Authors: Richard Hollingham
They never did find the secret of hibernation. The groundhog
farm was shut down and the researchers moved on to other things.
Bigelow would often cite the experience as a humbling example of
'intellectual humility'. However, the research did not go completely
to waste. It opened up a whole new area of study into the use of alcohol
in hypothermia. It turns out that alcohol dilates the blood
vessels, allowing smoother cooling and causing less long-term
damage. A refinement of Bigelow's hypothermia technique is still
being used in operating theatres today.
'Breakthrough' is one of the most overused words in science and
medicine. Most progress is incremental – small changes in procedures
or techniques, refinements of treatments and technologies.
However, when it came to surgery of the heart, the only way to
progress was through daring new breakthroughs: Hill sewed up a
wounded heart; Harken cut into a beating heart; now Lewis had
performed the first successful open-heart surgery. These surgeons
had the courage to try completely new ideas on real living patients.
Hypothermia was undoubtedly a major breakthrough, allowing
surgeons genuinely to cure some of the worst heart defects. But
hypothermia was severely limited by time. Doctors had only a few
minutes to clamp off the heart, open it up, fix the defect, close the
heart and restart the circulation. Hypothermia increased the time
they had, but it could not stop the clock altogether. And when it
came to open-heart surgery, there were so many things that could go
wrong. There could be a problem with the anaesthetic, or a difficulty
during the cooling of the patient. The surgeon might accidentally
sew through a hidden nerve, interrupting the heartbeat or even
stopping it altogether (this was known as 'heart-block').
What these pioneering surgeons feared most was a misdiagnosis.
Jacqueline Johnson, the first open-heart patient, was suffering
from an ASD (atrial septal defect). This was a hole between the
upper two chambers of the heart, the atria. Patients could also have
holes between the two ventricles – a much more serious condition –
or worse. There could be defects in valves, in muscle or nerves.
There were some heart defects that many surgeons thought might
never be conquered, not least the sinister-sounding tetralogy of
Fallot.
*
This disorder involves not only a hole between the ventricles,
but obstructions between the right ventricle and the lungs, a
thickening of the right side of the heart and a distortion in the
aorta, the main artery from the heart.
*
The peculiar name for this congenital condition comes from Etienne-Louis Fallot, a
Marseilles surgeon who first described it in 1884.
In the 1950s surgeons had a limited number of tools at their
disposal to work out what was wrong. They could X-ray the heart,
listen to the heartbeat and study the rhythm on an electrocardiograph.
Usually they got the diagnosis right, but sometimes it was
wrong. They would open up the heart to find a larger hole than they
expected, two holes instead of one, or multiple problems. And
however quickly they worked and however brilliant their technique,
the surgeons would run out of time. If that happened, the patients
– invariably children – died on the operating table.
Hypothermia slowed the clock down, but surgeons now wanted
to stop it altogether. To fix some of these more complex problems
they needed to be able to isolate the heart completely. They needed
some way of clamping off the circulation without jeopardizing the rest
of the body by shutting off its blood (and hence oxygen) supply. Back
at the University of Minnesota, surgeon, and now associate professor,
Walter Lillehei had a brilliantly simple, if somewhat bizarre, idea. Why
not keep the patient's blood circulating with someone else's heart?
The theory went like this: as well as the patient, a healthy person
would be brought into the operating theatre. Arterial blood from
the healthy person's body would be pumped across to the patient.
This oxygenated blood would be passed directly into the patient's
arteries to circulate around his body. Then, instead of returning the
blood to the patient's heart, deoxygenated blood would be returned
to the donor. The concept became known as cross-circulation and
held enormous promise. During the period the two people were
connected, their blood mingling together, surgeons would be free
to open up the patient's heart. They then had plenty of time to fix
any major defect.
The healthy donor would obviously need to have a matching
blood group. But as the donor would usually be a close family
member – ideally a parent – this would not be a problem. And what
parent wouldn't do all they could to help their dying child? Yes, OK,
it was risky taking a perfectly healthy adult into an operating
theatre, sedating them and hooking them up to someone else, but
wasn't it a risk worth taking? What could possibly go wrong?
