Authors: Richard Hollingham
It was the welfare of donors that finally brought an end to the
operations. On 5 October 1954 Geraldine Thompson was hooked
up to her daughter and the pump between them switched on.
Lillehei began to operate, concentrating on the girl's heart.
However, someone else in the operating theatre was not doing his
job properly. A bubble of air had got into the system. The operation
was halted, but it was too late. Mrs Thompson was left severely brain
damaged. The observation that this was an operation with the
potential for 200 per cent mortality had almost come true.
*
*
Lillehei told Mr Thompson that the failure of the operation was due to an error. He clearly
felt terrible about it and, as he held liability insurance, suggested that he sue on his wife's
behalf for a reasonable amount. Unfortunately, once the lawyers got involved, a reasonable
amount became millions of dollars, and the case ended up in court. The court ruled that Mrs
Thompson had been fully aware of the risks, so the family ended up with nothing.
No other surgeon in the world dared to attempt cross-circulation,
although some tried ideas that seem even more absurd. At the
Hospital for Sick Children in Toronto, surgeon William T. Mustard
was experimenting with monkey lungs. Just before the operation, he
would anaesthetize and kill several monkeys, remove their lungs and
clean out the disembodied organs with antibiotics. The lungs would
then be suspended in jars of pure oxygen and connected to the
patient. During a series of operations on twenty-one children, only
three of Mustard's patients survived.
Another surgeon and researcher, Gilbert Campbell, tried a similar
experiment with the lungs of a dog. After a successful trial during
a routine operation (not on the heart) he recruited Lillehei as lead
surgeon to give it a go during a tetralogy of Fallot case. The patient
died shortly after the operation, but later attempts were more
successful, most famously in an operation on Calvin Richmond, a
thirteen-year-old Afro-American boy from Arkansas who had been
badly injured in a road accident and was seriously ill. Doctors
concluded that he was suffering from a hole in the heart, but there
was little they could do. His only hope lay in the miracle surgery being
conducted by Walter Lillehei at University Hospital, Minneapolis.
A fund-raising campaign involving a Little Rock newspaper
and TV station raised enough money to send Calvin to Minnesota
for treatment and he was flown north courtesy of the Arkansas Air
National Guard. However, on learning of cross-circulation, the
boy's mother declined to participate in the operation. A volunteer
was sought from the local prison instead. When none came forward
– for fear of their 'white' blood and Calvin's 'black' blood mixing –
Lillehei decided to use the dog-lung method. The operation went
without a hitch, the animal lung oxygenated Calvin's blood while
the boy's damaged heart was repaired. The success was widely
reported, although most correspondents skated over the bit about
the lungs from the dead dog.
If cross-circulation had its faults – and its potential to leave
both participants dead was a downright terrifying one – then
employing monkey and dog lungs was hardly any better. Lillehei
used the dog-lung technique a few times more, but concluded that
it was far from ideal. At least Lillehei knew when to stop. As for the
monkey lungs, you can only have great sympathy for the desperate
parents who put their trust in William T. Mustard. Something
better was needed. And while the surgeons in Minneapolis were
using other humans or animals to oxygenate the blood, surgeons
elsewhere were turning to machines.
Philadelphia Jefferson Hospital, 6 May 1953
The operation was going well. Eighteen-year-old Cecelia Bavolek
lay on the table, her chest cut open to expose her beating heart.
Dr John H. Gibbon Jr was relieved that the diagnosis had proved
correct – Cecelia was suffering from an atrial septal defect – a hole
in the heart between the two atria. His blood-splattered hands
began to stitch the two sides of the one-inch hole together.
For Gibbon this was a well-practised procedure, though all his
previous successes had been on cats and dogs. His first, and until
now only, attempt on a human patient had ended in death on the
operating table.
