The Open Heart Club

by Gabriel Brownstein

  He put in a circle of sutures just like Harken’s. He cut a hole in the center of the circle. A fountain of blood shot upward. Bailey shoved his index finger into the hole while simultaneously pulling closed the purse strings. Instead of closing up the hole, the threads tore through the muscle, shredding it. “Severe bleeding occurred and a large metal clamp was hastily applied,” Bailey wrote in his notes. But the clamp also perforated the muscle, ruining the fabric of the heart. “Massive uncontrollable hemorrhage resulted in immediate fatality.”

  Bailey was not discouraged. His next patient, six months later, was Wilma Stevens, a twenty-nine-year-old mother of two, dying of heart failure on account of her closed mitral valve. She had fluid in her lungs and difficulty breathing, a puffy abdomen, a swollen, tender liver, and tiny spindly limbs.

  Again, Bailey spread her ribs. Again, he cut through the pericardium and made his circle of stitches on her left atrium. On his finger this time, he wore a narrow metal probe shaped like a tube. He pushed the metal probe into the scarred heart valve. The patient turned blue. Bailey had plugged her heart entirely. He used his finger and ripped at her valve. He pulled the finger out, pulled the purse strings shut, and sutured the exterior of her heart. Problem was, he had eliminated Wilma Stevens’s mitral valve altogether. With each heartbeat, blood flowed backward into her lungs. She died two days later, and that was when Bailey got his nickname, “Butcher.”

  Up in Boston, Harken was proceeding with similar operations and was also losing patients. But Harken was a war hero and a successful surgical pioneer. Hahnemann Hospital, where Bailey worked in Philadelphia, lacked Harvard’s resources. Bailey’s chief, Dr. George Goekler, summoned him to his office and delivered a long lecture. He gave Bailey a piece of paper on which he had typed out and explained the Hippocratic oath.

  “[Goekler] ended up telling me that it was his Christian duty to keep me from doing any more of these operations,” said Bailey. “I responded with some heat. I told him that I believed in this operation, that I believed I was right… and that it was my Christian duty to continue.”

  When Goekler revoked Bailey’s operating privileges at Hahnemann, Bailey scheduled another mitral valve surgery, this time at Wilmington Memorial Hospital in Delaware. He drove there to operate. This time the patient was a thirty-eight-year-old man, William Wilson. Bailey got him into the OR, opened his chest, cut into his heart—laying out the circle of sutures first—then pushed into the valve. Again, his metal tubular device got stuck in there. Again, he was forced to rip the device out, tearing the valve with his finger. Once again, he was able to sew up the heart. But again, he left his patient without a mitral valve. William Wilson lived on for five days after the operation. Wilmington Memorial, too, revoked Bailey’s right to perform surgery.

  He now had operating privileges in only two hospitals in Philadelphia. He was afraid that if he failed at either place, he’d lose the right to operate at both. But instead of giving up, Bailey decided to schedule two operations in one day, one in the morning, one in the afternoon. If he killed his first patient, he could hurry across town and still have the chance to operate on the second.

  At 8 a.m. at Philadelphia General, Bailey operated on thirty-year-old Jerome Randall. As soon as Bailey opened his chest, Randall went into arrhythmia and cardiac arrest. Bailey took the heart into his hands and massaged it back into beating. Randall’s personal doctor was there in the room and wanted Bailey to continue. Bailey didn’t want to; he didn’t want another death on his hands. He said he’d only go forward if Randall were first declared dead, and Randall’s doctor complied.

  Bailey sewed his circle of purse string sutures into the heart. He made an incision in the atrium. He plunged his finger through the clogged mitral valve, opening it. He pulled the purse strings shut and sutured the incision. Minutes later, Randall’s heart stopped beating. Bailey took off his scrubs, washed up, put on his sports jacket, got in his car, and drove across Philadelphia to Episcopal Hospital, where he had another appointment to perform the same surgery. He knew he was getting closer, getting better, that despite his failures, his technique could save lives.

