The patient was a thirteen-month-old boy with a ventricular septal defect—a hole between the two main pumping chambers of his heart. During the operation he would be connected to his father, whose heart and lungs would keep both himself and the boy alive while the child’s heart was opened and the hole repaired. Although the boy was certain to die without surgery, losing the father would have been catastrophic, bordering on criminal. “Whatever you do,” Lillehei warned his team, “don’t take your eyes off the father.”
Both father and son came through the operation. But the boy died of pneumonia eleven days later. Still, Lillehei believed he had demonstrated that the procedure—he called it “cross-circulation”—was sound. In the coming year, he performed forty-five open-heart surgeries on children using cross-circulation. Twenty-eight survived and went home. Thirty years later all but six of the survivors were still alive. The age of open heart surgery that had tentatively begun with Jacqueline Johnson had finally arrived.
Walt Lillehei doing the first open-heart surgery case with cross-circulation. The father, acting as the heart-lung machine is on the right. Norman Shumway, my future boss, is on the far left.
Photograph courtesy of Dr. Lillehei
Gibbon’s heart-lung machine was refined in the coming years, initially at the Mayo Clinic in Minnesota, and later by Walt Lillehei and his team at the University of Minnesota, who devised a “bubble oxygenator” that was simple and disposable. Lillehei used it in the OR for the first time in the spring of 1955. It would become the standard bypass machine for the next two decades.
Solving the problem of how to oxygenate the blood in a heart-lung machine was only one of a host of issues and open questions that had to be resolved. The machine also had to be able to heat the blood, because as it passes through the tubes and the machine it cools toward room temperature—which is much lower than body temperature. Eventually heart-lung machines would also be developed that could chill the blood for complex operations that involved both heart-lung bypass and hypothermia.
One question everyone wondered about was whether the continuous circulation of blood through the body at an even pressure would damage blood vessels. Normally, with the heart pumping, blood travels through the body in pulses and at different pressures—high pressure when it leaves the heart, and low pressure on the return. That’s why your blood pressure is stated as two numbers, say, 120/75. Your arteries and veins have tone—that is, elasticity—to accommodate this pulsing river of blood. A person on the heart-lung machine has no pulse. As it turned out, this wasn’t really a problem at all. The blood vessels tolerate the steady stream of blood from the heart-lung machine with no problem.
During the early days of repairing holes between the main pumping chambers (ventriculoseptal defects), the children and babies often suffered “heart block.” The heart would not beat again after the surgery. The conduction system of the heart runs immediately below the hole that is the defect and is invisible. Particularly in those early days, when the sutures had to be placed hurriedly, and often with imperfect visibility, it was possible to place stitches around or into the nerves that made up the conduction tissue, and the heart would not beat again. The child would die unless connected to a pacemaker, and the pacemakers of the time were large machines, about the size of a lecture podium, on a cart that had to be plugged into the wall for their electrical power. The team made an extension cord one hundred yards long to transfer power from electrical outlet to electrical outlet on the long way back from the operating room to the patient’s room.
On October 31, 1956, over Halloween, there was a large power outage affecting much of Minnesota and Wisconsin. One of Lillehei’s young patients who was connected to one of the pacemakers died, since the electrical stimulus keeping the heart beating failed. This tragedy emphasized the defects of a system reliant on 110-volt electricity.
The very next day, Lillehei took the problem to a young technician at the hospital, Earl Bakken, who serviced the monitors, oscilloscopes, and other hospital equipment. Bakken was born in Minnesota in 1924 and since childhood had been fascinated by electricity and electronics. After the war, and having studied electrical engineering at the University of Minnesota, he started a company repairing medical electronic equipment with his brother-in-law, Palmer Hermundslie. The company was called Medtronic (MEDical elecTRONIC). The company was based in a small garage in Fridley, Minnesota, and got by (barely) by servicing the equipment mainly from the University of Minnesota Hospital.
