actively resuscitating the patient: providing massive transfusions and balancing efficient pain relief against the hazards of bleeding out, hypothermia, and shock. For the anesthetist in these cases, it was like flying a plane on fire, hoping to hold it in the air long enough for the surgeon to be able to douse the flames.
Rates of blood loss of up to a quart and a half per minute were recorded, a torrent that could empty the patient’s heart and blood vessels and precipitate cardiac arrest in a matter of seconds. That phenomenon—shock caused by hemorrhage—came to be better understood later in the century as the compromise of the heart and circulation by rapid blood loss and the consequent failure to meet the metabolic demands of the body’s vital organs. Left unabated, this process leads inexorably to death, and though the physiology of shock and its consequences hadn’t been fully grasped by the time World War II arrived, Harken’s team had intuitively come to understand the great value of massive whole blood transfusion in keeping patients alive.
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.
—
THE SECOND WORLD WAR 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.
—
HARKEN’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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BAILEY 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.
Bailey, it seems, was driven by something more than simple ambition. As a twelve-year-old child, he witnessed his father dying in his mother’s arms of heart failure, breathless and coughing up bloodstained sputum. In his eyes, an operation that could spare someone that fate was worth all that he and his patients would suffer in its development. His Christian duty, as he saw it, was not to stop but to succeed.
It’s worth remembering that these events were also a product of their time. The absence of formally organized committees to oversee medical ethics contributed to a more permissive, less well-scrutinized style of practice. But perhaps also the war, so fresh in the collective memory, altered the perception of acceptable risk. Arguably society was more willing to accept sacrifice in the face of a war, whether against military foe or disease. Whatever your perspective, if it wasn’t for the dogged determination of Bailey, Harken, and their peers, the fate of the brave Claire Ward—and that of the many thousands of patients who followed in her footsteps—would have been very different.
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WHERE DOES THE LINE LIE BETWEEN innovative new therapy and experimentation? It is blurred at best, and pushing against the frontiers of physiology and medicine presents the physician with difficult ethical issues. Here the fate of explorers of the physical world departs sharply from that of our physician pioneers. Explorers risk their own lives; doctors risk only the lives of those under their care, making their endeavor easier and at the same time infinitely harder.
But it was in this way that the last great chasm in all of surgery was crossed: the yawning gap of an inch from the wall of the chest to the heart. The continent of the heart was finally open for exploration.