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An eye-opening and heroic story of pioneering heart surgeons, structured around eleven operations.
For thousands of years the human heart remained the deepest of mysteries; both home to the soul and an organ too complex to touch, let alone operate on.
Then, in the late nineteenth century, medics began going where no one had dared go before. The following decades saw the mysteries of the heart exposed, thanks to pioneering surgeons, brave patients and even sacrificial dogs.
In eleven landmark operations, Thomas Morris tells us stories of triumph, reckless bravery, swaggering arrogance, jealousy and rivalry, and incredible ingenuity: the trail-blazing ‘blue baby’ procedure that transformed wheezing infants into pink, healthy children; the first human heart transplant, which made headline news around the globe. And yet the heart still feels sacred: just before the operation to fit one of the first artificial hearts, the patient’s wife asked the surgeon if he would still be able to love her.
The Matter of the Heart gives us a view over the surgeon’s shoulder, showing us the heart’s inner workings and failings. It describes both a human story and a history of risk-taking that has ultimately saved millions of lives.
|Publisher:||St. Martin's Press|
|Product dimensions:||6.40(w) x 9.40(h) x 1.70(d)|
About the Author
THOMAS MORRIS worked for many years as a successful radio producer, with a particular interest in scientific and medical topics. He is now a freelance journalist working for the Times and Financial Times.
Read an Excerpt
BULLET TO THE HEART
Stowell Park, Gloucestershire, 19 February 1945
A few minutes' drive south of the pretty market town of Northleach, in the heart of the Cotswolds, is a pub called the Inn at Fossebridge. If you park here, as I did one blustery spring afternoon, and climb a steep hill, you'll soon come to a small wood that lies beside a Roman road, the Fosse Way. It's a peaceful spot filled with birdsong, and as you tramp through the undergrowth it seems scarcely possible that this was the scene of one of the great feats of modern medicine. But seventy years ago this unremarkable little wood was the birthplace of modern heart surgery.
The trees, although tall, were planted only a few decades ago, and beneath them some relics of what used to be here are still visible. Dozens of low brick structures protrude through a light covering of moss and dead branches: these are the bases of long-demolished Quonset huts, and just off the footpath I found one still intact, preserved – or so I hoped – as a reminder of what happened here in wartime.
In late 1944 you would have seen lines of these huts, hundreds of them, covering several acres of the Stowell Park estate. This was a huge military hospital, with its own airstrip, constructed in haste to cope with the flood of casualties expected to follow an Allied invasion of continental Europe. In April that year it became the headquarters of the 160th General Hospital of the US military, a unit specialising in chest injuries which at its peak had 500 patients under treatment – and in an improvised operating theatre in one of these huts, a young Iowan surgeon called Dwight Harken removed bullets and shell fragments from the chests of 134 soldiers without experiencing a single fatality. This was impressive in itself, but what makes his unblemished record all the more remarkable is that he extracted many of these pieces of twisted metal from inside a beating heart.
A metal hut is not the ideal environment for heart surgery. Sixteen feet wide by twelve high, Harken's ramshackle operating theatre had a roof of corrugated iron and was poorly insulated: the summer sun turned it into a stifling furnace, while in winter it was heated by a small stove. But the cold was the least of his concerns as he prepared for surgery on 19 February 1945. He already knew his patient well: Leroy Rohrbach, an infantry sergeant who had been involved in the Normandy landings the previous summer, a tricky case who had been in Harken's care for some time. A month after D-Day he had been caught up in the fierce fighting which obliterated the town of Saint-Lô, and an exploding shell had sent a piece of shrapnel through the lower part of his chest.