Bakken found a circuit diagram for a metronome in the magazine Popular Mechanics, and within just four weeks he built the first transistorized pacemaker. He delivered this prototype to Lillehei for his opinion. Bakken continued to refine and test the handmade device in his garage and went back to the hospital to give one that could be used in patients to Lillehei. Much to Bakken’s astonishment, when he came in the next day, he found the pacemaker already in use on a child. It was January 30, 1957.
Earl Bakken in his garage repairing hospital equipment. The very early days of Medtronic.
Photograph courtesy of Earl Bakken
Nowadays, of course, the regulation of medical devices through the Food and Drug Administration (FDA) would mean that a new device such as this could not be used in patients for years.
This was the birth of the first portable, wearable pacemaker. It was worn around the neck, like a necklace. Lillehei would later tell me how the children would often play with the knobs that controlled the device, which would have serious consequences! Technology continued to advance, however, and by 1960 Bakken had developed the first implantable pacemaker, with no wires going through the skin. Medtronic, which had struggled mightily in the early days just to pay the bills, would go on to become the world’s largest medical electronic manufacturing company.
All of this work was taking place as I packed my tin trunk for Whitestone back in Africa. By the time I got to medical school, open-heart surgery had advanced considerably. So had organ transplantation. Kidney transplants had been done since 1950. The first liver transplant, by Thomas Starzl at Colorado General Hospital in Denver, happened in 1963, though it would be four more years before one of Starzl’s liver-transplant patients survived at least a year. That left one milestone to be reached. As a medical student, I sometimes wondered idly if I might be the first surgeon to transplant a heart.
But on December 3, 1967, the world was stunned by the news that a young South African surgeon named Christiaan Barnard had performed a human heart transplant in Cape Town. Although Barnard had trained at the University of Minnesota under Walt Lillehei, no one outside a small circle of cardiac surgeons had ever heard of him—and none of them would have believed he was ready for such an operation. Everyone assumed the first transplant would have been done by either Norman Shumway at Stanford—another Lillehei disciple who had been scrupulously working out heart-transplant procedures in his lab—or Richard Lower at the Medical College of Virginia, who had worked with Shumway at Stanford. And in fact, Barnard had visited Lower and observed him do a heart transplant in a dog.
Now Barnard—handsome, charismatic, and seemingly hungry for celebrity—had come out of nowhere. His patient was a fifty-four-year-old grocer, Louis Washkansky, who suffered from diabetes and heart disease. Washkansky was in end-stage heart failure and had little to lose. And there was no shortage of donors in Cape Town, where people died in murders and car accidents all the time. South Africa was still rigidly segregated under its oppressive apartheid system. Barnard turned down a black donor, knowing the backlash it would have caused. Then on the afternoon of December 2, 1967, a young white woman, twenty-five-year-old Denise Darvall, was crossing the road with her mother to buy doughnuts. They were hit by a car, and the mother was killed outright. Denise suffered massive head injuries. Barnard had his donor. That night he called in his brother Marius, also a heart surgeon, and the rest of his team, and got to work. They finished just before six the next morning.
Even Barnard’s own tea
m had been caught off guard. As Marius later recalled, Barnard had done no research ahead of the operation to work out either the surgical procedure or the regimen of immunosuppressive drugs that would prevent rejection of the new heart. This was work that had consumed Shumway and Lower for years. Barnard simply skipped it.
Washkansky’s initial recovery was spectacular. He began to breathe more easily and within a few days could feed himself. The world followed his every move. But Washkansky’s second life was a short one. A shadow appeared on his chest X-ray. Barnard assumed this was caused by rejection and increased the immunosuppression regimen in the hope this would prevent Washkansky’s body from destroying the new heart. But it wasn’t rejection. It was pneumonia. The additional immunosuppression allowed the infection to rage out of control. Washkansky died on the eighteenth day after the transplant.
