Blood and Guts

by Richard Hollingham

  Everyone waited for the pigs.

  The farmer pulled up to the mews at the back of the hospital. The first inkling Longmore had that it was going to be a long night was when Thompson, the head porter, called him. 'Mr Longmore, is that pig in a Land Rover in the mews anything to do with you?'

  'Yes, it is.'

  'Well, it has just got out and turned left along Wimpole Street.'

  Reluctant to make its own valuable contribution to medical progress, the pig had escaped. It is surprising how fast a pig can run, especially when its life is at stake. Still dressed in their operating theatre gowns, caps, masks and boots, the entire surgical team gave chase.

  The pig ran as fast as its little legs could carry it, but was no match for London's finest heart surgeons, who eventually caught it halfway up the road. The pig squealed in protest, but Longmore herded it back towards the hospital. It was five o'clock in the evening and people were heading home from work, so the street was relatively busy. Most passers-by paid little attention to the odd group in the road. Only one gentleman seemed a little perturbed. Raising his bowler hat, he said, 'Excuse me, sir. You are going the wrong way along a one-way street.'

  Back in the operating theatre, the anaesthetized patient lay on the table. The heart-lung machine pumped and breathed on his behalf. The nurses and surgeons stood around. The clock ticked. Where was the pig?

  The pig was with Longmore in the lift. He wasn't going to let it get away this time. There were also a few hospital visitors in the lift, but no, they didn't mind if the lift went straight to the top floor marked 'mortuary'. What business was it of theirs if the surgeon fancied having pork for his supper?

  Arriving at the mortuary, Longmore had arranged for an anaesthetist to put the pig to sleep so that it could be killed and its organs removed. When the anaesthetist assigned to the task showed up, he turned out to be Jewish. He refused to kill the pig. Another anaesthetist was found, but by now Longmore was beginning to wonder if all this grief was going to be worth it.

  In the operating theatre, the heart-lung machine continued to pump. The surgeons and nurses waited.

  The heart and lungs were eventually removed from the pig, but now there was another problem: the patient was also Jewish. What were the chances? The patient himself was in no position to reassess the merits of the operation, so rather than panic (or pray), Longmore did the next best thing – he rang a rabbi.

  When Longmore explained what they were trying to do, the rabbi went very quiet. The surgeon apologized for putting him in such a difficult position and understood if he didn't want to get involved. There was another long, somewhat muffled silence. Finally, the rabbi could hold back no longer. 'Sorry,' he said. 'I was trying to stop laughing.' The rabbi told Longmore that if this was a genuine attempt to save the man's life, then certainly he should go ahead. First the escaping pig, then the Jewish anaesthetist, now this. Another obstacle overcome. At last the surgeons could get on with the operation.

  It was a relief to return to the operating theatre. Once he had changed and scrubbed, Longmore was ready to begin. The heartlung machine continued to pump. The dark red blood flowed in; the bright red blood flowed out. The patient was still alive, the pig heart was ready. The operation could get under way.

  The operation itself seems to be going surprisingly well. The heart is stitched into the patient's circulation ready to help keep him alive. The final part of the procedure involves a simple injection of calcium to the pig's heart. In humans calcium is used to increase muscle strength. However, as Longmore now discovers, it has a different effect altogether in pigs. The pig's heart sets like a stone. It is useless, and after all that effort the operation fails and the patient dies. It is little consolation to the surgeons that he would have died anyway, but at least they have learnt from the experience.

  The story became known as the 'night of the pigs', and to cap it all, the feared hospital matron had been woken up by pig squeals and was furious. A member of the surgical team sent her pork chops for breakfast, which hardly helped.

  FRAGILE HEARTS, FRAGILE EGOS

  Groote Schuur Hospital, Cape Town, 3 December 1967

  * * *

  Compared to bullet wounds, hibernating groundhogs, crosscirculation and porcine predicaments, heart transplantation itself is a relative anticlimax. In 1967 the race was on to be the first surgeon to transplant a human heart. There was no knowing who would get there first, and although many surgeons talked of sharing their results and cooperating with their rivals, secretly most of them would admit that they wanted to be the one to get the credit and possibly a little bit of glory.

  Many believed the first would be Norman Shumway, a surgeon at Stanford in California, who had been working for almost ten years on perfecting the heart transplant technique in animals. Shumway had presented his first heart transplant results on dogs in 1961, and was now ready to try it on humans. He had developed new combinations of drugs to prevent the heart from being rejected by the body (see Chapter 3). He even went on to suggest that transplanting a heart should be a relatively straightforward surgical procedure, and less likely to end in rejection than, say, a skin or kidney transplant.

  Elsewhere in the United States, down in Mississippi, James Hardy was waiting for a human donor for a terminally ill heart patient. With no suitable transplant available, he tried transplanting the heart of a chimpanzee, but this proved unsuccessful. Meanwhile, many European surgeons were keen to steal a march on the Americans – there was national, as well as personal, pride at stake. So far, most of the cardiac 'firsts' had been by Americans. In France, hospitals were said to be ready, and in London Donald Longmore at the National Heart Hospital was waiting for the right combination of patient and donor, having spent the previous few months battling with a bunch of 'oily' bureaucrats from the Department of Health.