  “Obviously, I felt there were irrelevant reasons for the loss of the first four patients and that the principle was entirely sound and could be developed but just needed further effort,” he said. He parked his car at Episcopal Hospital. He entered the building. He changed into scrubs and met with his team. “The poignancy is so great that I can’t really express it,” he said in an interview later. “You know that almost all the world is against it; you know that you have a great personal stake and might even lose your medical license.… In fact, the thought crosses your mind that maybe you really are crazy.”

  Harken in Boston had by this time killed six patients. Twenty-four-year-old Constance Warner lay anesthetized on the table before Bailey. He made his incision, used his rib spreader, and entered the chest. He put in his sutures; he cut into the heart. On his finger Bailey had a new instrument, a fine cutting blade, designed to separate the valve’s leaflets one from the other. He made his incision in the stenotic valve. He removed the cutting tool from his hand, put his finger back in the hole, and widened the space between the leaflets. By touch in the dark chambers of the heart, Bailey separated the leaflets of the valve. He pulled his finger out and pulled the circular suture shut. He sewed up the incision. He repaired the pericardium and closed the chest. Constance Warner recovered.

  By the third day after her operation, she was up and walking from her hospital bed to the bathroom, down the hall, and around the ward. She was still in the hospital when the news came in from Boston—Harken too had a patient who had survived. Bailey was nervous. Would Harken claim the prize and be known as the first? The American College of Chest Physicians was having its annual meeting 1,000 miles away in Chicago.

  Bailey bundled up Constance Warner, put her on a train, and rode with her to the convention. And there, before a conference of his peers, he presented her, the first patient to survive heart valve surgery.

  In Minneapolis, Walt Lillehei was beginning his residency. Ligation of patent ductuses had become the norm. Blalock shunts were being put in all over the country. At Bellevue in New York and at Johns Hopkins in Baltimore, Janet Baldwin and Richard Bing were using cardiac catheters and achieving precise images of the holes in children’s hearts. Doctors knew that if they could get into the heart, they could sew these atrial and ventricular defects shut, but it was at the time impossible to enter the heart without killing the patient. If you stopped the heart for four minutes, the patient suffered brain damage. If you stopped the heart for six and a half minutes, the patient died.

  Robert Gross in Boston invented a way to conduct cardiac surgery while the heart kept on beating. He called his invention the “atrial well.” Gross sewed a plastic funnel into the wall of the atrium of the beating heart of a child. The funnel diverted and controlled the heart’s bleeding. Gross used clamps to hold his thread and needle, and he dipped these into the pool of blood in the funnel and down into the heart of the child. Dr. Abraham Rudolph was in the OR, a junior member of the surgery team, the first time Gross attempted the technique, and Rudolph watched in horror as Gross, serenely confident, sewed shut not the atrial septal defect but the child’s mitral valve. The atrial well seemed unlikely to yield repeatable success. “Surgical procedures carried out under direct vision,” said Walt Lillehei dryly, “are far more likely to be satisfactory than those carried out blindly.”

  Another way to approach the heart was through induced hypothermia. By cooling their patients, doctors could slow blood movement and give themselves a few more minutes to work inside the heart. During World War II, German and Japanese doctors had experimented on prisoners to determine the effects of extreme cold and had studied the way hypothermia affects the body and the heart. In northern Manchuria, in the small town of Pingfan, Dr. Shirō Ishii had conducted quasi-scientific experiments on prisoners of war whom he called marutas, or “logs.” (He c
alled them that because his lab, Unit 731, was disguised as a lumber mill.) Ishii electrocuted, vivisected, poisoned, and shot his subjects, seeking to determine the limits of human endurance. He froze his marutas to discover the lowest temperature to which a living body could be safely reduced. These tortures were echoed by those conducted by Dr. Claus Schilling at the Dachau concentration camp.

  Reverend Leo Miechalowski, a Roman Catholic priest, was a subject of these Nazi experiments and at Nuremberg testified to their brutality. Starving on a work crew at the concentration camp, Father Miechalowski kept fainting and falling down, so in 1942 he volunteered for a new assignment, hoping he would get some bread to eat. Instead, he was brought to the hospital for his new “job,” where he was poisoned with malaria. After the Nazis had gotten him sick, nurses gave Father Miechalowski further injections. Some caused headaches; some caused renal pain; some left him unable to speak.