But Washkansky’s operation opened a logjam. Three days later, Adrian Kantrowitz of Brooklyn’s Maimonides Medical Center transplanted a heart into a nineteen-day-old infant boy—who died six and a half hours later. As Time magazine reported in a cover story about Barnard on December 15, there were more than twenty medical centers around the world that had been working toward a transplant. At Stanford, Dr. Shumway had been ready to go a full month ahead of Barnard, but accidental deaths were relatively rare in Palo Alto, a university town, and he’d been unable to find a donor before his patient died in November. Shumway, widely regarded as the leader in heart transplant research, would have to wait until January 6, 1968, to do his first transplant. That year there were one hundred heart transplants done around the world. But results were so poor that by 1970 the number had dropped to eighteen. The only surgeon doing them successfully was Norman Shumway.
Barnard did a second transplant on January 2, 1968. The patient, a dentist named Philip Blaiberg, lived for nineteen months after the surgery. Barnard basked in his fame and was happy to be seen as a great pioneer. He never gave credit to the researchers in America who’d done the real work that made heart transplantation possible.
I was much closer to developments in the surgical treatment of vascular and heart problems that were taking place at St. Mary’s. Felix Eastcott had come to St. Mary’s as a medical student in 1936 and studied immunology and bacteriology under the legendary Alexander Fleming. Eastcott’s real name was Harry, but because he often stood with his hands clasped behind him like the cartoon character Felix the Cat, he’d gotten a nickname that stuck. After graduating and going into surgery, he had been a visiting resident at the Peter Bent Brigham Hospital in Boston, where they were working on the use of artificial arterial grafts and also exploring the potential of kidney transplantation. One of Eastcott’s mentors in Boston was Charles Hufnagel, who later moved to Georgetown and teamed up with a pulmonologist named Ken Moser, who was working out how to operate on patients with pulmonary hypertension—high blood pressure in the arteries that supply blood to the lungs. This can be caused by a stenosis, or narrowing, of the artery itself, or by the presence of blood clots in the lungs called pulmonary emboli. Blood backs up behind these obstructions. The patient becomes short of breath and the heart fails as it labors to pump blood against increasing pressure. Hufnagel—at the urging of Moser—was the first to operate for this disease in 1961. Ken Moser took the procedure with him to the University of California, San Diego, in 1968, when I was still a medical student, and neither Moser nor I could have imagined that our paths would cross one day.
The surgery to relieve pulmonary emboli was Hufnagel’s second breakthrough operation. In 1952, the same year that Lewis did the first open-heart surgery on Jacqueline Johnson, Hufnagel implanted the first artificial heart valve. It was a simple device—a hollow ball inside a tube that allowed blood to flow in only one direction. Hufnagel designed it himself. It was placed in the descending aorta of a thirty-year-old woman, who did well after the surgery and resumed a normal life. The one drawback was that the valve was noisy—the clattering ball could be heard sliding up and down whenever the patient had her mouth open. But it worked and the woman lived another ten years before dying of an unrelated cause. Hufnagel’s prototype was so good that when I removed one from a patient thirty years after it had been implanted by Hufnagel, it was still working perfectly.
When Eastcott came back to St. Mary’s, he teamed up with Charles Rob, the chair of surgery. Rob was a charismatic man who had been decorated as a lieutenant in the Second World War after he continued to operate on wounded soldiers after his leg was broken in a bomb blast. When Rob and Eastcott learned that Hufnagel had developed a procedure for freeze-drying blood vessels removed at autopsy for use in other people, they brought him to St. Mary’s to show them how it was done. Alexander Fleming had just died. Eastcott and Hufnagel raided his laboratory for the equipment and set about creating a bank of frozen aortas.
Rob and Eastcott subsequently replaced many aortic aneurysms—enlargements of the vessel that causes the arterial wall to thin and weaken—with segments of these preserved human aortas called homografts. Homografts are structurally identical to the section of aorta being replaced, but because of the freeze-drying are no long living tissue. This was important because it meant the grafts would not be recognized by the recipient as foreign tissue—the critical step that initiates the process of rejection.
