Heart

by Sandeep Jauhar

  Three thirty in the morning is a strange time to be awake, the nexus between night and day, when things are supposed to move slowly and trying to speed them up seems almost obscene. When I pushed through the double doors of the surgical unit, it was like entering a casino, with flashing lights, chiming bells, and its share of lost souls. Family members were loitering in the hallways or sitting at bedsides, keeping vigil. The faintly pleasant smell of disinfectant and talcum powder wafted through the corridors. I poked my head into the conference room looking for the surgical fellow. The room was littered with printouts, X-rays, and the detritus of the previous evening’s meal. No fellow. I plodded to the nursing station, where a young woman was inputting data into a computer. Without looking up, she pointed to a room at the corner of the unit.

  I maneuvered my echo machine into the tiny space between the patient’s bed and the wailing monitor. The woman had a willful look, as if she were trying not to appear panicked, even though she obviously was. Short wispy hair stood up on her scalp like newly germinated grass. Her eyes darted back and forth, like a scared child’s, even as she insisted that she was fine. Her blood pressure, the monitor above her bed informed me, was dirt.

  The body attempts to compensate for a rapid drop in blood pressure (called shock) through a number of mechanisms. There is increased sympathetic and reduced parasympathetic activity in the autonomic nerves, speeding up the heart rate and increasing cardiac output. Salt and water are reabsorbed in the kidneys. Small peripheral arteries constrict to shunt blood away from nonessential areas of the body, like the skin and skeletal muscles, to vital organs, such as the heart, kidneys, and brain. Gas exchange in the lungs is impaired, causing blood acids to build up and the breathing rate to increase.

  All these changes seemed to be happening in my patient at once. In the jaundiced light she appeared pale, the color of bone. Her heartbeat sounded like a galloping horse. She was quiet, because she could not talk and breathe at the same time. When I applied the echo probe to her bandaged chest, where a breast tumor had been surgically removed, even I could tell that a massive amount of blood had accumulated in the pericardial sac. The heart looked like a small animal confined to a tiny pool, like one of Richter’s rats stuck in a swimming jar, struggling to get free. The right ventricle was compressed like a pancake. It was almost a relief to finally see the thing I’d feared and face it. I ran out to tell the surgical fellow, and almost immediately he was in a sterile gown, and I was being asked to step to one side, out of the way but still close enough to hold the echo probe in place to guide the drainage needle via ultrasound.

  A nurse threw a blanket over the patient. The fellow tore open a surgical kit. The woman had stopped moving under the drape. She was either being extremely cooperative or sinking into shock. After numbing the skin below the breastbone with lidocaine anesthetic, the fellow pierced it with a six-inch-long needle, directing the tip, with the aid of my ultrasound, directly at the heart. The right ventricle sits most anterior in the chest, protected only by the pericardium and a thin layer of fat. I remembered what our anatomy professor had told us: if we ever had to push a needle through the chest wall, the right ventricle is the first structure we would hit. On the echo screen the needle tip entered the pericardium, scattering the ultrasound into a white halo, like a white sun in a hazy black sea. The barrel of the syringe was pulled back, and maroon-colored fluid burst into the plastic column. The fellow removed the syringe from the needle, and the bloody effusion trickled out. Then he pushed a catheter through the barrel of the needle, attached it to a drainage bag, and quickly stitched it in. Within minutes, the drape was off, and as best I could tell, the patient had regained her color. Her blood pressure was now almost normal as bloody cancerous fluid drained into the bag.

  A few minutes of delay, arguing with the surgical fellow or waiting longer for a cab, and the woman would surely have died. The surgical fellow, a pleasant Indian man, was grateful. It turned out that he himself had had heart surgery as a child (he pulled down the V-neck of his scrubs to show me the pasty, indistinct scar at the top of the breastbone). We got along well after that night, a kinship born, as is common in a teaching hospital, out of facing a harrowing experience together. It was my first time confronting a live, beating heart in an emergency. And for a few more months, at least, I never argued another echo request.