  Eventually, the priest was moved to the so-called aviation lab, where he was dressed in an aviator’s uniform and fur-lined boots and then submerged in icy water. Wires attached to his back and up his rectum measured his internal and external temperatures. Miechalowski pleaded that he was freezing. The Germans laughed. “Well, this will only last a short time.” Periodically, samples of his blood were taken from his ears. His body temperature dropped from 99.7 to 86 degrees Fahrenheit. Finally, Miechalowski passed out. The findings of the torturers’ experiments crossed the Atlantic to America.

  Dr. Alfred Bigelow, a Canadian surgeon who worked under Alfred Blalock in Baltimore in 1946 and 1947, became interested in the possibilities of hypothermia in the cardiac operating room. Bigelow’s inspiration came not from Nazi torture but from observation of small animals. He had grown up in Alberta, where hibernating groundhogs slept in their burrows in the winter, their bodies almost as cold as their frozen nests. Bigelow wondered if one could chill a person similarly and then bring that person back to life. In 1948 and 1949, he tested his theory, operating on 120 dogs. So long as he kept their body temperatures above sixty-eight degrees Fahrenheit, the dogs survived operations to their hearts, with their brains seemingly undamaged. Bigelow presented his results at a conference in 1950, but the world of cardiology was not convinced. He never got a patient to undergo his surgery; he got no volunteers and no referrals.

  Charles Bailey, back in Hahnemann in Philadelphia, picked up on Bigelow’s ideas. He purchased a six-foot-long freezer to cool the dogs in—but the freezer didn’t work, or worked too well: it froze the animals solid as blocks of ice. So Bailey used rubberized cooling blankets that had been designed by psychiatrists for treating schizophrenics. This seemed to work well enough on dogs to convince Bailey that Bigelow was right: hypothermia would nearly double a patient’s window of survival, to twelve minutes. Ever resourceful, Bailey found a patient on whom to run his experiment, a twenty-seven-year-old woman with an atrial septal defect, a hole between the top chambers of her heart. In August 1952, he rolled her into the OR. He used his frozen rubber psychiatry blankets to cool her body. He clamped off her heart. He worked fast—he cut into her atria, sewed up the hole, and closed the heart, all in six minutes. But when Bailey unclamped her heart, the patient went into ventricular fibrillation: her heart started beating uselessly at more than two hundred beats per minute. Her great arteries went translucent. He’d let air into her heart accidentally. She died. Meanwhile, work continued on the heart-lung machine dreamed up by Alexis Carrel and Charles Lindbergh.

  In 1931, while Lindbergh and Carrel were working together at Rockefeller, Dr. John Gibbon was in training at Massachusetts General Hospital. As a young doctor, he stayed up all night watching a middle-aged woman die of pulmonary embolism. Just after dawn, Gibbon’s supervisors attempted surgery. They clamped off the coronary artery, knowing that they had to complete the procedure in less than four minutes. But it took them seven minutes to get into the lung and get the blood clot out. When the clamps were released, the patient was dead. Gibbon was crushed. It came to him with the force of revelation: he would build a heart-lung machine. For decades after, he devoted himself to this single project, to extend the amount of time surgeons had to operate. Initially, his work was driven more by the thought of lung surgery, surgery for pulmonary embolism, than for surgery on the heart.

  He worked on his heart-lung machine for five years at Mass General. Gibbon married Mary Hopkinson, also a medical student at Harvard, and Mary and John continued their work together at the University of Pennsylvania. In 1941, the Gibbons had built a prototype bypass machine that could keep a cat alive for twenty-six minutes. But their work was interrupted. John was called away to war. He served his tour on a remote South Pacific island.

  When Gibbon returned from war, he got back to work in Philadelphia. Mary and John were joined by Thomas Watson of IBM. They weren’t the only ones trying to design a heart-lung machine. In Detroit, Dr. F. Dewey Dodrill was collaborating with General Motors on a similar project. In Toronto, Dr. William Mustard was working on his organic heart-lung machines: those blanched monkey lungs hung in big sealed jars. In 1945, after the war, Clarence Dennis, one of Owen Wagensteen’s protégés, visited the Gibbons in Philadelphia, and John Gibbon was kind to Dennis and shared his plans for the machine. Even as Walt Lillehei was returning from Italy, Clarence Dennis, on the University of Minnesota campus, was working on a heart-lung machine.