Lillehei was not one to shy away from risk – particularly when
the reward was so great. If this worked, he would be able to save any
number of children from an early death. He began experimenting
on animals to refine the technique. He acquired a pump – normally
used in the dairy industry to move milk – and some plastic tubing
designed for beer taps. He had to work out the layout of the operating
theatre, the staffing and procedures for two patients. Above all,
he had to make sure that the system he devised to connect the two
patients was airtight. Any foaming from the pump, in fact just one
tiny bubble, was enough to induce a stroke. It could leave the
patient or the donor with permanent brain damage. If something
went awry during the operation, one or both of them could be
killed. Lillehei had invented the first surgical procedure with the
potential for 200 per cent mortality.
University Hospital, Minneapolis, 31 August 1954
Howard Holtz was an ordinary man with an ordinary job. He
spent most of his working life outside, maintaining the Minnesota
highways. The twenty-nine-year-old was married with three perfectly
healthy children, and another on the way. There was nothing
particularly unusual about Howard Holtz. Except his blood. He had
AB negative blood – the rarest of blood groups, found in only 1 per
cent of the population. The blood was on a donor register. Of
course, it's one thing to donate blood, quite another to donate your
entire circulation, but this is precisely what Howard was asked to
do when he was approached to act as a donor for one of Lillehei's
operations.
Lillehei had been performing cross-circulation operations since
March, and the procedure was reasonably well established, even
though the risk was still considerable. The first operation on a sickly
one-year-old baby boy had been successful. The patient and donor
were connected for some nineteen minutes. Unfortunately, the boy
died eleven days later from another complication.
In April the surgeon had operated on a three-year-old boy and
four-year-old girl. Both operations were successful – successes that
the proud showman Lillehei revealed to a press conference a week
or so later. He even wheeled out the cute little girl so that she could
be photographed with her parents, and her father, the donor, could
be questioned by the pressmen. They were told how close the poor
girl was to dying, the pneumonia she suffered from, and the oxygen
tent she once had to live in. Now she could grow up to lead a normal
and healthy life (and she would).
The papers described cross-circulation variously as 'miraculous',
'daring' or even 'impossible'. Some patients died, but those
cases didn't get reported. There were no official mortality figures.
In 1954 cross-circulation was the best chance many extremely sick
children had of surviving into adulthood. Whether to go ahead
with the operation was an awful decision for parents to make, but,
after careful consideration, most decided it was their child's best
hope. As Minneapolis was the only place in the world where this
operation was being performed, most parents considered themselves
lucky even to have the opportunity.
For Mike Shaw's parents, Lillehei offered the chance of a miracle
cure. Ten-year-old Mike was seriously ill. He had been diagnosed
as suffering from tetralogy of Fallot and had been in and out of
hospital since birth. You could tell he was sick just by looking at him.
The boy was thin and pale, his skin so tinged with blue that he was
practically translucent. His ears stuck out from his wan face, giving
him an emaciated appearance. Mike could walk only a few paces
before becoming breathless. Without surgery he had only months to
live. Lillehei might be able to save his life.
Mike's parents agreed that Lillehei should go ahead with a
cross-circulation operation. They were aware of the risks, but trusted
the surgeon, who was at least honest about their son's chances
(although as this was the first attempt to correct tetralogy of Fallot,
no one really knew for sure). The boy's blood was tested so that they
could decide which family member would make the best donor, but
then they hit the snag. With AB negative blood, neither Mike's
parents, nor seemingly any other relatives, matched. Would a
complete stranger be prepared to help?
When Lillehei explained the situation to Howard Holtz, the
highway worker agreed to lend his body to the procedure. A
complete stranger to Mike Shaw, Howard figured that if his own kids
were sick, someone would do the same thing for him. A child's life
was at stake, and Howard realized that a 'no' from him amounted to
a death sentence for Mike. As far as the safety of the operation was
concerned, none of the previous donors appeared to have suffered
any ill effects. Any risks (and Lillehei had explained clearly that
there were risks) were surely worth taking. Howard met Mike and
the boy's family. The operation was scheduled.