  •

  Inge Edler, a cardiologist, and Carl Hellmuth Hertz, a physicist, invented echocardiography at the University of Lund in Sweden in the early 1950s. They went to shipyards to study sonar, making the conceptual leap that if you can use ultrasound to see a ship five hundred meters away, maybe you can use it to see the heart, too, if only you could change the depth of penetration. They made a prototype probe and put it on Edler’s chest. They did not know what they were seeing at first, but they could tell it was a beating heart. In 1954, they published the first paper on cardiac ultrasound, titled “The Use of Ultrasonic Reflectoscope for the Continuous Recording of the Movements of Heart Walls.” In the mid-1960s, Harvey Feigenbaum first used ultrasound to study pericardial fluid accumulations. Soon, echocardiography was widely employed to rapidly localize a fluid collection and help surgeons direct their drainage needles. Ultrasound made treating cardiac tamponade almost protocol. Indeed, after a few months of my fellowship, tamponade did not seem like such a big deal.

  But tamponade was a very big deal in early operating theaters, where cardiac injuries loomed especially large. And it was the driving force on a revolutionary summer day in 1893, when Dr. Daniel Hale Williams, a surgeon at Provident Hospital in Chicago, drained a traumatic pericardial effusion in what was then believed to be the first open-heart surgery. The patient, twenty-four-year-old James Cornish, had been stabbed with a knife in the chest in a saloon scuffle. He was bleeding profusely when he was dropped off at the hospital by a horse-drawn ambulance. With no diagnostic equipment other than a stethoscope—X-rays would not be discovered for another two years—Williams examined him. The stab wound was slightly to the left of the breastbone and directly over the right ventricle. Initially, he thought it was superficial, but when Cornish started to exhibit lethargy, listlessness, and low blood pressure—signs of tamponade and shock—Williams knew he had to act.

  Nothing in Williams’s hardscrabble life could have predicted this epoch-making moment. His father, a barber, died of tuberculosis when Williams was only ten. He was sent to live with family friends in Baltimore. Largely self-taught, he took up odd jobs, becoming a shoemaker’s apprentice, then a barber and a guitar player on lake boats, before deciding to pursue medicine. He ended up in Chicago, working as a surgical apprentice and eventually completing his training at Chicago Medical College (later, Northwestern University Medical School). He set up his own practice on the South Side, working as a doctor in an orphanage and becoming the first black surgeon to work for the city’s railway system. Williams, whose ancestors were slaves, worked with the Equal Rights League, a black civil rights organization that was active during Reconstruction and beyond. In 1891, he founded Provident Hospital, the nation’s first racially integrated facility for young black doctors and nurses, in a three-story redbrick house in Cook County. The facility, championed by the social reformer Frederick Douglass, gave blacks in Chicago another place, besides overcrowded charity hospitals, to receive care.

  Until that summer day in 1893, surgery had scarcely ever been attempted on a live human heart.* Though it is difficult to fathom today, when invasive cardiac treatments are at the forefront of medicine, the heart was essentially off-limits to doctors until almost the beginning of the twentieth century. All major human organs, including the brain, had been operated on, but the heart stood apart, encased in historical and cultural prohibitions much thicker than its membranous pericardium. Heart surgery had been performed on animals, and in 1651, William Harvey himself had catheterized the inferior vena cava in a human cadaver, but suturing the dancing organ in a live person was considered beyond the realm of the possible
. “The heart alone of all the viscera cannot withstand injury,” Aristotle wrote, because it was believed to be impossible to mend a heart wound. Filled with blood, the heart bleeds quickly. There seemed to be no way to isolate it from the bloodstream to allow for careful stitching. Galen himself noted that heart wounds in gladiators were always fatal. “When a perforation penetrated one of the cardiac ventricles,” he wrote, “they died on the spot, mainly by blood loss, and even faster if the left ventricle was injured.” Therefore, as late as the early nineteenth century, the prescribed treatment for cardiac wounds leading to fluid accumulation and tamponade was absolute quiet and the application of leeches. Not surprising, then, that more than 90 percent of patients died.* But despite this awful mortality rate, Theodor Billroth, a distinguished Viennese professor and surgeon, still wrote in 1875 that “[drainage] of the pericardium is an operation which, in my opinion, approaches very closely to that kind of intervention which some surgeons would term a prostitution of the surgical act and other madness.” However, he added, “further generations may think differently.”