  By 1950, Lillehei was Owen Wagensteen’s chief resident and rising star, handsome, charismatic, brilliant, and adventurous. The building of Variety Club Heart Hospital was near completion. The work toward open-heart surgery seemed about to begin in earnest, and Lillehei was in the thick of the research. But his colleagues noticed something worrisome—Walt had grown a lump on his neck. Wagensteen had the lump biopsied. It was cancerous, a lymphosarcoma. In 1950, the cure rate for this cancer was 25 percent at five years and less than that at ten. Wagensteen decided to operate.

  One time, after throwing away the legs of a patient on whom he’d performed a hemicorporectomy, Wagensteen received an anonymous letter: “Now that you’ve done that,” it said, “why don’t you cut off your own head?” Some of his residents liked to say, “Wagensteen hates cancer because it kills more patients than he does.”

  Walt Lillehei went under Wagensteen’s knife. John Lewis, Lillehei’s best friend at the hospital, assisted in the surgery. At 7:15 a.m. on June 1, 1950, Lillehei was anesthetized. Wagensteen’s team began by working at the throat. David State, who had performed the initial exploratory surgery, cut out the remainder of Lillehei’s parotid gland. When that was done, a second surgeon scrubbed in. Richard Varco attacked the rest of Lillehei’s neck, taking out all the lymph nodes and glands. It was 11:15 a.m. Four hours had passed. Wagensteen noted that some of the glands by Lillehei’s jugular vein were enlarged. The surgeons conferred.

  Wagensteen scrubbed in. He split Lillehei’s sternum. He went into the chest cavity. He removed lymph nodes, glands, muscle, fat, an entire rib, and Lillehei’s thymus. The patient bled profusely. It was 6 p.m. when they sewed him up again. The operation lasted ten hours and thirty-five minutes. Lillehei had needed more than two gallons of blood. When he awakened from anesthesia, Walt was surprised. He had not expected Wagensteen to crack open his chest. He had not agreed to it. After two weeks in the hospital, he went home to his wife, Kaye. The chest wound became infected. When Richard Varco came by to clean it, Walt mixed them both martinis.

  More complications: Lillehei’s stomach dilated, which meant a trip to the emergency room and another hospitalization. He underwent twelve sessions of radiation treatment on his face. These left him nauseated. He feared he’d go blind. Wagensteen proposed a second surgery, to look around inside and see if there was anything else to take out. Lillehei declined. He was depressed, his body ruined, and his survival uncertain. The odds were good that cancer would come back and kill him.

  31.

  EVERYONE WAS TELLING me that I was doing great. Mike Freed said, “You look like an advertisement for heart su
rgery.” I was moved from the ICU to a more ordinary hospital room, a private room, which in retrospect I suppose my father had paid for.

  An intern came by and said, “I hope I look as good after my heart surgery.”

  He was young, fit, and Australian, and I couldn’t believe that he too was about to have an operation like mine. His father and his grandfather, he explained, had had heart troubles. When he got old, he was most certainly going to need open-heart surgery.

  “Dr. Freed maybe let you go longer than you should have,” he told me—the first person to say anything like that, that I had waited too long to have heart surgery—but he said that everything was looking good.

  The crisis had passed. The new pulmonary valve had stopped the backward flow of blood. The hope was that my swollen ventricle would strengthen and shrink, but that was far from a certainty. No one knew how long the new valve would last. Five years? Ten years? Twenty? The only certainty was that in time it would fail and need to be replaced and that another heart surgery lay in my future.

  My dad bought me three plaid shirts. I put one on instead of the hospital gown. I didn’t look entirely like myself, but I didn’t look like a heart patient either. My old uncle, a distracted mathematical genius, a man I’ve loved since childhood but who is by nature quite difficult to reach, came creeping down the hall and knocked, a surprise visit. I think he’d expected a dead man and was delighted to find me, and I was delighted to find him, too, smelling of cigarettes and citing Karl Marx. The human world was expanding again for me.