  They were all beaten to it by a relatively unknown, although hardly unqualified, South African surgeon. Christiaan Barnard had been trained by Walter Lillehei in Minneapolis and had a good, if inconspicuous, surgical pedigree. His record for complicated openheart surgery was remarkable. The chances of surviving a Barnard operation were extremely good. Like many of the most successful heart surgeons, he thought of the organ as merely a 'primitive pump' – one that demanded respect, but commanded no great mystical power, no soul.

  Barnard had been studying the problems of heart transplants for some time, although much of what he learnt was from other surgeons rather than his own experiments. He travelled to see Shumway at Stanford, and visited Longmore in London to witness his heart-lung transplants on dogs. Barnard was personable, antiapartheid and had something of a reputation – the handsome young man's interest in affairs of the heart extended beyond pure technical interest. While in London, he also attempted to seduce one of Longmore's nurses (with some success apparently).

  Barnard had learnt from the greats, and in an obscure South African hospital, undisturbed by the authorities, he decided the time was right to put his knowledge to the test. On 3 December 1967 he removed the beating heart of a twenty-five-year-old female car crash victim, pronounced dead by a neurosurgeon. The recipient of this fresh young heart was lying ready in an adjacent operating theatre. Fifty-three-year-old diabetic Louis Washkansky had already suffered several heart attacks and, quite frankly, did not have long to live. The operation took two hours. Washkansky's new heart started beating and kept beating. A day later he was awake and talking. A few days later he was out of bed. Eighteen days later he was dead.

  Washkansky died of pneumonia. The drugs used to suppress his immune system to prevent the heart being rejected had also left him open to infection. But no one remembers Washkansky. Christiaan Barnard was the hero of the day – an instant celebrity. Barnard would be received by the pope, entertained by presidents and prime ministers. He became the world's most eligible bachelor, dating a string of beautiful and famous women.

  Some of Barnard's rivals expressed more bitterness than others. Longmore was pleased for
him. Others muttered that they had done all the work only for Barnard to take the glory. And what glory. Who cared about the second man to fly across the Atlantic (Bert Hinkler), to run the four-minute mile (John Landy) or to climb Mount Everest (a matter of some debate)? Christiaan Barnard would be the man in the history books.

  But while Barnard had won the main prize, there was still a degree of national pride at stake. If South Africa could do it, why not the United States, Great Britain or France? The same bureaucrats who had been so reluctant for Longmore's London hospital to carry out a heart transplant were now asking what he was waiting for. In January 1968 the second heart transplant was performed by Adrian Kantrowitz in Brooklyn, so Shumway – the surgeon who had spent so long developing heart transplant techniques – didn't even get that honour. Shumway's operation was the fourth, and by the time he came to operate later that month, Barnard had already performed a second heart transplant.

  The first British heart transplant (the world's tenth) took place on 3 May 1968. The surgeon was Donald Ross (also a South African). Longmore's role was to collect and deliver the donor heart. For some reason this required a police escort through the streets of London. In fact, the whole affair became a major public event, with a large crowd of spectators, reporters and photographers gathered around the door of the National Heart Hospital. It was, of course, a great national achievement of a proud nation, etc., etc. However, the patient, Frederick West, died of an 'overwhelming infection' forty-six days later. And that was the problem: while the surgeons were getting the glory, none of their patients were lasting very long. In the first few years of heart transplant surgery, patients survived on average just twenty-nine days. Despite all the euphoria, the awful truth was that heart transplants were difficult, dangerous and complicated.

  There are few surgeons as well known as the pioneers of heart surgery. Heart surgeons were courageous, daring and bold. Heart surgeons stood apart from the rest, almost every operation a matter of life or death. When they succeeded, they saved lives. When they failed, they had to be prepared to come back the next day and try again. Many of them had personalities to match their abilities. Some were self-confident, others were egotistical or arrogant. A few were foolhardy or seemingly oblivious to risk. Most heart surgeons were revered by their patients; many became national or international celebrities – household names courted by the media, their faces on the front page of Time magazine. Few people could name one of today's heart surgeons, but then, thanks to pioneers such as Harken, Bigelow, Lillehei,* Gibbon, Melrose and Barnard, major open-heart surgery has finally become routine.

  * There is a curious footnote to Lillehei's career. In 1973 he was found guilty of tax evasion. Although he was undoubtedly at fault, his crime was more one of carelessness than deliberate evasion. He had always been bad at keeping financial records, and had performed many operations for free. He carried out his last operation in 1973, but was to maintain a keen interest in heart surgery until his death. At Lillehei's eightieth birthday party in 1998 many of those invited to celebrate owed their lives to his expertise. He died a few months later, but a great many of his patients live on.

  A photograph taken in 1848 of an operation to be carried out under anaesthetic at the Boston General Hospital, Massachusetts. Judging from the sprawled position of the unconscious patient, it looks as if he is about to lose a leg, although it is curious that he is wearing socks.