  Billroth did not have to wait a generation. Already, by the late nineteenth century, proscriptions against heart surgery were being eased. In 1881, at the Anatomical and Surgical Society of Brooklyn, the surgeon John Bingham Roberts announced that “the time may possibly come when wounds of the heart itself will be treated by pericardial incision to allow extraction of clots and perhaps to suture the cardiac muscle.” In 1882, M. Block, a German doctor, revealed that he had made and stitched puncture wounds in the hearts of rabbits, who had survived. He suggested similar techniques might work in humans. In New York, the surgeon Charles Albert Elsberg reported that his animal experiments “seem to show that a mammalian heart will bear a much greater amount of manipulation than has hitherto been suspected.”

  In their midst was Daniel Williams, a showboating surgeon who made up in boldness and technical prowess what he lacked in humility. Later in his career, when he was at Howard University, he would become famous for inviting the public into the hospital on Sunday afternoons to watch him operate—“when the Negro public had not become accustomed to Negro physicians and had not learned to have full confidence in them,” as the anthropologist W. Montague Cobb noted. “Many dreaded to cross the threshold of a hospital, any hospital,” Cobb added. “Dr. Williams took the boldest and most thorough-going step possible [to] combat this irrational fear. He threw open the doors of his operating room once a week to the public and said in effect, ‘Come watch us work, observe conditions and see for yourselves that there is nothing to be afraid of.’”

  James Cornish was no well-chosen public demonstration, though. When Williams opened his chest wound with a six-inch incision that sweltering day in 1893, he had no idea what he would find. On the inner surface of the ribs, a lacerated artery was trickling blood. Williams sutured it closed with catgut. The operating room was like a sauna; assistants wiped a similar dribble from Williams’s brow. Williams was getting ready to close the chest when he noticed the knife had traveled deeper, puncturing the pericardium with a hole about one-tenth of an inch in diameter. With little time to mull over his options, he asked for more catgut and needle and stitched the pericardial wound closed, carefully timing the movement of his needle with the beating heart in a sort of surgical tango. He noted that there was also a small wound in the thin-walled right ventricle—in the heart muscle itself—but it had formed a dark clot on its surface and was no longer bleeding. Williams decided to leave it alone.

  Cornish’s wound re-bled after a few days, so Williams took him back to the OR to evacuate more clot. The wound eventually healed, and Cornish escaped the clutches of sepsis, the great postoperative killer in those days. On August 30, nearly two months after he was stabbed, Cornish walked out of the hospital. Apart from a few more bar fights, he went on to live a normal life, even outliving his surgeon by twelve years.

  Williams’s operation, we now know, was not the very first pericardial surgery. Probably three others had been performed over the previous decade, though they had not been reported widely. Williams almost certainly did not know about them, and most patients had died soon after the operations. By applying needle to pericardium in “the first successful or unsuccessful case of suture of the pericardium that has ever been recorded,” as Williams himself declared, he did as much as any doctor in history to demystify the heart and advance the notion that it was a machine that could be repaired. For this he received worldwide acclaim. The fact that he was a black man living in the era of Jim Crow makes his achievement that much greater. In 1894, he moved to Washington, D.C., where he was appointed by President Grover Cleveland surgeon in chief at Freedmen’s Hospital, which provided care for former slaves. He eventually moved back to Chicago, where he had an honorable (and honored) career, dying in 1931 of complications from a stroke.

  Though Williams is often credited with performing the first documented open-heart surgery, he did not in fact cut into the heart. He only stitched closed the pericardium, the sac around the heart. Credit for the first myocardial stitch resulting in survival belongs to Ludwig Rehn, a German surgeon, who, on September 9, 1896, almost exactly three years after Cornish walked out of Provident Hospital, sutured a two-centimeter laceration in the right ventricle of a twenty-two-year-old Frankfurt gardener who’d been stabbed in the chest while walking in a park. The victim, Wilhelm Justus, was found by police in a state of collapse, his clothes soaked with blood. He was brought to Frankfurt State Hospital in the dark of the early morning. Though the track of the wound pointed toward the right ventricle, doctors admitted him for observation—aware, no doubt, that heart surgery conferred little benefit over prayer. But soon there were signs that blood was rapidly accumulating in his chest. Justus spiked a fever, and his respiratory rate rose to sixty-eight breaths per minute (six times faster than normal). Camphor, a stimulant, and ice bags were ordered, but Justus’s condition worsened. That evening, his skin blue, pulse weak, and breathing increasingly labored, Rehn finally took him to the OR.