He was evacuated to England, where an X-ray showed a small piece of metal lodged inside his heart. On the fluorescent screen it could be seen pulsating gently with the throb of his heartbeat, indicating that it had passed through the outer wall of the organ and was now inside one of the cardiac chambers. On 15 August Harken operated and came desperately close to removing it: after making a small incision in the heart he managed to grasp the metal fragment with a pair of forceps, but it was jerked from his grasp as the organ contracted, and slipped back into the bloodstream. He made frantic attempts to find it, but it had vanished from view and could not be felt through the heart's thick walls. Three months later he tried once more. Again he found it; and again it defied him, slipping from his forceps just as success seemed assured.
Yet despite these failures his patient continued to improve. This was not unheard of: soldiers with similar injuries might never need an operation, living quite happily with pieces of shrapnel – or even bullets – inside them as permanent reminders of their military service. The sergeant showed no signs of infection, and electrocardiograms revealed that his heart rhythm, which had been disturbed by the injury, was slowly returning to normal. Given that his patient had already endured two major and fruitless operations, Harken was reluctant to risk a third: it would be dangerous and possibly unnecessary.
But there was another consideration. Although many soldiers lived active lives after such injuries, others developed crippling anxiety about the alien shard of metal lodged deep inside their chests. They became depressed, fretful, and lived in perpetual fear of sudden death, terrified that a single careless movement could be enough to dislodge the shrapnel and kill them. This phenomenon was well known by 1945, and had been given a name: cardiac neurosis. Indeed, Harken's patient had become increasingly nervous about the inch-long shell fragment inside his body and begged the surgeon to persevere. Appreciating that such distress constituted a significant clinical consideration, Harken agreed to make a final attempt.
At thirty-four, Dwight Harken was already one of the most highly regarded surgeons in the US medical corps. A tall and muscular redhead, he had been born into medicine, delivered by his father, a doctor who ran the small Harken Hospital in Osceola, Iowa, and had grown up in a basement flat in the building. During his childhood the antiseptic smell of the wards had never been far away, and his father's hope was that he would eventually take over the family business; but small-town life had little appeal, and he left to study at Harvard. A few years later he moved to Britain to work with the country's leading chest surgeon, Arthur Tudor Edwards, at the Brompton Hospital in London. During the war Tudor Edwards had an immense impact on military medicine, training surgeons and developing new techniques in his treatment of air-raid casualties. Given this pedigree, and despite his youth, Harken was a natural choice to run the new specialist thoracic unit in Gloucestershire.
Although Harken's operating theatre was little more than a shack, he was otherwise in a fortunate position. By February 1945 he had state-of-the-art equipment and drugs, including the new antibiotic penicillin, and a close team of surgical colleagues who had assisted him in over a hundred operations. Charles Burstein, the anaesthetist, had been with him since the beginning; he now put the patient to sleep, administering a mixture of ether and air through a facemask. Today the hut was more than usually cramped. Word had got around about this remarkable young American doing wondrous things in a field in Gloucestershire, and a delegation of eminent British surgeons, including Tudor Edwards, had come to watch Harken at work. Above the operating table a cameraman was lying on a scaffold, ready to film proceedings for the benefit of medics in America.
The sergeant's body bore obvious scars from the first two operations, one a snaking line across his back from shoulder blade to hip, the other a smaller curve around his left nipple. Harken chose to renew his attack through the chest, using a scalpel to reopen his earlier incision. With a pair of Tudor Edwards retractors, an instrument named after his mentor, he separated the patient's ribs and exposed the heart by cutting through the pericardium, the tough sac around it. He could see the scar in the cardiac wall left by his first operation, and elsewhere the tissue appeared flabby and discoloured, evidence of trauma. By gently squeezing the beating heart he was able to locate the foreign body, a small area of hardness in the right ventricle, near the organ's base.
Now the shell fragment had been found, the delicate task of removing it could begin. Harken held it in place with a finger placed firmly on the outside of the heart, while inserting two rows of catgut sutures on either side, an otherwise straightforward procedure rendered more difficult by the constant contraction and relaxation of the muscle. In the event of catastrophic bleeding these could be pulled together, a simple but effective way of staunching the flow of blood. As Burstein watched the electrocardiogram nervously, looking for signs that this manipulation was disturbing the heart's rhythm, Harken's assistant picked up the loose ends of the catgut and waited for a signal. This was the critical moment.