Gibbon worked slowly, methodically and precisely. As usual,
the operating theatre was crowded. There were other surgeons
huddled around the table, plus assistants and scrub nurses to pass
instruments. The anaesthetist monitored the girl's blood pressure;
an assistant passed the surgeon some scissors. Gibbon was not
relying on hypothermia to cool his patient; neither was he using
cross-circulation or some other animal's lungs to pump and
oxygenate the girl's blood. He was trying out the latest version of his
great invention – the heart-lung machine – which was gurgling,
humming and clunking beside him.
Gibbon's heart-lung machine looked (and sounded) like something
out of a 1950s B movie, where the unhinged scientist meddles
with forces he doesn't fully understand. But, on the face of it, there
was nothing even slightly eccentric about Gibbon. He had a reputation
for calm professionalism; he was well respected by his
colleagues and, remarkably for a heart surgeon, was shy and selfeffacing.
Colleagues described him as a 'perfect gentleman', kind
and considerate. If there was anything eccentric about Gibbon, it
was his obsession with developing a machine to keep a human being
alive during major surgery.
Gibbon had been working on the project since the 1930s. The
early attempts were crude mechanical affairs, the size of a grand
piano. Visitors invited to his lab to see the machine in action were
issued with wellington boots. The giant machine needed buckets of
blood to get it started, but once under way could sustain the life of
a very small cat. Pretty soon the visitors would notice that the floor
was getting wet and that they were walking around in blood. 'Uh
oh,' said Gibbon, as pints of cats' blood sloshed across the floor.
'We've got a leak again this morning.'
Emulating the human heart and lungs within a machine proved
to be a tough challenge. Replacing the heart itself was relatively
simple: this could be done with a pump. As long as the circuit had
some pressure controls and there was a safeguard against air getting
into the system, an artificial heart pump could employ off-the-shelf
technology (such as the dairy pump Lillehei used for his crosscirculation
operations). The problem was the lungs.
Human lungs consist of a branched network of tubes, where
gases are exchanged between the air and the blood. Oxygen from
the air passes into the blood, and carbon dioxide passes from the
blood into the air. The total surface area available for this exchange
is an astounding 84 square yards – about the same area as a tennis
court. Any machine needed either to include a similarly massive
surface area (much bigger than your average operating theatre) or
find some other way of getting oxygen into the blood. The obvious
way was to bubble the oxygen into the liquid, but this was fraught
with difficulties. If even the slightest single tiny bubble remained
and was allowed to pass back into the patient's bloodstream, it could
kill them. Gibbon favoured pumping the blood over a flat surface –
a plate or screen – to expose a film of blood to oxygen. As long as
he could keep the blood flowing, this method seemed to work. The
trouble came when the blood started to clot.
Over the years Gibbon's heart-lung machine became more
refined. After the war the International Business Machine
Corporation (IBM) offered its support and an engineer. Electronics
were introduced to control the flow of blood and monitor the pressure
and oxygenation process. The experimental animals got bigger
and bigger, while the machine became smaller and more efficient.
Even so, the heart-lung machine was still bulky and incredibly
complex. Around the size and shape of two large top-loading washing
machines bolted together, the contraption was so big that when
it arrived at the hospital it had to be winched in through a window.
But with IBM's help, it no longer resembled a crude Heath
Robinson affair. Now it looked more like cutting-edge technology.
The machine was covered in switches, pipes and dials. Dials to
measure acidity and pressure; electronics to monitor and control the
flow of blood; even a back-up battery should there be a power failure.
The top was a mass of plastic tubing, the sides hung with glass bottles.
Rising from the upper surface was a rack of screens down which the
film of blood would cascade to be exposed to oxygen. Snaking from
it were two tubes – an input tube that would take blood from the
patient's veins, and an output tube that would return oxygenated
blood to the patient's body. Once it was hooked up, the machine
would take the place of the patient's heart and lungs.