  The hospital in Frankfurt, Germany, where Ludwig Rehn performed the world’s first successful heart surgery (Courtesy of the Journal of Medical Biography 20, no. 1 [2012])

  Born in 1849 in Allenstein, Germany, Rehn, like Williams, experienced the death of his father, a physician, when he was young and went to live with relatives. But unlike Williams, when he was presented with the opportunity to stitch a myocardial wound, he took it. He made a fourteen-centimeter incision in the space between Justus’s fourth and fifth ribs along the nipple line, cut through the fifth rib, and then bent it upward, still attached to the breastbone, to create space to operate. He found an inch-long wound in the right ventricle spitting blood, spurting wildly with every contraction. “The sight of the heart beating in the opened pericardial sac was extraordinary,” Rehn wrote. “Digital pressure controlled the bleeding, but my finger tended to slip off of the rapidly beating heart.” He inserted a digit into the wound, then stitched the hole closed with three fine silk sutures. “It was very disquieting to see the heart pause with each pass of the needle,” he wrote. But the heart soon “resumed its forceful contractions.” After placement of the final stitch, the pulse was strong. Rehn turned down the rib, realigned the skin and soft tissues, and bandaged up the chest.

  In that essentially pre-antiseptic era, the Grim Reaper appeared more often bearing a thermometer than a scythe. Ten days after the operation, Justus spiked a temperature of 104 degrees Fahrenheit. Pus leaked from his chest wound. He had developed sepsis. Rehn took him back to the OR to drain the infection. Fortunately, the fever quickly resolved, and Justus’s condition improved. He was discharged home a week later.

  Six months later, on April 22, 1897, Rehn described his operation at a surgical meeting in Berlin, where he pronounced that “the feasibility of cardiac repair no longer remains in doubt.” “I trust that this case will not remain a curiosity, but rather, that the field of cardiac surgery will be further investigated,” he
said, adding that “many lives can be saved that were previously counted as lost.” Rehn wrote a detailed account of his operation in a surgical journal. His wording was careful, even a bit defensive. Scarcely a decade earlier the great Billroth had proclaimed that “the surgeon who would attempt to suture a wound of the heart should lose the respect of his colleagues.” Perhaps feeling the weight of history bearing down on him, Rehn wrote, “I was forced to operate. There was no other option open to me, with the patient lying before me, bleeding to death.”

  Rehn’s and Williams’s operations ushered in a new era in medicine in which the scalpel was finally applied to the most celebrated and elusive organ in the human body. Doctors took heed of their results. In 1899, the German surgeon Sanitatsrath Pagenstecher wrote, “I am far from wanting to make heart operations into typical procedures practiced by any physician, although efforts so far have shown very good results.” On September 14, 1902, on a kitchen table under the flickering lights of two kerosene lamps in a slum shack in Montgomery, Alabama, Luther Hill became the first American surgeon to successfully suture a cardiac wound, in the left ventricle of a thirteen-year-old boy who had been stabbed five times. At a conference in 1907, Rehn reported that 120 surgeries on the heart had been performed around the world, with 40 percent of them successful, a fourfold improvement in mortality compared with the pre-surgical era. Several years later, the German surgeon Rudolf Haecker wrote, “Since ancient times, the heart has been regarded as ‘noli me tangere’ [but] with [heart surgery] the last organ of the human body has now fallen to the hand of the surgeon.”

  The dawn of heart surgery was long, however, and the full light of day would not break for several decades. Though attempts to repair almost uniformly fatal heart wounds were greeted with resigned acceptance, cutting open the organ to fix diseased valves, pitted walls, or misplaced vessels that killed slowly was still wholly rejected. The obstacles were many, but the major one was lack of time. As G. Wayne Miller writes in his authoritative book King of Hearts, “To open the living heart was to kill, in a river of blood that ran dry in less than a minute.” To prevent such bleeding, the heart had to be isolated from the circulation and stopped before being sliced open. But stopping the heart for more than a couple of minutes would result in brain and other organ damage. How to circulate blood and oxygen after interrupting the heartbeat? This was a challenge on a scale that medicine had never encountered. Could the heart, nature’s ultimate machine, be replaced by a man-made pump?