  This photograph, taken in 1883 to demonstrate Lister's antiseptic operating technique, appears to be somewhat staged. The carbolic spray is being operated by the man on the right.

  Galen attends to a wounded gladiator as the crowds bay for more blood.

  Simpson's butler walks in to find the surgeon collapsed on the floor – another successful experiment on the properties of anaesthetics.

  A 'muscleman' illustration from Vesalius' De Humani Corporis Fabrica (1543) alludes to his foray into body snatching.

  Robert Liston: 'sharp features, sharp temper'.

  The man of wounds. Suggesting most of these were curable seems wildly optimistic.

  You can sense the intensity in the operating theatre as Walter Lillehei performs open heart surgery using crosscirculation. The first of these operations took place in 1954.

  Walter Lillehei operating on a beating human heart.

  One of the few pictures ever taken of John Gibbon with his fearsome looking heart-lung machine. At the top left of the machine is the screen where the blood was oxygenated.

  Christiaan Barnard with the world's first heart transplant patient, Louis Washkansky, in 1967. The plastic sheet was used to help protect Washkansky from infection.

  The dramatic assassination of President Sadi Carnot on 25 June 1894. The murderer is being grabbed by the crowd as he attempts to make his escape.

  The weird and wonderful world of Alexis Carrel in an illustration taken from a French periodical. It's difficult to tell whether they were proud of their countryman.

  Another experiment in the laboratories of Alexis Carrel. Heaven knows what is going on behind the sheet. This picture is undated, but was probably taken in the 1930s.

  Alexis Carrel and Charles Lindbergh make the cover of Time magazine in June 1938. Not long afterwards, their reputations would go into freefall.

  The appalling result of Vladimir Demikhov's 1959 operation to transplant the head of a puppy onto the head of another dog.

  Richard Herrick is wheeled out of hospital by his identical twin brother, Ronald, on 19 January 1955.

  Clint Hallam enjoying the use of his recently transplanted hand in 1998. Even before Hallam's body started to reject the transplant, its appearance was disconcerting.

  CHAPTER 3

  DEAD MAN'S

  HAND

  THE STORY OF A TRANSPLANT

  March 2000

  * * *

  From a distance, there was something odd about New Zealander Clint Hallam. When he walked towards you it became obvious that one arm was longer than the other. Up close the arm was even more disturbing, verging on the grotesque. Anyone who saw his hand would remember it for ever, perhaps in their nightmares.

  Hallam recalls sitting in an aircraft next to a nice old lady. They got talking. The lady recognized Hallam from somewhere, but couldn't quite place him. Then she happened to glance down at his right hand. Recoiling in shock, she pressed the call button to summon the flight attendant and asked to be moved to another seat. The lady turned to Hallam to apologize. She said she had nothing against him personally, only she couldn't bear sitting next to someone who was wearing a dead man's hand.

  One of Hallam's close friends made a similar confession. Hallam could never understand why, when they met, his friend would always grasp Hallam's wrist rather than shake his hand. Hallam reckoned it was an act of kindness, to avoid any risk of injury to his limb. When he asked about it, his friend confessed to finding Hallam's hand quite horrific. He wasn't the only one. The recipient of the world's first hand transplant was beginning to realize that many people found his new hand repulsive. Now, eighteen months after the operation, even Hallam was beginning to have some doubts.

  From the shoulder down, the upper part of Hallam's right arm was perfectly normal. Its skin tone matched Hallam's dark complexion and was covered in black hairs and dotted with freckles. Then, just beyond the joint of the elbow, there was a sharp division where the skin became pale and practically hairless. It was as if Hallam was wearing a long white glove. There was a bulge – a swelling – where the brown skin met the white. It was a long white glove that didn't quite fit.

  The underside of Hallam's lower right arm was bruised and damaged. The skin was inflamed, raw and angry – as if he had been burnt. Beyond the wrist the hands were similarly swollen. The skin was peeling; there were ulcers and the flesh was shiny. It looked like the outer layer of skin had been stripped away. When it came to the fingers, the decay was even more pronounced. The fingertips were crusty and sore, the yellow nails gradually separating from the flaking ski
n underneath. Small wonder the woman on the plane chose to move to another seat.

  Hallam had received his hand transplant on 23 September 1998 at the Edouard Herriot Hospital in Lyon, France. The operation took almost fourteen hours and was a brilliant technical achievement. Earl Owen led a team of some the world's most experienced transplant specialists from Australia, Britain, France and Italy. France was chosen to host the operation because of its laws on organ donation. There you have to opt out of donating your body to medicine, rather than opting in. As a result, almost everyone who dies becomes a potential donor, so many more donors are available – perfect if you are waiting for a new arm and hand.

  The donated limb came from that all too frequent source of body parts – a motorcyclist. The limb was matched for blood type and tissue type, but, as it turned out, not appearance.

  The surgical technique used to join together Hallam's stump and the dead motorcyclist's lower arm is known as microsurgery and is fantastically intricate. The surgeons wore powerful magnifying lenses and employed precise instruments, tiny needles and the finest of threads.