It is twenty-six minutes into the operation and Cecelia Bavolek
is doing well. Blood that would normally pass through her heart
and lungs is being diverted into the machine. It is being oxygenated
and returned to her body. But something has gone wrong. The
blood on the oxygenator screens is no longer running freely. It has
started to clot. The pumps keep working and the pressure in the
machine starts to build. On the operating table Cecelia is no longer
receiving enough oxygen. The machine begins to foam. It is going
to explode.
Vic Greco is responsible for the machine.
*
He has been working
in the research lab with Gibbon and guesses what has gone
wrong. Before it is hooked up to the patient the machine has to be
'primed' with blood. When they had done this earlier in the day,
they had probably not added enough of the blood-thinning chemical
heparin. But there is no time to analyse why it has gone wrong.
They have to solve what is rapidly turning into a very messy crisis.
Unless they can fix the machine, Cecelia Bavolek is going to die.
*
The machine was usually the responsibility of Jo-Anne Corothers, but it had been decided
that it would be 'better for the historical record' if a doctor ran the machine that day.
At the operating table Gibbon tries his best not to get too
distracted. He works as quickly as he can, but the foaming is getting
worse. The blood is beginning to back up around Cecelia's body,
and her circulation is coming to a halt. Greco climbs up a stepladder
to hold down the lid of the oxygenator to prevent Cecelia's
blood from spraying around the room. Then Bernard Miller, who
has been intimately involved in the technical development of the
machine, starts rerouting the pipes. He figures that the only chance
they have is to bypass the now useless oxygenating screens and turn
the heart-lung machine into just a heart machine. This will at least
get the blood moving and restart Cecelia's circulation.
The blood starts to flow again, only this time it is not getting any
oxygen. This is circulation of sorts, but what hope does Cecelia have
without any means of getting oxygen into her system? Gibbon
carries on anyway. Cecelia's heart loses its rhythm and goes into
fibrillation. Gibbon begins to stitch together the incision he has
made. He uses an electric shock to get her heart beating again and
it goes into a normal rhythm. She could yet live. At least nothing else
can go wrong. But it isn't Gibbon's day. As the surgeon continues to
work, Cecelia starts to come round from the anaesthetic. She struggles
on the operating table. Gibbon closes her chest and puts the
final stitches in her skin. Remarkably, her heart continues to beat;
her breathing is normal. Within a fortnight, Cecelia Bavolek is
discharged from hospital, the hole in her heart successfully closed.
The operation had lasted forty-five minutes. For twenty-six of
those minutes her life had been sustained by a machine. It was
proclaimed an 'historic operation'; the twenty-six minutes 'the
most significant in the history of surgery'. Gibbon shied away from
the publicity the operation generated, shunned the press and only
grudgingly gave a few quotes to
Time
magazine (although he
declined to be photographed with the machine). As far as Gibbon
was concerned, the successful operation was the result of more
than twenty years of research, and he had proved that a heart-lung
machine could work.
Nevertheless, Cecelia's operation was a close-run thing – she was
lucky to be alive. Just how lucky would soon become clear. Gibbon
attempted two more operations using the heart-lung machine. Both
operations were carried out on five-year-old girls. Each of them died
in the operating theatre. Gibbon had had enough. He did not have
the resilience of some of his colleagues to carry on regardless. Three
of his four patients had died while connected to the machine. The
surgeon decided not to operate with his machine again, and
ordered a year-long moratorium on its use. Gibbon never returned
to cardiac surgery.
But others believed that Gibbon was on to something. At the
Mayo Clinic in Rochester, less than an hour and a half's drive away
from where Lillehei was developing cross-circulation, another
surgeon began work on refining Gibbon's machine. After two years
of research, on 22 March 1955, John W. Kirklin was ready to
operate. He decided to test the machine on eight patients – no more,
no less. During the first operation on a five-year-old girl, the machine
practically exploded. There was blood everywhere, but the patient
survived. By May Kirklin had operated on his target of eight patients.
Four survived. The odds were improving, although patients still had
only a fifty-fifty chance of coming out of the operating theatre alive.
Minneapolis, 1955