Close to the Sun

by Stuart Jamieson

  Eastcott had a patient, a forty-five-year-old man, with a stenosis in his brachiocephalic artery, the one that connects the aorta to the right carotid and subclavian arteries. Eastcott was out of town when the man went into distress, so Kenyon decided to operate. I scrubbed in to assist.

  Kenyon opened the chest, just to the right of the sternum, and exposed the artery. Something happened, and it started to bleed. In almost the same instant, a tear near the juncture with the aorta appeared and immediately began extending downward into the aorta, like a zipper opening, disappearing beneath the sternum and out of reach. Blood gushed from the chest with each fading heartbeat and splashed to the floor. Kenyon kept working, but it was hopeless. In twenty seconds the patient was dead. The operating room went silent. We all looked at each other in disbelief. I’d never seen someone die on the operating table before.

  Tiger country.

  When I completed my six months with Eastcott and Kenyon, I moved on to the second six-month rotation, this one in general medicine, which would complete my year of internship. I went to the Royal Lancaster Infirmary, where I worked with a doctor named Adamson. Lancaster, in the west of England, north of Blackpool, was a nice place to live. Adamson saw a lot of cardiac patients. Watching many of them die in the intensive care unit convinced me that there must be better ways to care for people with critical coronary disease. Being treated in intensive care did not seem to have any predictive value as to who would get better and who would not. Coronary-artery surgery was in its infancy then. In 1971, only two hundred coronary-artery bypasses were done in the whole of England. If you had a heart attack or bad angina, the treatment was medical, involving drugs, which helped to alleviate pain but did nothing to alter the patient’s outcome.

  The nursing staff at Lancaster was spotty. Some were great, and a few were terrible. One day a senior nurse came to me and complained there was a patient refusing to take his medication. I went to see the patient, who was propped up in bed with a cold tray of breakfast in front of him. He looked asleep, so I shook him. He fell over. He must have been dead for some time, because his fingers and arm were already stiff from rigor mortis.

  If a patient died and was to be cremated, you had to sign a form saying that there was no need for any further investigation or autopsy before the body could be disposed of—paperwork for which you were paid two and a half pounds. This was a lot of money to a houseman. We called it ash cash. It was enough to fill up my car with a tank of gas. I had a Triumph Spitfire, which I had bought new. From the moment I drove it home, it had made a knocking sound from the rear wheels. I suspected it was one of the bearings, but every time I took it back to the dealer, he said he couldn’t hear anything. I eventually traded that car for a Triumph TR7 at the same dealership. The dealer took the Spitfire for a test run. When he came back, he asked, “What’s that knocking sound coming from the back?” I told him I couldn’t hear anything.

  CHAPTER ELEVEN

  THE DIFFICULTY OF NOT SELF

  I was a doctor now, but not yet a surgeon. I still had to complete my general surgery rotations, which would take another four years. This would include heart surgery, which I looked forward to. I also had to do six months of trauma and emergency work. And, most daunting of all, I had to take the first part of the Fellowship of the Royal College of Surgeons examination. In those days, to pursue a specialty like heart surgery, you had to do a full residency of general surgery first. That meant you had to be a Fellow of the Royal College of Surgeons—your FRCS being the final step.

  The examination was in two parts. The “primary” FRCS was an exhaustive test on anatomy, physiology, and pathology. The anatomy section was particularly difficult. The standard textbook was Gray’s Anatomy, written by Henry Gray in 1858, updated continually ever since, and running to more than two thousand pages. We had to memorize each one.

  The primary FRCS exam was customarily taken about two years after the house jobs. It was an essay exam in which you had to write on three subjects over three hours. The subjects were often obscure. I’ll never forget one that I got: vesico-vaginal fistula, which is an abnormal connection between the vagina and the bladder. Most physicians would go a lifetime without ever seeing a case.