Working as quickly as he could, Harken now made a small incision in the heart wall and inserted a pair of forceps to widen the opening. Through this aperture he introduced a clamp and fastened it around the elusive piece of metal. For a moment all was quiet. And then, as he related in a letter to his wife, '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.' His assistant pulled the control sutures taut, but the wound continued to bleed. Harken put a finger over it, and picking up a needle started to sew it shut. The opening was closed, but when he tried to remove his finger he discovered that he had sewn his glove to the wall of the heart. Finally his assistant cut him loose, and the job was done. Opening the heart, removing the shell fragment and repairing the incision had taken three minutes. His distinguished guests were deeply impressed: this was surgery of a sophistication and audacity which none had seen before.
Some of Harken's operations were still more dramatic. Sometimes when he cut into the heart the resulting jet of blood entirely obscured his view, and he was forced to fish around blindly for the metallic fragment in a churning scarlet sea. The degree of haemorrhage was often so severe that patients had to be given rapid transfusions. Today, blood comes pre-packed in plastic bags which are hooked on a drip stand, and enters the body under atmospheric pressure; in 1945 the blood bag had yet to be invented, and so it was instead poured into a bottle into which air was then pumped to create the high pressure necessary to force it into the patient's veins. Most of the time this worked without any problems, but every so often the bottle would explode, showering the entire operating theatre and its staff with blood and shards of glass.
On another occasion Harken tried a novel method of removing foreign objects. During the First World War several surgeons had realised that since many bullets were made of iron it should be possible to remove them magnetically. Harken took up this idea, ordering a huge mains-powered electromagnet which was mounted above the operating table. After the patient's chest had been opened it was turned on. The bullet remained stubbornly in place, but every surgical instrument in the room flew lethally through the air and landed on the surface of the electromagnet with an alarming metallic clink.
In an age when open-heart surgery takes place in thousands of hospitals all over the world every day, it is difficult to appreciate quite what a momentous achievement Harken's work was. He was not the first to remove bullets from the heart, but never before had a surgeon operated on so many patients without a single death, or made a terrifying procedure look almost routine. The magnitude of the accomplishment is noted in the official account of British surgery in the Second World War: 'His outstanding success, his daring interventions, and his brilliant results underline one of the most striking chapters of surgical achievement in any war, and in a symposium of this type all British surgeons will unite in offering their tribute to him.'
Such hyperbole is easier to understand if you consider that less than half a century earlier heart surgery was widely regarded as impossible. In 1896 the author of the most widely read British textbook on chest surgery, Stephen Paget, wrote, '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.' One of his contemporaries, the American Benjamin Merrill Ricketts, observed gloomily that 'there is probably no organ or disease about which so much has been said and written, with so little accomplished, as the heart with its diseases.'
By the end of the nineteenth century surgery had made great strides, thanks to two recent discoveries: anaesthesia and antisepsis. The first anaesthetic agents, ether and chloroform, were discovered in the 1840s and made it possible to undertake quite radical procedures without inflicting excruciating pain. Twenty years later Joseph Lister showed that if instruments and dressings were sterilised, infections could be prevented, and the age of modern surgery had begun. It was now possible to operate at leisure on an unconscious patient, and to be reasonably confident that they would not then succumb to gangrene.
Progress was rapid. Within a few decades surgeons were operating on virtually every part of the human body. By 1890 detailed surgical textbooks were available for the skeleton and its muscles, the mouth and jaw, the ear, the eye, the kidney, the reproductive organs, the urinary system, the intestines and the rectum. Not even the brain was out of bounds: in 1884 Rickman Godlee successfully removed a tumour from inside the skull of a twenty-five-year-old man in an operation in London, prompting editorials in national newspapers.