Because cross-circulation involved two patients, it required two
teams of surgeons. It is incredible that so many could fit into the
small operating theatre. The room seems to be teeming with
people, with little space between them. Everyone is gowned and
masked, all slightly anxious. On the left lies the heart patient. At his
head the anaesthetist and his assistant. They need to keep the
patient's lungs replenished with air until the cross-circulation is
connected; after that they are unusually powerless. A low curtain
separates the anaesthetist from Lillehei and his assistants.
Even with his hat and mask on, it is easy to spot Lillehei. A long
scar runs down his neck and disappears beneath his gown. The scar
is evidence of major surgery to remove a tumour, and gives his head
a lopsided appearance. Above the table a set of lights is angled
downwards, but Lillehei also wears a head lamp on his forehead so
that he can see clearly into the bloody hole in the boy's chest. The
lamp, which is plugged into a socket in the floor, looks like it has
been cobbled together from an old desk light, and becomes uncomfortably
hot above the surgeon's face.
To the right of the main operating table lies Howard. He has
also been put to sleep. This is not strictly necessary for the operation,
but avoids any distress (or even boredom) on the donor's
part. It is important to keep the anaesthetic as light as possible –
any drug circulating in Howard's body will also circulate in Mike's.
The anaesthetist also makes sure the donor's breathing is regular.
As long as the two patients are connected, Howard is breathing for
two. A surgeon has made an incision in Howard's right leg (left as
you look at him) and inserted a tube into his femoral artery.
Another tube enters the main vein in the leg – the great saphenous
vein.
Between the two operating tables snake the beer tubes full of
blood. Brightly coloured oxygenated blood flows one way across the
operating theatre and darker venous blood flows back the other.
The blood passes through the dairy pumps to regulate the pressure
and make sure the boy's fragile circulation is not overloaded. The
pumps make a smooth, rhythmic sound as a line of small mechanical
fingers press the blood along the tubes. Nurses move between
the two patients, a surgeon monitors the flow of blood, Lillehei cuts
away at Mike Shaw's heart.
For those observing through the windows of the gallery above –
even the most experienced of surgeons – this is a remarkable operation
to witness. Probably the most daring, ambitious and perhaps
downright foolhardy they have ever seen undertaken. As Lillehei
cuts and sews slowly, methodically beneath them, some of those
watching are mentally calculating the odds on Mike Shaw and
Howard Holtz both coming out of the operating theatre alive.
The pump is switched off. Mike's heart takes up the strain.
Howard is disconnected. The donor leaves hospital after a few days.
Not long after, so does Mike Shaw – he is cured. It is another miracle
for Lillehei's revolutionary and 'impossible' surgery.
The operation had transformed Mike Shaw from a sickly patient
to a healthy, active boy. At the time of writing, Mike and Howard are
still very much alive. Mike grew up to become a musician – a bass
guitarist – and, thanks to Lillehei's operation, has lived life to the
full. At eighty-two, Howard is also fit and healthy, and regularly goes
line dancing. Several years after leaving hospital, Mike's mother
complained to Lillehei that her son was now playing in a band, staying
out late at night and dating a lot of girls. Before the operation
she had been worried that he couldn't do anything; now she worried
he was doing too much!
Lillehei was a hero to the patients he saved, but unfortunately
not every case was so successful. Later that year he had a series of
failures – complications arose or a misplaced stitch resulted in
heart-block. Sitting with parents telling them the worst news possible
is something few surgeons get used to but, unlike some, rather
than delegate the responsibility Lillehei made it his job to talk to the
parents himself. Despite his self-belief and bravado, Lillehei shared
their grief. But somehow he was able to recover, ready to attempt
another operation the following day. At one point he was close to
abandoning the procedure altogether, until persuaded by his boss
to keep going. In the end he performed cross-circulation operations
on a total of forty-five sick children. Twenty-eight survived surgery
and most went on to lead normal, healthy lives.