  If you passed the written examination, you went on to the oral portion, which was even more intimidating. You spent an entire day answering questions from two-person teams of examiners, again on the subjects of anatomy, physiology, and pathology. There was no latitude for wrong answers. The pass rate for the primary FRCS was between 10 and 15 percent. Once you got past that hurdle, it was back to clinical work for two or three more years until you accumulated the experience necessary to take the final FRCS.

  The final FRCS was a three-day obstacle course of written examinations, followed by oral examinations if you passed the written part. The oral portion usually involved examining actual patients, making diagnoses, and discussing treatment options. Most of the examiners were well-known surgeons, and it was prudent to know who they were and to be able to quote from books they had written.

  At the end, everyone gathered at the bottom of a staircase in the great hall of the Royal College of Surgeons. If you passed you were called up to the balcony, where your name was checked against the list. Then you joined the examiners in an oak-paneled room where they were drinking sherry. From that point forward, your title was no longer Doctor, but Mister. This tradition goes back to the days of Charles I, when surgeons were not physicians but barbers—hence the Mister. But now to be called Mister is a great honor.

  In 1968, two years into medical school, I had approached the chief of pathology at St. Mary’s, Ken Porter, about working in his lab. Porter wore glasses, had black hair, and worked in a small office adjacent to his lab that was zealously guarded by his secretary. Porter was studying immunosuppressive drugs, which were essential to overcoming rejection, the major problem in organ transplantation. He worked closely with Tom Starzl, the American surgeon who was pioneering liver transplants. Starzl sent tissue samples from failed or biopsied organs to Porter, who studied what happened in the rejection process. Porter was the world’s leading authority on rejection, how it happened, and how it might be controlled. Porter was generous with me and let me have research space in his lab.

  When someone gets an organ transplant from another person, the body’s immune system recognizes that it does not belong, but is instead foreign, or “not self.” This protective mechanism helps you get rid of bacteria, viruses, and even some early cancer cells that are not meant to be there. This is why we usually survive a cold or other infection. When an organ is transplanted to replace one that has failed, the body will also do its best to get rid of the transplant.

  Porter knew that there are two types of rejection. One involves lymphocytes, white blood cells that destroy the organ. The other process is driven by antibodies in the bloodstream that destroy the blood vessels supplying the organ. Lymphocytes can cause rejection in a matter of days, whereas antibody-caused rejection may happen quickly or take months or even years. Porter noticed that in kidney transplants, after two or three years, atheromas developed—a hardening of the arteries supplying blood to the kidneys. Porter wanted me to look at this type of rejection. Soon I was interested in heart transplantation and started doing experiments in which I’d implant a rat with another rat heart alongside the existing heart and connect it to the blood supply so that it would beat, even though it was not a working heart. You could feel this transplanted heart directly through the abdomen. I did lots of tests, but I could always tell how the heart was doing just by feeling it.

  We tried many drugs, mostly on rats. Because rats are so commonly used in research, you can get inbred strains that are essentially identical twins. So if I transplanted a heart from an A strain of rat into another A, it would not be rejected. But if I transplanted from A to B—a different strain—the heart would be rejected. Interestingly enough, I also discovered that if I transplanted a heart from A to B, and then back again int
o another A, it would also be rejected. That was because the heart picked up all kinds of cells from B—so-called passenger cells.

  I met every week with Porter’s pathology group. At one point he suggested that I wasn’t cut out for surgery, that I was too “sensitive.” I think what he meant, but was too circumspect to say directly, was that I was too thoughtful to be a surgeon. There was prevailing view then that surgeons weren’t as bright, that they were more like mechanics than doctors. But I was determined to become a surgeon, and in the end Porter was supportive.

  During my general surgery rotation, I continued to work with Porter. By now he had moved into a new research facility. Porter was one of the first to use electron microscopy to explore the process of organ rejection. The device occupied most of an entire floor of the building and could produce a magnification of ten million times actual size.