So why was the heart, alone among the major organs, still taboo? There were certainly practical difficulties: its position beneath the ribcage made it inaccessible, and operating inside the chest could cause the lungs to collapse as air entered the space around them, causing catastrophic respiratory failure. And then there was the fact that if the patient were to remain alive the heart had to keep pumping: how could you possibly operate on an organ that wouldn't stay still?
But there was something else, too: a reverence for the heart rooted in centuries of tradition. It was not merely another organ, but an object far more mysterious and freighted with significance. This was eloquently expressed in the sixteenth century by the French surgeon Ambroise Paré, who described the heart as 'the chief mansion of the Soul, the organ of the vitall faculty, the beginning of life, the fountain of the vitall spirits'. This attitude is even apparent in the oldest surviving medical texts, those from ancient Egypt. The heart was then believed to be the seat of the intelligence, the emotions and the soul, and was preserved after death: admission to the afterlife could only be granted when it had been weighed by the god Anubis. Later, Greek scholars agreed on the fundamental importance of the heart. In the fourth century BC Aristotle pointed out that it was the first organ to form, and the last to die; it occupied a central position; it moved; and it communicated with all other parts of the body. He also saw the heart as the source of the 'animal heat', the life force inherent to all organisms.
Given the fundamental importance assigned to the heart by early thinkers, it was natural to assume that injuries to it must necessarily be fatal. In his great 37-volume encyclopaedia Natural History, compiled in the first century AD, Pliny described the heart as 'the primary source and origin of life'. He claimed that it 'is the only one among the viscera that is not affected by maladies, nor is it subject to the ordinary penalties of human life; but when injured, it produces instant death'. A century later the most celebrated surgeon of the ancient world, Galen, was able to describe the effect of cardiac injuries at first hand. For a few years he was the official doctor to the gladiators of his hometown of Pergamon, and witnessed many die from the effects of a stab wound to the heart. He noted that such a death was often instantaneous, but that the length of survival depended on the location of the wound:
When a wound pierces the ventricle of the heart, they die immediately with great flow of blood, and especially so if the ventricle of the left part has been wounded; but if it does not reach the ventricle, but the wound stops in the substance of the heart, some of those affected can survive not only the day on which they were wounded but as long as the following night.
Galen's writings remained the foundation of medical education until superseded by Renaissance scholarship almost 1,500 years later, so it is unsurprising that his conclusions went undisputed for centuries. In a wince-inducing treatise on the treatment of wounds, the seventh-century Byzantine physician Paul of Aegina gave a vivid description of a cardiac injury and its fatal consequences: 'When the heart is wounded, the weapon appears at the left breast, and feels not as if in a cavity, but as fixed in another body, and sometimes there is a throbbing motion; there is a discharge of black blood if it can find vent, with coldness, sweats ... and death follows in a short time.'
Excerpted from "The Matter of the Heart"
Copyright © 2017 Thomas Morris.
Excerpted by permission of St. Martin's Press.
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Table of Contents
Chapter 1: Bullet to the Heart
Stowell Park, Gloucestershire
February 19th, 1945
Chapter 2: Blue Babies
November 29th, 1944
Chapter 3: “A Sensible Hissing”
January 5th, 1953
Chapter 4: Ice Baths and Monkey Lungs
May 6th, 1953
Chapter 5: Rubber Balls and Pig Valves
September 21st, 1960
Chapter 6: Metronomes and Nuclear Reactors
October 8th, 1958
Chapter 7: “Strong and Peculiar Symptoms”
October 19th, 1967
Chapter 8: One Life, Two Hearts
Cape Town, South Africa
December 3rd, 1967
Chapter 9: Clinical Trial by Media
Salt Lake City, Utah
December 2nd, 1982
Chapter 10: Fantastic Voyage
June 12th, 1986
Chapter 11: I, Robot (Surgeon)
November 7th, 2005