This was life-saving surgery. An aortic aneurysm is like a balloon being inflated to the bursting point. When an aortic aneurysm ruptures, the victim can bleed out in seconds.
Rob and Eastcott also performed the world’s first carotid endarterectomy operation, in May 1954. It’s a procedure to remove obstructing plaque from the inner wall of an artery going to the brain. This could only be done by stopping blood flow to the brain, and so hypothermia was used.
The patient was Mrs. Ada Tuckwell, a woman who was having repeated transient ischemic attacks—ministrokes. An angiogram had been taken in which contrast dye was injected into the suspect artery and then observed in a series of X-rays. This was itself a pioneering and hazardous procedure at the time. The angiogram showed a narrowing, or stenosis, of the left internal carotid artery that supplied the brain. Eastcott worried that the operation itself would result in a stroke. But everyone agreed that without surgery, Tuckwell would shortly have a crippling stroke anyway. Tuckwell was put under and packed in ice. Although the nurses’ teeth were chattering, the all-day operation went well, and Tuckwell awoke without complications. She lived another twenty years, a period during which carotid endarterectomy became the most frequently performed vascular procedure in the world.
Rob eventually left for America, where he developed techniques for using veins to bypass arterial blockages that would later be essential in coronary bypass operations. Eastcott teamed up with Kenyon. They began using synthetic grafts instead of homografts to repair aortic aneurysms. These worked better than the homografts, which tended to dilate over time and form a new aneurysm.
The operation on Ada Tuckwell had been big news, though perhaps not as big a story as the one that broke a few days later when a St. Mary’s medical student and track star named Roger Bannister broke the four-minute barrier in the mile. Bannister became a neurologist and was later one of my teachers.
As exciting as the vascular program was, I was even keener about work at St. Mary’s on kidney transplantation. Dickson Wright had done what was probably the first in the world in 1949, when he sewed a kidney onto the arm of an elderly patient in a nursing home. The idea was that the kidney would do the dialysis that was failing in the patient’s own kidneys. But the graft never functioned, and because the procedure was gruesome, Dickson Wright never wrote it up.
The first recorded kidney transplant in Britain was done by Charles Rob at St. Mary’s in 1955. The operation was on a young woman with kidney failure caused by sepsis—an often fatal condition in which an infection leads the body’s immune system to overreact and attack its own organs. Nobody would do a kidney transplant in someone with sepsis today. The kidney failed, though it probably woul
d have done so even without the complication of sepsis because of the unresolved issue of rejection. Rejection and how to suppress it was not well understood then. As it turns out, preventing rejection without killing the patient is the central problem in organ transplantation—one that I was eager to work on solving.
CHAPTER EIGHT
ANOTHER WORLD
Wilson House, my home as a student, was supervised by a retired naval captain named Gregory-Smith, who ran a tight ship. Though parking in London was scarce, some students had cars. A limited number of parking places in front of Wilson House were allocated to us. A medical student named Dalton had an old car that did not run. By virtue of his seniority, he had a parking place and somehow managed to leave his car in it. It never moved the whole time I lived there. This was a source of irritation to the captain. Every day he would say, “Dalton, when are you going to move that car?” It became a cause with him. I believe Dalton would have got rid of the car if it hadn’t annoyed the captain so much. When Gregory-Smith retired, there was a big party. Dalton wasn’t there. It transpired that Dalton had used the time to tow the decrepit car to the captain’s newly purchased cottage in the country, where he left it in the driveway.
Almost everybody at St. Mary’s was involved in rowing or rugby—or both. I played a little rugby, but it was rowing that I liked. I was on the eight-man crew. At first I worried that the training—we rowed every evening on the Thames and worked in the weight room a couple of times a week—would get in the way of my studies. But I found that the workouts and the fitness actually made it easier for me to concentrate.
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