  I had my own office and an assistant. And Porter paid me, which was most generous. Whenever I had time, usually at night and on weekends, I was in the lab doing heart transplants in rats. I was still studying the rejection process itself, something that even today is not completely understood. But my real goal was to figure out how to prevent rejection by modifying the body’s response to foreign tissue. Finding drugs that could depress the immune system wasn’t hard. The trick was to figure out the fine balance between too much and too little. Too much immunosuppression and the patient cannot ward off ordinary infections. Too little and the transplant will be rejected. In the early day of trial and error, this was as much art as science.

  But for me it had a special appeal, because I wanted to do heart transplants. If you transplant a kidney and it’s rejected, the patient can go on dialysis and live until a new kidney can be found. But when a heart is rejected, life can end quickly.

  Eventually I focused on a process called “hyperacute” rejection, in which organ rejection takes place not over the course of days, but within minutes. This reaction occurs when the body has been pre-sensitized, meaning that it has preexisting antibodies to the transplanted organ. Such antibodies are present when a patient has already had a transplant, or multiple blood transfusions from different people. There are also preexisting antibodies that will attack organs transplanted from other blood types and from other species. I reasoned that drugs that could control hyperacute rejection, which happened fast, would also work on more ordinary, slower rejections. And there was the tantalizing possibility that if you could prevent hyperacute rejection, it might be possible to use transplants from other species—pigs, for example. A major difficulty with organ transplantation is finding enough donors. If animals could become donors, it would change everything.

  My first scientific papers—aside from my survey of eye disease in Africa—were published in 1974, on the subject of hyperacute rejection. I used guinea pig hearts transplanted into rats. The hearts were rejected within minutes. The electron microscope showed that the blood clotted within the blood vessels, starving the heart of oxygen and stopping it. This kind of rejection was so severe that nothing could prevent it. In the years since I did those early experiments, little progress has been made in modifying this type of rejection. Though it is now possible to create genetically modified pigs to make their organs seem more human when they are transplanted, cross-species transplants are still not possible. Stanford’s Norman Shumway was famous for his thoughts on the subject. “Cross-species transplantation is in the future,” Shumway said, “and always will be.”

  I was still finishing up my requirements for the FRCS. I spent six months as casualty officer at St. Mary’s, doing emergency medicine. This was usually routine, as we were in central London. Severe traffic accidents from the motorways would go more often to the suburban hospitals. Two cases do stick in my mind. Late one night we received a young man who had had a motorcycle accident. The gas tank between his legs had ruptured, covering him in gasoline, which then ignited. When he was brought in, his clothing and flesh were still smoking. I tried to remove his boots and trousers, but most of his flesh and skin came, too. This was beyond what we could treat. I transferred him to a burn hospital, where he soon died. I was scolded for sending them a hopeless case.

  On another occasion, a man had been working under his car when the jack slipped. The car came down on his face. They were able to remove him, but his face was completely destroyed, a mess of jellylike flesh. Somehow his forehead and brain had been spared, and he was still conscious and trying to talk. The moving mass of flesh below his brow was like a horror movie. He was accompanied in the ambulance by his girlfriend, who was hysterical. She showed me a photograph of how he used to look, asking to have him put back that way, which was of course out of the question. We eventually got him out of hospital, but he looked different from the way he used to.

  Mostly we dealt with cuts and bruises and the odd knife wound. Unlike American emergency room doctors, we never saw gunshot wounds. The pubs in Paddington had last orders at eleven p.m. and closed at 11:10. That gave time for the locals to finish their drinks, pick a fight, get beaten up, and be brought to the hospital. We would get busy at around eleven forty-five p.m.

  I did a general surgery rotation at Northwick Park Hospital, just outside London, and then came back to St. Mary’s one final time to work as a registrar on the surgical unit, where the professor of surgery at the time was Hugh Dudley. Dudley was fifty-one when I worked for him. He always wore a white coat with short sleeves, a unique uniform. He had an interesting background. He studied in Edinburgh, followed that with a fellowship in Boston, and was appointed senior lecturer in the Department of Surgery at Aberdeen University. He had a bright future, but he made an abrupt move to Australia to take up the first chair of surgery at Monash University in Melbourne. The move to the other side of the world was probably precipitated by the scandal that erupted after he shot his neighbor’s dog for being a nuisance. He’d come back to Britain, to St. Mary’s, in 1973.

  Dudley was widely published in medical journals, which is undoubtedly how he got the job. He was a poor surgeon, a pedant, and a terrible bully. As his registrar, I was his designated whipping boy. Though I am sure he had some good qualities, I thought him a tyrant.

  One of my main jobs was to accompany Dudley on morning rounds, which started at seven a.m. Normally this would be easy work, but Dudley had a habit of asking for obscure blood test results that seemed to have no relevance to the patient at hand. I had to review every patient’s chart ahead of time, which meant that I had to start rounds at five a.m. I tried to think of the rigid discipline of my boarding school days, but it didn’t help much. I was on my guard from the start. On my first day, I had knocked on Dudley’s door for rounds at two minutes past seven. “Come in,” he said, and looked at his watch. “I said seven a.m., not two minutes past.” I told him I would do better in the future.

  Dudley’s senior registrar, one step up from me, was Peter Fielding, who served as a buffer between me and Dudley when things got particularly bad. Peter, who was a much better surgeon than Dudley, taught me a lot about general surgery. One morning, after I had been working all night without rest or sleep, I had to help Dudley do one of his strange and complicated operations. I wondered why he was doing it so awkwardly. I had never seen this method before. Of course, I didn’t dare to say anything. After an hour or two, he realized he had sewn everything backward. You might imagine that he would have been embarrassed about it, but no. He considered it entirely my fault for not stopping him.

  I refused to call Dudley at night when an uncomplicated emergency case came in. It was easier—and in my view better for the patient—for me to deal with it myself. This eventually got me in trouble.

  Dudley had an elaborate way of doing a bowel anastomosis, a surgery in which a portion of the bowel that is blocked is removed, and the ends are then sewn together. Dudley’s suturing, which was absurdly complex, often fell apart after a few days. Because this could be dire for the patient, he invariably took the additional step of making a small incision
above the repair and then temporarily diverting the bowel out through the abdomen, where a colostomy bag collected feces. After the original repair was healed, he put the bowel together again.

  I thought this was a terrible thing to do to the patient, and also unnecessary if you did the anastomoses correctly. I’d seen Fielding repair a bowel with a much less complicated technique that seemed almost always to work and did not result in a colostomy bag. But Dudley insisted I do it his way, which I had to do when he was around. At night, it was a different story.

  On rounds one day, Dudley happened to read the operative report of a bowel case I had done two nights before. He was outraged that I had not used his method. He told me that if I ever did it again, I would be fired. But I ignored this, and shortly thereafter a woman with a bowel obstruction came in in the middle of the night. I did it my way, thinking this time I would have to make sure the patient was discharged before Dudley had a chance to read the operative report. But Dudley unexpectedly showed up early for rounds. I knew I was about to be dismissed.

  I quickly explained the situation to Fielding, who was sympathetic. Dudley’s routine was to spend about ten or fifteen minutes on each patient, asking questions, making an examination, and then discussing the case with students. During this time the curtains around the bed were drawn. While Dudley was attending to a patient, Fielding slipped out and enlisted a couple of nurses to help shuffle several patients around so that my bowel case was at the end of the ward where Dudley had begun rounds. Dudley thought he had already seen her. I lived to fight another day.

  My last recollection of Dudley is from December 1976. I had a wisdom tooth that was causing me great difficulty. A dentist removed it along with some of the bone in my jaw. My face was so swollen I couldn’t talk, and I missed three days of work. Dudley thought this was inappropriate and refused to pay me for the whole month.